NURSING & MIDWIFERY WORKFORCE RISKS AND OPPORTUNITIES

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1 NURSING & MIDWIFERY WORKFORCE RISKS AND OPPORTUNITIES A report to review the key workforce risks and opportunities within the Nursing and Midwifery workforces. Laura Dunkley and Saira Haider Sa November 2010

2 TABLE OF CONTENTS 1. Introduction Overall Context Finance Workforce and productivity Liberating the NHS: Developing the Healthcare Workforce (Department of Health, 2010a) Independent Review of Higher Education Funding and Student Finance in England, Securing a Sustainable Future for Higher Education in England (Browne, 2010) The Operating Framework for the NHS in England 2011/ Social care Management of risk Research by the University of Manchester... 7 Generic context papers... 7 Field-related research papers Data Sources NURSING Introduction Key workforce risks Key workforce opportunities MIDWIFERY Key workforce risks Key workforce opportunities Summary References CfWI July

3 1. INTRODUCTION The Workforce Risks and Opportunities project sets out the major risks and opportunities facing the health and social care workforce in 2011 and beyond. The purpose of this project is to provide an assessment of current workforce issues and potential opportunities for improvement. For each professional group within health and social care, existing analysis and data have been reviewed and updated. This grouping is based on the Department of Health Professional Advisory Boards (PABs). A suite of reports has been produced for each group outlining the main opportunities and risks facing the workforce. The purpose of the Nursing and Midwifery Workforce Risks and Opportunities report is to present the Centre for Workforce Intelligence s (CfWI) initial findings around key workforce risks and opportunities within nursing and midwifery, to be reviewed and discussed with appropriate stakeholders. Its target audience is wide and encompasses those responsible for and interested in aspects of workforce planning, development and commissioning at all levels in the system. CfWI July

4 2. OVERALL CONTEXT When reviewing workforce risks and opportunities, it is important to consider the wider environment in which activity is taking place. The following section provides an overview of the external factors that may impact on workforce, in particular the current changes that are taking place within the system landscape. 2.1 Finance The NHS is facing a period of sustained and significant financial constraint. Following the Comprehensive Spending Review, health spending is set to increase from 104 billion in to 114 billion in , a total increase of 0.4 per cent in real terms, or an annual real terms increase over inflation of around 0.1 per cent. Since its inception, the NHS budget has grown by an average of over 4% each year in real terms. In order for the NHS to meet shifting demand resulting from demographic change and new treatments and technologies, significant savings will need to be achieved. To address these challenges, the Department of Health (DH) is aiming to improve efficiency and productivity while maintaining quality of care and health outcomes through the Quality, Innovation, Productivity and Prevention (QIPP) agenda, setting a savings target of 20 billion by These savings will be reinvested to support quality and outcomes. 2.2 Workforce and productivity Around 70 percent of NHS provider expenditure relates to staffing (House of Commons Health Select Committee, 2007). As NHS organisations seek to balance their budgets and achieve savings, future workforce activity should be fully considered to reduce the risk of incurring increased long-term costs. Large cuts to administrative and managerial staffing costs can make a modest contribution to savings, but the most significant savings can be achieved by increasing the productivity and efficiency of existing resources. For example, savings can be made by adjusting skill mix. The healthcare workforce has historically been characterised by rigid role definitions across different professional groups and grades. NHS Workforce Planning: Limitations and Possibilities (King s Fund, 2009) recommends placing increased focus on further developing the skills of staff already involved in delivering services. It suggests that a more flexible approach can be more productive and improve the quality of services via role enhancement (a person taking on new skills), role substitution (working across professional divides), delegation (moving a task up or down grades within a profession) or innovation (creating new roles to fill competency gaps). Staffing resources can be allocated within service delivery as efficiently as CfWI July

5 possible, with care pathways designed to avoid hospital admissions. Where clinically appropriate, care can also be brought closer to the community. Research suggests that there are potential productivity improvements of 4.5 billion from reducing variation in clinical practice in hospitals alone (King s Fund, 2009). 2.3 Liberating the NHS: Developing the Healthcare Workforce (Department of Health, 2010a) Equity and excellence: Liberating the NHS (DH, 2010b) outlines radical plans to restructure the NHS. This was followed by proposals for planning and developing the NHS workforce, outlined in Liberating the NHS: Developing the Healthcare Workforce (DH, 2010a). In April 2011, the Government took the decision to pause, listen, reflect on and improve our plans, and established an NHS Future Forum to listen to patients, professionals and members of the public and report. In its response to the Forum s report on Developing the healthcare workforce (DH, 2011a), the Government confirmed that it would: ensure a safe and robust transition for the education and training system, taking action to put Health Education England in place quickly to provide national leadership and strong accountability while moving towards provider-led networks in a phased way; ensure that, during the transition, deaneries will continue to oversee the training of junior doctors and dentists, and give them a clear home within the NHS family; improve the quality of management and leadership, for example by retaining the best talent from PCTs and SHAs and through the ongoing training and development of managers; further consider how best to ensure funding for education and training is protected and distributed fairly and transparently, and publish more detail in the autumn. (DH, 2011a) 2.4 Independent Review of Higher Education Funding and Student Finance in England, Securing a Sustainable Future for Higher Education in England (Browne, 2010) The Browne review, published in October 2010, sets out changes on how higher education will be funded by students and the government. The full implications of the review on health and social care training will need careful consideration. CfWI July

6 2.5 The Operating Framework for the NHS in England 2011/12 The NHS operating framework sets out the national priorities for 2011/12, including maintaining tight financial control, performance on key waiting times, continuing to reduce healthcare associated infections and reducing emergency readmission rates. Changes need to be effected in order to meet the specific targets for individual healthcare groups outlined in the framework. 2.6 Social care The Operating Framework sets out the redistribution of funding allocations from health to social care, in line with the current government priority of strengthening social care services. The implications of this shift, as well as the personalisation agenda, should be considered as drivers of workforce change. 2.7 Management of risk Reorganisation raises a number of challenges for successful workforce planning. There is a risk that the impending organisational changes of the next two years will distract from the QIPP agenda. This risk will benefit from careful management, if the NHS is to continue delivering high quality services. GP consortia and healthcare providers taking on functions from SHAs and PCTs should consider how to capture the knowledge and expertise of staff currently managing those functions. It is vital that security of workforce supply is maintained during the transitional period: PCTs and SHAs will be working with GP practices over the next two years to help prepare for the new arrangements. As the number of foundation trusts increases and commissioning is further decentralised, commissioners should carefully manage the risk of fragmentation of decision making and a potential lack of alignment of decisions on workforce supply. CfWI July

7 3. RESEARCH BY THE UNIVERSITY OF MANCHESTER The University of Manchester is an academic partner of CfWI. In this capacity, it has drawn on research in a number of focus areas to support the WRO project and has produced papers to complement the WRO reports. These include two generic papers on the economic context and options for future ways of working, as well as a suite of papers relating to workforce issues within specific professional groups. The following section details the research papers that are relevant for nursing and midwifery. The background context papers will be of interest to a broad audience, including workforce planners, and those specifically related to the field will provide a more detailed insight into certain workforce risks and opportunities for those with a particular interest in the nursing and midwifery workforce. All papers can be accessed in full from the CfWI website at Generic context papers Recession, Recovery and the Changing Labour Market Context of the NHS (Rafferty, Rubery, Grimshaw, 2011a) This briefing synthesises findings on the changing labour market within the NHS and identifies the key implications for workforce planners and human resources. Focus areas include: Increased unemployment and fewer opportunities in the wider labour market potentially alleviating shortages in NHS labour supply. The development of strategies to attract EEA migrant labour. Increased opportunities for women, partly as a result of past changes to the welfare and benefit system. The paper also highlights the need to continue to monitor the situation regarding: the changing labour market further welfare reform which may shift financial incentives the impact of immigration policy developments on labour market needs by occupations, professional groups, service pathways and region. CfWI July

8 Labour Substitution and Efficiency in Healthcare Delivery: General Principles and Key Messages (Sibbald, McBride, Birch, 2011) The substitution of one kind of worker with another is one strategy for improving the effectiveness and efficiency of health care provision. This briefing paper aims to inform managers and workforce planners about the likely consequences of such changes. It draws on economic principles and studies across a number of occupational work groups in the healthcare sector. Findings indicate that labour substitution: Is a plausible strategy for addressing workforce shortages Can reduce (wage) costs - under certain conditions which can be challenging to meet Can improve efficiency - under certain conditions which can be challenging to meet The paper emphasises the need for healthcare planners and managers to give careful consideration to the economics of labour substitution, in order to ensure it does not lead to an increase in costs and reduced efficiency. It also describes other factors which affect the feasibility of labour substitution, including training and regulation requirements. CfWI July

9 Field-related research papers Working time practices in nursing and midwifery (Rafferty, Rubery, Grimshaw, 2011b) This briefing paper considers some key workforce risks, opportunities, monitoring, and research needs related to working time practices in nursing and midwifery. Implications for workforce planners and HR managers in the NHS include: Longstanding workforce organisation issues around part-time and other flexible forms of working continue to be important to recruitment, retention, and career advancement within the nursing and midwifery workforce. Despite these persistent challenges, there is a risk that the current economic climate will reduce the impetus for work-life balance policies. The nursing and midwifery labour force remains predominantly female and issues around combining paid-work and parenthood persist. Assumptions regarding work-life balance being a motherhood issue or something confined to the primary carers of children should be challenged. A greater focus on work-life balance amongst both older women and men, for example, could help utilise the skills and experience of people seeking a gradual transition into retirement, or encourage workforce re-entry. Workforce redesign is increasing in its prominence as an issue in other areas of the NHS. The increased feminisation of the medical workforce may provide new opportunities to modernise work organisation around interdependencies between medical and nursing roles. CfWI July

10 4. DATA SOURCES Qualitative and quantitative data has been gathered from a number of sources in order to establish both the workforce risks and opportunities within this document, including a review of key policy documents and papers. Quantitative data has largely been gathered from the following sources: NHS Information Centre Non-Medical Census and Bulletin Tables ( ): This census is undertaken annually using data collected via the Electronic Staff Register (ESR). It provides headcount and FTE data by selected area of work, age band and type of nursing and midwifery staff employed by the NHS in England. It will therefore exclude nurses working in private hospitals, hospices or the voluntary sector. At the time of writing, the most recently available census was of the workforce as at September Multi-Professional Education and Training (MPET) Non Medical Education and Training (NMET) Commissions, : This dataset is collated by DH and contains actual pre-registration education and training commissions for nursing and midwifery degree and diploma courses by SHA from 2002/03 to 2009/10, and planned commissions for 2010/11. Commissioning numbers may underestimate actual training places, depending on the policy of the University to over-recruit to compensate for first year attrition. Conversely, it will not accurately reflect the number of students recruited if some training places fail to be filled. Organisation for Economic Co-operation and Development (OECD)/ The European Statistical Agency (Eurostat)/The World Health Organisation (WHO): These sources hold international data on a variety of indicators to allow for comparison of, for example, nurse to population ratios between countries. Such data has to be interpreted with caution as definitions of various nursing groups, and data collection methods, may differ between countries. The OECD holds a range of data items including population, staff levels and health indicators for its 34 member countries (the majority being regarded as developed countries with a high human development index), as well as some non-member countries and territories. Eurostat holds similar data for European Union (EU) countries with the aim of providing the EU with statistical information at European level, and promoting the harmonisation of statistical methods across the member states. The WHO is the public health arm of the United Nations and compiles data annually from its 193 member states. CfWI July

11 UKCC/NMC: Registration data from the Nursing and Midwifery Council (NMC) shows the number of nurses annually registering to work in the UK, and records their country of origin. The NMC also holds data on the number of nurses who have requested their UK registration to be verified, as part of the process of applying for a job in another country. However, there are limitations in using NMC data to monitor the inflow and outflow of nurses to and from the UK, as it registers EU/overseas nurses who intend to work in the UK, and UK nurses with intent to nurse abroad, rather than those actually working. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) undertook the maintenance of the nursing, midwifery and health visiting register before the NMC was established, and allows data comparisons to be undertaken using data on pre-2002 registrations. CfWI July

12 5. NURSING 5.1 Introduction The purpose of this section is to identify and discuss key risks and opportunities to the nursing workforce, including secondary care, community and practice nurses. For the purpose of this report, the NHS nursing workforce has been the key focus of the analysis, since this is the staff group for which the most complete and timely data set exists. However, in terms of workforce planning, it is recognised that the NHS provides training of nurses for both the public and private sector, for both health and social care. Additionally, especially with the onset of Any Qualified Provider, consideration of the private and voluntary sector nursing workforce is important in determining the supply of nurses available for overall service provision. It would also be useful to be able to track the movement of nurses to and from the private sector. However, analysis of the wider nursing workforce is currently hindered by a lack of available data. Risks and opportunities are discussed in terms of how they relate to the key nursing fields of: Adult nursing Children s nursing Mental health nursing Learning disabilities nursing. These are categorised by the Nursing and Midwifery Council (NMC) standards for pre-registration nursing education, released in There is also a focus on health visitors, because of the Government s pledge to place them at the centre of the community healthcare team to promote children s and young people s health (DH, 2009a), and to increase the numbers by 4,200 full time equivalent (FTE) to do so (DH, 2011b). An additional 6,000 health visitors will be required in order to reach this figure accounting for retirements and other loss from the workforce. CfWI July

13 5.2 Key workforce risks The following section of this report identifies key workforce risks within the nursing workforce Supply Intelligence indicates that some specialist nursing roles remain difficult to recruit to. As a result, the following nurse specialist groups appear on the Migration Advisory Committee s National Shortage Occupation List (NSOL) as of 2009: o specialist nurses working in operating theatres o operating department practitioners 1 o specialist nurses working in neonatal intensive care units. This list may not accurately reflect all nursing areas in which there is a shortage, as one of the criteria for inclusion on the list is that international recruitment must be a sensible mechanism for alleviating shortages. For example, overseas recruitment is not recommended for this purpose within learning disability nursing, due to the lack of comparable training programmes offered in overseas settings. Anecdotal evidence also indicates that nursing homes in particular have difficulty filling vacancies and in the past have been heavily reliant on international recruitment. 1 Operating department practitioners (ODPs), in contrast to specialist nurses working in operating departments, have no requirement to be a registered nurse. They are however registered health professionals, many with nursing backgrounds, and perform some nursing functions, and appear under the occupation title of Nurses on the NSOL. CfWI July

14 Supply Workforce Risks and Opportunities Nursing & Midwifery Figure 1 illustrates the change in headcount and full-time equivalent (FTE) of NHS nurses since 2000, and shows that the number of practising nurses in the NHS has increased by 5.3% over the last five years. Figure 1: Historical Supply of NHS Nurses and Health Visitors, ,000 Supply of NHS Nurses (including practice nurses) and Health Visitors, England ( ) 400, , , ,000 Headcount FTE 200, , ,000 50, Year Source: Information Centre (IC, 2011a) Non-medical Bulletin Tables, Totals include bank staff. Please note that there have been improvements to the IC headcount methodology which make it a more stringent count of absolute staff numbers. As a result 2010 headcount data is not fully comparable with that of previous years. CfWI July

15 Degree and Diploma Commissions Workforce Risks and Opportunities Nursing & Midwifery However, in 2008 the NHS Workforce Review Team s (WRT s) modelling forecast showed that, if the 2008 commissioning levels were maintained, there would be a reduction in the number of trained nurses available in the future. This was due in part to a sharp reduction in total nursing commissions (degree and diploma) in England between 2005/06 and 2007/08 (as shown in Figure 2 below), which resulted in fewer trainees coming through the system from 2009 onwards and lower numbers of newly qualified nurses than in previous years. SHA commissioning intentions show that further reductions were planned for 2010/11, and SHAs should plan in the context of actual commissions historically being lower than planned commissions. Figure 2: National Nursing Pre-registration Planned and Actual Commissions, ,000 Nursing Pre-registration Planned and Actual Commissions, England ( ) 25,000 20,000 15,000 Planned Commissions Actual Commissions 10,000 5, Year Source: Multi Professional Education and Training (MPET) 02B - Non Medical Education and Training (NMET) Commissions, 2002/ /11 CfWI July

16 Headcount Workforce Risks and Opportunities Nursing & Midwifery Supply of Nursing Sub-Groups Figures 3a-b show that the supply profile of nurses is variable across all nursing groups. For example, Figure 3a shows that the headcount of learning disability nurses has reduced by 30% since This reduction may not be as severe as it appears, as it is likely to be due in part to a portion of the NHS workforce transferring to social care providers. As a result, the genuine reduction in nurses providing learning disability services is difficult to gauge. Figure 3a also shows that the headcount of health visitors has fallen by 15% over the same time period. The headcount of district nurses has also decreased by 30% between 1999 and Figures 3a-b: Historical Supply of Nurses by selected type, by a) Headcount and b) FTE Headcount of Nurses and Health Visitors in England, , , ,000 Health Visitors Nurses in Paediatrics Nurses in Psychiatry 100,000 Nurses in Learning Disabilities Practice Nurses Nurses in Acute, Elderly & General Services 50, Year (as of 30 September) CfWI July

17 FTE Workforce Risks and Opportunities Nursing & Midwifery FTE of Nurses and Health Visitors in England, , , ,000 Health Visitors Nurses in Paediatrics Nurses in Psychiatry 100,000 Nurses in Learning Disabilities Practice Nurses Nurses in Acute, Elderly & General Services 50, Year (as of 30 September) Source: Information Centre (2011a) Non-medical Bulletin Tables, Here nurses are categorised according to the field they are currently working in, not the discipline in which they trained. The headcount and FTE include that of bank staff. Please note that there have been improvements to the IC headcount methodology which make it a more stringent count of absolute staff numbers. As a result 2010 headcount data is not fully comparable with that of previous years Migration Active recruitment campaigns have also resulted in increased numbers of UK nurses applying to work overseas. A combination of a reduction in international recruitment of nurses and increasing migration of UK nurses has had the result that there is currently a net outflow of nurses from the UK (Buchan and Seccombe, 2010). International comparisons of nursing numbers International comparisons of health workforce numbers and ratios are fraught with difficulty, because of differences in data definitions and data collection methods. The main sources for data for such comparisons include the World Health Organisation (WHO), the Organisation for Economic Co-operation and Development (OECD) and Eurostat; and interpretation and analysis should always be undertaken with caution. CfWI July

18 Staff per 1,000 population Workforce Risks and Opportunities Nursing & Midwifery The most recent data published by OECD/Eurostat, in late 2010, gives some scope to look at nurse to population ratios for European countries. Figure 4 presents the OECD collated data for selected European countries and the EU average, for three defined categories of nursing staff: professional nurses, associate professional nurses and caring personnel. For some countries, breakdown between professional nurse and associate was not available, and some countries included caring personnel, while others did not. Figure 4: Prof Nurses, Associate Prof. Nurses and Caring personnel per 1000 population, selected EU countries 30 Prof Nurses, Associate Prof. Nurses and Caring personnel per 1000 population, selected EU countries Caring Personnel Associate Nurses Professional Nurses 0 Country Source: OECD Health at a Glance, OECD EU Edition, 2010 As noted above, such data should be interpreted with caution, and different data sources may use different definitions and/or present different data. For example, the WHO Global Atlas of the health workforce, which presents data from 193 member states, provides data on nursing and midwifery personnel which includes professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses. Data from this source shows the UK at a slightly higher nursing staff: population ratio than that reported by OECD/Eurostat. CfWI July

19 Inflow of nurses to the UK Over the last ten years there has been a marked decline in the international inflow of nurses to the UK. In the early part of this decade, between 10,000 and 16,000 international nurses were added annually to the UK register. This figure has fallen to less than 3,000 per annum in recent years. There are two main reasons for the drop in inflow: reduced UK demand, and because entry to the UK for non EU nurses has become much more challenging, as the nursing occupations included on the National Shortage Occupation List have reduced from all registered nurses in 2005 to just a few specialist nursing fields as of 2009 (MAC, 2009b). In addition, the Overseas Nurse Programme (ONP), which since 2005 has been a requisite course for all nurses trained outside of the EEA to be able to work as a nurse in the UK (NMC, 2005), has increased both the time required to register in the UK and the cost to the funder, which may either be the employer or the nurse who is applying. Increases in registration requirements from the Nursing and Midwifery Council and a shift to a points based work permit system has reinforced the government policy of making international recruitment a more difficult option for employers. The reduction in inflow is shown in Figure 5, which is based on registration data from the Nursing and Midwifery Council (NMC) and shows that the number of international nurses registering annually in the UK has dropped markedly since (There are limitations in using NMC data to monitor the inflow of nurses to the UK, because it registers nurses who intend to work in the UK, rather than those actually working). CfWI July

20 Number of registrations Workforce Risks and Opportunities Nursing & Midwifery Figure 5: Admissions to the UK nursing register from EU countries and other (non EU) countries 1993/ / Admissions to the UK nursing register from EU countries and other (non EU) countries 1993/ /09 Non-EU EU Year Source: NMC/United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC); Buchan and Seccombe (2010) The overall marked decline in international nurses has also masked another important trend. The UK is now proportionately much more reliant on nurses registering from the EU than from other international sources. In 2008/09, 71% of international registrants were from the EU-compared with less than 7% in 2001/02. More nurses are now registered each year from EU countries such as Poland or Romania than from traditional source countries such as Australia. EU nurses are not subject to the same constraints on entry to the UK as are nurses from other countries, and this will have been a major factor in this switch in the pattern of source countries. The relative contribution of UK and of international sources to new nurse registrations since 1989/90 is shown in Figure 6. In the early 1990s, overseas nurses were the source of about one in ten entrants to the UK register. The international contribution rose rapidly in the late 1990s, both in terms of numbers and as a percentage of total new entrants, peaking in 2001/02 when more than half the new registrants were from non UK sources, and then dropping back in more recent years. CfWI July

21 Percentage of new admissions Workforce Risks and Opportunities Nursing & Midwifery Figure 6: International and UK sources as a percentage of total new admissions to the UK nursing register, 1989/ /09 (Initial registrations) International and UK sources as a percentage of total new admissions to the UK nursing register, 1989/ /09 (Initial Registrations) Int UK Year Source: UKCC/NMC data Outflow In 2008/09 more than 11,000 UK registered nurses requested their UK registration to be verified, as part of the process of applying for a job in another country 2. Figure 7 shows the trend in annual numbers of nurses applying for verification to nurse abroad ( outflow ) alongside the numbers from other countries registering to practise in the UK ( inflow ). 2 This NMC data indicates an intention to nurse in other countries; it does not necessarily record an actual geographical move CfWI July

22 Headcount Workforce Risks and Opportunities Nursing & Midwifery This gives an overall picture of the trends in flows to and from the UK. It is clear that the UK has shifted rapidly from being a net beneficiary of international flows in the early part of this decade, to a situation in the last three years when there has been a marked net outflow of nurses. Figure 7: Inflow and outflow of nurses to and from the UK, 1993/ / "Inflow" and "Outflow" of Nurses to and from the UK, 1993/ /09 Inflow Outflow Source: NMC/UKCC In 2008/09, the most recent year for which data is currently available, four English speaking developed countries- Australia, USA, New Zealand and Canadaaccounted for nearly all (88%) of the verifications issued by the NMC. More than half of all the verification requests from UK based nurses were for just one destination country: Australia. The Australian economy has suffered less from the global economic crises than most developed countries. It has been investing in increasing its health workforce, both by increasing home based training and by active international recruitment. Year CfWI July

23 Headcount Workforce Risks and Opportunities Nursing & Midwifery Figure 8: UK nurses applying to move to Australia; Australian nurses first registering in the UK: 2000/ / UK nurses applying to move to Australia; Australian nurses first registering in the UK: 2000/ /09 To Australia From Australia / / / / / / / / /09 Year Source: NMC In 2000/01, approximately 1,000 Australian nurses registered in the UK and about twice as many verifications were issued for nurses from the UK to practise in Australia. In 2008/09, less than 200 Australian nurses registered in the UK while more than 6,000 verifications were issued to practise in Australia. As a result of these changing patterns of migration and immigration, the UK is now less proportionally reliant on nurses from outside of the EU. However, they are now more reliant on immigration of EU nurses, especially since increasing numbers of UK trained nurses are choosing to move abroad, particularly to Australia and other developed English-speaking countries. Improved recruitment and retention strategies need to be considered in order to retain more UK trained nurses. CfWI July

24 Proportion of total workforce group Workforce Risks and Opportunities Nursing & Midwifery Ageing workforce According to the NHS Information Centre Census, 9.2% of all nurses and health visitors in 2004 were aged over 55. In 2009 this had increased to 12.8%. This percentage varies depending on the type of nursing staff group. The impact of the ageing workforce will not be consistent across the whole of nursing. The profession has specifically raised concerns that the ageing of the academic nursing workforce, combined with planned cuts to student numbers, will potentially result in a shortage of nurse educators in the future, with the associated loss of teaching skills and evidenced practice and research. In addition, Figure 9 shows that the community nursing workforce (in this case those defined as Community Psychiatry, Community Learning Disabilities or Community Services nurses in the IC Census) has an older age profile than the remaining nursing workforce, with a higher proportion of the community nursing workforce in all the over-40 age bands and the non-community workforce having a greater proportion of members in the under-39 age bands. Figure 9: Relative age profiles of the community and non-community nursing workforce, % Age profile of Community vs Non-community Nurses % 15% Community nurses 10% Non - Community nurses 5% 0% Under to to to to to to to to & over Age band Source: Information Centre Non-medical Census (2011a) The health visitor workforce is particularly at risk of retirements, as the age profile of the current NHS workforce indicates that 22% are aged over 55 years. This may lead to attrition from the experienced health visitor workforce in the future, which sits within the challenge of increasing numbers to meet the 4,200 FTE target. CfWI July

25 5.2.5 Service reconfiguration and changing terms and conditions With savings needing to be made across the whole of the NHS and nursing being one of the largest staff groups within the healthcare workforce as well as one of the leading professional staffing groups, the nursing profession will have a key role in supporting the delivery of high quality, safe patient care while contributing effectively to efficiency savings. This may have an effect on the size and shape of the nursing workforce and also on the overall commitment the nursing profession makes to additional responsibilities such as clinical leadership. Any changes to terms and conditions within employment contracts which impact negatively on nurses salaries or pensions may result in increased attrition from the workforce. In terms of choice on retirement, it could mean a skills drain of the more experienced nursing group. For example, any significant change in public sector pensions will pose an additional risk to mental health and learning disability nursing, as the majority of those aged over 55 hold Mental Health Officer Status which permits them to retire immediately, which could lead to a sudden loss of experienced nurses from the workforce. Mental health officer status also applies to other professionals who have been treating or caring for mental health patients, or working in an approved place used for the treatment of such patients, since before the 6 March 1995 (NHS Business Services Authority, 2008). Any professionals who have held mental health officer status for over 20 years will also have the right to retire immediately, if they are aged over 55, and may also choose to exercise this right in the wake of any pension changes. This may include doctors, therapists and social workers, the loss of which may place additional pressure on the remaining nursing workforce Data availability There is little data on the higher specialist nurse workforce. Currently, the NHS Information Centre s workforce census does not collect data at the level of granularity of specialist nurses working in specific care areas. Therefore, it is difficult to quantify any shortages in these specialist staff groups. Accurate data on the number of learning disabilities nurses is also limited and there are no official, relevant statistics. This restricts the validity of any potential recommendations in this area. CfWI July

26 5.2.7 Increasing demand The ageing population is likely to place increasing demands on the nursing workforce as it is linked to increasing prevalence of co-morbidities and long-term conditions. The Fourth report from Mental Health Minimum Dataset (IC, 2011b) shows a significant increase in demand for mental health services, with a 4% increase in the number of people using mental health services between 2008/09 and 2009/10, and a 5.1% increase in the number of people receiving inpatient care. This may be due to increasing awareness in mental health and because of circumstances relating to the economic recession, and places additional pressure on the service. The Improving Access to Psychological Therapies (IAPT) programme (DH, 2008) was developed in order to improve access to evidence based talking therapies in the NHS. A new workforce of 3,600 extra therapists are being trained over three years to 2010/11 in order to treat up to 900,000 people over the same period, which may improve the service s ability to meet increasing demand. The health visitor workforce is also likely to face increasing demand as the Child Health Strategy places health visitors at the centre of the community healthcare team to promote children s and young people s health (DH, 2009a). It is expected that the health visitor workforce will work in a variety of settings, including children s care centres and GP surgeries, in addition to providing intensive schedules of healthcare visits in the home. It is likely that growth in the current health visitor workforce will be necessary to ensure each Sure Start Children s community care centre has access to one named health visitor, assuming the number of such centres is maintained. The coalition government has reaffirmed a pledge made by the previous administration to recruit an extra 4,200 FTE Health Visitors (DH, 2011b). A Review of field-specific workforce risks Other mental health nursing risks An assessment of healthcare workforce priorities made in 2009 by the NHS WRT highlights the need for nurses to be adequately trained and supported in the delivery of child and adolescent mental health services. There are challenges for mental health nursing to provide nursing care and management of physical health conditions alongside acute mental illness, as well as concerns that newly qualified mental health nurses have limited experience and knowledge in medication management and in nursing patients with physical health conditions. CfWI July

27 5.3 Key workforce opportunities The following section aims to highlight key workforce opportunities within the nursing workforce. Workforce opportunities can be broadly defined as innovative solutions for ensuring a high level of quality in the delivery of care, through ensuring the optimum use of the existing workforce All-graduate entry nursing The Nursing and Midwifery Council (NMC) has now released updated standards for pre-registration nursing education, which will apply to the approval of all new pre-registration nursing programmes from September 2011 (NMC, 2010a). The standards state that the required minimum outcome award for a pre-registration nursing education programme is a degree in nursing (all of these programmes are planned to be in place by 2013). The standards set out the competencies required for entry to the register, that is, the knowledge, skills and attitudes that nurses need, to provide safe and effective care to all patient and client groups. They also include Standards for Education - ten standards for programme approval and delivery. Potential consequences of graduate entry to nursing may be an improvement in standards of care in nursing and a change in the number of people interested in becoming nurses. All-graduate entry may enhance the professional profile of nursing, and in doing so make it attractive to a higher number of applicants. However, academic entry requirements are higher for a degree than a diploma, and so the number of applicants who are academically eligible to train as a nurse may be reduced, with potential consequences for equality and diversity within the workforce. This may result in a workforce which less closely reflects the community it serves. Additionally, as bursaries for degree students are currently means-tested and consequently, on average, lower than the non-means tested bursaries available for diploma students, some potential students may be financially unable to undertake a nursing degree. This may lead to a reduction in those willing or able to take up nursing training. In the move to all-graduate entry nursing, it is important that the impact on nursing support staff, such as healthcare assistants and assistant practitioners, is understood. CfWI July

28 5.3.2 The Quality, Innovation, Productivity and Prevention (QIPP) agenda Appropriate use of bank and agency nurses The NHS is expected to significantly reduce management and agency costs (by 45%) and make 500 million in savings by 2013/14. According to a Briefing Paper produced by NHS Employers in partnership with DH and workforce leaders (NHS Employers, 2010), there is an opportunity to improve the cost-efficiency and quality of the service through appropriate use of the flexible workforce. The National Audit Office (2006) reported that the average cost of an agency nurse is around per hour, compared to only for a bank nurse ( for NHS professionals) or for a permanently employed nurse. From October 2011, when the Agency Workers Regulations (2010) come into force, the cost of agency workers is expected to rise as agencies may increase their fees in order to manage the increased costs involved in granting agency workers the same working and employment conditions as substantive employees. Therefore the report suggests that employers should consider moving away from agency staff to planned/flexible use of bank/substantive staff. In addition to the higher cost per hour of using an agency nurse, there may also be indirect costs involved in the time taken to induct, train and supervise these nurses. The lack of specific organisational knowledge of agency staff (for example of local procedures or patient history) may also induce indirect costs or affect the quality of the service. The paper reports that recent research has called into question the quality of agency staff, citing problems with continuing professional development and with agencies embellishing staff skills. However, the report does propose that agency nurses may be the most appropriate option in certain circumstances, for example in highly specialised areas where there may also be skills shortages. Examples given were in theatre, intensive care and paediatrics, as well as in response to rapid changes in activity levels. CfWI July

29 Extending roles and the use of assistant practitioners Employers should consider the support roles to nursing, including the assistant practitioner roles. This will allow them to develop skill mixed teams ensuring best use of skills within the team. Currently there is no clear infrastructure for assistant practitioners in terms of training and movement between positions. There may also be opportunities for improving skill mix through increased numbers of apprenticeship placements. The DH response to the report of the National Apprenticeship Advisory Committee (DH, 2010c) states that they will invest 10m in the apprenticeship programme for 2010/11 to support increased numbers of apprentices, training and employment costs and additional administration/infrastructure. It also reports that the emergences of new clinical support roles, such as assistant practitioners, are increasing the scope for apprenticeships. These new roles provide the opportunity to develop Advanced Apprenticeship programmes in the health sector. In some geographic regions, the role of assistant practitioner in learning disabilities services, linked to foundation degrees in higher education, has been created. Further investigation and individual, regional review may be required before blanket adoption of this approach across the country. The commencement of the all graduate nursing programme could support an expansion of the non qualified workforce e.g. Band 4 associate practitioners supported and supervised by a competent graduate nurse. There are also opportunities for extended roles for experienced mental health nursing staff including nurse prescribing, which may support skill-mix changes in mental health services. Strategic Health Authorities (SHAs) are looking at a variety of innovative career structures and roles within the health visiting workforce to enable training provision and take-up of vacancies at lower bandings. Using improved skill mix to make efficiency savings, by using nurse substitution for some tasks which are currently carried out by doctors, also provides the opportunity for advanced roles and responsibilities within nursing Supporting the delivery of increasing care in the community Increasing emphasis on care outside of hospital, support for self care and a growing public health agenda will result in an increased need for nurses working in primary care. Initiatives should be developed to encourage nurses to work in these settings. Primary Care Trusts (PCTs) and employers need to consider increasing the availability of community placements. CfWI July

30 Service redesign could potentially move children s nurses into nurse-led clinics, increase community posts, and support care in the home. As a result, there is likely to be more activity in safeguarding, school settings, under local authorities and for children in state care. There could also be an increase in nurse consultant posts and specialist nurses eg asthma, epilepsy, diabetes and child and young people s mental health. There are opportunities for mental health nurses to work more collaboratively across organisational boundaries in acute hospitals and in primary care Improving recruitment and retention strategies Recruitment initiatives may be required to fill the immediate vacancies for senior posts and specialties that have historically been hard to recruit to (e.g. theatre nursing). Employers need to focus on retaining their current workforce through initiatives such as improving work environments, flexible approaches to child care and school holidays, commitment to the NHS constitution and through flexible retirement. The Government has pledged to fund 4,200 new health visitor FTE by 2015 (DH, 2011b), to provide the growth required to deliver the objectives set out in the Child Health Strategy (DH, 2009a). This, together with further definition of roles and responsibilities, particularly to ensure children are safeguarded, is set to be undertaken as part of the Government s Action on Health Visiting programme. Current mitigation strategies include: o Each SHA is investigating whether a return to practice health visiting programmes would assist recruitment. o There is a focus on recruitment and retention strategies for health visitors. For example, flexible retirement opportunities are being publicised more widely. o Work with the Nursing and Midwifery Council (NMC) and others continues to explore the potential for a fast-track option into health visiting for appropriate candidates. o The profile of careers in health visiting is starting to be raised, demonstrating the breadth, extent and responsibility of the work. The action plan states that revitalising the image of health visiting is vital in order to attract new recruits. (DH, 2009c) CfWI July

31 6. MIDWIFERY 6.1 Key workforce risks The following section of this report identifies key workforce risks within midwifery Supply As at June 2011, the NMC Registrations Department reported 40,288 registered midwives (NMC, 2011a). At the end of May 2011, the NMC recorded 37, 317 Intentions to Practise (ItP) (NMC, 2011b). The disparity between these two figures is due to the number of midwives who do not intend to practise in the current practice year. Additionally some midwives have kept their registration active while working abroad or might only have intended to practise as nurses or specialist community public health nurses. The NHS Information Centre reported there were 26,825 midwives and full-time equivalent (FTE) of 20,790 in England as at September Projected midwifery workforce needs are generally calculated using Birthrate plus (BR+), a 'bottom up' workforce planning tool widely used in maternity services. A historical overview of midwifery workforce planning and the Birthrate methodology is provided by Ball & Washbrook (2010a). This tool has been in existence since1997. It is used to estimate the number of FTE midwives required to meet the demand for midwifery care in individual services. BR+ measures the workload volume for a particular maternity unit by considering the range of models of care available while applying recognised quality standards in service delivery. The National Institute of Health and Clinical Excellence (NICE) has developed evidence-based recommendations for maternity care. The NICE guideline on intrapartum care (NICE, 2007) recommends that a woman should receive one-toone care in labour. The Clinical Negligence Scheme for Trusts also advocates workforce requirements regarding midwifery staff published by the NHS Litigation Authority (2010). The RCM (2010) advocated a ratio of 28 births per FTE midwife in hospital/labour wards and 35 to 1 for home births, along with an additional five per cent specialist staff presence. The development of the BR+ methodology to provide a prospective indication of midwifery requirement in delivery suites would appear to be an opportunity to plan adequate resources to meet clinical standards (Ball and Washbrook, 2010a). CfWI July