Nursing Workforce Shortage: England

Justin Madders Excerpts

Tuesday 3rd March 2020 Westminster Hall

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to see you in the Chair, Ms McDonagh. I congratulate my hon. Friend the Member for Bedford (Mohammad Yasin) on having secured this important debate, and on the thoughtful and knowledgeable speech he has given about the challenges currently facing the nursing workforce. He made some very interesting points: the reference to nurses being there at our birth, at our death and throughout our lives was an important and moving reference to how much we all rely on nurses. He mentioned the 10.7% nursing vacancy rate in his region, which is a staggering statistic; there are actually some variations within that, because the vacancy rate for mental health is even higher, at 15.3%. Those huge variations across disciplines need to be addressed by the Government.

My hon. Friend also referred to the RCN’s survey of its members, in which a staggering 95% of nurses said that patient dignity is compromised and 92% felt worried that patients may be receiving unsafe care. That should be a red-light warning for us all about what is going on in our NHS. What he said about the professional attitude and sense of duty that nurses feel was particularly important: when a nurse is at the end of their shift but sees something that needs to be done, they carry on. They are professional, but they carry the impact of that with them, and we have been relying on their good will to keep the NHS going for far too long. Finally, my hon. Friend referred to this being the year of the nurse and the midwife, and was absolutely right to say that we should celebrate this diverse and dynamic profession.

We heard from the hon. Member for Strangford (Jim Shannon), as we often do in these debates, who gave his own perspective from Northern Ireland. He referred to the recent dispute there, and it was clear from what he said that the concern was as much about working practices as it was about pay. He was right to say that workforce challenges there are often mirrored here. The hon. Gentleman also referred to a worrying increase in the agency bill in Northern Ireland, which may well be partly related to the greater flexibility that agency work can sometimes provide to nurses. That is something we need to reflect on when we consider working practices.

As always, it was a pleasure to hear from my hon. Friend the Member for Gower (Tonia Antoniazzi), who I congratulate on her appointment as chair of the all-party parliamentary group on cancer. She was right to highlight patients’ concerns that they are not getting the care they need, the reason for which is inextricably linked with the staffing shortfall. She was also right that it is vital that the full people plan be published as soon as possible, and to raise the concern that the plan will not include the funding it needs to meet our ambitions. Only last month, the Government introduced the NHS Funding Bill 2019-21, so we already have the parameters for funding the healthcare system over the next three to four years. Really, it should have been the other way around; we should have established what the staffing need was before we put a financial envelope around it.

My hon. Friend also referred to the excellent Macmillan report, “Voices from the frontline”, and the concerns it expresses about the lack of ability to access continuing professional development. She highlighted the impact on retention caused by cuts to the CPD budget, and the report’s references to many nurses feeling that their current workloads are unmanageable. My hon. Friend has said that we are on the edge of a full-blown crisis; I could not agree more.

I pay tribute to the 1.9 million or so dedicated and hard-working people who work across both the health and the social care sectors; it is always an honour to speak up on their behalf. Our NHS is built on its staff, and in particular our nurses and midwives who, as we have heard, go the extra mile day in and day out, despite too often finding themselves under intolerable levels of pressure. It is a damning indictment of this Government’s record that despite this being the 37th debate in this place over the past three years on workforce shortages in health and care settings, there is still no plan to address this crisis. It is not over-dramatising matters to describe it as an existential crisis, because following nearly a decade of mismanagement and underfunding, we are facing a very real recruitment and retention crisis in the NHS. Years of pay restraint, cuts to training budgets and growing pressures have left us with a chronic shortage of over 100,000 staff.

Those shortages affect patient care every single day. They manifest themselves in the NHS performance data, which month after month show hospitals with the worst performance data on record. That will not change unless the workforce shortages are acknowledged and addressed. The proportion of people being seen within four hours in A&Es is the lowest on record, and the number of people waiting four hours or more on hospital trolleys is the highest on record, as is the number of people waiting 12 hours to be admitted and the total number of people on the waiting list in England. Targets for patients to receive treatment within 18 weeks have not been met for four years now, and there is no sign that that situation will improve any time soon.

The Government need to take seriously the growing gap between the number of nursing staff and the number of people who need healthcare. As we know, the Royal College of Nursing estimates that there are about 43,000 nursing vacancies in the NHS in England alone and warns that the nursing shortfall will rise to almost 48,000 by 2023 and a mind-boggling 108,000 by the end of the decade. That is a staggering figure. To put that in context, it is more than every man, woman and child living in the Minister’s constituency—picture that. That is how much of a shortfall we could face by the end of the decade, if action is not taken.

The effect of staffing shortfalls on patients must never be underestimated, but they also have an effect on staff. NHS staff are consistently asked to take on additional responsibilities, to work harder, to do more intense shifts and to take on excessive numbers of patients. All the surveys show the effect that that has on them. It is worrying, but not surprising, that only a quarter of respondents to the NHS staff survey published last month agreed that there were enough staff for them to do their job, and that more than two thirds per week worked additional unpaid overtime. As we heard, higher numbers of emergency care nurses—more than nine in 10—are worried that patient dignity is being compromised and that patients may be receiving unsafe care.

I am sure that all hon. Members were moved by the testimony that my hon. Friend the Member for Bedford quoted. No one, patient or staff, should be in that situation. The testimony used the word “dignity” repeatedly, which should cause us to reflect on the situation that we are putting people in. I am sure that we would not want that for our family.

Staff are working in a high-pressure environment without adequate resources or support, which not only puts patients at risk but damages the mental health of staff and leads to low morale, poor wellbeing and a poor work-life balance. It is no surprise that conditions are becoming intolerable for some staff. More than 40% of NHS staff were unwell as a result of work-related stress in the last year—that is an unsustainable figure.

An analysis of NHS Digital data finds that more than 200,000 nurses have left the NHS since 2010-11; there has been a 55% increase in voluntary resignations from the NHS with staff citing a poor work-life balance as the primary reason; and the number of voluntary resignations for health reasons has increased threefold in the past 10 years. It is no wonder that the recent “Interim NHS People Plan” states that hard-pressed staff are “overstretched” and admits that people no longer want to work in the NHS. It is our pride and joy. People should positively want to go to work every day full of joy about what they are delivering for the people of this country, but the pressure is becoming too great.

It is damning that we still have no funded workforce plan, despite the Government’s promise of one when the funding settlement was first announced in summer 2018. We also still have no framework that sets out the roles, responsibilities and accountabilities for workforce supply and planning.

As has been mentioned, last month’s NHS Funding Bill was an opportunity for the Government to show their commitment and set out plans for a proper costed strategy for the workforce but, frankly, it was a publicity stunt. Despite every trust chief executive reporting that understaffing is their biggest challenge and a hindrance to delivering safe care, there was nothing in the Bill on protecting and enhancing training budgets. I acknowledge that staffing shortages are the responsibility of multiple decision-makers across all levels of the health and social care system, but ultimately, they are outside the control of frontline staff and trusts. The Government need to act to ensure that there are enough skilled staff to ensure safe and effective care.

The standards of protection and safety that are rightly expected by staff and enshrined in the NHS constitution appear to have been abandoned by the Government. Things have become so bad that NHS England has recommended that the Government review

“whether national responsibilities and duties in relation to workforce functions are sufficiently clear.”

The public are concerned and want action too. In a recent YouGov poll, 80% of respondents in England agreed that

“the Government should have a legal responsibility to ensure there are enough nursing staff to meet the country’s needs”.

The Royal College of Nursing, other royal colleges and health organisations are all calling on the Government to take action to ensure clear workforce accountability in law. Unfortunately, there has been a continued failure of leadership to bring forward the required legislation to guarantee and enshrine safe staffing levels in the NHS in England. That has left us lagging behind Scotland and Wales, which have already established explicit accountability for workforce provision.

It is vital that, as the royal colleges are calling for, an NHS long-term plan Bill for England sets out a framework of explicit roles, responsibilities and accountabilities for workforce supply and planning, through all levels of decision-making. Like other hon. Members, I am keen to see the detail of the Bill and whether it will contain the long-awaited commitment to safe staffing, in addition to a bold and fully funded workforce strategy. I welcome the Minister to her place; perhaps she will indicate when that Bill might be introduced when she responds.

The election promise of 50,000 more nurses in five years is all well and good, but without a plan for how that will be delivered and maintained in the long term it is pie in the sky. As it is British Pie Week, I cannot think of a more apposite metaphor. We all know that that figure does not stand up to even the most cursory inspection. It is not 50,000 extra nurses, but the retention of 19,000 existing nurses and the recruitment of an additional 31,000. As has already been clearly set out, retention is a huge challenge that the Government are failing on.

The Minister will no doubt tell us there has been an increase in the number of nursing staff in the last year. Of course, in such desperate times, any increase is welcome, but as my hon. Friend the Member for Bedford said, it is a miniscule 0.4%. Let us be honest: the scale and pace of the increase is not happening fast enough. There are also concerns that the figures do not reflect what is really happening on the ground, because they were taken at the optimum time to capture the new registrations before the impact of annual departures is felt.

The Government’s failure to train enough nurses will not be reversed by the recent announcement of maintenance grants for nursing students, as the grants will cover only living costs, not tuition fees. Many student nurses are slightly older and may have family responsibilities, yet the sum on offer from the Government to support them through their training is slightly less than £100 a week.

Evidence shows that, since the Government scrapped the bursary scheme in 2016, applications to study nursing have dropped by 25% in England. As we and many others repeatedly warned at the time, that was bound to happen. Adequate funding for nursing students is crucial to attract more people to study nursing. I hope, again, that the Government listen to us when we say that the U-turn is only partial and not enough to undo the damage done. It is still the case that the prospect of accruing large debts is a huge disincentive for those who want to train in nursing, especially prospective mature students who may already shoulder debt from a previous degree in another subject.

With Labour’s analysis showing that the first cohort of students who started their nursing degrees in 2017 will graduate with £1 billion in tuition fee debt, everything possible must be done to remove the financial burden for prospective students. If the Government are serious about recruiting more nurses, they need to match our commitment to bring back the nursing bursary in full, including the abolition of tuition fees.

I agree with my hon. Friend the Member for Bedford that the new maintenance grants must be increased to cover actual living costs. Given that the Government have admitted the error of their ways in removing the bursary in 2016, I hope that the Minister will set out whether any maintenance loan debt incurred by students between 2017 and 2019 will be written off.

I cannot end without mentioning immigration. The NHS plans to increase the international recruitment of nurses to reduce workforce pressures, but, at the same time, the Government are planning to raise the health surcharge that those staff have to pay. Unison and the RCN are calling for nursing staff to be exempt from the immigration health surcharge. Those staff already make their contribution to the NHS by working in it. Alongside their colleagues, they often go beyond their contractual hours to keep the service from crumbling under the pressure. It is indefensible to continue to apply the surcharge to them.

The RCN also calls for nursing to remain on the shortage occupation list and for nurses to be exempt from the salary threshold when the points-based immigration system comes into force. Given the challenges outlined today, could the Minister set out when responding what representations she has made to the Home Office about bolstering the workforce and ending the uncertainty and red tape in international recruitment? Nursing is a global recruitment market, and a challenging one at that. If the Government’s workforce strategy is over-reliant on international recruitment, it will fail, particularly when barriers are put in the way of recruitment. The myriad of reasons that have been set out about failing to improve retention rates will not lead us to a better place.