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The COVID-19 pandemic has had major implications for the health and social care workforce in England and the impact will extend far beyond the immediate crisis. Many front-line staff have gone above and beyond to provide care in very difficult circumstances. Against this backdrop, it is easy to see why the government’s proposal for a 1% pay increase for nurses and other NHS staff in the coming year has generated so much controversy and threats of strike action.

Even before the pandemic, workforce shortages were a huge concern for the NHS and social care and nowhere are they more visible than in nursing staff numbers. Registered nurses account for one in four full-time equivalent (FTE) jobs in NHS hospital and community health services, but represent one in two vacancies within the NHS. Better understanding how the pandemic may have affected nurse labour market outcomes in the NHS and social care is therefore critical if the workforce shortages in these sectors are to be addressed effectively.

Here we summarise findings from recent research undertaken by Decision Analysis Services Ltd (DAS), commissioned by the REAL Centre, to develop a model of nursing workforce supply in England. The research focused on potential COVID-19 impacts and wider changes in the NHS nursing workforce between March and October 2020. In addition to an evidence review, it involved interviews and a virtual workshop attended by key stakeholders.

What are the major concerns?

The work by DAS emphasises that the pandemic poses serious long-term challenges around nurse recruitment and retention in England, but much more research will be needed once relevant data become available. It’s also important to note that nurses’ experiences and career choices during the pandemic will have varied dependent on their field of work, personal circumstances, age and ethnicity.

Nurses have had to make significant changes to the way they deliver care, with established nurses redeployed from their usual settings to COVID-19 wards, and student nurses being offered the option to spend the final 6 months of their programme on clinical placements or an emergency register. This involved considerable risks of exposure to COVID-19 – more than one in ten hospital nurses were reported to be on sickness absence in January 2021, largely due to coronavirus exposure or having to self-isolate. Ways of working have changed across the NHS due to COVID-19, as the move to digital-first services in primary care and outpatients highlights – but more research is required to understand how these changes have affected the nursing workforce.

Mental health and wellbeing are also key concerns, with growing awareness of the potential long-term impact on health and care workers on the front line of the pandemic. In a survey of 2,600 nurses and midwives, one in three reported severe or extremely severe depression, anxiety or stress, with nearly all respondents expressing concern about the risks their clinical roles posed for family members. It is possible that the resulting strain on nurses’ mental health will impact current nurses negatively in the long term. For instance, these pressures might lead some nurses to retire earlier than they otherwise would or leave the profession entirely.

At least in the short term, the disruption of international travel due to COVID-19 also led to a sharp drop in ‘new’ nurses from other countries being able to register with the Nursing and Midwifery Council (NMC). With international recruitment being a significant NHS nurse employment channel, this compounded the pressures on the existing nursing workforce in 2020.

Initiatives such as ‘#LightItBlue’ and ‘Clap for our Carers’ have demonstrated the public’s appreciation for nurses and the wider health and social care workforce over the past year. However, the government’s 1% pay rise proposal has added fuel to the debate around whether the applause will be backed by a commensurate pay reward. The pandemic has exposed a number of longstanding problems in social care in particular, including issues around low pay and insecure work. The long-term impact of COVID-19 on nurses in social care calls for greater research.

Are there any silver linings?

Fortunately, the picture is not entirely bleak. COVID-19 has promoted the image of nursing being a stable and rewarding career with relatively high job security. In tandem with the palpable increases in public support for NHS staff, this is a huge positive. Stakeholder input suggests that this feeling is strengthened in circumstances where opportunities outside nursing are limited, or nurses’ partners or family members are made redundant, struggling to find work or furloughed. One key stakeholder suggested that, as with economic downturns in general, job leaver rates among nurses appear to have fallen in 2020 following the pandemic-induced recession. However, lower leaver rates could also be explained by a heightened sense of professional duty during challenging times. Whether these lower leaver rates persist beyond the first wave of COVID-19 remains to be seen.

Nursing is seen as a stable job in times of economic uncertainty and the [NHS People Plan 2020/21] is committed to increasing flexibility and inclusivity and providing more staff which, if translated into reality, should encourage more nurses to stay in the profession and increase nurse supply.
Stakeholder interview

There are other positives: the number of people seeking information on nurse training and the number of people applying for and being accepted to nursing degree programmes in 2020 all increased markedly relative to 2019. Acceptance numbers in particular reached a 2-decade high, with UK universities accepting 28,920 students to nursing degree courses in 2020 (an increase of 25% from the previous year). The data also point to a diversifying nurse labour market – applications from men and mature applicants increased in 2020 relative to previous years.

In addition to the enhanced profile and increased appreciation for nurses during the pandemic, the introduction of cost-of-living grants for student nurses in 2020 is likely to have contributed to these increases in people joining the profession. Moreover, the government initiated important emergency measures to boost the nursing workforce in response to COVID-19. A temporary register was set up for nurses who had recently retired or otherwise left the workforce. Overseas nurses who were already in the UK but yet to complete only their final clinical qualification were offered the opportunity to join this temporary register. The latest data suggest this will lead to a small increase in the nursing workforce in the long term. Of more than 14,000 people on the temporary register, only 1,985 had moved to the permanent NMC register in the 6 months to September 2020.

Looking to the future

The long-term impact of COVID-19 on nurse numbers in England is uncertain. As this blog suggests, there are likely to be positive and negative effects. The overall impact will become more apparent as relevant data around the drivers of change emerge in the coming months. Our work on nurse supply modelling will provide further insight, with initial projections of nurse numbers in England in the next 10–20 years due to be published later this year. Watch this space.

Nihar Shembavnekar (@NShembavnekar) is an Economist in the REAL Centre team at the Health Foundation

Emma Woodham is a Lead Consultant at Decision Analysis Services Ltd (DAS)

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