Maintaining the supply of nurses has been compared to pouring water into a leaking bucket. The NHS furiously recruits more people so that it can keep on pouring, and now and again there are attempts to patch up the leak. Things improved during the first part of the 1990s, but the bucket has started leaking again, and now we have dire warnings about a recruitment and retention crisis from the unions, prompting a response of 'crisis, what crisis?' from the government. It all sounds very familiar.
The staff side evidence to the pay review body expressed 'concern about the growing shortage of nursing and midwifery staff against a background of increasing demand for their skills and expertise and a continuing reduction in the size of the traditional recruitment pool'.1 That's not this January's PRB report, but the 1988 edition. On recruitment and retention the two bear remarkable similarities.
Then, the Department of Health denied union claims that there was a national shortage of nurses, while conceding there was evidence of problems 'in some locations and specialties', which is pretty much their current line.
So what is the true picture? Is there cause for real concern? Or is the NHS Confederation right to maintain that the gloomy predictions of long- term recruitment problems and an ageing nursing workforce are exaggerated?
Ten years ago, you knew where you were with the demographic time bomb, or at least it seemed like it at the time. The birth rate had dropped, there were going to be fewer school leavers, and nursing could no longer rely on its traditional pool for new recruits, young females with five O-levels. The bomb failed to detonate, because there was a recession. With jobs in short supply nursing posts were snapped up and people tended not to leave. But the NHS may yet feel the fall out as a result of that lost generation of school leavers.
And there are several other factors at work. The number of nurses on the United Kingdom Central Council register is tailing off (it used to increase year on year). The council also reports that a quarter of all registered nurses will be eligible for retirement over the next two years, and the next five years sees the number of nurses over the age of 55 set to almost double.
The DoH believes that the effects of the ageing nurse population will really start to bite from 2005. Meanwhile, the English National Board reports that, for the first time ever, in 1996-97 there were more nurse education places than there were applicants to fill them (15,400 applications for 16,100 places). The previous government cut the number of places but that decision has been reversed by the present administration, which has boosted the figure by 1,300. Only time will tell if that is enough.
Jim Buchan, Reader in the Department of Management at Queen Margaret College, Edinburgh, and author of several reports on the nursing workforce, believes current indicators suggest there is more cause for concern now than was the case with previous so-called crises.
'The issue of whether there's a shortage of nurses or not could easily lapse into a very sterile debate. The key question is whether there are sufficient people with the skills needed to meet the demands of today's health service.
'The upward shift in the skills profile, with nurses moving into areas previously occupied by doctors, may lead to a reduction in the numbers required. But you have to look at other sectors continuing to make demands on the nursing population, for instance nursing homes and the private sector.
'Then there's the big unknown: the extent to which there is the skills base for greater use of healthcare assistants (HCA) and support workers.'
Mr Buchan predicts a fairly rapid increase in the training of healthcare assistants to fill staffing gaps arising from the factors already mentioned, plus other influences such as the phasing out of enrolled nurse training.
'Most managers recognise there are quality constraints on the extent to which they can substitute HCAs for nurses. But cost pressures mean it's difficult to get the balance right. There is increasing pressure to dilute skill mix, and managers are making decisions with little hard evidence to back them up, which is ironic in the light of the white paper's emphasis on making evidence-based decisions'.
Another irony is that part of the rationale behind Project 2000 was to reduce wastage during training and thereby help recruitment problems. But by moving nurse education into universities the close link between student nurses and the hospital they trained at has been severed. This has made it harder for trusts to recruit from their local community, leading to retention problems as people drawn from outside an area are more likely to move on.
Tom Bolger, Royal College of Nursing assistant general secretary, believes trusts must put renewed emphasis on retention, in addition to recruitment, and work harder to engender loyalty among their nurses.
'If you show you value people they'll stay, but over the past decade any idea of a career structure for nurses has been blown out of the water. There are fewer people in higher clinical grades because of a deliberate policy of downgrading posts, and that has to be a demotivator.
'What happened with the clinical grading exercise was a classic display of how to spoil a good idea. But now it's encouraging to see trusts such as Ealing Hospital working in partnership with their staff on initiatives such as competence pay in nursing, which motivates nurses and encourages them to develop professional skills. The white paper's emphasis on future opportunities for nursing is also a boost.'
Mr Bolger challenges claims that pay is not a factor that greatly influences a nurse's employment choices. 'Pay is an issue for any employee and nurses are no different. When jobs are hard to come by that's one thing, but we've seen in the past that when the economy is doing well and there are better-paid, lower-stress alternatives, then you will lose nurses to Marks and Spencer or wherever.
He continues: 'When we surveyed nurses after the latest pay rise was announced they were very hacked off about it being staged. They told us pay was important to them, but they also wanted other things, such as help from their employers in meeting their post-registration development - PREP - requirements. In reality, that would cost trusts very little as it's only five days' study every three years, and they probably give people that anyway. All they have to do is package it better and say 'Look, we're offering you this'. It's all down to making people feel valued.'
David Lucas, executive director of acute affairs at the Independent Healthcare Association, believes the NHS could learn from the private sector when it comes to valuing staff and creating a good working environment for nurses, although he concedes that even independent hospitals are now finding it harder to recruit nurses in some specialties.
'We regularly survey nursing staff in independent hospitals and the most common response on the question of working conditions is that because their workloads are not as heavy as in the NHS, nurses feel they have more time to focus on providing a good standard of care.'
It's a point echoed by Karen Hunter, who has just switched jobs from senior nurse in accident and emergency at St Mary's Paddington to take up the post of director of nursing at the London Independent Hospital in the East End. 'When I was in A&E it was sometimes like hanging off a cliff face. I'm not saying I didn't enjoy my work, but there's a limit to how much you can take.
'I've worked in the private sector in the past and the attraction is that you know you will have time to do your job well, you know you'll get a break at some point in a 12-hour shift and you know you'll be going home tired, but not completely exhausted.'
As part of a thesis on recruitment and retention, Ms Hunter interviewed senior NHS nurse managers, ward managers and staff nurses and asked them to list reasons why nurses were leaving.
'All three groups said 'workload', but high on the staff nurses' list was poor quality management. Yet that was hardly mentioned by the other two groups,' says Ms Hunter.
'What came over was that the really key person is the line manager and the worst crime you can commit is failing to listen and failing to support your staff.'
Jonathan Asbridge, chief nurse at the nearby Royal London Hospitals trust, agrees. 'One thing we have learned is that hard, nasty, macho general management doesn't work. What keeps people is professional recognition and self-regulation.
'We're in the first stage of implementing a shared governance model which is about recognising work, and they are the ones taking the decisions. I'm very positive about it and I think we have everything to go for.'
But in the meantime, Mr Asbridge, along with his counterparts across London, and indeed in trusts in many other urban areas, has to deal with the immediate problem of staff shortages.
An increasingly common solution is to look abroad for new recruits. Successful hunting grounds have included Australia, New Zealand, Finland, Germany and Spain. Spain has some 10,000 nurses on the dole. Others with an oversupply of nurses include some Scandinavian countries and parts of central Europe, though language and culture issues can limit the scope for staffing trawls.
David Amos, director of human resources at
St Mary's Hospital, Paddington, believes recruiting abroad does offer a solution, albeit a short-term one.
'Part of the problem is that in this country we are all competing for the same pool of nurses, so going abroad has its attractions. It is particularly true for London, and on the London Recruitment Group (a network of inner London trusts) we are putting our minds to how we can draw people to come and work in the capital, not just from overseas but from the rest of Britain. D and E grade nurses tend to move round the system so we're looking at rotating staff among London trusts, giving them a three-year contract, then letting them go and work at the hospital (?) down the road, but without all the hassle of having to reapply for a job. The name of the game these days is being imaginative.'
Trusts in rural areas are also reporting recruitment difficulties although for them retention is less of a problem. Philip Walker is head of personnel for Highland Community trust, which covers the largest geographical area of any UK trust but with the lowest density of population.
'Getting staff can be hard and so we offer relocation packages up to pounds4,000 or more. But the good thing is that once you manage to attract someone they tend to stay. Our problem is that we have always relied on staff with dual or triple qualifications so they can be midwife, district nurse and health visitor. But increasingly these days we find we are looking for an animal that's no longer there. It means we have to offer training, but it's not always easy to take people out of service to do that.'
The national picture then is one of a tight labour market for nurses in many parts of the country and there are questions about the adequacy of current workforce planning arrangements.
When the NHS Confederation surveyed its members, many respondents looked to the new education consortia as having a crucial role to play in helping the system become more sensitive to demand.
Jane Keep, Confederation human resources spokeswoman, says there are other encouraging developments.
'Following the reforms, the health service wasn't national any more, but now it's going back to being national again and that helps with workforce planning.
But there's still a lot of work to do, particularly around family-friendly work practices, as well as areas such as reducing violence, racism and bullying. I think we have come to take for granted that some of these awful things will happen, and that's wrong. We're all so busy with our nose to the grindstone, but there's something missing. We've lost the 'human' out of 'human resources' and this has got to be tackled or staff won't put up with it. We'll just lose them.'