Efforts to lure nurses both in the UK and from overseas into the health service - and keep them there - have met with a mixed response.Anne Gulland reports on progress so far

Over the past three or four years, human resources managers and nursing directors have pulled out all the stops in their bids to attract nurses. From much-criticised overseas trips to wooing back nurses who have left the profession, trusts have been tireless in their efforts to recruit staff and to hit the government's target of getting 20,000 more nurses into the NHS by 2004.

But is there light at the end of the tunnel? In its latest submission to the nurses' pay review body, the NHS Confederation indicated that the government's various initiatives on nurse recruitment were beginning to pay off. 'The national recruitment strategy has had a lot of success and many trusts have done well in recruiting additional staff, ' the evidence states.

At first glance, the government's own figures seem to bear this out.

According to its latest staffing bulletin, released in July, there were 256,280 nurses, midwives and health visitors working in the NHS in April 2000 - a year-onyear rise since 1995 when there were 246,820 nursing staff.

James Buchan, professor in the faculty of social sciences and health at Queen Margaret's University College in Edinburgh and an expert on NHS workforce issues, agrees that the picture does not look as bleak as it did a few years ago. But he warns against complacency.

'We have turned the corner on nurse recruitment but there is still a long haul ahead of us, ' he says. 'The situation has improved but by no means can we suggest that the problems with recruitment, retention or shortages are resolved.

'It is not just a question of having 20,000 more nurses; It is about deciding whether 20,000 is enough and ensuring that nurses are in the right place, with the right skills and are properly motivated, ' says Professor Buchan.

Head of NHS employment David Amos is especially pleased with the campaign to get nurses back in the profession. The carrot of£1,000 for nurses and£1,500 for midwives seems to have proved irresistible, with 1,500 lured back this year and a further 2,000 currently undertaking refresher courses. Details of some of the government statistics suggest a less positive story (see panel, far right).

But Mr Amos insists: 'There are definite signs of growth in the nursing workforce. Long-term vacancies are starting to be filled and trusts are able to open more wards and departments. There were two things we had to do in the short term - the first was to increase training numbers and the second was to attract people back. The success of that campaign has surprised some people, who thought it wasn't worth the effort. But there was a huge amount of effort at local level in getting people back and that has paid off.'

Increasing training places was one of the government's first initiatives in its battle to increase the number of staff. The Conservative government slashed the number of nurses in training to around 12,000, but the figures have since been expanded to around 20,000.

Some educationalists are worried that the government's recent decision to axe the bursary to overseas students could have an impact on numbers. According to the Council of Deans and Heads of Schools of Nursing, Midwifery and Health Visiting, about a third of students on courses in London and the South East are from overseas, the majority of whom are likely to seek jobs in the UK after graduation.

International recruitment has also been a priority, but many in the NHS are worried that a reliance on overseas nurses could backfire in the long term.

Eyebrows were raised over the summer when the UK Central Council for Nursing, Midwifery and Health Visiting revealed that the number of nurses registered to work in this country rose by 41 per cent last year to over 8,400.

The UKCC expects a further 15,000 nurses to make it onto the register this year.

Nigel Turner, human resources director at the Royal Free Hampstead trust in north London, says he prefers to see overseas recruitment as a temporary weapon in trusts' armoury.

'Given the current gap between the number of nurses we need and the number that are available, we still need to go abroad to recruit staff. However, the increase in the numbers of nurses in training should allow those gaps to be filled, ' he adds.

Human resources directors in London like Mr Turner are at the sharp end of the recruitment battle. He says nursing numbers are up in his trust but in specialties such as theatres and critical care shortages are still biting.

Royal College of Nursing general secretary Beverley Malone is adamant that recruitment is not the only issue.

'My concern is that nurses are coming through the front door but are falling out through the back door. Retention is as critical an issue as recruitment.

Recruitment has no real effect if it focuses solely on how many nurses We are bringing into the service. The overall picture hasn't changed that much - we need to focus on retention.'

To keep nurses in the workforce, says Ms Malone, they need to be paid and valued more.

'Nurses will enter the system after they graduate on about£15,500 and after a 20-year career they're really not doing that much better than that.

'It was proposed that nurse consultants would be paid about£45,000, but I do not know of one nurse who is at that point.'

Professor Buchan warns of a demographic timebomb ticking away in the health service.

'Over the next five or 10 years a significant number of current nurses will be eligible to retire.

There will be a big challenge there in how to replace them with equally skilled and qualified staff.

'The other side of the demographic equation is that we have an ageing population, which will increase the demands on healthcare over the next decade.'

David Amos can hear the timebomb ticking and his department is looking at 'flexible retirement' - a system whereby nurses delay the golden handshake by working part-time but preserve their pension rights. He also predicts that NHS Professionals, the health service's own employment agency, will be popular among staff who want to work flexibly.

But Mr Amos's department is now turning its attention to gaps in other professions, such as pharmacy and speech and language therapy.

But he adds: 'In essence all the policy is in place, but what has become clear is that you can never take your eye off the ball with nurse recruitment.

We will never think that It is an area we will not have to worry about.'

Refugees: a mutually beneficial option There is one pool of potential nursing recruits that remains untapped - refugees.Various initiatives have been put in place to train refugee doctors, but refugee nurses are a resource which has so far been ignored.However, last week at the Labour Party conference home secretary David Blunkett confirmed plans to introduce a new work permit system which could benefit qualified health workers.

In the West Midlands, where there are thought to be around 100 refugees with nursing qualifications, Birmingham Specialist Community trust has realised that it suits both parties to consider refugees.The refugees get the chance to earn money and the trust can fill vacancies in its elderly care and learning disabilities directorates.

Initially the trust plans to recruit six refugee nurses to work as healthcare assistants, while the trust assesses them to find out what sort of top-up training they need.Monitors will be appointed from staff at the trust to advise them.

A recent bid to the Home Office for£85,000 has been turned down but Jo Thanki, the trust's community development manager, is undeterred and hopes to look elsewhere.'Initially we plan to train just six nurses - we think this is a comfortable number that we can keep a handle on.They need to receive adequate supervision and support rather than being scattered across the city.

'They will work under supervision for six months, and after that we will hopefully take them on as permanent nurses.They were trained as nurses in their own countries but they need to be recognised and do a UKCC [UK Central Council for Nursing, Midwifery and Health Visiting] adaptation course.'

The trust hopes to work with the Midlands Refugee Council, which has a list of 20 nurses with a range of experience and expertise.Some refugees have even been ringing up hospitals to offer their services.