The Ward Round: Filling the leaky bucket

Leaked documents seen by HSJ this week revealed NHS People Plan modelling depends on thousands of nursing associates helping to reduce demand for registered nurses.

The document, dated October 2019, sets out the workforce impact of various People Plan initiatives, which are estimated to produce over 45,000 “full-time equivalents” by 2024.

Within this total, a figure of 10,200 was attached to what has been referred to as “skill mix between nursing associates and registered nurses” — a figure which does not represent actual additional RNs, but the impact of a growing NA workforce.

This has stoked the concern held by critics of the nursing associate role, which was designed in part as a career path for band two and three healthcare assistants and also to free-up time for pressurised RNs.

There is plenty of research stating there is a link between numbers of RNs and outcomes — and on the dangers of getting the nursing skill mix wrong — but the nursing associate programme has been rapidly expanded, and the leaked document confirmed the NA pipeline would continue to recruit 7,500 trainees a year from 2019-20.

Alison Leary, professor of healthcare modelling at Southbank University, described the model in the document as “simplistic”, as it assumed nursing work was a hierarchy of technical tasks — under which, the modelling said, two NAs could reduce demand for RNs by one.

Concerns have also been expressed that NAs could be put in a difficult — or even dangerous — position and asked to complete tasks they are not qualified to do by some employers who are short of nurses.

However, where used safely and appropriately and properly integrated into the multidisciplinary team, rather in the place of nurses, NAs have a valuable part to play in caring for patients.

Another key nursing supply driver set out in the document was the conversion of NAs to RNs — the People Plan modelling estimated this would result in over 3,000 new nurses.

Sources close to the planning have stressed this conversion will play a key part in the final plan and it is recognised that nursing associates alone can’t reduce RN demand.

Unsurprisingly, improved retention also played an important part in the model, with 12,400 cited as the figure to aim for over the next five years. The analogy of a leaky bucket has often been used when talking about the NHS workforce, referring to the sometimes very high level of leavers.

Although the key factors and constraints on the nursing workforce are hard to escape, the model is undoubtedly fluid and, partly because of the election, it will have changed by the time the final plan is published.

An international health service

Reading through the modelling document, it was impossible to ignore the similarities between the NHS’ figures and those briefed by the Conservatives last month.

In fact, the overseas recruitment figure was exactly the same at 12,500.

The document emphasised international staff would be the “largest single contributor of extra nurses” and stressed the need for the level of growth seen in international staff numbers before the Brexit referendum to resume.

Briefings published by both the Health Foundation and the Nuffield Trust in recent days have reinforced how much the NHS relies on its international staff — and how damaging ending free movement of workers from Europe could be for the health service.

Nuffield Trust analysis demonstrated workers born outside the UK accounted for 50 per cent of the increase in care staff over the last decade and now within hospitals the proportion of workers born outside the UK has reached one in four.

A slowdown in migration could not have come at a worse time, warned the think tank. Although it acknowledged both Labour and the Conservatives have discussed exemptions for NHS workers — for example, the Tories have pledged a cheaper “NHS visa” — the Nuffield Trust is clear a new visa system could be more restrictive overall.

If the rate of international recruitment — of both health and social care staff — is to recover to pre-Brexit levels and be boosted if needed in the future, clarity on a sensible immigration policy is paramount. The outcome of the Migration Advisory Committee’s consultation on the “refined points system”, commissioned by the government, will be crucial.

What cuts through?

A few weeks ago, The Ward Round lamented how politicians are not focussing enough on the issues that could really cut through with the public, with little attention on the NHS workforce.

Shortly after this, the controversial “50,000 nurses” pledge landed, which was met with derision by some. This tapped into the wider issues of trust in this election campaign.

Anastasia Knox, associate partner at consultancy Britain Thinks, told a King’s Fund panel this week that, although the nursing numbers announcement has had “some cut through”, ultimately, most people are not engaged enough with the debate to notice differences in the numbers, whether its 50,000 or 30,000.

“If politicians massage the figures, I don’t think anyone would be surprised,” Ms Knox said.

The important thing, according to Bill Morgan, former special adviser to Andrew Lansley when he was health secretary, is the Conservative campaign is stirring up controversy and the message about “more” nurses is spreading.