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Report
by the Comptroller
and Auditor General

Department of Health & Social Care

The NHS nursing workforce

HC 109 SESSION 2019–2021 5 MARCH 2020

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Department of Health & Social Care

The NHS nursing workforce

Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 4 March 2020
This report has been prepared under Section 6 of the
National Audit Act 1983 for presentation to the House of
Commons in accordance with Section 9 of the Act
Gareth Davies
Comptroller and Auditor General
National Audit Office
3 March 2020

HC 109 | £10.00
Prior to publication of the delayed NHS People Plan, this report
sets out the facts on the scale of the NHS nursing workforce
challenge, the main entry routes to NHS nursing and progress
made on the NHS People Plan. This report does not evaluate
the People Plan process or progress against the published
Interim People Plan.

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 Contents
Key facts 4
What this report is about 5
Summary 8
Part One
The nursing workforce challenge 12
Part Two
Challenges in the main entry
routes to NHS nursing 23
Part Three
The NHS People Plan 39
Appendix One
Our methodology 47
Appendix Two
Challenges to workforce The National Audit Office study team
planning and supply 50 consisted of:
Matt Beaumont, Charlie Bell,
Rosie Buckley, Oliver Evatt,
Claire Hardy, Sue Leveson,
Natalie Low, Michael Woodrow,
under the direction of Jenny George
and Ashley McDougall.
This report can be found on the
National Audit Office website at
www.nao.org.uk
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4 Key facts The NHS nursing workforce

Key facts

5% 43,590 5%
increase in overall nurse number of nursing increase in students
numbers in hospital and vacancies reported starting undergraduate
community services by NHS trusts, nursing degrees,
between September 2010 July–September 2019 2017–2019, compared
and September 2019 (full-time equivalent) with target of 25%
(full-time equivalent)

38% decrease in learning disability nursing numbers between

September 2010 and September 2019 (full-time equivalent)

17% proportion of nursing workforce from outside the UK

(headcount, March 2019)

519,000 estimated number of people registered to practise as a nurse

in England, September 2019

320,000 number of NHS nurses working in hospital and community

services (headcount, September 2019)
 The NHS nursing workforce What this report is about 5

What this report is about

1 Nurses are critical to the delivery of health and social care services, working across
hospitals, community services, care homes and primary care. In 2019, around 519,000
people in England were registered to practise as a nurse, while the NHS employed 320,000
nurses in hospital and community services, making up about a quarter of all NHS staff.

2 In January 2019, the NHS Long Term Plan acknowledged the need to increase
staff numbers, noting that the biggest shortfalls were in nursing. The NHS set up the
People Plan programme to decide how it would secure the workforce it needed to
meet its future service commitments. In this report, we define workforce planning as
the analysis and plans required to ensure that the NHS has the number and type of
staff it needs, now and in the future.

3 A range of national and local NHS bodies are responsible for (nursing) workforce
planning as well as supply, which includes training, recruitment and retention of staff.
Figure 1 sets outs a basic overview, with fuller details in Figure 8 on page 20.
Figure 1 shows Responsibilities for nursing workforce planning and supply

Figure 1
Responsibilities for nursing workforce planning and supply in England

Department of Health & Social Care: overall policy for NHS

and social care workforce.

Health Education England NHS England and NHS Non-NHS bodies, such
(HEE): oversees workforce Improvement (NHSE&I): as universities, can
planning, education and supports and oversees play a role in individual
training. Also funds the performance of NHS supply routes.
providers to host clinical trusts, including in relation
placements, an essential to workforce retention
part of nursing degrees. and other workforce
responsibilities.

Local NHS trusts, foundation trusts and GPs (‘providers’)

employ nursing staff, and are responsible for their recruitment,
retention and day-to-day management.

Accountability

Note
1 Figure 8 provides a fuller description of roles and responsibilities.

Source: National Audit Office summary of responsibilities

6 What this report is about The NHS nursing workforce

4 While this report focuses on NHS nurses, nearly one in ten nurses works in adult
social care, for which the Department of Health & Social Care (the Department) also has
policy responsibility. The social care sector relies on similar entry routes for nurses as
the NHS, but is made up of many providers who individually recruit and employ staff.
The NHS People Plan primarily focuses on the health sector but envisages that local
partnerships will cover health and social care workforce planning (see paragraph 14).

5 We have published a number of reports on workforce planning and supply,

including coverage of the NHS, adult social care, the military and teachers.
Departments have different approaches and systems for securing the workforce
needed to deliver services. However, our studies found common challenges in
identifying the true workforce need; recruiting and retaining staff; underperformance
of workforce initiatives to address these; and managing the impact of shortages on
existing staff. Figure 2 sets out the general challenges we have observed that any
future NHS People Plan must take care to address, and how these link to the current
situation for NHS nurses.

6 The NHS People Plan has, for a variety of reasons, been delayed (see Summary,
paragraph 11). Rather than delay for an uncertain time our own reporting, this report
sets out the facts on:

• the scale of the NHS nursing workforce challenge;

• the challenges to the main entry routes to NHS nursing and more general
workforce-related challenges that any future plans will need to address; and

• the progress made on the People Plan.

 The NHS nursing workforce What this report is about 7

Figure 2 shows Observed challenges to workforce planning and supply

Figure 2
Observed challenges to workforce planning and supply from National Audit Office reports
Commonly observed challenges in workforce Relevant sections of this report
planning and supply
Accountability Ensuring responsibilities and accountabilities Roles of national and local bodies and new workforce
for workforce planning and supply are clear and model (summary paragraph 13).
well understood, and aligned with organisational
Funding arrangements (summary paragraph 12).
influence, priorities and incentives.
Interim People Plan (summary paragraph 10).

Having effective national, regional or central Roles of national and local bodies (summary paragraph 13).
coordination and oversight in workforce
planning and supply.

Workforce Demonstrating a robust understanding of the NHS Long Term Plan planning (summary paragraph 4).
planning future need for staff based on evidence and
National modelling (paragraph 3.11).
reliable forecasting, including key policy changes.
Local plans (summary paragraph 11).

Understanding the performance of current and future National modelling (paragraph 3.11).
supply routes for staff and how these address overall
See also individual supply routes (summary paragraphs 5–9).
staffing requirements and any identified shortfalls.

Setting out an overall workforce plan that People Plan process (summary paragraphs 10-13)
meets government’s objectives, and is
actively managed and reviewed.

Having reliable information/data on workforce. National modelling (paragraph 3.11).

Local plans (summary paragraph 11).

Integrating workforce, finance and performance NHS Long Term Plan planning (summary paragraph 4).
strategies and planning.
People Plan process (summary paragraphs 10–13).

Ensuring coverage of all types of staff in planning. National modelling (paragraph 3.11).
See also introductory paragraph 4.

Workforce Ensuring training places reflect future staffing Higher education market (summary paragraphs 5 and 6).
supply needs, as well as factors such as attrition and Apprenticeship routes (summary paragraph 8).
subsequent participation in the workforce.

Ensuring funding arrangements for training and

recruitment provide the right incentives for
individuals, education providers and employers
to achieve overall workforce objectives.

Addressing differences in staffing challenges by Scale and nature of nursing workforce challenge
area and role in workforce planning and supply. (summary paragraphs 2–3).

Providing adequate support and funding for local Higher education market (summary paragraphs 5 and 6).
bodies to implement workforce strategies. Apprenticeship routes (summary paragraph 8).
Ensuring workforce objectives are supported by International recruitment (summary paragraph 7).
wider cross-governmental policies and initiatives.
Retention improvement (summary paragraph 9).

Addressing Identifying a cost-effective, sustainable approach Not in scope of current report, but see paragraph 1.8.
short-term for filling shortfalls in staff, and supporting
shortfalls employers to fill shortfalls.

Appropriately managing the risk of an undesirable level Not in scope of current report, but see paragraph 1.6.
of competition between employers for the same staff.

Source: National Audit Office analysis of published reports

8 Summary The NHS nursing workforce

Summary

Key findings

The NHS nursing workforce

1 The NHS publicly acknowledged problems with current nursing shortages
in 2017. In December 2017, Health Education England (HEE) published a draft workforce
strategy on behalf of the NHS that noted pressures on the nursing workforce. By the
time of the NHS Long Term Plan in January 2019, indicators such as the nursing
vacancy rate had worsened. There is a significant time lag (at least three to four years)
before policies to train more new nurses can have impact, meaning greater reliance
in the short term on strategies such as overseas recruitment and improving retention
(paragraphs 3.2 and 3.12).

2 Despite overall increases in the number of nurses, the NHS does not have
the nurses it needs. Between 2010 and 2019, the overall number of NHS nurses in
hospital and community services increased by 5%, although there were substantial
reductions for some types of nurse - for example, a 38% reduction for learning disability
nurses. Analysis by the Health Foundation for the shorter period 2010-11 to 2016-17
shows that the growth in nurse numbers (1%) was lower than increases in the amount
of activity in hospital and community health services (23%). As at September 2019, the
NHS had a nursing vacancy rate of 12%, a rise of 1% from September 2017. The Long
Term Plan sets a target of reducing nursing vacancy rates to 5% by 2028. NHS England
and NHS Improvement (NHSE&I) has estimated that around 80% of vacancies are filled
by temporary staff (paragraphs 1.2 to 1.5).

3 The nature of the nursing workforce challenge varies by trust and region.
Nursing vacancy rates are particularly high for mental health trusts (16%) and in
London (15%). Levels of international recruitment vary considerably by trust and region.
The proportion of overseas nurses varies from 30% to 36% in London regions to 5% to
8% in the north‑east, north-west, and Yorkshire and Humber regions. Some sectors,
such as primary care and community providers, also have a higher proportion of older
nurses, who are closer to retirement (paragraphs 1.4, 1.6 and 2.21).
 The NHS nursing workforce Summary 9

4 In January 2019, the NHS Long Term Plan set out service commitments for
NHS England’s £33.9 billion additional funding settlement that did not include
detailed plans to secure the workforce needed to deliver them. The Long Term
Plan contained service commitments – for example, on cancer care – and workforce
commitments, including on nursing student numbers and retention, recognising that
nursing workforce growth had not kept up with demand. It did not include detailed plans
for how it would secure the nursing workforce required to deliver the commitments:
it stated that a workforce plan would be published in 2019, as HEE budgets for workforce
education and training beyond March 2020 were not yet agreed. Based on a review of two
service areas, we found that, at the time of drawing up the Long Term Plan, there were
quantified estimates of the nursing staff required for mental health service commitments.
For cancer service commitments, there were no separate estimates of the overall cancer
nursing capacity required, but an assumption that cancer needs would be met from the
overall increase anticipated for the nursing workforce (paragraphs 3.1, 3.4 and 3.5).

Challenges in the main entry routes to NHS nursing

5 From 2017, the government changed the funding arrangements for nursing
degree students, a major source of new NHS nurses. HEE has not been responsible
for commissioning undergraduate nursing places since 2017, and the higher education
market now determines the numbers of students, in response to demand from
prospective students. A different approach is used in medical education, where HEE
has a commissioning role and places are regulated and subject to targets. The changes
in funding arrangements also removed NHS bursaries for nursing students, moving
them on to the existing student loan arrangements. The Department of Health & Social
Care (the Department) hoped to increase the number of places on nursing, midwifery
and other health professional degree courses by up to 10,000 through these changes.
In December 2019, the government announced the introduction of new maintenance
grants for nursing students from September 2020 (paragraphs 2.5, 2.6, 2.10 and 2.16).

6 The number of applications for nursing degrees dropped significantly

following the funding changes and subsequent numbers of new students have
been below the Department’s targets. In 2017, the first year of the new arrangements,
the number of applicants fell by 11,000 (21%). Universities accepted a higher
proportion of applicants than previously, so there was only a 3% fall in the number of
new nursing students. Since 2017, numbers of nursing places have not increased as
anticipated, and did not meet the Department’s 2018-19 and 2019-20 commitments
to a 25% increase. Trends in numbers of new students also differ markedly by nursing
degree specialism (for example, mental health), region where applicants lived and for
mature versus younger students. Early indications are that the number of applicants
for September 2020 has risen by 6% compared with 2019, but is still lower than the
number of applicants in 2017 (paragraphs 2.6 to 2.9 and 2.16).
10 Summary The NHS nursing workforce

7 The NHS Long Term Plan signals the need for a step change in the
recruitment of overseas nurses, but recent national initiatives to increase
numbers have not met their targets. Overseas recruits are already a major source
of new nurses, making up around 20% to 25% of nurses joining the NHS. The number
of overseas nurses working for the NHS rose by 28% between September 2014 and
March 2019, with the proportion that they make up of the workforce remaining fairly
steady since 2009 (17% as at March 2019). Since 2018, the Nursing and Midwifery
Council has made a number of changes intended to improve and streamline the
process for overseas nurses to register to practise in the UK. However, against a target
of 2,500, the HEE-led global learner programme only attracted around 1,600 nurses
in the two years 2018 and 2019. It now has an increased target of 15,000 nurses
between 2020 and 2024 (paragraphs 2.20, 2.22 to 2.23 and 3.3).

8 Trusts and universities told us that there are financial and bureaucratic
disincentives to increasing numbers through apprenticeship routes. Employers,
supported by HEE, have developed a nursing degree apprenticeship route into
nursing. They have also developed a new nursing associate role, which bridges the
gap between registered nurses and healthcare assistants and aims to provide a new
pipeline for registered nurses. Numbers of nursing degree apprentices were as expected
(1,041 in 2018-19, up from 304 the previous year). For nursing associates, HEE projects
that it will recruit 7,529 trainees between 1 January 2019 and 31 March 2020, against a
target of 7,500 for this period. By December 2019, it had recruited 2,739 with regional
trajectories in place for the remaining quarter. All the local trusts we visited were planning
to make more use of apprenticeships, primarily nursing associates. Larger employers
(including NHS providers) must pay an apprenticeship levy, which they can use to
pay for apprenticeship training and assessment. In 2018‑19, NHS organisations spent
less than 30% of their levy payments. We heard about disincentives to the expansion
of apprenticeships - in particular, that NHS trusts cannot use the apprenticeship levy
to cover ‘back-fill’ costs. These refer to the costs of employing additional staff while
an apprentice is doing clinical training, because during training apprentices cannot
count towards the staffing complement. Universities also told us it was difficult to
make apprenticeship courses sustainable, given factors such as the levels of scrutiny,
bureaucracy and funding, and numbers of students (paragraphs 2.24 to 2.28).

9 Since 2017, NHSE&I has supported trusts with an intensive retention support
programme. Between 2012-13 and 2018-19, although the number of nurses joining the
NHS increased, so did the numbers leaving. NHSE&I’s retention support programme,
which started in 2017, has seen reductions in leaver rates for the first groups of trusts
receiving support from the programme. The retention support programme works
with trusts to help them address some of the key issues identified by available data
on reasons for leaving, including: career progression; health and well-being; and
support for new starters (paragraphs 2.30, 2.32, 2.34 and 2.35).
 The NHS nursing workforce Summary 11

The NHS People Plan

10 NHSE&I and HEE have brought together bodies from across the sector to
produce a full People Plan for the period up to 2025. The new Chief People Officer
for NHSE&I chairs the National People Board, which oversees delivery of the People
Plan and led collective efforts to bring together the Department, its arm’s-length bodies,
and representatives from across the sector. Eight working groups support the board,
one of which has a specific focus on increasing nurse numbers (paragraph 3.6).

11 NHSE&I and HEE did not publish the People Plan as expected in 2019; it is
now expected in spring 2020. The Long Term Plan stated that a workforce plan would
be published in 2019. An Interim People Plan, published in June 2019, included an aim
for a fully costed five-year plan later that year. The full People Plan was delayed and is
now expected to publish in spring 2020, at least 12 months into the five-year funding
settlement. External factors such as the postponement of the full spending review, and
the December 2019 general election, have contributed to the delay. Local five‑year
strategy plans, including actions to increase nursing numbers, were due to be
published in November 2019 but as at March 2020 have not been agreed or published.
In December 2019, the government made a new pledge to increase the number
of NHS nurses by 50,000 by 2025 (paragraphs 3.3, 3.4, 3.9 and 3.15).

12 While NHS England’s budget is agreed up until 2024, this is not the case for
HEE’s budget, which covers workforce education and training. The £33.9 billion
cash‑terms increase for the NHS only applied to NHS England’s budget, which covers
the costs of employing staff to deliver the Long Term Plan commitments. It excluded
HEE’s budget – in particular, for workforce education and training - which the Long
Term Plan anticipated would be agreed in a multi-year spending review later in 2019.
The September 2019 spending round allocated a further £150 million to HEE for continuing
professional development for nurses (and other groups) in 2020-21. Up to 2020-21,
HEE also has access to funding for an additional 5,000 clinical placements (the practical
training that nursing students must do as part of their degree). The spending round also
allocated £60 million to People Plan activities for 2020-21 (paragraphs 3.1, 3.5 and 3.10).

13 The People Plan will detail new workforce-related roles for national, regional
and local bodies, as well as responsibilities for delivery of the overall plan.
The National People Board and supporting structures will be reviewed once the full
People Plan is published. As part of the plan, NHSE&I and HEE are intending to set out
each organisation’s responsibilities for future delivery of the plan and to produce a new
workforce operating model covering national, regional and local roles. The new model
also includes a greater role in workforce for local partnerships of NHS bodies and local
authorities, which is intended to cover both NHS and adult social care. Our previous
work has noted that such partnerships are not statutory and are reliant on the
goodwill of constituent bodies (paragraphs 1.12 to 1.14 and 3.10).
12 Part One The NHS nursing workforce

Part One

The nursing workforce challenge

Background to the nursing workforce

1.1 Nurses are critical to the delivery of health and social care services. To practise as
a nurse, people must be registered with, and qualified to a standard set by, the Nursing
and Midwifery Council. As at September 2019, 519,000 people living in England were
registered to practise as a nurse. The NHS employed 320,000 nurses in England in
hospital and community services as at September 2019, making up its single largest
group of clinical staff and about a quarter of all staff.1 In addition, 24,000 nurses were
employed in GP practices.2 Within NHS hospital and community services, nurses work
across a wide variety of care settings, with the majority in acute, elderly or general care
(Figure 3). Around two thirds (64%) have full-time contracts.3

Nursing shortages
1.2 Between September 2010 and September 2019, the overall number of NHS
nurses in hospital and community services rose by 5%, from 272,000 to 286,000,
but this masks very different patterns for different groups of nurses (Figure 4 on
page 14).4 The number of children’s nurses increased by 55% in this period, while adult
nurse numbers increased by 10%. By contrast, numbers of learning disability nurses
fell substantially (by 38%), with smaller reductions for community and mental health
nurses. In primary care, the number of nurses rose by 9% between September 2015
(when data first became available) and September 2019. As set out in more detail in
paragraphs 2.31 and 2.33, the nursing workforce as a whole is getting older, which
means a higher proportion of nurses approaching pensionable age.

1 Unless otherwise stated, analysis in this report excludes health visitors, whose services are commissioned by local
authorities. In March 2019, the NHS employed about 9,000 health visitors.
2 Other nurses not employed by the NHS may also provide NHS services, such as agency and bank nurses,
who provide temporary staffing cover, and those working for independent providers commissioned to deliver
NHS services. However, national data on these groups are unreliable or incomplete.
3 Figures in this paragraph are based on headcount data. Analysis of contracts includes health visitors.
4 Figures in paragraphs 1.2 and 1.3 are based on full-time equivalent (rather than headcount) data, which take account
of contracted hours as well as numbers of nurses.
 The NHS nursing workforce Part One 13

Figure 3 shows Care settings for NHS nurses, hospital and community services in England, March 2019

Figure 3
Care settings for NHS nurses, hospital and community services in England,
March 2019
NHS nurses work across a wide variety of care settings

Other Care Settings

6%
Paediatric Nursing
6%
Other Mental Health
6%

Community Mental Health

6%
Acute, Elderly and General
Community Services 63%
12%

Notes
1 Based on the number of nurses working in each care setting, which exceeds the overall headcount by around
600 due to some nurses working in more than one care setting. Percentages based on the overall headcount
were the same as those based on the number of nurses working within each care setting, when rounded.
Percentages may not sum to 100% because of rounding. Excludes health visitors.
2 Other care settings include neonatal nursing and learning disability settings.

Source: National Audit Office analysis of NHS Digital data

1.3 Although nurse numbers have increased over the past decade, so has demand:
our 2016 report on managing the supply of NHS clinical staff highlighted the rising
demand for nurses following the review into failures in care at Mid Staffordshire.5
The growth in NHS nurse numbers between September 2010 and September 2019
was also lower than for other clinical staff – for example, a 20% increase in doctors
(excluding GPs). Analysis by the Health Foundation shows that, between 2010-11 and
2016-17, the growth in nurse numbers (1%) has been lower than in Office for National
Statistics measures of activity in hospital and community health settings (23%), which
could imply increased productivity but also increased workloads and pressure on staff.6

5 Comptroller and Auditor General, Managing the supply of NHS clinical staff in England, Session 2015-16, HC 736,
National Audit Office, February 2016.
6 Health Foundation, Health service output has increased faster than nurse numbers this decade, April 2019, available
at: www.health.org.uk/news-and-comment/charts-and-infographics/health-service-output-has-increased-faster-than-
nurse-number. The Office for National Statistics publishes measures of “output growth” in hospital and community
health services, which is the growth in activity (inpatient, outpatient and day-case procedures as well as other
hospital activity), adjusted to account for the fact that some types of activity are more expensive than others, and
for quality. The Health Foundation states that it therefore “gives an indication of the amount being ‘done’ in hospitals
and community health settings”.
14 Part One The NHS nursing workforce

Figure 4 shows Percentage change in the number of nurses in NHS hospital and community services in England, 2010–2019

Figure 4
Percentage change in the number of nurses in NHS hospital and community services
in England, 2010–2019
The overall increase in NHS nurses masks very different patterns for individual groups

Percentage change from September 2010 (%)

80

60

40

20

-20

-40

-60
Sep Sep Sep Sep Sep Sep Sep Sep Sep Sep
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

September September September Change Percentage change

2010 2014 2019 2010-19 2010–2019
(000) (000) (000) (000) (%)
All 272 270 286 14 5
Of which
Childrens 15 20 23 8 55
Adults 169 173 186 17 10
Mental health 40 37 37 -4 -9
Community 41 36 36 -6 -14
Learning disabilities 5 4 3 -2 -38

Notes
1 Full-time equivalent data. Excludes health visitors.
2 Excludes data for primary care as the data are not yet reliable and are only available from September 2015.
3 Based on NHS Digital staff groups.

Source: National Audit Office analysis of NHS Digital data

 The NHS nursing workforce Part One 15

1.4 In January 2019, the NHS Long Term Plan acknowledged the need to increase
staff numbers, noting that the biggest shortfalls were in nursing.7 It set a target of
reducing nursing vacancy rates to 5% by 2028. For the period July-September 2019,
vacancy rates as reported by NHS trusts were 12% for nursing, equivalent to 43,590
full-time vacancies and higher than the overall staff vacancy rate of 9%.8 There were
particularly high nursing vacancy rates for mental health trusts (16%) and London
(15%): vacancy rates in London mental health trusts reached 20%. Vacancy numbers
and rates follow a seasonal pattern: they have generally risen over the past two years,
by 1% between July–September 2017 and 2019 (Figure 5).
Figure 5 shows Trends in NHS nurse vacancy rates in England, 2017–2019

Figure 5
Trends in NHS nurse vacancy rates in England, 2017–2019
Vacancy rates have generally risen between 2017 and 2019

Nursing vacancy rate (%)

14

12

10

0
Apr–Jun Jul–Sep Oct–Dec Jan–Mar Apr–Jun Jul–Sep Oct–Dec Jan–Mar Apr–Jun Jul–Sep

2017 2018 2019

Quarter
Vacancy rate (%) 10.9 11.2 10.2 10.2 12.0 12.1 11.1 11.1 12.3 12.1
12 months average (%) 10.6 10.9 11.1 11.4 11.6 11.7 11.7

Note
1 Full-time equivalent data.

Source: National Audit Office analysis of NHS England and NHS Improvement data

7 NHS, The NHS Long Term Plan, January 2019.

8 In addition to trust returns, NHS Digital also publishes experimental figures on numbers of advertisements, which is
only a proxy as one advert can cover a number of vacancies.
16 Part One The NHS nursing workforce

1.5 It is not straightforward to monitor nursing shortages centrally. NHS providers

must follow safer staffing guidance, although there are no prescribed staffing levels in
England.9 The main published measure is care hours per patient day, which is focused
on particular hospital settings and indicates average staff levels across a month.
There are also practical difficulties in interpreting vacancy rates. NHS England and
NHS Improvement (NHSE&I) has estimated that around 80% of vacancies are filled by
temporary staff, which can also be covered by overtime. Increases in vacancy rates can
also reflect expansion of a service area.

1.6 Workforce characteristics also vary by factors such as type of trust or region,
which affect the staff recruitment and retention issues that may arise (Figure 6).10
Levels of international recruitment vary considerably: for example, 20% of nurses in
acute trusts come from outside the UK compared with 7% in both community and
mental health trusts. Paragraph 2.21 on page 33 also highlights regional variations
in international recruitment. Overall, nursing remains a predominantly female
profession (88%), but mental health trusts have a much higher percentage of male
nurses (20% compared with 12% in all trusts). A higher proportion of primary care
and community nurses are older (35% and 23% respectively, aged 55 and over).
Primary care nurses are also distinctive in terms of the higher proportion of part‑time
working (84%). In our local visits, we found that the nature of local competition for
nursing staff varied from place to place, and could include private healthcare providers,
other NHS trusts and primary care, as well as social care and local employers
(not in healthcare).

1.7 Concerns about the impact of nursing shortages have persisted since
Mid Staffordshire,11 with a 2019 review by the University of Southampton finding that
registered nurse staffing levels had not risen to meet demand.12 In its 2018-19 State of
Care report, the Care Quality Commission raised general concerns about the impact
of low staffing levels affecting the quality of patient care, as well as increasing pressure
on staff and further contributing to staff shortages.13 Other studies have shown an
association between registered nurse staffing and increased mortality during hospital
admission,14 and patient care more generally.15

9 In Scotland and Wales, legislation is used to regulate NHS staffing. For example, in Scotland, health boards and service
providers have a statutory duty to follow appropriate methodology and ensure appropriate numbers of suitably qualified
staff providing care.
10 Figures in this paragraph are based on headcount data. Analysis of contracts includes health visitors.
11 Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2016.
12 Ball J, Barker H, Burton C, Crouch R, Griffith P, Jones J, Lawless J, Rycroft Malone J., Implementation, impact and
costs of policies for safe staffing in acute trusts, University of Southampton, 2019.
13 Care Quality Commission, The state of health care and adult social care in England, HC 9, October 2019.
14 Griffiths P, Maruotti A, Recio Saucedo A, Redfern O, Ball J E, Briggs J, Dall’Ora C, Schmidt P, Smith G and Missed
Care Study Group, Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study,
BMJ Qual Saf, 28(8), 609-617. doi:10.1136/bmjqs-2018-008043, August 2019.
15 Redfern O, Griffiths P, Maruotti A, Recio Saucedo A, Smith G and Missed Care Study Group, The association between
nurse staffing levels and the timeliness of vital signs monitoring: a retrospective observational study in the UK,
BMJ open 9(9), e032157. doi:10.1136/bmjopen-2019-032157, September 2019.
 The NHS nursing workforce Part One 17

Figure 6 shows Demographic and job characteristics of NHS nurses, hospital and community services (September 2018) and primary care (March 2019) in England

Figure 6
Demographic and job characteristics of NHS nurses, hospital and community services
(September 2018) and primary care (March 2019) in England
Workforce characteristics vary by type of trust

Of which
All hospital/ Acute trusts Community Mental health Primary care
community providers trusts
services
(%) (%) (%) (%) (%)
Age:
Under 25 4 5 2 3 1

25-34 25 28 17 19 8

35-44 25 25 23 24 20

45-54 29 28 35 34 37

55+ 16 15 23 19 35

Gender:
Female 88 90 93 80 98

Male 12 10 7 20 2

Ethnicity:
White 76 74 87 80 92

Black African/Caribbean/Black British 8 7 7 13 3

Asian/Asian British 10 12 4 4 4

Mixed/Other 6 7 3 3 2

Nationality:
United Kingdom 83 80 94 92 *

European Economic Area 7 8 3 3 *

Rest of the world 10 12 4 5 *

Grades:
Band 5 (and below) 47 51 41 34 *

Band 6 31 28 33 42 *

Band 7 17 16 20 18 *

Band 8 and above 6 5 7 6 *

Non Agenda for Change grade 1 1 0 0 *

Hours worked:
Part time ( <1 FTE) 36 + + + 84

Full time (1+ FTE) 64 + + + 16

Notes
1 Headcount data. Excludes health visitors, with exception of hours worked.
2 * = data not collected; + = data not accessed for this study. Percentages may not sum to 100% because of rounding.
3 Ethnicity and nationality exclude unknown or not stated. FTE stands for full-time equivalent. Agenda for Change is the national NHS pay
and grading system which covers nurses: band 5 is the entry-level grade for nurses.
4 As of March 2019, except for primary care which is September 2018.

Source: National Audit Office analysis of NHS Digital data

18 Part One The NHS nursing workforce

1.8 Shortages of nursing staff also have an impact on value for money. Our 2020
report on NHS financial sustainability highlighted the continued risk that the NHS will
be unable to use the extra funding from the long-term settlement optimally because of
staffing shortages and having to use more expensive agency staff to deliver additional
services.16 In 2018-19, trusts spent £2.4 billion on agency staff and £3.4 billion on bank
staff, which will include nurses.17

Recent developments affecting the nursing workforce

1.9 In 2019, in addition to the publication of the NHS Long Term Plan, a number of
developments affected the nursing workforce and workforce planning more generally.
These included the publication of the Interim People Plan supporting the Long Term
Plan, and the announcement of the introduction of new maintenance grants for
nursing degrees. These are summarised in Figure 7, and discussed in more detail
in Parts Two and Three.

NHS workforce roles and responsibilities

1.10 At the national level, a number of different bodies are responsible for oversight
of the NHS nursing workforce:

• the Department for Health & Social Care (the Department) has overall policy
responsibility for the NHS and social care workforces;

• Health Education England (HEE), an arm’s-length body of the Department,

oversees workforce planning, education and training;

• NHSE&I, also an arm’s-length body, provides oversight and support to NHS

trusts and foundation trusts (including on workforce-related activities and staff
management), and leads on quality and diversity, professional leadership and the
negotiation of primary care contracts;18

• providers (including NHS trusts, foundation trusts and GP practices) are

responsible for recruiting and employing staff and their day-to-day management.

Figure 8 on page 20 details general roles in relation to the workforce, while Part Two
contains more details about roles in workforce supply, which vary by entry route.

16 Comptroller and Auditor General, NHS financial management and sustainability, Session 2019-20, HC 44,
National Audit Office, February 2020.
17 While agencies are private bodies, NHS staff banks are managed by or on behalf of a trust to supply staff. NHS
Professionals, owned by the Department of Health & Social Care, is the largest NHS staff bank. NHS staff may work
bank or agency hours in addition to their contracted hours.
18 Since 1 April 2019, the two previously separate organisations of NHS England and NHS Improvement have been more
closely aligned under a single chief executive officer.
Figure 7 shows Timeline of recent developments in national workforce strategy and planning

Figure 7
Timeline of recent developments in national workforce strategy and planning
In 2019 there were a number of developments affecting the nursing workforce

December January April June September December March Spring

2017 2019 2019 2019 2019 2019 2020 2020

Draft health and care NHS England Interim People Plan Maintenance grants for Budget Full People Plan
workforce strategy and NHS NHS publishes its Interim nursing degrees Scheduled Scheduled for
Health Education England Improvement People Plan. This sets out Announcement of new for March. publication.
issues consultation, Chief People actions for 2019-20 and maintenance grants for
but resulting strategy Officer promises a full, costed nursing degrees
(scheduled for 2018) A new role five-year plan later in 2019.
never published. is appointed.

NHS Long Term Plan Spending round Sustainability and Transformation/Integrated Care
NHS publishes its Long Term Plan (LTP) One-year spending round replaces System (STP/ICS) strategic plans
which includes new service models five-year spending review. Includes Scheduled publication of STP/ICSs local 5-year plans
and clinical commitments, measures to an additional £150 million for Health for delivering the LTP commitments. This includes
support staff, and changes to financial Education England in 2020-21 for workforce plans, changes to workforce operating
and payment systems. continuing professional development, model and priority actions to address nursing
and £60 million for people plan priorities. shortages. Delayed from November 2019.
This commits to a detailed workforce
implementation plan later in 2019.

Source: National Audit Office analysis of published plans and strategy documents
The NHS nursing workforce Part One 19
Figure 8 shows National roles and responsibilities in NHS nursing workforce in England

Figure 8
National roles and responsibilities in NHS nursing workforce in England
A number of different bodies are responsible for oversight of the NHS nursing workforce

Department of Health & Social Care: overall policy for health and social care workforce
and accountable for overseeing delivery of the Government’s commitments

National

Health Education England (HEE) NHS England and NHS Improvement (NHSE&I)
Oversees education and training for current/future healthcare workforce to deliver Leads National Health Service in England; oversight and support of NHS trusts
high quality and responsive care. and foundation trusts.
20 Part One The NHS nursing workforce

Responsibilities include:
Prior NHS Improvement responsibilities for performance management of NHS
• workforce planning and intelligence; providers with respect to: workforce productivity; workforce retention; reducing
reliance on agency staff; and organisational workforce and finance plans.
• clinical education and training (including funding of nursing clinical placements);
Prior NHS England responsibilities for workforce include: workforce equality
• quality of education and training; and and diversity; NHS professional leadership; and primary care commissioning,
• workforce transformation. performance and workforce.
The Department holds Health Education England to account through its annual Nursing workforce issues may come under remit of Chief People Officer
mandate. To ensure greater alignment in activities, from 2019-20 onwards, HEE and functions (e.g. general workforce planning or supply) and/or Chief Nursing
NHSE&I agree the mandate prior to approval by the Secretary of State. Officer functions (e.g. if clinical or professional issues are raised).
7 regional HEE teams now aligned to NHSE&I. 7 regional NHSE&I teams.

Local

Local Education and Sustainability and Transformation Partnerships (STPs)/ Clinical commissioning
Training Boards (LETBs), Integrated Care Systems (ICSs). Will include CCGs, NHS trusts, groups: Commission
4 statutory committees of local authorities. Together, develop local workforce delivery plans. most health services for
HEE, lead on local NHS the local population.
workforce education
and training. (Until end Local Workforce Action Boards (LWABs), the workforce arm
March 2020). of STPs, align STP intentions and work with local universities, etc.

Local NHS trusts and foundation trusts: Recruit and employ nurses, and responsible for day-to-day management. GPs: Recruit and employ nurses in primary care,
Can provide clinical placements for nursing staff, and provide apprenticeships. and responsible for day-to-day management.

Government Departments Arm’s-length bodies Healthcare providers Other local bodies Accountability Support/engagement

Source: National Audit Office analysis of Department of Health & Social Care, NHS England and NHS Improvement and Health Education England information
 The NHS nursing workforce Part One 21

1.11 The Interim People Plan set out, at a high level, new national and local roles for
workforce planning (Figure 9). In 2016, we reported that the creation of HEE in 2012
meant that there was a national body tasked with making strategic decisions about
workforce planning.19 Since then, HEE has aligned more closely with NHSE&I:
in October 2018, HEE announced it would restructure its local teams to match
NHSE&I’s new regional structure and from 2019-20, it agreed its mandate with NHSE&I
prior to approval by the Secretary of State. HEE-led initiatives appear to have been
superseded by the Long Term Plan and supporting People Plans (see paragraph 3.6).
These include the national workforce advisory board, which coordinated system-wide
action on workforce challenges and a 2017 draft health and social care workforce
strategy, which was never finalised. NHSE&I’s role in relation to workforce has expanded,
including the appointment of a new chief people officer. The Long Term Plan noted that
NHS Improvement now had lead responsibility for the NHS workforce. An internal HEE
paper in November 2019 noted a number of areas of overlap with NHSE&I, including
future workforce design, workforce planning and intelligence, data and analysis.
Figure 9 shows Workforce planning roles of national and local health bodies in England

Figure 9
Workforce planning roles of national and local health bodies in England
The Interim People Plan sets out a more pivotal role for local partnerships in workforce planning

The Department of 7 Regional NHSE&I 42 Sustainability Providers lead on

Health & Social Care, teams provide oversight and Transformation planning workforce
Health Education and support in their Partnerships and where it relates to the
England (HEE) and areas. HEE teams Integrated Care services they provide
NHS England and NHS now aligned to and work Systems (STP/ICS) and their employees.
Improvement (NHSE&I) alongside NHSE&I teams. develop population
plan over the long term based plans, supported
and define the strategic by Local Workforce
and policy direction. Action Boards.

National bodies/regional teams review and assure Provider plans feed into STP/ICS plans; also
local/provider workforce plans demand model providers produce workforce plans as part
and use them to inform national policy. of annual operational planning.

Source: National Audit Office analysis of Interim People Plan

19 Comptroller and Auditor General, Managing the supply of NHS clinical staff in England, Session 2015-16, HC 736,
National Audit Office, February 2016.
22 Part One The NHS nursing workforce

1.12 The Interim People Plan also envisages a more pivotal role for integrated care
systems, which are local partnerships of NHS bodies and local authorities working
across an area.20 These, in common with previous initiatives like sustainability and
transformation partnerships and local workforce action boards, aim to bring together
health and social care bodies for activities such as workforce planning and strategy.
However, as we have set out in previous reports, they are not statutory and are reliant
on the goodwill and resources of constituent bodies.21 In 2018, the Care Quality
Commission reported, on the basis of 20 local system reviews, that it had not been
assured of effective joint workforce planning across health and social care.22

1.13 Partnerships vary in their readiness and capacity to take on this wider workforce
planning role. Previous NAO work on financial sustainability found that sustainability
and transformation partnerships started from different positions because, in some
areas, partnership working already existed.23 Our visits confirmed that partnerships
were at different stages in terms of system workforce planning and setting up the right
structures to support this. Two areas also raised issues with their capacity to access
or make use of data on workforce. Recognising these issues, NHSE&I has provided
a framework that areas can use to self-assess and improve their maturity in system
workforce planning.

1.14 As part of the full People Plan, the NHSE&I and HEE are planning to produce a
new workforce operating model, meaning that the system will be in transition. As noted
in our 2020 report on NHS financial sustainability, NHSE&I itself is still in a period of
transition as its two predecessor organisations come together.24 Regional NHSE&I
teams, an important source of support, are still setting up and recruiting staff. Of the
seven regional teams, five had appointed directors of workforce and organisational
development by April 2019, one was appointed in January 2020, and one had an acting
director in place. All the partnerships we visited were generally positive about regional
HEE teams, although two noted that the role of HEE more generally was changing.

20 As set out in the Long Term Plan, all areas are expected to become integrated care systems by April 2021.
21 Comptroller and Auditor General, NHS financial sustainability, Session 2017–2019, HC 1867, National Audit Office,
January 2019; Comptroller and Auditor General, NHS financial management and sustainability, Session 2019-20,
HC 44, National Audit Office, February 2020.
22 Care Quality Commission, Beyond barriers: how old people move between health and social care in England,
CQC-411, July 2018.
23 Comptroller and Auditor General, NHS financial sustainability, Session 2017–2019, HC 1867, National Audit Office,
January 2019.
24 Comptroller and Auditor General, NHS financial management and sustainability, Session 2019-20, HC 44,
National Audit Office, February 2020.
 The NHS nursing workforce Part Two 23

Part Two

Challenges in the main entry routes to NHS nursing

2.1 This part looks at the recent performance of different entry routes into NHS nursing
as well as nurse retention, and therefore where there may be challenges in the future in
securing staff. We examine roles and responsibilities for managing supply for each route,
recent performance, and current and future interventions.

2.2 We focus on the biggest pipelines currently or where the NHS anticipates the
largest increases in numbers. This comprises undergraduate degree routes; overseas
recruitment; apprenticeships and nursing associates. We also include initiatives to
improve retention: keeping existing nurses for longer could mean higher numbers of
nurses working in the NHS in the future, although these would not be new nurses.
We do not cover in detail smaller pipelines such as return to practice.

Entry to nursing through undergraduate degrees

2.3 Recent graduates are a major source of new nurses to the NHS, although there is
no definitive data set which directly links graduates with NHS employment. Each year,
around 30,000 nurses join the NHS in England. In 2018, 17,000 (English‑domiciled)
nurses graduated with an undergraduate degree, and around 4,500 with a post‑graduate
degree.25 Smaller numbers also graduate through apprenticeship routes. However, not
all new graduates go on to work as nurses, and not all of those who become nurses
will join the NHS.26

2.4 Nursing degrees are provided by higher education institutions (referred to as

‘universities’ from here on) and must be approved by the Nursing and Midwifery Council
and university. Figure 10 overleaf sets out the main planning, provision and funding
responsibilities in relation to undergraduate nursing degrees. Undergraduate courses
generally last for three years, with half the time spent in the classroom and half the time
(at least 2,300 hours) on clinical placement. Student nurses on clinical placement work
in a range of health and care settings under supervision to gain practical experience.

25 Based on Higher Education Statistics Agency data for England-domiciled graduates from UK providers.
26 All figures in Part Three are based on headcount data, unless stated otherwise.
Figure 10 shows Responsibilities for planning, provision and funding of undergraduate nursing degree courses in England

Figure 10
Responsibilities for planning, provision and funding of undergraduate nursing degree courses in England
Numbers of nursing degree places are determined by the market in response to demand from prospective students

Department of Health and Social Care: overall policy for

Department for Education: policy responsibility for education and wider skills
health and social care workforce

Health Education England (HEE)

Relevant responsibilities include:

• Funding clinical placements at health and care providers, with specific objectives to expand the number of placements.
24 Part Two The NHS nursing workforce

• Working with universities and placement providers to improve student experience and reduce attrition during training.

• Helping to stimulate demand for nursing, including through recruitment campaigns and career information
(jointly with NHS England and NHS Improvement).

Office for Students (OfS) Nursing and

Universities NHS trusts and foundation Midwifery Council
Independent regulator trusts (and other health and (NMC)
of higher education Autonomous bodies provide nursing degrees including
care providers) work directly
in England. classroom training. Responsible for student support. Professional
with universities to provide
Collectively, through market, determine number clinical placements. regulator of nurses
Also provides additional
of nurse degree places – ensuring that all approves and
funding to universities,
students have clinical placements – in response quality assures
including grants for
to student demand. nursing degrees.
nursing courses as a
higher-cost subject.

NHS Business
Students on nursing degrees Services Authority
Local Education and
Undergraduate students undertake 3 years of Administers additional
Student Loans Company Training Boards (LETBs),
training split between classroom and clinical training. non-repayable grants
statutory committees of HEE,
Administers student Eligible for student loans from 2017 to cover tuition lead on local NHS workforce to cover childcare, travel
loans for tuition fees (paid fees and living costs. education and training. and accommodation
directly to universities) costs on placements,
and maintenance. and hardship funding.

Government Departments Arm’s-length bodies Regulators Healthcare providers Other local bodies Local system

Accountability/regulation Funding flows/fees Support/engagement

Source: National Audit Office analysis of published documentation from health and higher education bodies
 The NHS nursing workforce Part Two 25

2.5 Prior to autumn 2017, Health Education England (HEE) directly commissioned
nursing undergraduate places, paying tuition fees to universities and bursaries
to students to cover their living costs. As set out in the 2015 spending review, from
autumn 2017, the government changed from this direct commissioning model to reliance
on the market (universities) to provide places in response to demand from prospective
students. It also removed bursaries for nursing, midwifery and allied health professional
students. Instead, new student nurses moved on to the existing student finance
arrangements, with most eligible to take out full loans for tuition fees and maintenance
costs, creating a legal obligation to make repayments based on earnings. In the first
year of the new arrangements, the maximum student maintenance loan available
was £8,430.27 In 2016-17, the main components of the NHS bursary were a £1,000
non‑means tested grant plus a means-tested grant worth up to £3,191. Students eligible
for an NHS bursary also qualified for a non-means tested maintenance loan of £2,324.28

2.6 The Department of Health & Social Care (the Department) intended to increase the
number of places on nursing, midwifery and other health professional degrees (such as
occupational therapy or physiotherapy) by up to 10,000 through the change in funding
arrangements.29 Its rationale was that this removed the funding constraint on the number
of places and left universities free to respond to demand from students. In 2017, the
first year of the new arrangements, the number of applicants to undergraduate nursing
degrees fell by 11,025 (21%) from 2016 (Figure 11 overleaf).30 However, universities
accepted a larger proportion of applicants, which helped to maintain numbers of
students: the number of acceptances dropped by 3% between 2016 and 2017.
One university we visited detailed a number of steps it had taken to sustain its adult
nursing course, including more promotion of the course, moving to a single intake
per year, closer links with health bodies for placements, extending access to university
bursaries and offering more routes to a full nursing degree (eg the introduction of a
fast‑track postgraduate route into nursing). Although offers are based on a combination
of interview, qualifications and previous experience, there is some indication that
students had lower A-level grades. Based on 18-year-olds with three A-levels accepted
on to nursing courses between 2016 and 2018, our analysis suggests a decrease in
grades equivalent to one A-level dropping by one grade.

27 This is the full year rate of maintenance loan for students with household incomes of £25,000 or less who are not
eligible for benefits and who are living away from the parental home and studying outside London. Higher rates of loan
were available for low-income students eligible for benefits and those living away from home and studying in London.
28 This is the full year rate of maintenance loan for students living away from home and studying outside London. A higher
rate of loan applied to students living away from home and studying in London.
29 According to Higher Education Statistics Agency data, around three-quarters of students on nursing, midwifery or
health professional degrees in 2017/18 were studying nursing.
30 Analysis of published UCAS data in paragraphs 2.6 and 2.8 and Figure 11 includes midwifery courses. Based on
analysis of UK-domiciled students and English providers, around one in six applicants and one in ten acceptances were
for midwifery courses.
Figure 11 shows Nursing degree applicants and acceptances, 2010–2019

Figure 11
Nursing degree applicants and acceptances, 2010–2019
Applications to nursing degree courses fell sharply in 2017
26 Part Two The NHS nursing workforce

Numbers of applications/acceptances Percentage of applicants accepted

60,000 70

50,000 60

50
40,000
40
30,000
30
20,000
20

10,000
10

0 0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Applicants 49,495 49,960 48,900 49,845 53,280 52,095 52,740 41,715 37,470 39,665
Acceptances 21,165 18,895 18,955 19,165 21,205 21,450 22,630 22,045 21,745 23,060
Percentage of applicants accepted (%) 43 38 39 38 40 41 43 53 58 58

Notes
1 Based on England-domiciled applicants, UK providers.
2 Includes midwifery courses.

Source: National Audit Office analysis of Universities and Colleges Admissions Service data
 The NHS nursing workforce Part Two 27

2.7 The Long Term Plan committed to increase clinical placements by up to 25% in
2019-20, to support the Department’s intended 25% increase in nursing undergraduate
places, equivalent to an additional 5,000 places. This reiterated a similar commitment for
2018-19 (see paragraph 2.5). As part of the Interim People Plan, NHS England and NHS
Improvement (NHSE&I) worked directly with trust directors of nursing in 2019 to increase
capacity among existing placement providers, which identified potential additional
capacity of around 7,700 placements.

2.8 Since 2017, numbers of nursing undergraduates have not increased as hoped,
failing to meet the 2018-19 and 2019-20 commitments of a 25% increase (Figure 11).
Compared with 2017, the number of students starting undergraduate degrees in 2018
fell by 1%, while in 2019 numbers were 5% higher.

2.9 There is substantial variation in the trends in student numbers for different groups
(Figure 12 overleaf). Between 2016 and 2018, acceptances onto nursing degrees rose
for children’s and mental health nursing degrees, compared with a large fall for learning
disability nursing (which also had a larger than average fall in applications). There were
also larger falls for students aged 20-39, who historically have been more likely to apply
for mental health nursing. Previous research has suggested that mature students are
generally more affected by available funding and financial considerations. For applicants
living in the north-east, north-west and Yorkshire and Humber, numbers of acceptances
rose by 7% to 10% compared with falls of over 20% for those in the east of England and
the south-east.

Higher education market

2.10 The Department and national health bodies told us that the policy decision to
rely on the higher education market is not providing the number and type of nurses the
NHS needs. The Office for Students told us that it may still be too early to judge the
success of the market approach and that it is currently working with HEE and others
to understand this and to identify any actions that may be needed. When a public
service is delivered through a market mechanism, we would expect the responsible
bodies to understand their levers to improve how the market delivers and, if the market
cannot support the objective, consider alternative mechanisms. In September 2018,
the Department established the Nursing Supply programme board to oversee delivery of,
and provide assurance to the Department’s ministers on, actions to increase nursing
workforce supply. The reliance on the market contrasts with approaches in other areas,
principally medical education, where HEE has a commissioning role, numbers of places
are regulated, and the Office for Students allocates and operates targets for places.
28 Part Two The NHS nursing workforce

Figure 12 shows Percentage change in acceptances to nursing degree courses by region, nursing specialism and age of applicant, 2016–2018

Figure 12
Percentage change in acceptances to nursing degree courses by region, nursing specialism
and age of applicant, 2016–2018
There is substantial variation in student numbers following the removal of the nursing bursary

All
-6

Nursing specialism

Adult -10

Children 10

Mental health 2

Learning disability -41

Place of residence
at application
North East 10 17

North West 7

Yorkshire and 8
the Humber

East Midlands -13

West Midlands -6

East of England -21

London 1

South East -24

South West -18

Age at application

18 13

19 -8

20–24 -14

25–39 -18

40 and over 21

-50 -40 -30 -20 -10 0 10 20 30

Percentage change 2016–2018

Note
1 Based on UK-domiciled students, English universities.

Source: National Audit Office analysis of Universities and Colleges Admissions Service data, supplied to Department of Health & Social Care
 The NHS nursing workforce Part Two 29

2.11 One NHS influence over the higher education market is the provision of clinical
placements. The policy intention has been to increase placements in order to support
an increase in the number of university places. HEE is responsible for funding
clinical placements and oversight of placement capacity, but has not met previous
commitments to increase placements (see paragraph 2.8). However, placements are
a limited lever for expansion because they are not the only barrier, given the large and
sustained fall in applications after 2016 (Figure 11). A survey by the Council of Deans
of Health found that a “significant proportion of universities” felt unsure of their ability
to increase nursing student numbers even if there were additional placements available.

2.12 Placements are not managed centrally: each university negotiates these locally
with health and care providers. Universities we visited described the logistical
complexities of this process, which include identifying suitable locations for students
to travel to and varied placements for each student; ensuring adequate supervision
capacity; and coordination with other placements (other universities or placements
for doctors and other professions). In interviews with higher education stakeholders,
we heard that some previous announcements about increased placement capacity
had come too late in the academic cycle for universities to respond.

2.13 At the time of reporting, HEE could not aggregate the regional data from its teams
that funded clinical placements, so did not have central oversight of costs and what
sectors or providers were hosting placements. HEE is planning to introduce more
consistent reporting and validation from April 2020.

2.14 HEE leads on career promotion, with the Department, NHSE&I and HEE working
jointly on a general recruitment campaign for nurses in 2018/19. They estimate that the
online campaign resulted in 70,000 referrals to the NHS jobs website and contributed
to the increase in applicants between 2018 and 2019.

2.15 HEE also leads on work to reduce attrition during training, supporting universities
(and placement providers) who are primarily responsible for addressing this. Students
can drop out for various reasons including: financial pressures, making the wrong career
choice, clinical placement experience, academic ability, workload and lack of support,
as well as personal reasons. Measuring attrition is not straightforward as there is debate
about the best indicators to use, particularly in relation to students who may be delaying,
rather than permanently stopping, their studies. The Office for Students’ general measure
of attrition is the continuation rate – broadly, the proportion of students still studying a
year after starting their course – which was 93% for nursing students starting courses in
2016, similar to levels for all subjects. However, HEE has estimated that 33% of students
starting courses in 2013 and 2014 did not complete their studies on time, although
attrition generally decreased between 2009-10 and 2016-17. In 2015, HEE started its
RePAIR project, which included aims to identify and promote best practice in, and agree,
a national approach to improving retention. In 2019-20, it set a target of increasing the
proportion of students completing their studies on time to 85% by 2024.
30 Part Two The NHS nursing workforce

2.16 In December 2019, the government announced the introduction of new

maintenance grants for nursing students, effective from September 2020. This consists
of a non-repayable grant of between £5,000 to £8,000 to help with living costs.31
Students will still pay their own tuition fees and the higher education market will therefore
still determine the number of places. As at 15 January 2020, 32,490 people living in
England had applied for nursing degrees starting in September 2020. This represented
a 6% rise on the same time in the previous year (30,650), but was still 4% lower than the
equivalent numbers in 2017 (33,810).32

2.17 The NHS expects that local health systems and bodies will work with universities
in their area, but in our visits we found a variation in approaches.33 All four universities
we spoke to worked closely with local healthcare providers to coordinate placements
and on course-related issues such as recruitment or curriculum, with three saying
relationships were very good. However, one university mentioned that they were not
involved in wider system workforce planning or decisions that might affect them.

Overseas recruitment
2.18 NHS providers are responsible for overseas recruitment, singly or in partnership
with other providers in their area. Both NHSE&I and HEE provide support for overseas
recruitment strategy and planning through their regional teams, and HEE also runs
international partnership and exchange programmes.

2.19 International recruitment to the NHS is influenced by other bodies and external
factors outside the NHS’s control (Figure 13). Overseas nurses must meet qualification,
competency and language standards as set by the Nursing and Midwifery Council in
order to register to practise. Nurses are also subject to immigration policies set by the
Home Office. Currently, nurses are on the shortage occupation list and also do not have
to meet the minimum salary requirements for Tier 2 visas (which, as at March 2020, was
£30,000 per annum).34 In December 2019, the government announced planned changes
to immigration, including a move to a ‘points-based’ system and the introduction of
a new visa for NHS healthcare staff. Research by the Department estimated costs of
recruiting a nurse from overseas at around £12,000 on average.

31 Eligible students will receive an annual grant of at least £5,000, with additional funding of up to £3,000 in regions or
specialisms that have difficulties with recruitment, and to help cover childcare costs. Students will still be eligible for
student loans for both tuition fees and maintenance costs.
32 Based on England-domiciled applicants for UK universities and includes midwifery courses. These figures are based on
UCAS data on applicants as at 15 January, and will differ from the applicant numbers in Paragraph 2.6 and Figure 11.
33 At the national level, the Department told us that it convened a group called the Higher Education National Strategic
Exchange with membership from across the higher education sector, which is an informal discussion group with no
recorded governance or actions.
34 Tier 2 visas are one of the main immigration routes for working in the UK, which apply to skilled workers holding a job
offer in the UK. The shortage occupation list is drawn up by the independent Migration Advisory Committee and allows
fast-tracking of skilled migrants into the UK to meet a national shortage.
 The NHS nursing workforce Part Two 31

Figure 13 shows Key elements in recruitment of overseas nurses to the NHS, and factors affecting recruitment

Figure 13
Key elements in recruitment of overseas nurses to the NHS, and factors affecting recruitment
International recruitment to the NHS is also influenced by other bodies and external factors outside the NHS’s control

Factors affecting overseas recruits within NHS control

Trust recruitment Trust/agency screening Level of financial subsidy Trust induction

process (e.g. level of and recruitment process, for applicants’ costs. and pastoral
clinical involvement, which will cover checks support, including
scale of campaign etc) of qualifications, Nursing accommodation.
and relocation package. and Midwifery Council
Support for NMC
Trusts can work with (NMC) requirements and
tests/requirements.
agency to recruit. language ability.

Level of coordination/ Level of support and

competition with other financial subsidy for
NHS providers. applicants’ costs.

Key elements of overseas recruitment

Trust or agency recruits Trust or agency ensures Trust and applicant Trust employs overseas
overseas nurse applicant meets complete immigration recruits, who must pass
pre-employment checks and visa requirements Nursing and Midwifery
Council requirements

Factors affecting overseas recruits out of NHS control

Attractiveness of NMC requirements Immigration and visa NMC requirements

UK as a destination (see box to right). requirements. Costs and include standards
(e.g. exchange rates). time of process for trusts for qualifications,
Competition from and applicants. competency tests
other countries for and language tests,
overseas recruits. and evidence on
health and character.
Domestic factors
in applicants’ home Homesickness/cultural
countries (e.g. economic differences in health care
conditions, change and wider environment.
in domestic policy).

97 countries from
which NHS cannot
recruit because of
economic status or
number of healthcare
practitioners available.
For India, China and
the Philippines, trusts
can recruit to certain
professions or locations
with restrictions.

Source: National Audit Office analysis of Department of Health & Social Care, Nursing and Midwifery Council and Home Office information,
and stakeholder interviews
32 Part Two The NHS nursing workforce

2.20 Overseas recruits are a major source of new nurses, making up between a fifth and a
quarter of all joiners since 2012. The number of overseas nurses working for the NHS has
particularly increased in the past five years, rising by 28% from 40,000 in September 2014
to 51,000 in March 2019 (Figure 14). As a proportion of the workforce, this has remained
fairly steady at between 14-17% since 2009 (17% as at March 2019). Three countries
account for around half of non-UK nurses: the Philippines (25%), India (15%) and Ireland
(9%). The number of nurses from the European Union increased steadily from 2009 to
2016, but then declined to around 20,000 (Figure 14). The fall in European Union nurses
followed the June 2016 referendum result to leave the European Union, as well as the
introduction of new language requirements in January 2016. Conversely, numbers from
the rest of the world have increased since 2016, to around 31,000.35
Figure 14 shows Numbers of NHS nurses from outside the UK, 2009–2019

Figure 14
Numbers of NHS nurses from outside the UK, 2009–2019
Numbers of European Union nurses have dropped since 2016, while those from elsewhere in the world have increased

Number of nurses
60,000

50,000

40,000

30,000

20,000

10,000

0
Sep Sep Sep Sep Sep Sep Sep Sep Sep Sep Mar
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Rest of the world 29,879 30,368 28,959 27,577 26,218 25,408 24,937 25,388 26,219 28,726 31,193
European Union/ 6,991 7,966 8,744 9,220 10,942 14,609 18,870 22,336 21,343 20,148 19,945
European Economic Area
Total overseas 36,870 38,334 37,703 36,797 37,160 40,017 43,807 47,724 47,562 48,874 51,138

Notes
1 Excludes ‘don’t know’s (which fell from 65,510 staff in 2009 to 15,324 in 2019), and primary care nurses. See footnote 35. Trend analysis includes around
300-400 health visitors a year joining from outside the UK.
2 The Total overseas figure differs to published NHS Digital data by one for September 2009, September 2012 and September 2013 due to the way that
headcount totals are calculated.
3 Based on self-reported information from individual employees.

Source: National Audit Office analysis of NHS Digital data

35 There are also high and changing levels of missing information, which complicate the interpretation of trends.
This analysis excludes nurses whose nationality was not recorded, which made up 21% of all nurses in
September 2009, decreasing to 5% in March 2019.
 The NHS nursing workforce Part Two 33

2.21 NHS Digital data shows that the proportion of overseas nurses varies from 30% to
36% in London regions to 5% to 8% in the north-east, north-west, and Yorkshire and
Humber regions. Our visits confirmed variation in the use of international recruitment
between regions and types of trust: two (one acute and one community trust) were
actively planning to expand; one (acute) was already heavily reliant, while for three
(two community and one acute) it was not currently a major source. To support trusts
with international recruitment, the Department, NHSE&I and HEE are developing
procurement frameworks and best practice guidance.

2.22 In the Interim People Plan, health bodies undertook to work with professional
regulators to help improve and streamline regulation processes. From October 2019,
the Nursing and Midwifery Council introduced an online application procedure, and
streamlined the documentation requirements, for overseas nurses. In December
2018 and January 2020, following a consultation and review of the appropriateness
of the required standards, it reduced the required pass grade for the written element
of the language tests.36 The Home Office has also exempted nurses from having to
take a separate language test for immigration purposes, given the existing Nursing
and Midwifery Council language requirements. In our visits, trusts emphasised the
importance of supporting overseas recruits to pass the tests required for Nursing and
Midwifery Council registration, as well as proactive pastoral care and support.

2.23 HEE lead a global learners programme that supports trusts to build relationships
overseas and bring nurses to work in England who can return to their home country with
improved skills. The programme missed its targets of appointing 1,000 nurses in 2018,
achieving 600, and 1,500 nurses in 2019, achieving around 1,000. In 2018-19, around
100 of the nurses who were appointed subsequently withdrew. The programme has
increased its targets to bring 15,000 nurses to England between 2020 and 2024.

Apprenticeships and nursing associates

2.24 Employers, supported by HEE, have developed a new apprenticeship-based
route into nursing. Nursing degree apprenticeships have been available since 2017.
In contrast to students on nursing degrees, healthcare providers employ nursing degree
apprentices while they work and train, including external study at an approved education
institution. Apprentices study for four years towards a nursing degree. At their launch,
the government anticipated up to 1,000 nursing degree apprentices a year. In the
academic year 2018/19, this expectation was met, with 1,041 people starting a nursing
degree apprenticeship (up from 304 in the previous year).

36 There was no change to the pass mark for other elements of the language tests (reading, speaking and listening).
34 Part Two The NHS nursing workforce

2.25 In January 2017, a new nursing associate role was introduced, which bridges
the gap between registered nurses and healthcare assistants. Although intended as a
role in its own right, which can free up registered nurses to carry out more advanced
roles, another aim was to develop a new route into nursing. Nursing associate training
lasts two years and leads to a level 5 qualification (such as a foundation degree
apprenticeship). To become a registered nurse, a nursing associate must study for
around a further two years to ‘top up’ their qualification. From July 2019, courses for
trainee nursing associates have to be approved by the Nursing and Midwifery Council.
Based on a survey of the first trainees in the pilot phase, 47% said they intended to enrol
on a nursing degree within one year. The evaluation also estimated an overall attrition
rate of 16%.

2.26 HEE met its target for providers to recruit 5,000 trainee nursing associates in 2018
and expects to meet its target for 2019-20. The NHS Long Term Plan set a target of 7,500
in 2019 although the delivery date for the target was later changed to 31 March 2020.
As at December 2019, HEE reported that providers had recruited 2,739 associates
with a projection of 7,529 for the 15 months to 31 March 2020. It had put regional
trajectories in place for each quarter, and was also liaising with the Nursing and Midwifery
Council to take into account the timeline for individual universities to receive approval to
provide courses.

2.27 All the local trusts we visited were planning to make more use of apprenticeships,
primarily nursing associates. Perceived benefits included improvements in service areas
where a clear nursing associate role had been identified; an alternative to degree routes
appealing to a wider range of people; and better retention.

2.28 Larger employers (including NHS providers) must pay an apprenticeship levy,
which they can use to pay for apprenticeship training and assessment. In 2018-19,
NHS organisations spent less than 30% of their levy contributions. In our interviews
with national bodies and local visits, we heard about barriers to wider roll-out, arising
from the need to satisfy both higher education and healthcare regulation, which echoed
those noted in a 2018 Education Committee report:

• Use of the apprenticeship levy. The Nursing and Midwifery Council requires
apprentices to undertake at least 2,300 hours of clinical training, during which
they must have ‘supernumerary’ status (ie they do not count as part of the staffing
complement required for safe and effective care).37 Trusts must therefore pay
‘back-fill’ costs for additional staff, but cannot use the levy for these costs. Four
of the eight NHS providers we visited said this was a disincentive. The Council is
allowing an alternative approach for trainee nursing associates, which does not
require students to be supernumerary and which it will evaluate in due course.
Stakeholders also raised issues about the levy funding not being able to cover
supervisory costs or overseas recruits, and the fact that GP practices were not
levy-paying employers.

37 The Education Committee report noted that nursing degree apprentices must undertake off-the-job training for 50% of
their hours, whereas the levy was designed to cover the cost of an apprentice undertaking off-the-job training for 20%
of their contracted hours.
 The NHS nursing workforce Part Two 35

• Complexity and costs of the process. In our local visits, three out of four
higher education providers said it was difficult to make apprenticeship courses
sustainable, given factors such as the levels of scrutiny, bureaucracy and funding,
and numbers of students. Some national bodies referred to a burden imposed
by the requirement for apprentices to have both a Nursing and Midwifery Council
registration assessment and a separate endpoint assessment, which the higher
education provider requires to receive full payment.

Retention
2.29 As nurses’ employers, NHS providers and GP practices are primarily responsible
for day-to-day management of staff and therefore addressing any retention issues.
In its oversight role for trusts, NHSE&I also provides support on retention. Some
features of nurses’ employment that may affect retention, principally pay and pensions,
are set nationally.

2.30 Between 2012-13 and 2018-19, although the number of nurses joining the NHS
increased, so did the numbers leaving: in the period September 2017 to September 2018,
31,000 nurses left the NHS, compared to a similar number who joined (Figure 15 overleaf).
The overall leaver rate increased from 9% in 2012-13 to 10% in 2017-18.38

2.31 Historically, leaver rates vary by age, with highest rates expected for older people
as they approach pensionable age. However, between 2012-13 and 2017-18, leaver
rates for older age groups decreased, while rates for younger age groups increased.
For example, the leaver rate for 55-59-year-olds reduced from 12% to 11%, while that
for under 25-year-olds increased from 10% to 14%. Our analysis shows that, if the leaver
rate of nurses aged under 55 had remained the same between 2012-13 and 2017-18,
the NHS would have had 11,000 additional nurses in 2017-18.

2.32 NHS Digital publish data on reasons for leaving, which, although they have
relatively high levels of reasons that are unknown (26%), provide some insight into why
nurses may leave mid-career. Based on nurses resigning from the NHS, the most
common reasons given were relocation (26%) and work-life balance (21%, Figure 16 on
page 37). NHS Digital data were consistent with survey data on the reasons that nurses
gave for leaving the Nursing and Midwifery Council register: younger age groups were
more likely to cite leaving the UK, Brexit, poor pay, staffing and too much pressure.
The NHS Staff Survey shows that 68% of nurses work additional unpaid hours each
week and that health and well-being more generally have declined among NHS staff.
In four out of seven discussion groups we held with nursing staff, we heard about
workload pressures with staff having to work late or through breaks to meet their duty
of care to patients, cover staff sickness or shortages, or deal with families.

38 Leaver rates are calculated as the proportion leaving in a set period divided by the average number of staff at the
beginning and end of that period.
36 Part Two The NHS nursing workforce

Figure15showsNumberofleaversfromandjoinerstotheNHS,hospitalandcommunityservicesinEngland,September2012–September2013toSeptember2017–September2018

Figure 15
Number of leavers from and joiners to the NHS, hospital and community
services in England, September 2012–September 2013 to
September 2017–September 2018
In 2017-18, approximately 31,000 nurses left the NHS, compared with a similar number who joined

Number of nurses
35,000

30,000

25,000

20,000

15,000

10,000

5,000

0
2012-13 2013-14 2014-15 2015-16 2016-17 2017-18
Joiners 28,805 31,042 30,501 32,314 29,977 31,070
Leavers 27,587 29,399 31,220 31,396 31,888 31,036

Note
1 Headcount data. Excludes health visitors. Each period runs from September to the following September.

Source: National Audit Office analysis of NHS Digital data

2.33 The NHS nursing workforce as a whole is getting older, which means a higher
proportion of nurses are closer to retirement: between September 2012 and March 2019,
the proportion of nurses in hospital and community services aged 55 and over rose by
5% (from 12% to 17%). The NHS lacks good data to understand retirement but, based
on NHS Digital data on reasons for leaving, around 20% of leavers said they were retiring.
HEE modelling forecasts that approximately 41,000 nurses, or 13% of the workforce, will
retire between 2018 and 2024. Our visits suggest that some trusts were working with
older staff to work flexibly or on reduced hours as an alternative to retirement.
Figure 16 shows Reasons for leaving for nurses and health visitors resigning from the NHS in England, June 2017 to June 2018

Figure 16
Reasons for leaving for nurses and health visitors resigning from the NHS in England, June 2017 to June 2018
The most common reasons nurses gave for resigning were relocation and work-life balance

Percentage of reasons (%)

30

25 26 26

20 21

15

10

7
5
4 4 4 1 1
2 2 0
0
Resignation Relocation Work-life Promotion Better Child Health To undertake Lack Adult Incompatible Mutually
reason balance reward dependants further of dependants working agreed
unknown package education opportunities relationships resignation
or training
Reason for leaving

Note
1 Based on approximately 14,000 nurses and health visitors resigning June 2017 to June 2018.

Source: National Audit Office analysis of NHS Digital data

The NHS nursing workforce Part Two 37
38 Part Two The NHS nursing workforce

2.34 Recognising this issue, since 2017, NHSE&I has run a retention support programme,
which initially aimed to reduce nursing turnover rates in acute and community trusts,
and clinical turnover rates in mental health trusts. It includes direct support to individual
trusts to draw up their own plans and priorities to improve retention. NHS Improvement’s
analysis of trust plans identified eight main areas that these addressed, namely: career
progression; health and well-being; understanding data; culture and leadership; support
for new starters; flexibility; supporting experienced workforce (eg retire and return
schemes); and trust brand. Most of these directly or indirectly address the reasons
given by people leaving the NHS (with the exception of reward, Figure 16).

2.35 One of the programme’s main metrics is the leaver rate.39 Programme analysis
showed that between March 2017 and March 2019, nurse leaver rates reduced by
0.6%, from 8.0% to 7.4%. The first group included in the programme, with the highest
leaver rates, saw a bigger reduction (1.4% compared with 0.6% overall). The second
group had a similar reduction (0.6%) and the third group saw a smaller reduction (0.3%).

2.36 The Long Term Plan commits to improving overall retention by at least 2% by
2025, which it states is the equivalent of 12,400 nurses. This figure of 12,400 is based
on analysis of the NHSE&I’s support programme. It assumes that nurse leaver rates will
reduce by 1%, returning to between 2012-13 and 2013-14 levels, improvements continue
for five years, and trusts with higher leaver rates make more improvement (1.9%). To date,
overall performance has been better than predicted, although not for all individual groups.

39 The programme’s calculation of leaver rates differs from the rates published by NHS Digital. In particular, NHS Digital
rates count those who cease to be paid for activity for potentially temporary reasons, such as maternity and other
long‑term leave, as leavers, whereas the programme’s rates exclude them.
 The NHS nursing workforce Part Three 39

Part Three

The NHS People Plan

The Long Term Plan and implications for the nursing workforce
3.1 In June 2018, the Prime Minister announced a funding settlement for the NHS,
which will see NHS England’s budget rise by an extra £33.9 billion in cash terms by
2023-24. In January 2019, the NHS Long Term Plan set out what the NHS would
deliver with this additional funding (Figure 17 on pages 40 and 41). The plan contained
a number of substantive service commitments (eg in cancer care and prevention of
illnesses such as cardiovascular disease) and new models of working (eg in primary
care). It recognised that workforce growth had not kept pace with demand, with the
greatest shortfalls in nursing, and that achieving its service commitments required
increases in the number of, and greater support for, NHS staff.

3.2 Prior to the Long Term Plan, Health Education England (HEE) published in
December 2017 a draft workforce strategy on behalf of all NHS and public health
bodies that noted pressures on the nursing workforce and stated that “despite the
overall increase in [nurse] numbers, we still need to do more to meet increased
demand”. It cited initiatives such as the pilots of the new nursing associate role and
the retention improvement programme. That workforce strategy was never finalised
and, by the time of the Long Term Plan, indicators such as the nursing vacancy rate
had worsened.

3.3 The Long Term Plan stated a general ambition to increase the domestic
supply of nurses over the next 10 years and in the short term signalled the need
for a “step change in the recruitment of international nurses”. It made a number
of quantified commitments for the nursing workforce – for example, to reduce the
vacancy rate to 5% by 2028 and fund an additional 5,000 clinical placements from
2019-20, as well as wider staff commitments that are relevant for nursing (Figure 17).
In December 2019, the government confirmed a pledge to increase the number of
NHS nurses by 50,000 by 2025.
40 Part Three The NHS nursing workforce

Figure 17 shows NHS Long Term Plan and Interim People Plan commitments relevant to nursing

Figure 17
NHS Long Term Plan and Interim People Plan commitments relevant to nursing
The NHS aims to increase the domestic supply of nurses, with a range of specific and wider commitments
in the Long Term Plan

Long Term Plan Commitments Interim People Plan

2019-20 Actions for Commitments

deliverables full Plan
Commitments specific to nursing
Overall aim of reducing nursing vacancy rate to 5% by
2028 (through increasing number of undergraduate
nursing degrees, reducing attrition from training and
improving retention).

Funding for additional 5,000 clinical placements from  Actions to increase infrastructure,
2019-20; and up to 50% increase, from 2020-21. alongside further review.

Five-year NHS job guarantee for every nurse in region  Consider options for job guarantee
they qualify. approaches (for full plan).

New online nursing degree, with guaranteed placements  Develop proposals for ‘blended’
(from 2020). learning programme.

7,500 new nursing associates in 2019, and investment   Support for STP/ICS in use of levy, alongside
in training to create meaningful career ladders. Terms of expansion of nursing associates pilot.
levy might need to change if NHS to provide opportunities
to more clinical staff.

Explore ‘earn and learn’ support premiums for mental health  Review of actions required to support growth
or learning disability nursing, with aim of additional 4,000 in mental health, learning disability and other
people training by 2023-24. shortage areas in nursing.

Two-year fellowship scheme for newly qualified nurses   Roll-out of voluntary fellowship. New set of
entering general practice. actions for full plan to identify how to support
growth in primary care workforce.

  Launch new return to practice in 2019-20

and develop clear model of entry routes
to inform people plan.
 The NHS nursing workforce Part Three 41

Figure 17 shows NHS Long Term Plan and Interim People Plan commitments relevant to nursing

Figure 17 continued
NHS Long Term Plan and Interim People Plan commitments relevant to nursing

Long Term Plan Commitments Interim People Plan

2019-20 Actions for Commitments

deliverables full Plan

Wider staff commitments relevant for nursing

Annual campaigns in conjunction with Royal Colleges   Consolidate existing campaigns and further
and trade unions for most urgently needed roles. review into high-need nursing areas.

New national arrangements to support NHS organisations  Development of procurement framework,

in recruiting overseas. best practice toolkit, and improvement of
regulatory processes.

Extend Retention Collaborative to all NHS employers,  Expand and extend existing programmes
and improve staff retention by at least 2% by 2025. & provide additional support.

Increase investment in continuing professional development  Review, pending Comprehensive

over the next five years (following Spending Review). Spending Review.

Expand multi-professional credentialing - including  Develop standards and credentialing for

development of credentials for mental health, cardiovascular specific areas and update Employment
disease, ageing population, preventing harm and cancer, Staff Record to reflect advanced roles.
with published standards in 2020.

Shape modern employment culture for the NHS – promoting  Local areas produce first set of plans.
flexibility, wellbeing and career development, and addressing
discrimination, violence, bullying and harassment.

 Improvement of financial support for

students through Learning Support Fund,
and awareness of student finance package.

Source: NHS Long Term Plan and Interim People Plan

42 Part Three The NHS nursing workforce

3.4 The Long Term Plan did not include detailed plans to ensure that the right
workforce was in place to deliver the commitments. It set out that a workforce plan
would be published later in 2019, following agreement of workforce education and
training budgets (see paragraph 3.5). To develop the Long Term Plan, an early iteration
of a national workforce supply–demand model developed by HEE was available
and each service area also drew up workforce plans. We reviewed submissions for
two areas, mental health and cancer, which showed the following:

a For mental health, there were indicative demand estimates of the staff required,
broken down for nurses and by the service areas due to expand. With respect
to cancer services, NHS England and NHS Improvement (NHSE&I) told us that
demand estimates are primarily based on rises in the incidence and prevalence
of cancer. In developing the Long Term Plan, it did not separately estimate the
overall cancer nursing capacity required (ie from specialist or general nurses) and
assumed that cancer needs would be met from the overall increase in the nursing
workforce envisaged in the plan. Proposals noted the need for, but did not quantify,
increases in specialist cancer nurses.

b There was no, or very limited, documentation of what actions the NHS would have
to take for different service areas to understand whether the required workforce
was achievable. For mental health nurses, the Long Term Plan did commit to
explore “earn and learn premiums” to increase numbers but NHSE&I told us it
subsequently ruled this out because of cost and implementation concerns.

3.5 The £33.9 billion funding settlement for the NHS only applied to NHS England’s
budget, which would cover the costs of employing staff to deliver the Long Term Plan
commitments. It excluded HEE’s budget – in particular, for workforce education and
training. The Long Term Plan anticipated a five-year spending review in autumn 2019
to set these budgets for 2020-21 onwards, but this was replaced by a more limited
spending round, with a fuller review rescheduled to 2020. This affected HEE budgets for:

a continuing professional development (CPD). Spending on CPD decreased

sharply in 2016-17, and the Long Term Plan cited this as an important factor in
retention. The spending round allocated a further £150 million to HEE for CPD for
nurses (and other groups) in 2020-21.40 This would raise funding back to 2014-15
levels (in real terms) (Figure 18).

b funding of clinical placements, that nursing students must undertake as part

of their degree. At the time of the Long Term Plan, HEE had access to further
funding to deliver an additional 5,000 clinical placements in 2018-19 and 2019‑20,
which was subsequently extended to 2020-21. For 2018-19, HEE did not draw
down any additional funding: it estimated that, if required, this could amount
to around £5 million.

40 At the time of writing this report, HEE was awaiting formal confirmation of the £150 million funding from the Department.
As set out in the spending round, this would be based on a per head budget of £1,000 over three years for each nurse,
midwife and allied health professional.
 The NHS nursing workforce Part Three 43

Figure 18 Health Education England workforce development: budget, spend and spending round estimates, 2013-14 to 2020-21

Figure 18
Health Education England workforce development: budget, spend and
spending round estimates, 2013-14 to 2020-21
The 2019 spending round raised 2020-21 funding on continuing professional development back to 2014-15 levels (in real terms)

Budget/spend (£m)
300

250 264
239 236
200
205
199

150

100 113 119 114

104
84 78 84
50

0
2013-14 2014-15 2015-16 2016-17 2017-18 2018-19 2019-20 2020-21
Financial year

Budget (£m)
Spend (£m)
Spending round 2019 (£m)

Notes
1 Figures are shown in cash terms.
2 The spending round estimate assumes the 2019-20 budget plus an additional £150 million.

Source: National Audit Office analysis of Health Education England annual accounts and business plans, and spending round summary

The supporting People Plans for the Long Term Plan

3.6 In the Long Term Plan, the NHS committed to publish a full People Plan later
in 2019. NHSE&I, HEE and the Department established cross-body governance for
this programme. The chief people officer at NHSE&I chairs the National People Board
overseeing development of the People Plan, which includes representatives from all
the major health bodies. Underpinning this are eight workstreams, including a dedicated
workstream on nursing supply (Figure 19 overleaf). As well as representatives from
national NHS bodies, the nursing supply group includes a wide range of stakeholders
from the Royal Colleges, higher education, NHS trusts and trade unions.
Figure 19 shows Governance of the NHS People Plan programme

Figure 19
Governance of the NHS People Plan programme
NHS England and NHS Improvement, Health Education England and the Department of Health & Social Care have established governance structures for
the People Plan programme supporting the Long Term Plan

NHS England & NHS Improvement, Delivery,

Quality and Performance Committee

Health Education England Board

NHS People Plan Advisory Group
Chair: Chair of NHS Improvement
44 Part Three The NHS nursing workforce

National People Board Programme Director,

People Plan, NHSE&I
Chair: Chief People Officer
Social Partnership Forum at NHSE&I

Professional workstreams
medical, nursing, allied health professions, healthcare science,
pharmacy and dental

Programme workstreams

Delivering 21st century care

Making the NHS Improving the Releasing time Workforce Securing current Urgent 2019-20 A new operating
the best place leadership culture for care redesign: & future supply actions on model for
to work optimising skills nursing supply workforce

Analysis, insight and affordability

Source: NHS England and NHS Improvement documentation

 The NHS nursing workforce Part Three 45

3.7 In June 2019, the NHS published an Interim People Plan with actions for 2019-20.41
This highlighted further actions targeted at, or relevant to, nursing (eg about return to
practice or recruitment campaigns, Figure 17). The majority of actions involved further
review or development to lay foundations for later changes; others, like an increase in
university places, might result in changes in three to four years, and would not have
an immediate impact on nurse numbers.

3.8 HEE and NHSE&I have separate routes for monitoring progress against the
Interim People Plan. NHSE&I reports progress on a quarterly basis to its internal people
committee against the interim actions it is leading on, as well as the actions that HEE is
leading with NHSE&I’s support.42 The Department also monitors progress against some
of the interim actions that HEE is leading and overall progress towards the full People
Plan through quarterly accountability meetings, but it does not systematically monitor
progress against all the actions in the Interim People Plan. National People Board
papers do not systematically track progress against targets or deliverables for individual
workstreams or Interim People Plan commitments, or overall progress of the work
against milestones.

3.9 The Interim People Plan included an aim to publish a full, costed five-year People
Plan in 2019. NHSE&I and HEE did not meet this commitment and the programme
has been delayed in part by the replacement of the autumn 2019 spending review
by a one‑year spending round, and the December election, including the associated
pre-election restrictions on government activity from November.43 The full People Plan
covering the period 2019–2025 is now due to publish in spring 2020. NHSE&I told us
that this plan will be refreshed annually.

3.10 The Interim People Plan set out that the Long Term Plan and full People Plan
would provide the basis for an overall workforce strategy. NHSE&I told us that the
governance structures will be reviewed after the full People Plan, which will set out
each organisation’s responsibilities for future delivery of the plan. The spending round in
September 2019 allocated £60 million to People Plan activities for 2020-21, and NHSE&I
told us the National People Board would be responsible for prioritising which national
actions to undertake. The Department told us that it will use metrics to track progress
in delivering the plan. In February 2020, it also established a central programme board
aiming to coordinate the government’s strategy, policy and delivery of the commitment
to provide 50,000 more nurses.

3.11 NHSE&I and HEE are jointly developing an overall model of supply and demand
of nurses to the NHS to support the People Plan. This primarily covers NHS-employed
nurses in hospital and community services. It excludes primary and social care, as well
as other nurses who may provide NHS services such as agency or bank staff.44

41 This report does not evaluate the People Plan process or progress against the Interim People Plan.
42 The NHSE&I People Committee is a sub-committee of NHSE&I and HEE’s boards.
43 During an election campaign, there are restrictions in place on what the government can do. The restrictions cover
activities such as initiating new policies, announcements and communications and extend to arm’s-length bodies
such as NHSE&I and HEE.
44 NHSE&I told us that, since our review, the model has been extended to cover primary care.
46 Part Three The NHS nursing workforce

3.12 There is a significant time lag before policies to train new nurses can have impact.
For example, in relation to undergraduate degrees, the announcement of maintenance
grants in December 2019 came a month before the closure of applications for
September 2020 courses. These students will graduate in 2023 at the earliest, in the
final year of the funding settlement period. This increases the reliance on strategies
such as overseas recruitment, improved retention and reducing attrition from training,
which can have more of an immediate impact.

Local partnership plans

3.13 In June 2019, NHSE&I set out what approach local partnerships (that is,
sustainability and transformation partnerships or integrated care systems) should take
to create five-year strategic plans to implement the NHS Long Term Plan.45 This is
an essential element in ensuring that local planning and actions are compatible with
national ambitions and targets, including for the nursing workforce.

3.14 With respect to workforce, the guidance instructed partnerships to set out
“realistic workforce assumptions, matched to activity and their financial envelope”.
Plans had to include:

a planned growth in workforce numbers, including separate estimates for nursing

staff in trusts and general practice;

b local actions to improve retention, international recruitment and use of the

Apprenticeship Levy;

c how partnerships would ensure that efficiency and productivity plans include
actions to improve workforce efficiency and release greater time for care; and

d changes to local workforce operating models, to develop capacity, capability,

governance and ways of working. This specifically included prioritising urgent
action on nursing shortages.

3.15 Local partnerships submitted their draft plans to NHSE&I in September 2019,
with final plans due to be published in November 2019. As at March 2020, these plans
were yet to be published.

45 NHS England and NHS Improvement, NHS Long Term Plan Implementation Framework, June 2019.
 The NHS nursing workforce Appendix One 47

Appendix One

Our methodology

Scope
1 On the basis of evidence we collected between April and November 2019,
this report sets out the facts on:

• the scale of the NHS nursing workforce challenge;

• challenges to the main entry routes to NHS nursing, and more general
workforce‑related challenges, that any future plans will need to address; and

• progress made on the NHS People Plan. This report does not evaluate the People
Plan process or progress against the Interim People Plan, or supporting processes
such as the modelling of nursing supply and demand.

Methods
2 We spoke to a range of staff across the Department of Health & Social
Care (the Department), NHS England and NHS Improvement (NHSE&I) and
Health Education England (HEE). This was to understand roles and responsibilities
for workforce planning and supply; the development of the NHS Long Term Plan and
supporting People Plans; ongoing analysis, work and initiatives relating to nursing
supply and demand; and performance and management of routes into nursing. We also
interviewed staff at the Department for Education.

3 We reviewed and analysed a wide range of documentation from the

Department, NHSE&I and HEE. This included:

• the Long Term Plan, Interim People Plan and supporting papers, minutes and
analysis for the National People Board and People Plan teams, along with
descriptions of governance structures;

• for Long Term Plan commitments relating to mental health and cancer care,
submissions and supporting documentation relating to workforce commitments;

• published guidance including on Long Term Plan implementation, safe staffing

and workforce safeguards;
48 Appendix One The NHS nursing workforce

• NHSE&I’s retention improvement programme overviews, papers and

progress reports;

• Department deep dives on nursing and minutes and papers from the
Nursing Supply Board;

• progress reports, papers and documentation relating to funding and expansion

of clinical placements; and

• performance and progress reports on international recruitment and

nursing associates programmes.

4 We examined documentation of the model of nursing supply and demand

being developed by HEE and NHSE&I. We examined documents relating to the main
supply model, which was based on existing work by HEE. However, we did not review
other components of the model, namely the demand model or estimates of the impact
of potential actions to increase supply.

5 We accessed and analysed NHS Digital data on the nursing workforce.

These included:

• trends and patterns in the nursing workforce by trust and care setting, nursing
specialism, region and socio-demographic characteristics such as age, gender
and nationality;

• socio-demographic profile of the nursing workforce;

• trends and patterns in turnover, leaver and joiner numbers and rates; and

• other datasets including earnings data; bank nursing staff; reasons for leaving;
vacancy indicators and sickness absence statistics.

6 We accessed and analysed data from other bodies, principally:

• Nursing and Midwifery Council registration and revalidation statistics, and its
survey of people leaving the register;

• University and Colleges Admission Service (UCAS) published data and data
provided to national health bodies, including trends and patterns in nursing
degree applicants and acceptances; and

• Higher Education Statistics Agency (HESA) published data on nursing

degree graduates.
 The NHS nursing workforce Appendix One 49

7 We visited four local areas (south-west London; Kent; Teeside and

Northamptonshire) between August and September 2019. This work was
designed to understand local roles and responsibilities for workforce planning;
the main challenges for nursing recruitment and retention; local workforce planning and
interventions; and interactions with regional teams and national bodies. In each local
area we included two NHS providers (either acute, community or mental health), and
spoke to staff with responsibilities for nursing and workforce planning); one university;
sustainability and transformation partnership staff, including local workforce action
boards; and local HEE teams. Where possible, we spoke to the regional NHSE&I team
and people with responsibilities for primary care workforce planning, and carried out
discussion groups with nursing staff. We selected areas and trusts with contrasting
characteristics and experiences, as indicated by: NHS England’s July 2017 ratings of
progress for sustainability and transformation partnerships; geographic location; trusts’
financial performance; levels of nurse turnover, leavers, joiners and sickness absence;
Care Quality Commission assessments of system working; and trends in numbers of
new nursing students since 2017.

8 We interviewed a range of health and higher education stakeholders, and

accessed relevant analysis and documentation from them. This work was designed
to get views on main challenges to, and interventions designed to improve, nursing
recruitment and retention; and identify other relevant data, analysis or reports on nursing
supply and demand. We consulted with:

• professional and sector regulators: the Nursing and Midwifery Council;

the Care Quality Commission; and the Office for Students;

• professional and staff bodies: the Royal College of Nursing and Unison;

• health sector stakeholders: NHS Providers; NHS Employers; the King’s Fund;
the Nuffield Trust; and the Health Foundation;

• higher education stakeholders: Universities UK; and the Council of Deans

of Health. We also spoke to staff at Oxford Brookes University and the
University of Roehampton; and

• other stakeholders: the Office for Manpower Economics.

9 We reviewed previous National Audit Office reports on workforce planning

and supply. This identified what workforce-related challenges other government bodies
had experienced. Appendix Two sets out the reports we reviewed.
50 Appendix Two The NHS nursing workforce

Appendix Two

Challenges to workforce planning and supply

1 The National Audit Office has carried out a number of workforce studies that, in the past five years, include
ones on the NHS, adult social care, the military, teachers, the Civil Service and the BBC. All these studies found
common challenges in difficulties with recruiting and retaining staff; underperformance of workforce initiatives to
address these;
Figure 20 shows and
Examples managing
of common challengesthe impact
to workforce of shortages
planning and supply on existing staff.

Figure 20
Examples of common challenges to workforce planning and supply 1
National Audit Office Report Accountability Workforce planning

Responsibilities and National Understanding Understanding Overall Reliable

accountabilities oversight future needs supply plan information

Managing the supply of NHS

clinical staff

Improving patient access to

general practice

The adult social care workforce

Army 2020

Ensuring sufficient skilled

military personnel

Reforming the civilian workforce

Training new teachers

Retaining and developing

the teaching workforce

Managing the BBC’s workforce

Capability in the civil service

Note
1 References for NAO reports in the table are as follows: Comptroller and Auditor General, Managing the supply of NHS clinical staff in England, Session
2015-16, HC 736, National Audit Office, February 2016; Comptroller and Auditor General, Improving patient access to general practice, Session 2016-17,
HC 913, National Audit Office, January 2017; Comptroller and Auditor General, The adult social care workforce in England, Session 2017–2019, HC 714,
National Audit Office, February 2018; Comptroller and Auditor General, Army 2020, Session 2014-15, HC 263, National Audit Office, June 2014;
Comptroller and Auditor General, Ensuring sufficient skilled military personnel, Session 2017–2019, HC 947, National Audit Office, April 2018; Comptroller
and Auditor General, Reforming the civilian workforce, Session 2017–2019, HC 1925, National Audit Office, March 2019; Comptroller and Auditor General,
Training new teachers, Session 2015-16, HC 798, National Audit Office, February 2016; Comptroller and Auditor General, Retaining and developing the
teaching workforce, Session 2017–2019, HC 307, National Audit Office, September 2017; Comptroller and Auditor General, Managing the BBC’s workforce,
Session 2016-17, HC 1133, National Audit Office, April 2017; and Comptroller and Auditor General, Capability in the civil service, Session 2016-17, HC 919,
National Audit Office, March 2017.

Source: National Audit Office analysis of published reports

 The NHS nursing workforce Appendix Two 51

2 Figure 2 in the Summary sets out the general challenges we have observed in workforce planning and the
implementation of workforce initiatives. Figure 20 shows how these link to published reports on workforce.

Workforce supply Addressing

short-term shortfalls
Integration with Coverage Planning Funding Addressing Support Cross- Approach Managing
finance and of all staff for training arrangements differences in for local government to filling competition
performance places challenges bodies policies shortfalls
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