Nursing numbers in Britain: the argument for workforce planning

British Medical Journal, April 15, 2000 by James Buchan, Nigel Edwards

When the Labour government in Britain took office in 1997 it inherited a growing problem of nursing shortages, which finally hit the headlines in 1998. The shortages have been recurring ever since, particularly during the influenza "crisis" last winter. How has the government fared in dealing with nursing shortages, and has it put the worst behind it?

Roots of the problem

The roots of the recent nursing shortages lie in the early 1990s. As part of the NHS reforms and the introduction of the internal market, there was a move towards an employer led system to determine intakes to nurse training. The involvement of NHS trusts was to be welcomed, but the narrow focus, varying capacity of local training and education consortiums, and lack of a national overview meant that most trusts underestimated required staffing numbers. The system also underestimated non-NHS demand for nurses, particularly in the rapidly expanding nursing home sector. The effect of this new "planning" system was to reduce markedly the number of student nurses. In 1984 England had more than 75 000 nursing students and pupil nurses. By 1994 that number had more than halved. The register of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting showed its largest annual decline in the number of practitioners in 1998 as a result of the reduction in trainees and failures to re-register. Although the number for 1999 has risen, it is still 6000 lower than the 1990 figure of 19 000.

Because of reductions in the number of nurses staying in Britain to work, international recruitment has increased markedly. Nearly 5000 new nurse entrants from overseas joined the central council's register in 1998-9--that is, 28% of the total registration.[1] The Department of Health has since issued guidance to NHS trusts to advise them not to over-recruit and damage nursing labour markets in developing countries.[2] Increased use of agency staff has been another solution, particularly in the south east of England, but this may damage the care process and add unacceptable costs. Problems of supply have been exacerbated by increases in job turnover, as more nurses have taken jobs in the growing private sector. This has taken place against a background of increasing workload. From 1990 to 1998 all acute activity, as measured by "finished consultant episodes," rose by 38%, from 6 936 000 to 9 549 000. The number of emergency admissions has also risen hugely, and from 1992 to 1998 the number of non-elective finished consultant episodes rose by 28%. As a result there has been a significant increase in the ratio of nurses to finished consultant episodes (table). Measured in admissions instead of finished consultant episodes, the rise in workload seems lower, but referrals among consultants do generate real extra work for nurses. Changes in skill mix have been highlighted as one solution to nursing shortages.

Nursing workloads for acute, paediatric, and maternity services for 1990 and 1998 in England

                                                1990        1998
Qualified nurses:
 Total No                                      148 640     167 410
 No per 1000 finished consultant episodes        21.4       17.5
Unqualified nurses:
 Total No                                       47 110      46 750
 No per 1000 finished consultant episodes         6.8         4.9

The total numbers of nurses (except students), as whole time equivalents, in England were 336 520 in 1990, 337 603 in 1994, and 332 200 in 1998[3]

The last nursing shortages in Britain, in the mid-1980s, and those of previous decades, occurred primarily because an increased demand for health care and staff outstripped available supply. This current cycle looks more problematic. It relates both to further increases in demand and to supply difficulties. Various supply factors--in particular, the ageing of the nursing profession and the dwindling pool of potential nurse "returners" (former nurses returning to paid employment)--are likely to constrain future supply, even though demand for health care is expected to continue growing.

Nursing supply and demand could become even more problematic in the next 10 years if there is no sustained approach to planned intervention.[4] The NHS nursing workforce is ageing--in this decade compared with the last, proportionately more nurses will be in their 50s and beginning to consider retirement (fig 1). Coupled with increasing demand for health care, the impact of retirement rates could worsen the imbalance between supply and demand.

[Figure 1 ILLUSTRATION OMITTED]

When nursing shortages hit the headlines in 1998-9 the government took action. The NHS Executive set up a recruitment and retention unit. National advertising campaigns, efforts to attract returners, and an emphasis on friendly flexible working were underpinned by the full implementation of the Pay Review Body awards. National targets were set by the secretary of state for health to employ "up to" 15 000 more nurses in the NHS.

Some progress has been made. The number of applicants to pre-registration nurse education has grown rapidly over the past year. The NHS Executive claims that the nurse returner scheme is working, but this represents only a partial solution to the problem of shortages. A longer term improvement in the planning and career structure of the nursing workforce is also required.