Why can't the UK solve its nursing shortage? James Buchan examines the pattern of problems and solutions

The current nursing shortage will generate a feeling of deja vu in anyone who had to deal with the previous bout of major staffing difficulties in the NHS in the late 1980s. It demands that we ask: is the UK locked into a recurring sequence of nursing staff boom and bust, or are there ways of breaking the cycle?

The reasons for the current difficulties in recruitment and retention lie as much in our inability to learn from previous experience as in facing up to new challenges. In the early 1990s, NHS reforms and general economic recession had reduced nurse mobility and vacancies, and concern about staff shortages largely disappeared. On the basis of a weak and eroding information base, the Department of Health signalled that there were no real recruitment difficulties - partly, at least, because it wished to prevent any significant pay rises for nurses.

Many trusts took a similar narrow focus when working out their future requirements for nursing staff.

The move towards an 'employer-led' system in the mid1990s, in which trusts played a role in determining nurse training intake, was to be welcomed, but the narrow focus and lack of a national overview meant that most trusts were very conservative in determining future staffing numbers. The aggregate of several hundred localised 'conservative' assessments led to a marked reduction in the number of student nurses. In 1984 there were more than 75,000 nursing students and pupil nurses in England. By 1994 that number had more than halved, as enrolled nurse training was ended, Project 2000 was implemented, and the effect of the new 'employer-led' system was felt. One major weakness in the system was that it underestimated non-NHS demand for nurses, particularly in the rapidly expanding nursing home sector.

As a result, from the late 1980s, the number of nurses employed in the NHS has remained largely static, after four previous decades of employment growth. This has happened despite a continuing increase in NHS activity.

More patients are being treated, and patient care has become more 'intense', with higher dependency patients requiring more care in a shorter time period. The effects of this increased activity are reflected in feelings of increased workload and stress among the nurses.

1The supernumerary status of nursing students since the implementation of the new system for nurse education, Project 2000, has heightened the sense of a staffing shortfall. There are fewer nursing students, and they spend much less time contributing to work on the wards.

The DoH has now stopped denying the existence of nursing shortages. It has embarked on yet another advertising campaign to attract recruits and returners to NHS nursing and has acted to increase intakes to nurse education. The advertising/recruitment pack includes useful resource material for trusts, but critics will argue that once again the response has been late in coming. It will take another four years before the increased number of nursing students joins the nursing workforce, and in the meantime nursing shortages are becoming ever more pronounced.

The last cycle of nursing shortages in the mid to late 1980s, and those of previous decades, were primarily due to increasing demand for healthcare and for staff outstripping available supply. Current concern focuses both on supply and demand. Various supply-side factors - in particular the ageing of the nursing profession and the dwindling pool of potential returners - are likely to reduce future supply, while demand for healthcare will continue to grow.

2Projections made in 1997-98 regarding future supply of nurses suggested that the number of newly qualified nurses would have to be increased if demand is to be met (see bar chart, page 24).

Cycle of shortages

In the UK, there have been a number of 'official' reports attempting to examine the reasons for shortages and proposing solutions. It is clear that the cycle of nursing shortages has been accompanied by a process of reidentifying the same solutions - such as attracting returners, improving skill-mix and making better use of part-timers. Reforming nurse education, for example, was repeatedly highlighted, but did not happen to any extent until the implementation of Project 2000 at the beginning of the 1990s. Many of these proposed solutions continue to be identified, without ever being properly evaluated or fully implemented. We risk repeating the same mistakes in dealing with the current shortages.

Lessons from abroad

We are not alone in experiencing a cycle of nursing shortages, but in some ways are better equipped to break that cycle than some other developed countries. As nursing is funded from public money there is some leverage for central planning. Both the US and Canada face the same challenges of increasing demand for healthcare, and ageing of the nursing workforce. The US has experienced a recurring problem of shortages, and national committees have made recommendations similar to those made in the UK. But the US's free-market approach to providing healthcare and education has meant that there is not the same scope for national government policy intervention. Where the US does have lessons for us at a national level is in the use of integrated monitoring of staffing in multi-employer labour markets;

and at an operational level in terms of management approaches to providing attractive working environments for nurses - such as 'magnet hospitals'.

3Matching supply and demand

How then can supply and demand for nurses be most effectively balanced? The indications are that the demand for healthcare is likely to grow beyond the year 2000. The reasons for the projected increase in demand are well documented and are related to demographics, advances in medical practice and technology, the impact of 'new' diseases and infections - for example, HIV/AIDS - and changes in public expectations of the healthcare system.

The projected increases in demand would not necessarily be met in totality, and there will be continuing debate about how much demand will be met by the NHS, where, and what mix of staff and other resources will be used.

There are several possibilities for action.

Improving conventional recruitment

To maintain or improve the supply of 'conventional' recruits, nursing has to adopt strategies aimed at improving the 'image' of the service among potential recruits and promoting nursing as a career. It is equally important that image matches reality. The current DoH initiative represents the latest attempt to market the profession to potential recruits.

The career opportunities and financial and emotional rewards of working in nursing need to be made explicit, but they also need to be compared objectively with the attractions of other sources of employment. The 'stop-go' nature of nurses' pay determination in previous decades meant that declines in their relative pay rates often undermined the attempts of campaigns to promote the image of nursing.

4Improve recruitment from 'non-conventional' sources

Any source of recruits other than young women is often regarded as a non-conventional 'alternative' in nursing.

Nursing has traditionally relied primarily on young entrants to training - 17-year- old female school leavers.

Mature entrants provide one possible additional source of recruits, and it is apparent from the early cohorts to Project 2000 courses that nursing is beginning to attract applicants from a broader age profile.

For such a policy initiative to be fully effective, it will have to be recognised that the requirements and objectives of mature entrants may differ markedly from those of younger recruits; for example, provision of part-time training (virtually non-existent) and childcare support may act as incentives for some mature entrants.

Many potential mature entrants to nursing may prefer to enter national vocational qualification-based care assistant training, with its shorter training time and broader entry gate.

Another alternative source is male recruits. Only one in 10 nurses is male. While some advances have been made in increasing the proportion of male nursing student entrants this has been from a low base.

A third 'non-conventional' source of nurses is to recruit staff trained in other countries. Britain has a long and not very glorious tradition of recruiting healthcare staff from abroad into 'hard to fill' posts which are often career limiting. The latest target for overseas recruitment is the Philippines. Recruiting from abroad has usually been a stop-gap measure, and is rarely part of an integrated strategy. The flow of nurses to the UK tends to fluctuate in line with the level of recruitment difficulties in the UK, and many stays are of a temporary nature.

5Nurses who have stayed on, such as those recruited from the West Indies in the 1960s, have often have had a frustrating time in the NHS, experiencing discrimination: this is one explanation for the low level of recruitment from ethnic minorities in Britain.

6Improve retention

Staff retention is likely to be the key element in the human resources strategy of trusts over the next few years.

Retention can be improved both by increasing the initial entry rate of those who have successfully completed training for the profession and by reducing wastage rates of nurses in employment.

The complex interaction of pay, job satisfaction, career prospects and non-work issues means that there is often no quick fix to the problem of retention. Ensuring that pay rates are competitive is one obvious part of the solution, particularly where nurses' work has traditionally been undervalued as 'women's work'. Not even the unions are arguing that pay is the only solution, and there is a growing consensus that the current clinical grading pay system is ill suited to support a clinical career structure for nursing as it enters a new century.

Raising pay levels is certainly not the only answer, and a number of non-pay initiatives to improve retention have been repeatedly highlighted. These measures can include job-sharing, childcare facilities, flexible hours, 'keep in touch' schemes, managed career breaks and refresher courses designed to assist re-entry of nurses to employment by maintaining and updating their skills.

Overuse of short-term employment contracts is likely to cut across such initiatives - which is one reason why the new health service human resource strategy in Scotland is emphasising that the use of short-term contracts will be monitored.

Improve use of staff

Healthcare is a 24-hour, 365-day a year industry, and its resources have to be deployed effectively to match continuous, but changing demand. Improvements in matching staffing levels to 'peaks and troughs' in the workload are required, by devising effective rota systems and evaluating the benefits of different shift patterns.

We can expect much activity from trusts, attempting to implement flexible working patterns through zero-hour contracts, and annualised-hours contracts.

The continued use of additional payments of 30 per cent and 60 per cent for 'special duties' - nurses working nights and weekends - is also likely to come under increasing pressure. Employment 'flexibility' will have to become a more positive factor for nurses than it was middecade, when it often meant marginalised part-time posts or short-term contracts with little career development potential.

Use of the comparatively scarce resource of qualified nurses will be maximised when the appropriate mix of nurses and other healthcare staff has been determined, and when suitable support staff are available.

This brings us to the thorny quest ion of staff substitution.

Staff substitution

Healthcare assistants are regarded by some as the 'solution' to the nursing shortage. These workers can often be recruited from a larger pool of potential recruits; they require less time and resources to train and are less expensive to employ. Achieving a balance of skill-mix, with the optimum proportion of first-level nurses and these support workers is one of the main challenges facing management in healthcare (not forgetting the continued need to manage enrolled nurses and 'old-style' auxiliaries).

As yet, NVQ-trained care assistants are not in widespread use, but we can expect a marked increase in their deployment over the next few years - constrained as much by the limited capacity of the training system as by opposition from the professions. The optimum balance of staff has to be achieved across hea lthcare disciplines (nursing, medicine, therapy professions etc) as well as within them.

The recent emphasis on integrating workforce planning in the NHS should help, but this has to happen in two ways: it should be about integrating the planning process across disciplines and professions, but it should also be about planning for the outcome of an integrated workforce, with the different professions and groups being deployed effectively as an integrated team.

There is nothing much new or novel in the list of potential solutions. Some have been recommended for longer than the NHS has been in existence. What has been missing in the UK is the capacity to monitor the nursing labour market at a national level, and a commitment to do this on a continuing basis. This is required to track trends in employment behaviour and to give early warning of recruitment difficulties, and has to be combined with support for the networking of proven solutions to local recruitment problems.

We need to develop and maintain an independent national oversight of the UK nursing labour market, and support general improvements in trusts' workforce planning capabilities. Sustained commitment to this mixed 'top down/bottom up' approach would dampen down the cycle of shortages, and release more time (and more nurses) to manage the delivery of patient care.

REFERENCES

1 Seccombe I, Smith G. Taking Part; registered nurses and the labour market. Institute for Employment Studies Report 338. Brighton: IES, 1997.

2 Buchan J, Seccombe I, Smith G. Nurses Work: an analysis of the UK nursing labour market . Aldershot: Ashgate, 1998 (forthcoming).

3 Buchan J. Magnet Hospitals: are they still attractive? Nursing Standard 1997; 12(5): 22-25.

4 Buchan J. Flexibility or Fragmentation: trends and prospects in nurses' pay . London: Kings Fund Institute, 1992.

5 Buchan J, Seccombe I, Thomas S. Overseas mobility of UK nurses. International J of Nursing Studies 1997; 34(1): 54-62.

6 Beishon S, Virdee S, Hagell. Nursing in a Multi-Ethnic NHS. London: Policy Studies Institute, 1995.

Lessons from the past?

The Lancet Commission on Nursing (1932) examined nurse vacancy rates, turnover rates and application rates. Its recommendations included improved salary scales; reform of nurse education; better provision of in-service training; and 'provision of sufficient ward maids to relieve nurses of domestic duties'.

The Inter-Departmental Committee on Nursing Services (Ministry of Health: Interim Report, 1939) noted that 'there exists an acute general shortage of State Registered Nurses' (para 19). The committee's recommendations included: salaries and pensions should be dealt with on a national basis; restructuring of nurse education courses; reduction in hours of work; additional 'off duty' for nurses working excess hours; 'increase in the number of orderlies and ward maids'; 'extension of the practice of employing married nurses'; and universal and interchangeable pensions.

The Report of the Ministry of Health Working Party on the Recruitment and Training of Nurses (1947) noted that 'the fact that the difficulties in the health service are still acute in all fields must be ascribed to the growth of the services and the consequent demand for increased staff. . .' (para 28). Main recommendations were that nurses in training should have full student status; all restrictions on employment of married nurses should be removed; a part-time service should be developed; and the use of male nurses should be extended.

The report of the Committee of Nursing (1972) (the Briggs report) noted that 'it is not possible to measure shortages without first establishing needs' (para 446) and acknowledged staff shortage difficulties in the staff nurse grade, and in geriatric/long-stay and psychiatric settings. Main recommendations included:

recruiting 'mature entrants'; recruiting male nurses; encouraging nurse returners and improving part time opportunities; establishing a 'keep in touch' scheme for nurses on maternity leave; improving shift patterns and the allocation of staff to workload (paras 433-501).

Key Points

Shortage of nurses is a longstanding problem which was the subject of official inquiries long before the launch of the NHS.

There has been persistent inertia about acting on the recommendations of these reports.

Despite a continuing increase in activity rates, the number of nurses in the NHS has remained largely static for a decade. Another 5,000 will be needed by 2015 The UK should use its capacity for centralised planning to tackle the issue.