WORKFORCE RISKS AND OPPORTUNITIES LEARNING DISABILITY NURSES EDUCATION COMMISSIONING RISKS SUMMARY FROM 2012

WORKFORCE RISKS AND OPPORTUNITIES LEARNING DISABILITY NURSES EDUCATION COMMISSIONING RISKS SUMMARY FROM 2012 AUGUST 2012

Welcome to the 2012 CfWI workforce risks and opportunities: education commissioning risks summary (WRO ECRS 2012) for learning disability nurses. The WRO ECRS 2012 reports cover all professions across health and social care, except the medical profession, which was covered in a report in 2011 (http://www.cfwi.org.uk/publications/medical-shape-2011). Each report describes the key issues facing the different professions over the next three years, and aims to support local decisions on future education and training commissioning. The reports do not make specific recommendations for local commissioning decisions as these decisions are made through consultation between the education and training commissioner and employers. The reports will be submitted to the Department of Health in several tranches between November 2011 and the end of August 2012. This is a time of great change in the NHS. Employers are considering how best they can transform their services to maximise the quality of patient care, improve productivity and release the 20 billion savings to be reinvested in front line clinical care. This work could have a major impact on the future shape of the workforce and so needs to be considered alongside education and training commissioning decisions that are being made now. Financial allocations are a pivotal component of the overall education and training annual process across England. Presently the Department of Health secures funding to invest in the workforce through the Multi-Professional Education and Training (MPET) levy which is around 4.9bn for 2011/12. This funding is currently allocated to Strategic Health Authorities (SHA) largely based on historic patterns of training. The Department sets out key priorities and holds SHAs to account through a Service Level Agreement. SHAs develop plans for education commissions based on local workforce plans and then commission and fund training from education and clinical placement providers. Looking towards 2012/13, a flat cash settlement for MPET is likely. This allocation will have to accommodate a range of cost pressures which will include new costs, price increases and volume changes. In setting local investment priorities for the MPET allocation, SHAs are encouraged to consider the evidence presented within the WRO ECRS 2012 and the medical specialty training numbers reports. We hope you find the reports useful, and as always, appreciate your constructive feedback. Professor Moira Livingston Commissioning Director CfWI 2

Purpose This information has been collated to inform decisions on education commissioning over the next three to five years. It considers the key factors influencing the estimation of future need of nurses with a learning disability qualification and gives an assessment of the current workforce supply. It includes regional perspectives and a summary analysis of risks in education commissioning. work in partnership with people with learning disabilities and family carers, to provide specialist healthcare. Their main aim is to support the well-being and social inclusion of people with a learning disability by improving or maintaining their physical and mental health. Learning disability nursing is provided in settings such as adult education, residential and community centres, as well as in patients' homes, workplaces and schools. A first degree or diploma in learning disability nursing is a prerequisite to practice. KEY FINDINGS The population of children, adults and older people with learning disabilities is increasing and changing. For example, medical conditions are becoming more complex. Recent Government policies seek to improve access to services for people with learning disabilities. About 35 per cent of registered learning disability nurses work in the NHS and there is a lack of data available for the workforce outside of the NHS. The supply of NHS nurses with a learning disability qualification has decreased since 2006. The supply of nurses with a learning disability qualification available to work in NHS and non-nhs sectors is forecast to remain approximately at the current level. There has been an overall reduction in the number of commissions for students on training courses since 2002/03. Next steps Social care commissioners to work with education commissioners and providers across all sectors to confirm models of care, review clinical demand and assess the required numbers of nurses with a learning disability qualification for the service. This is particularly important for learning disability nursing because MPET funds training places despite a large shift of service provision from the NHS to the non-nhs sectors. Employers in the non-nhs sectors to ensure robust mechanisms are in place to accurately record and make available data on the workforce to enable improved forecasting. The CfWI to feed into the Department of Health (DH) Workforce Information Architecture Review Board with identified gaps in data for this workforce to improve future modelling possibilities. 3

The CfWI to carry out further work on attrition rates in the CfWI Nursing Reference Group as part of its nursing work in 2012 to inform improved modelling. The strategic health authorities (SHAs), to review attrition rates, and together with higher education institutions take appropriate action. CONSIDERATIONS FOR FUTURE REQUIREMENTS Policy drivers Table 1 summarises the key policy drivers and the relevant references. Table 1: Policy drivers affecting the workforce learning disability nurses Key drivers 1. Improvement of service quality, including the development of appropriate skills to understand and meet the individual needs of people with learning disabilities The inclusion of individuals with learning disabilities in all aspects of community life has been listed as one of the Government s social policy priorities, with a view to provide people with learning disabilities with the opportunity to lead as independent a life as possible. This move to a more inclusive lifestyle for those with learning disabilities could mean a greater demand for learning disability nurses. Relevant policy Valuing people now: A new three-year strategy for people with learning disabilities (DH, 2009a) Six lives: The provision of public services to people with learning disabilities (Local Government Ombudsman, 2009) Healthcare for all: Report of the independent inquiry into access to healthcare for people with learning disabilities (DH, 2008) The Mental Health Act (DH, 1983, revised 2007) The Government aim to make learning disabilities a mainstream health and social care consideration. To support improvements in learning disability care provision, the Government has made learning disability nurses responsible for supporting patients access to services and improving the care pathway. Recent policies encourage regular training and professional development of nurses in order to deliver this. 2. Promotion of joint working between learning disability nurses and other professions to facilitate access to services This could be achieved through enhanced services and the collaboration of specialists in learning disabilities. Valuing people now: A new three-year strategy for people with learning disabilities (DH, 2009a) 3. Move to degree-level registration A mo The move to degree-level registration has being rolled out from 2011 in order to produce only newly qualified graduate nurses from 2013 onwards. The potential impacts of this are improved standards of care in nursing, Standards for pre-registration nursing education 2010 (NMC, 2010) 4

a change in the number of people interested in becoming nurses, and a change in the student attrition rate. It is as yet unknown whether potential students will be attracted to the profession or discouraged by the removal of the diploma option. Similarly, it is unknown whether this may also impact on attrition. 4. Care in the community Government guidelines recommend the introduction of regular health checks for people with learning disabilities. This would require an increase in the number of staff who are adequately trained and experienced in working with people with learning disabilities. Lone working is more common in the community setting, but this type of working needs to be supported in order to protect the safety of both nurse and patient. The nursing workforce will also need to be skilled, capable and competent at managing community caseloads autonomously. Care in the community may also drive a change in working practice, from daytime working to round-the-clock care. Healthcare for all: Report of the independent inquiry into access to healthcare for people with learning disabilities (DH, 2008) Lone working survey (RCN, 2007) Strategic health authority (SHA) perspective SHAs work in partnership with employers (service providers), service commissioners, education providers and each other to assess workforce requirements. This then informs education commissioning plans in each region. SHAs work with local employers to inform their decision making. This is a requirement of the service level agreements between SHAs and the DH for the investment of education and training funds. The CfWI has therefore engaged primarily with SHAs as the agreed route to ensuring the views of employers are considered, as part of this work. Following NHS reform, it is likely that the CfWI will engage with employer-led Local Education and Training Boards to gain this perspective. There is a continuing slight downward trend in learning disability nurse commissioning numbers in most SHAs. The South Central SHA also notes that employers are finding other ways of increasing capacity, for example by using assistant practitioners. This indicates that skill mix could be a viable solution to shortages in order to maintain service provision in future. There are some variations around this overall picture, reflecting organisational and structural change specifically integration into social care. There is a small number of combined learning disability and social work training programmes, but the professionals working in these roles would not necessarily be identified as learning disability nurses. It is often difficult to identify learning disability nurses, as job titles change regularly. 5

Profession s view 1 The Royal College of Nursing (RCN) reports that there is a growing need for nurses in the field of learning disability (RCN, 2011). Workforce supply and demand are hard to measure as many trained learning disability nurses move into non-nhs sectors, for example into the criminal justice system. With the drive to improve access to services for people with learning disabilities, the need for learning disability nurses is likely to increase in future. Additionally, as a result of improved pre-term neonatal survival rates, improved diagnosis of rare learning disabilities and an increase in substance abuse among the population, the incidence and complexity of learning disabilities in children and adults is increasing (RCN, 2011). Demographics Around 985,000 people in England have a learning disability, which is about 2 per cent of the population. Of these, there are approximately 55,000-75,000 children with a moderate or severe learning disability in England. 210,000 people have severe learning disabilities in England (Foundation for People with Learning Disabilities, 2011). In the last five years this group has increased by 25 per cent and is anticipated to increase by a further 29 per cent in the next five years (RCN, 2011). Additional drivers According to research, the prevalence of learning disabilities is significantly underestimated (Centre for Disability Research, 2008). Changes in practice Demographic changes and policy drivers will demand a range of new roles for learning disability nurses. For example, learning disability nurses will need to support and facilitate healthcare in general hospitals, provide psychosocial interventions for those with mental illness, and work with colleagues in primary care to provide health screening (RCN, 2011). In the future, learning disability nurses will work more in child and adolescent mental health teams, and will support people with learning disabilities in behavioural distress (RCN, 2011). Community learning disability nurses are already developing new and specialist areas of practice such as sexual health, epilepsy, challenging behaviour, early onset dementia and end-of-life care, while maintaining a core learning disability background to their practice (Gates, 2009). 1 The CfWI engaged with representatives from each profession to inform this report. Although in some cases the source is not explicitly named, this information may be available on a case-by-case basis. Please contact the CfWI if more information is required. 6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Education commissioning risks summary CURRENT AND FORECAST SUPPLY Existing workforce Supply Figure 1 shows the historical variation in headcount (HC) and full time equivalent (FTE) of NHS learning disability nurses since 2000, demonstrating that the number of learning disability nurses (HC) has decreased by 37 per cent from 9,497 in 2000 to 6,026 in 2010 (Health and Social Care Information Centre (HSCIC), 2011a). The participation rate (FTE/HC) was 0.89 in 2010, and has remained relatively static since 2000 (0.88), with a lower rate of 0.83 in 2005. Little is known about the non-nhs learning disability nurse workforce. Despite the reduction in NHS-employed learning disability nurses over the last five years, the total number of registered learning disability nurses has increased (see figures 6a and 6b). This suggests that there has been a shift of service from the NHS to other sectors. Figure 1: HC and FTE of NHS workforce, 2000-2010 learning disability nurses 12,000 Headcount and full time equivalent - NHS learning disability nurses 10,000 8,000 6,000 4,000 2,000 Headcount Full time equivalent 0 Year Source: HSCIC Non-Medical Bulletin Tables, 2000-2010 (HSCIC 2011a) *Please Note: The new headcount methodology for 2010 data is not fully comparable with previous years data due to improvements that make it a more stringent count of absolute staff numbers. Further information on the headcount methodology is available in the HSCIC publication (HSCIC, 2011). 7

Under 25 25-34 35-44 45-54 55-64 65 and over Total Education commissioning risks summary Table 2 shows the HC and FTE for the different nurse types within learning disability nursing. Table 2: HC and FTE by type learning disability nurses Staff type HC FTE FTE/HC Nurse consultant 37 37 1.00 Modern matron 75 72 0.96 Manager 328 316 0.97 Other 1st level 5,522 4,883 0.88 Other 2nd level 76 67 0.88 Qualified staff 6,038 5,376 0.89 Source: HSCIC Non-medical Census (HSCIC, 2011b) The Nursing and Midwifery Council (NMC) recorded 17,113 nurses with learning disability registration in England in 2011. This number includes nurses who were registered while no longer practising. Age profile Figure 2 shows the age profile for learning disability nurses in the NHS in England. Figure 2: HC and FTE age profile by ten-year age band, April 2011 learning disability nurses 2,500 2,000 1,500 Age profile (HC and contracted FTE) - learning disability nurses Contracted FTE Headcount 1,000 500 0 Age bracket (years) Source: HSCIC Monthly Workforce Extract, April 2011 Note that the Under 25 age bracket only contains those between the ages of 21 and 24, whereas the other groups are in 10-year bands, therefore the relative numbers for that age band in figure 1 will be smaller. Figure 2 shows that the majority of learning disability nurses are in the 35-54 age group, with the largest group of learning disability nurses in the 45-54 bracket. Some NHS learning disability specialist staff are able to retire at the age of 55 under their maintained Mental Health Officer (MHO) status, and many could take early retirement (Gates, 2011). The age 8

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Commissions Education commissioning risks summary profile therefore shows a large group in the ten-year age bracket preceding possible retirement. Current vacancies and employment The latest HSCIC vacancy survey (2010) records a low national three-month vacancy rate of 0.2 per cent with the highest value at 2.6 per cent in the London SHA. The rate for all nurses is 0.6 per cent overall. Students Figure 3 shows that commissions of diploma courses for learning disability nurse training in England have followed a downward trend since the academic year 2002/03. In contrast, commissions of degree courses have been gradually increasing since the academic year 2005/06. In the academic year 2010/11 approximately half of learning disability nurse commissions were for degrees. However, reflecting the move to degree-level registration, the number of degree course commissions is planned to surpass the number of diploma commissions in 2011/12. Figure 3: National commissions of pre-registration training, planned and actual 2 learning disability nurses Planned and actual commissions of pre-registration courses, England (2002/03 to 2011/12) - learning disability nurses 900 800 700 600 500 400 300 200 100 0 Degree - planned Degree - actual Diploma - planned Diploma - actual Year Source: Multi Professional Education and Training (MPET) 02B - Non Medical Education and Training (NMET) Commissions, 2002/03-2011/12. 2 The 2011/12 planned commissions should be regarded as indicative. 9

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Commissions Education commissioning risks summary The increase in degree course commissions has not matched the decline in diploma course commissions, resulting in an overall downward trend in pre-registration course commissions as shown in Figure 4. This reduction is significant in the context of the increase in overall registered learning disability nurses (see figure 6a and 6b). Figure 4: Total national commissions of pre-registration training, planned and actual learning disability nurses 1,200 1,000 Planned and actual commissions of pre-registration degree and diploma courses, England (2002/03 to 2011/12) - learning disability nurses 800 Planned 600 Actual 400 200 0 Source: Multi Professional Education and Training (MPET) 02B - Non Medical Education and Training (NMET) Commissions, 2002/03 to 2011/12 Recruitment Year Currently, 20 universities offer learning disability nursing pre-registration education. Figures 3 and 4 show the number of planned commissions was greater than the number of actual commissions for all years between the academic years of 2002/03 and 2010/11. This may suggest that there has been difficulty in attracting students to study learning disability nursing, particularly through the diploma route. Attrition rates for learning disability nursing courses varied from 8 per cent to 38 per cent in 2010 (Gates, 2011). The SHAs should review attrition rates and take appropriate action with the higher education institutions (HEIs). 10

Geographical distribution Figure 5 shows the HC of learning disability nurses in each SHA in September 2010 (HSCIC, 2011a), the actual commissions for training in learning disability nursing in the academic year 2010/11, planned commissions in 2011/12 (DH, 2011b), and weighted capitation (DH, 2011c). Figure 5: Map showing NHS staff, planned and actual commissions in relation to weighted capitation by SHA learning disability nurses Source: HSCIC Census 2011 (headcount); DH NMET Monitoring Quarter 4, 2010/11 (commissions); DH 2011b (weighted capitation). The 2011/12 planned commissions should be regarded as indicative. The data is also presented by SHA as percentages of the total for England, thereby allowing for comparison with the weighted capitation for each SHA. The CfWI recognises that it is also important that 11

all training posts are of high quality, and high-quality training placements may not be equally available across England. Figure 5 is intended for use in conjunction with local knowledge. Based on weighted capitation alone, Figure 5 indicates that the East of England, South East Coast, South West and London SHAs plan to commission significantly fewer training places for learning disability nurses than if provision were to follow weighted capitation, while the remaining SHAs plan to commission significantly more training places for learning disability nurses than if provision were to follow weighted capitation. According to representatives from the DH, there are significant regional variations in recruitment. In some areas, newly qualified learning disability nurses are having difficulty finding NHS jobs and are therefore finding employment in the independent sector. SHA variations There has been specific feedback from the SHAs on their commissioning plans. In the West Midlands SHA, learning disability nurses now mainly work in social care. Many nurses in this sector are moving into social care to support assisted living initiatives. The London SHA projects an oversupply of learning disability nurses, but will maintain current levels of commissions as this could be an area of national commissioning in the future in light of the overall changes such as campus closures affecting this workforce. The South Central SHA agreed a new learning disabilities contract in 2010 with the purpose of establishing a South Central Institute for Learning Disabilities (SCILD). This aims to ensure courses and training for learning disability nurses are more accessible and modernised to meet service needs as well as to improve fill rates. Feedback from the North East SHA suggests that the apparent overcapitation in their commissioning is not accurate or current for this area, due to cross-boundary issues. As a result of the Transforming of Community Services (TCS) agenda (DH, 2011d), organisations are increasingly providing services to patients from other SHA areas, which is reflected in the staff numbers and commissions. The East of England SHA has reduced commissions due to reduced demand from the service and the changing service pattern, with a greater reliance on practitioners with learning disability skills rather than registered learning disability nurses. This is supported by evidence of an increase in post-registration continuing professional development (CPD) study in learning disability. Supply projections Figures 6a and 6b show that the NHS learning disability nurse workforce decreased by 20 per cent between 2006 and 2010, although registration of learning disability nurses increased. This indicates that there has been a shift of care provision from the NHS to the non-nhs sectors. CfWI modelling estimates that the supply of learning disability nurses 12

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Full time equivalent 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Headcount Education commissioning risks summary available to the NHS and any other services in England will decrease slightly to approximately 17,000 HC (15,131 FTE) in 2016 which is change of less than 1 per cent from 2010. Figure 6a: Historical and projected workforce supply and requirement by HC learning disability nurses Summary of available workforce headcount - learning disability nurses 18,000 High and low scenarios of supply forecast 16,000 14,000 Historic NHS headcount 12,000 10,000 Forecast of register staff (HC) 8,000 6,000 4,000 Weighted change in demand based on estimated growth of population with learning disabilities 2,000 Historic NMC registrants 0 Year Other demand drivers exist, but they have not been shown on this graph Source: Historical supply data is from the HSCIC (2011). Forecasts are based on HPC data and workforce assumptions. Figure 6b: Historical and projected workforce supply and requirement by FTE learning disability nurses Summary of available workforce full time equivalent - learning disability nurses 18,000 16,000 14,000 High and low scenarios of supply forecast Historic NHS FTE 12,000 10,000 Forecast of register (FTE) 8,000 6,000 4,000 2,000 Weighted change in demand based on estimated growth of population with learning disabilities Estimate of historic registrants potential FTE 0 Year Other demand drivers exist, but they have not been shown on this graph Source: Historical supply data is from the HSCIC (2011). Forecasts are based on NMC data and workforce assumptions. The model uses a method of mapping occupation codes to areas of learning disability nursing in order to obtain HC and FTE for the NHS learning disability nurse workforce. This 13

method of mapping is in its infancy and will be reassessed in future in order to improve its accuracy. The forecasts are based on the NMC register for England, which includes those who are not working in the NHS, including the independent sector and local authorities. There are approximately 11,072 registered learning disability nurses not working in the NHS, which includes non-practitioners and those working within the scope of practice without direct patient contact, for example: those who may have retired but remain on the register until their current membership requires renewal; at that point they will leave the register those in management posts both in the NHS and private organisations those who provide education to undergraduate courses those working with other professional bodies. CfWI modelling 3 from 2010 onwards is based on current commissions, assumptions reached by analysing past trends, and engaging with the profession to identify other indications. The most likely scenario (black line) indicating the estimate of future supply uses the agreed baseline assumptions in Table 3. The darker shaded area on the right of the graph shows the forecast range of learning disability nurses and is based on the low and high scenario assumptions in Table 3. Table 3: Summary of assumptions used in the supply forecast learning disability nurses Variable Low scenario Baseline High scenario Training pipeline Trainee commissions Diploma (3 years) and degree (3 years) Commissions 5% lower Diploma (3 years) and degree (3 years) 614 per year from 2011/12 onward Diploma (3 years) and degree (3 years) Commissions 5% higher Training attrition 30% 27.6% 25% Trainees registration on graduation Net international flow 98% with NMC 99% with NMC 99% with NMC 25% higher 45 per year out of England 25% lower FTE/HC ratio 99% of current As current 101% of current Retirements Retirement trends shifted 2 years earlier, and 50% greater Retirement profile as 2006-2009 Retirement trends shifted 2 years later It is assumed that new graduates start work within the year of graduation. The training attrition rate in the model is based on those completing training from the 2005 cohort (RCN, 2010b). The assumptions used for these calculations are based on a participation rate of 0.89. 3 Further details of the modelling used in the CfWI workforce risks and opportunities education commissioning risk summaries (WRO ECRS) can be found in the WRO ECRS methodology report. 14

The upper line (small green dashes) indicates the estimated future demand for learning disability nurses (17,812 HC and 15,852 FTE) required to deliver service in 2016. The modelling uses the workforce headcount in 2010 (all registered learning disability nurses NHS and non-nhs) as a baseline, and calculates the future weighted change in demand due to the forecast of change in population and prevalence rate of learning disabilities in different age groups from the report by Emerson (2008). This model assumes that service activity continues to be delivered in the same way as now. We accept that service reconfiguration and skill mix are likely to alter future demand, so future modelling can be adapted as we know more about these changes. The modelling shows that in the base scenario there will be approximately 720 fewer learning disability nurses (FTE) than we expect may be required if nothing else changes by 2016, although in the high scenario the workforce supply will be adequate. However, it should be noted that the situation in the non- NHS sector is unclear due to data limitations. Interplay with related groups frequently interact with colleagues in primary care, social care (care managers, social workers, senior support workers) and healthcare (speech and language therapists, occupational therapists), typically working in inter-professional teams (Gates, 2009). work closely with psychiatrists to explain the processes to the patient and ensure health professionals are disability aware. The Valued People Project advocates the need for the development of a new practitioner role in learning disabilities with specialist educational preparation. The new practitioner would be able to support qualified and registered practitioners in both health and social care (Gates, 2009). 15

CONCLUSION The demand for learning disability nurses is rising due to an improved survival rate into adulthood and greater life expectancy for people with learning disabilities. Government policies to improve access to services for people with learning disabilities may increase demand further. Despite the projected increase in demand, commissions for learning disability nursing courses are declining. Analysis of the supply and demand forecast shows that the projected registered workforce in the base and low scenarios will not meet the future requirement for learning disability nurses. However, in the high scenario, demand is projected to meet supply. If demand does not meet supply in future, it is possible that effective use of skill mix may provide a solution. For example, the South Central SHA notes that employers are already finding other ways to increase capacity, such as through use of assistant practitioners. Services are increasingly moving into the community, and also into the non-nhs sectors. The reduction in commissions for learning disability nursing courses may be a reflection of the shift of much of the care provision for people with learning disabilities out of the NHS into the non-nhs sectors. However, none of the existing data sets have information on learning disability nursing from outside the NHS and therefore little is known about this workforce. In order to meet demand in the future, commissioners and providers across the sectors will need to determine models of care. The current dilemma for the NHS is that many learning disability nurses funded by NMET training do not go on to work in the NHS, and other service providers require a supply of trained learning disability nurses or a suitably trained alternative. Further debate is required to establish the training requirements of any such alternative workforce. 16

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Available at: http://www.acutecareprogramme.org.uk/silo/files/green-light-for-mentalhealth-part-a.pdf [Accessed October 2011]. Gates, B. (2009) The Valued People Project: Report of a strategic review of educational commissioning and workforce planning in learning disabilities. [online] Available at: http://www.workforce.southcentral.nhs.uk/primary_areas/healthcare_workforce/educatio n_commissioning/valued_people_project.aspx [Accessed October 2011]. Gates, B. (2011) Learning Disability Nursing: Task and finish Group: Report for the Professional and Advisory Board for Nursing and Midwifery. [online] Available at: https://uhra.herts.ac.uk/dspace/bitstream/2299/6289/1/gates3.pdf [Accessed October 2011]. Health and Social Care Information Centre (HSCIC) (2011a) Non-medical staff census as of 30 September 2010. [online] Available at: http://www.ic.nhs.uk/statistics-and-datacollections/workforce/nhs-staff-numbers/nhs-staff-2000--2010-non-medical. [Accessed June 2011]. Health and Social Care Information Centre (HSCIC) (2011b) Vacancies survey March 2010. [online] Available at: http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhsand-gp-vacancies/nhs-vacancies-survey-england-31-march-2010 [Accessed June 2011]. Local Government Ombudsman (2009) Six Lives: the provision of public services to people with learning disabilities. [online] Available at: http://www.ombudsman.org.uk/improvingpublic-service/reports-and-consultations/reports/health/six-lives-the-provision-of-publicservices-to-people-with-learningdisabilities&sa=u&ei=rcmltrojeoqh8qoa_fxvbq&ved=0ca8qfjaa&usg=afqjcnfn5zio3p Q4bofKaHPQsr7SvLV5hA [Accessed October 2011]. NHS Careers (2012) Nursing. [online] Available at: http://www.nhscareers.nhs.uk/nursing.shtml [Accessed January 2012]. Nursing and Midwifery Council (2010) Standards for pre-registration nursing education (2010). [online] Available at: http://www.nmcuk.org/documents/circulars/2010circulars/nmccircular07_2010.pdf [Accessed August 2011]. Royal College of Nursing (2007) Lone working survey [online] Available at: http://www.rcn.org.uk/ data/assets/pdf_file/0009/78759/003167.pdf [Accessed October 2011]. Royal College of Nursing (2010) Sustaining the long view, The UK nursing labour market review 2010. [online] Available at: http://www.rcn.org.uk/ data/assets/pdf_file/0004/347953/003862.pdf [Accessed October 2011]. 18

Royal College of Nursing (2011) Learning from the past setting out the future. An RCN position statement on the role of the learning disability nurse. [online] Available at: http://www.rcn.org.uk/development/researchanddevelopment/newsevents/research_poli cy_and_practice/rcn_position_statement_on_the_role_of_the_learning_disability_nurse [Accessed October 2011]. Parish, C. (2011) Supply and demand, Editorial. 14 ( 8). [online] Available at: http://learningdisabilitypractice.rcnpublishing.co.uk/news-and-opinion/editorial [Accessed October 2011]. 19

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