The NHS has been a source of national pride and gratitude throughout the pandemic as health care workers have risked their own lives to care for others in extraordinary ways. But systemic weaknesses in the health service are making it hard for the UK to cope with the latest surge of COVID-19 patients. The very real risk of the NHS being overwhelmed has now led to a third lockdown.

Workforce shortages are a critical barrier to increasing NHS capacity, and are reportedly a key reason why the Nightingale field hospitals have not been fully mobilised despite the intense pressure on health services.

But while the pandemic is out of the ordinary, staffing shortages – particularly for nursing – are not. Between 2010 and 2018, the number of doctors working in the NHS increased by 15%, but the number of full-time equivalent nurses hardly increased at all – despite the amount of care provided by the health service growing by a third.

Capacity in the NHS is about skilled workers – and that tap can’t be turned on in an instant. We are reaping the seeds of years of workforce policy and planning failures.

In 1919, the Nurses Act established the first professional nursing register. As early as 1932 there were already concerns about staffing shortages. Fast forward to the foundation of the NHS after the Second World War, and from the outset, the NHS was estimated to have 48,000 too few nurses. Much has changed in the intervening 70 years, but going into the pandemic the NHS was once again facing a shortfall of over 40,000 nurses.

The root cause of shortages is the failure to invest in training. OECD data on the number graduating with a nursing qualification per head of population shows the UK was towards the bottom of the table, below both the OECD average and the EU-14 average (see chart 1 below). In 2019 we had around a third of the proportion of new graduate nurses as Australia and around half the proportion as the US.

The failure to train is not new. Previously nursing degrees were funded by government bursaries, with the number of places set nationally and capped. That system cost over £1bn a year in England. With austerity, the nurse training budget was an easy target. As a consequence, fewer places were funded and the numbers starting a nursing degree in 2011 fell by a sixth relative to 2009.   

In 2017, the government abolished the bursary and with it lifted the cap on numbers, shifting nursing students onto tuition and maintenance loans. Part of the rationale was to break this cycle of undertraining: nursing could become demand-led and universities would have the freedom and flexibility to respond. The government hoped this would lead to up to 10,000 additional people starting nursing, midwifery and allied health profession courses by 2020. This increase would have taken nursing numbers back above the level achieved in 2004, the last major expansion of the NHS workforce. Before the pandemic there was some growth in the numbers training, but the uptick was very modest.  

One of the silver linings of COVID-19 is that it has led to a substantial increase in the numbers wanting to work in the NHS. Applications to nursing courses in England rose by 17 per cent last year compared to 2019, with 26,590 students starting a nursing degree in the Autumn (see chart 2 below). This is above the previous peak under Tony Blair, which was itself the highest number for at least 20 years. 

Those students, while a welcome investment in the future, come too late to help solve the current crisis of capacity as COVID-19 surges. But the pandemic is a stark lesson in the dire consequences of not investing in training. Capacity in the NHS is about skilled workers – and that tap can’t be turned on in an instant. We are reaping the seeds of years of workforce policy and planning failures.

On current trends, workforce shortages are still set to grow further, as demand for NHS care continues to increase owing to an ageing population with more complex health conditions. As the pandemic subsides, it’s imperative that the government builds on the renewed interest in nursing to support a sustained expansion. Despite the shift to student loans, this will require some government funding – firstly to support nurses’ clinical placements in the NHS, a key part of their training. But also to fund the new, non-means tested cost-of-living grant to top up trainee nurses’ incomes, designed just before COVID-19 to reduce drop-out rates and attract more mature students.

The pandemic highlights the risks associated with the traditional approach of relying on overseas recruitment. This is no longer the 'get out of jail free' card it might once have been. COVID-19 has disrupted international travel and the UK has witnessed a sharp reduction in new registrations from nurses trained abroad. International mobility will return, but the WHO estimates that the world faces a shortage of some 13m nurses by the end of this decade. Building NHS capacity for the future means we must address the nursing shortfall with a sustained increase in the numbers training in the UK. A long-term strategy is urgently needed.

This blog was originally published by Prospect.

Further reading

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Building the NHS nursing workforce in England

December 2020
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Addressing the nursing shortfall

13 December 2020
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REAL Centre

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