Staffing is the issue keeping NHS leaders awake at night – and which consumes two-thirds of trusts’ spending. The fortnightly The Ward Round newsletter, by HSJ workforce correspondent Annabelle Collins, ensures you are tuned in to the daily pressures on staff, and the wider trends and policies shaping the workforce.

The latest Nursing and Midwifery Council registration data reiterated once again the NHS’s deep reliance on international staff. According to this mid-year report, almost half of all new joiners trained overseas, which has contributed to the register hitting a record high.

For nurses, midwives, and nursing associates who trained in England, the picture is stagnant. Over the last four years there has been just a 9 per cent increase in staff whereas international numbers have quadrupled.

The growth can easily be spun as only good news, but the increasing reliance on international, acute nurses in particular, is problematic. It is unsustainable and – as discussed in previous columns – is not ethical at a time when there are severe global workforce shortages. It is arguably risky too, leaving the health system vulnerable to international shocks such as covid, conflict and natural disaster — the sort of thing, sadly, becoming much more frequent. 

This, The Ward Round understands, will be a key battleground when the long-term workforce plan for the NHS is taken to government — crucially, the Treasury. NHS England bosses hope they might find a window to publish it in the spring, a timeframe underlined by NHSE chair Richard Meddings at its public board meeting last week.

As noted by Rishi Sunak’s new health advisor Bill Morgan in his recent report on why politicians struggle to give the NHS the staff it needs, ministers typically “spurn” international recruitment as a long-term solution to the NHS’ workforce crisis. They instead “champion the aim of long-term self-sufficiency”. They go on, however, to ignore the necessary consequence of training more staff in the UK.

The workforce plan needs to be honest about our reliance on international staff – the new community diagnostic centres confirmed by the government this week will surely not be up and running without them – but also seek to address the balance and work towards some form of self-sufficiency. 

‘Productivity paradox’

When the knotty discussions with HM Treasury do start, there are likely to be difficult conversations around productivity and whether the NHS can work in a more efficient way that requires fewer staff overall.

It is a fair argument that increasing the number of staff doesn’t necessarily increase productivity. Billy Palmer, senior fellow at the Nuffield Trust, pointed out over the last couple of years that although there has been a substantial increase in the number of staff working in the NHS, activity has not increased in line with this number.

“There is potentially an unrecognised cost of ‘on-boarding’ new staff and issues about skill mix and these might partly explain the apparent productivity paradox,” Mr Palmer said.

Mr Palmer is also clear the workforce plan must be a full strategy and not just set out staff projections.

“Nationally you should be able to say ‘these are the costs and benefits’ of different workforce levers and then make sure the right governance and incentives are in place. National leaders then need to leave space to local areas to deliver to their needs.”

The right investment?

This autumn marked three years since the first nursing associates joined the register, although the role was first announced by the government in 2016, with the first trainees enrolled in 2018.

It was described as a “new route in nursing”, with ambitions to see 3,000 nursing associates become registered nurses between 2023 and 2025. NHSE invested £40m in 2020 to enable more NAs and to take this route.

NMC data has shown nursing associates have grown faster than nurses and midwives over recent months, with an almost 15 per cent increase from April to September. However, data also reveals that of almost 7,900 nursing associates working in the NHS, just 391 have gone on to become a registered nurse, which had been one of the big hopes.

The experience of nursing associates working in the NHS is diverse, from very positive to feeling frustrated, unsupported, and at worst, exploited.

From regularly reading trust board papers, its clear trusts are relying on NAs to plug gaps and often count on a certain proportion to then train to become RNs.

But how realistic is this? Jamie Walker, a former nursing associate and now registered nurse working in the north of England described how he found himself working in “a role akin to a registered nurse”, as the associate role was “not well understood”.

He also found it difficult to secure funding from his trust via the apprenticeship levy route and instead decided to self-fund his nursing degree.

“A lot of NAs are trapped in their roles and are unable to progress as they can’t afford to self-fund, and as far as the trust is concerned, they already have a registered nurse,” he said.

Alison Leary, chair of healthcare and workforce modelling at London Southbank University, warned concerns about the “exploitative” nature of the role are beginning to surface, and stressed it is still yet to be fully evaluated for safety.

And alongside the safety implications, wider questions remain about whether creating new roles has had the opposite affect in terms of efficiency and productivity. This recent paper by the NIHR, although not about nurses but instead GPs, raised some interesting questions about the impact of new clinical roles on GP workload and job satisfaction. 

One week until strike day

Speaking at the Safety for all conference this week Royal College of Nursing director for England Patricia Marquis – stepping in for general secretary Pat Cullen - described the “tipping point reached by its members”, with nursing strikes due to take place in just a matter of days.

“Pay and safety go hand in hand,” Ms Marquis told the room, which will need to be a crucial part of the staff case if they are to succeed. 

Ms Marquis said “just one quarter” of union members reported that they were working with the planned number of registered nurses and 18 per cent said they were able to provide the care they thought they should be providing.

“Our nursing staff are left working with too few staff to deliver the care they want to and also that patients need and deserve,” she told the conference, adding the nursing profession has not been properly respected for “years and years and years”.

She acknowledged it was not a decision the union or its members took lightly and stressed how important maintaining patient safety will be. With reports suggesting the government will make no further money available for pay offers, any hope of the strikes being called off is very unlikely.