labour market review 2001 - behind the headlines: a … and examines salient features of the...

February 2002

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Behind the headlines:A review of the UK nursinglabour market in 2001

1855 Labour market review A4 6/2/02 4:44 pm

Behind the headlinesA review of the UK nursing labour market in 2001

ContentsPreface 1

1 The headlines: ‘growing’ the NHS nursing workforce 3Behind the headlines: the real workforce challenge for the NHS 9

2 Students – the future nursing workforce 11Student population 12Applicants and intakes to education 12Discontinuations 14Completions 16Summary 16

3 The pool of registered nurses 17Entries to the Register from training 17Entries to the Register from overseas 19Leavers 21The registered population: trends and characteristics 21Summary 22

4 Registered nurses and the wider nursing workforce 24The NHS workforce 24Vacancies 25Turnover 27Returners 27Health care assistants 28GP practice nurses 29The non-NHS sector 29

Non-NHS nursing 29Independent sector 29Nursing agencies 30

An ageing workforce 31Ethnicity 32Participation rates 33Summary 34

References and notes 35

Review prepared byJames Buchan and Ian Seccombe

Faculty of Social Sciences and Health CareQueen Margaret University College, Edinburgh

Published by the Royal College of NursingFebruary 2002

A review of the UK nursing labour market in 2001

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PrefaceThe purpose of this publication is to provide an objective and succinct briefing onthe UK nursing labour market for 2001. It includes key facts, figures andcommentary on the main changes influencing student supply and demand, thechanging characteristics of the nursing and midwifery population, and trends in theworkforce. The Royal College of Nursing (RCN) commissioned the review.This is the second annual labour market review, and it builds on the analysisconducted for the review published in December 20001. Its primary purpose is toget behind the headline data and beyond the short-term focus of much recentcommentary on the UK nursing labour market.The nursing workforce is at the core of health care provision in the UK, in both theNHS and the independent sectors. It is central to government plans to ‘modernise’the NHS. With over half a million registered nurses in work, nursing remains thelargest source of professional employment for women in the UK. The NHS alsoemploys tens of thousands more health care assistants and auxiliaries working aspart of the wider nursing and midwifery workforce, many of whom are managed orsupervised by registered nurses. At an estimated £10,910 million in 2001-2002, theNHS nursing paybill accounts for 3% of all public sector expenditure2.The current modernisation of National Health Services in the four countries of theUK is based on a range of initiatives related to restructuring and re-organisation atnational and operational level, with an emphasis on establishing and achievinghealth gain targets and maintaining a performance management culture. The detailis different in the four countries, but the overall approach recognises the need toinvolve health care staff in decision making and to ensure that they areappropriately skilled and deployed. Scotland has developed an inclusive approachto workforce planning, involving a significant element of “bottom up” gathering ofprojections from individual employers. More recently, England has established arange of “top down” numerical staffing targets3. Whilst the approaches to planninghave varied, the Health Departments in the four countries are all committed toincreases in staffing numbers.It is widely acknowledged that the supply of skilled and experienced nursing andmidwifery staff is not meeting current demands. The first stage of the 2001 LocalModernisation Reviews (LMR) assessed local progress in achieving planned healthtargets in England. Workforce issues and a shortage of skilled staff were“consistently identified” as one of the main risk areas in achieving the targets4. Theevidence to the Review Body from the Health Departments in 2001 alsoacknowledged that “the biggest constraint on the NHS’s capacity to deliver was theneed to increase the number of staff”5. A similar message was presented inevidence from the NHS Confederation, and the Wanless report on long-termfunding of the NHS identified that “the UK does not have enough doctors andnurses”6.The survey conducted on behalf of the Review Body in 2001 found that 78% ofNHS trusts in England and Wales reported that they had “quite a problem” or a“major problem” with nursing and midwifery recruitment difficulties, up from 69% inthe previous year. The same survey reported that a total of 46% of trusts had “quitea problem” or a “major problem” with retention of nursing staff, again primarily atgrade D and E level7. The Audit Commission review of Accident and Emergencyservices pointed to staff shortages as one factor contributing to a deterioration inperformance8.After a period of consultation9, the Department of Health in England has overhauledits approach to workforce planning. The main changes being initiated include the

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establishment, on 1 April 2001, of Workforce Development Confederations(replacing the Education Purchasing Consortia and Local Medical WorkforceAdvisory Groups). These bring together NHS and other employers of health carestaff to ensure greater coherence, to provide information to support central planningand to contract for NHS-funded education. A separate approach to achievinggreater integration of planning across the professions is underway in Scotland10,and the Scottish Executive has also supported a specific initiative on nurserecruitment and retention11. This review sets out some of the national trends andchallenges that will have to be faced by these new planning mechanisms.This publication brings together a wide variety of existing data sources ranging frompublished official statistics to studies and estimates provided by professional bodiesand researchers12. Sources used include:• The annual Statistical Analysis of the UKCC’s Professional Register. At the time of

completing this report, the Analysis for the year ending March 2001 was not available,although some figures on overseas nurses had been released

• The annual reports of the four national boards for nursing, midwifery and health visiting.At the time of writing, the English National Board (ENB), the National Board for Scotland(NBS) and the Welsh National Board had published reports for 2000-2001

• Information on applications to full length pre-registration nursing and midwifery diplomaprogrammes in England

• The annual census of NHS hospital and community health services non-medical staff asreported in the Department of Health’s Statistical Bulletin 2000/3 (Feb 2001)

• The written evidence to the Review Body Review for 2002, from the Health Departmentsfor Great Britain

• The NHS in Scotland’s Scottish Health Statistics 2000 and other figures compiled by theInformation and Statistics Division

• Student Nurse Numbers Report - the annual reports of the Reference Group on StudentNurse Intake Planning (SNIP) commissioned by the Scottish Executive HealthDepartment

• Health Statistics Wales 2000, National Assembly for Wales

• HRIS Data provided by the IAU, Department of Health, Social Services and PublicSafety, Northern Ireland

• The Department of Health’s Recruitment, Retention and Vacancies Survey for 1999,2000 and 2001

• The Office of Manpower Economics Workforce Survey, 2000 and Workforce Survey,2001.

Chapter 1 begins the review by considering the issue that is currently in theheadlines - can the NHS meet its targets for nurse staffing growth? The remainderof the review then gets behind the headline figures for a more considered anddetailed analysis of trends and pressures in the UK nursing labour market.Chapter 2 examines the future registered nursing workforce, looking at trends inapplications, enrolments and discontinuations from the population of student nursesand midwives.Chapter 3 considers the pool of registered nurses, midwives and health visitors, aswell as the key flows into and out of the professional Register.Chapter 4 assesses recent trends and developments in the registered nursingworkforce, and examines salient features of the “wider” nursing and midwiferyworkforce, including health care assistants.


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Chapter 1: The headlines - “growing” the NHSnursing workforceThis chapter examines the key current headline issue - can the NHS meet itsstaffing growth targets? All four UK countries are planning to increase studentnumbers and to achieve growth in the number of registered nurses and midwivesworking in the NHS.

“Top down” staffing targets are being used in England. The NHS Plan target forEngland was that 20,000 (headcount) more nurses would be employed by the NHSin England in 2004 than in the year 2000 (this growth target is now being extendedto 2005). Recent press releases from the Department of Health have claimed that“three quarters of the NHS Plan nursing targets” have already been met13. Thischapter examines if this claim is likely to be realised, but in so doing it aims to putthe NHS Plan targets in a broader context. Meeting a short-term notional headlinestaffing target is a necessary measure of political commitment and has requiredimproved resource allocation, but it will not in itself be sufficient to guarantee long-term effective planning and deployment of the NHS nursing workforce.

In the previous report, the challenge of meeting the NHS Plan nurse staffing targetwas summarised, and it was concluded that it was achievable, but only by aconcerted effort across the range of potential initiatives:

• to increase the numbers of applicants accepted into pre-registration nursing andmidwifery education

• to minimise the number of “discontinuations” from those programmes

• to maximise recruitment – and subsequent retention - of the newly qualified

• to improve retention and provide for more flexible retirement

• to maximise return to the NHS of the non-working pool of nurses.

The emphasis on “headcount” rather than on whole time equivalents in the NHSPlan was not helpful in assessing the actual increase in nursing hours availabilitythat was needed or that would be achieved, and that this therefore fell short ofbeing a planning based target. In meeting the notional headcount target twointerventions were likely to be crucial – returners and international recruitment.

It appears from the latest UKCC data that just such a change in internationalrecruitment may have occurred, with significant growth in overseas registrants tothe UK. The UKCC has released two provisional figures for the number of newregistrants from overseas in 2000-2001. In July they reported that the total numberof overseas registrants for 2000-2001 was 7,705. Two months later they releasedadjusted detailed data for the same period, for non EEA countries. This gave afigure of 8,403 non EEA overseas registrants in 2000-2001, and if correct, wouldsuggest that the actual total figure for overseas registrants, including EEA countries,would have been around 9,700 in 2000-200114.

A crude working of the available data (Table 1) reveals the extent of recruitmentneeded over the period 2000-2004 to meet the NHS Plan target for England of“20,000 more nurses and midwives”.


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Table 1: "Growing" the NHS nursing workforce, England: NHS Plan (England) Target 2000-2004Headcount

Current staff in post(1999/2000)

310,000

Leavers from the NHS 95,000Staff in post target (2003/2004) 330,000Recruitment need 115,000

A net growth of 20,000 by 2004 implies an NHS nursing and midwifery workforce(headcount) of approximately 330,000 in 2003/4. But, the NHS will also lose staff –to retirement, to non-NHS employment and elsewhere – over these years. If currentrates continue, this wastage is likely to be around 8.7% a year†, which would equateto a loss over the period of approximately 95,000. In order to achieve the 2004target, assuming that there are no significant changes in current rates of retirementand wastage, and assuming that none of the “additional” 20,000 staff were to leaveduring the period, the NHS will actually need to recruit approximately 115,000registered nurses and midwives.

Before examining how the target may be met by recruitment and returners, we mustalso consider if the NHS can improve it’s retention rate - can it retain more nursesfor longer? Current and planned policy initiatives to improve working lives, offerflexible working and encourage delayed retirement are all aimed at improving NHSnursing staff retention. If and when the promise of a new responsive pay and careerstructure for NHS nurses and midwives is achieved through “Agenda for Change”there could also be a positive impact on retention. Broader changes in the labourmarket could also have an effect in reducing turnover of staff. Previous experiencesuggests that if the UK was to slip into economic recession, nurse participation inemployment may increase and turnover reduce. However, as yet, the limited andincomplete information that is available on NHS nurse retention does not suggestthat there has been a marked reduction in nurse wastage from the NHS. The OMEsurvey in 2001 reported a slight reduction in wastage rate of NHS registered nursesin England and Wales, from 8.6% in March 2000 to 8.4% in March 2001 (matchedsample of NHS trusts)15.

Setting aside the issue of retention, there are three other interventions to assess:intakes of “new” nurses and midwives from pre-registration education; returnersencouraged back into NHS nursing; and international recruits. Of the three,international recruitment is an intervention that currently can be most rapidlyincreased or decreased, according to policy requirements. However, with currentdata, we can predict with some accuracy only the impact of the first interventionover the next three years. The impact of returners and of international recruitmentare less open to analysis because of data limitations.

It is possible to make a crude estimate of the inflow of ‘new’ nurses and midwivescompleting pre-registration education and joining the Register for the first time overthe period to 2003/04 (see Table 13). On current and projected intakes,16 andassuming that the NHS continues to recruit about 90% of those who successfullycomplete and register, we could expect that there would be between 59,200 and66,070 ‘new’ nurses and midwives entering NHS employment in England from pre-registration education in the same country, depending on attrition rates during andon completion of pre-registration education. The latter figure assumes attainment ofan ambitious target of reduced attrition set out by the Department of Health. Thecontribution of new inflow would therefore be around half or more of the total † Office of Manpower Economics survey reported a wastage rate of 8.7% for registered nurses,England, 2001.


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required increase of 115,000. If there is no significant improvement in rates ofretention (i.e reductions in wastage), this would leave a shortfall of between 48,930and 55,800 to be met from the other two sources – returners and internationalrecruits.

Data on returners is limited. The Department of Health has issued a series ofstatements on the ‘success’ of returner initiatives, but it is difficult to determine acomplete overview of the actual annual trends in numbers of nurse returners to theNHS in England. The Department reported in September 2001 that, “By the end ofMarch 2001 over 7,500 former nurses and midwives had returned to work in theNHS since February 1999. A further 1,300 have returned since April 2001 with2,000 more in the pipeline”17. In December 2001 it reported that, “since April 2001alone, 2,414 nurses, allied health professionals and scientists and technicians havereturned to practice. There are a further 2,261 either currently on a return topractice programme or preparing to start a course”18. Other details from theDepartment were reported in a parliamentary written answer in November 2001which indicated that 2,579 (part time) and 1,518 (full time) nurses returned topractice in the NHS in the period 1 February 2000 to 31 January 200119.

The introduction in April 2001 of a ‘returner package’ of free refresher training andfinancial support during training may accelerate the pace of return. Return ratescould also increase if there was to be broader economic recession. What cannot beidentified using these Department claims is how many of these returners stay on inthe NHS after return to practice courses (RTP), or how many other returners are notrecorded centrally, or come from other nursing employment which does not requireformal participation in RTP20.

The incomplete data that is available suggests a “not less than" annual return rateof around 4,200 in 2000-2001, with the possibility of a rising trend. This points to atotal number of returners in England, for the period 1999/2000 to 2003/04 ofbetween 20,000 and 30,000. In the previous report, projected total returners overthe period would be 29,000 nurses and midwives, on the basis of surveyevidence21.

If 29,000 returners re-enter and stay in the NHS in England, this leaves a shortfall ofabout 20,000 to 26,800 to be recruited from overseas if the total recruitment targetis to be met. The UKCC reports that overseas nurses are applying to the UK inrecord numbers. However, whilst we can assess the inflow of overseas registrantsto the UK Register, we cannot determine accurately how many will work in, and stayin the NHS. The recent trend is for co-ordinated active recruitment abroad byEnglish NHS employers, combined with a shift of recruitment activity towardscountries such as the Philippines where work permits will be required for nurses toenter and work in the UK. This suggests that a growing proportion of the increasingnumbers of overseas registrants is likely to be working in nursing in the UK.

Can overseas registrants fill the gap of 20,000 plus posts? International recruitmenthas the potential to be the most rapid (if not necessarily the most cost effective)intervention aimed at increasing staffing numbers, holding out the promise ofadditional ‘ready made’ nurses. Given the fast tracking of work permit applicationsthat has been initiated in England, it is feasible to achieve rapid growth in intakesfrom abroad. Despite concerns in some quarters about the “ethics” of this approach,this is precisely what has been happening. UKCC data highlights a growth in theannual number of overseas nurses and midwives joining the UKCC registrants with4,300 in 1997/98, 7,383 in 1999/2000, and 9,700 in 2000/2001, with further growthpredicted for 2001/02. If we assume that average annual inflow of registrants to theUK over the period 1999/2000 to 2003/2004 is around 9,700 and that only half of


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this annual number of entrants actually take up, and remain in, NHS employment,then the overseas contribution could be around 24,250.

The simple analysis conducted above suggests that the NHS Plan targets will bemet, as the Department of Health has claimed, but with a crucial contributioncoming from international recruitment. It is reported by the UKCC that there hasbeen a significant year on year increase in overseas applicants and admissions tothe Register. This growing reliance on international recruitment may be a short-termphenomenon, and intakes from overseas may reduce in the future to a more‘natural’ level. In the short term it appears likely that the actual level of internationalrecruitment over the next three years may be the key factor in determining if theNHS Plan target is met or not.

Some of the commentary on international recruitment has suggested that it is a“stop gap” measure. The Health Department's evidence to the Review Body statesthat international recruitment has made a “key contribution” to the NHS and is beingused to “boost the numbers of nurses and allied health professionals in the shortterm”22. The foreword to the recently published Code of Practice on internationalrecruitment is more downbeat, suggesting that recruiting from abroad is only “asmall but significant part of initiatives”23 to achieving NHS staffing targets.

Yet without continued emphasis on the use of international recruitment over thenext three years the NHS Plan target may not be met. Many of the new recruitsfrom overseas are working in the UK on one or two-year (potentially renewable)work permits; many are likely to be working in “hard to fill” regions and posts. Ifthese overseas recruits choose not to extend their stay in the UK, or are not allowedto do so, it is likely that the impact of staffing shortages in London and elsewherewould be exacerbated.

The above analysis is littered with assumptions (see Table 2 below). A shift in thesize of any one of the assumptions over the next three years could radically alterthe results of the analysis. This review has had to assume trends and numbers inthe absence of hard data. One of the key continuing concerns for planning andanalysing the UK nursing labour market, is the paucity of consistent, high quality,pertinent and timely workforce information. In the previous review, it was noted thatthe absence of consistent data between sectors and UK countries, and across time“can lead to confusion and futile debate.” Therefore, the RCN welcomes thesuggestion of the Review Body in its 2001 report that the various stakeholders withan interest in improving the information base on the UK nursing labour marketshould collaborate to support more effective data gathering and analysis.

In some ways the quality and availability of data has in fact eroded over the last 12months. One key source is UKCC data; access to a final report for 2000-2001 hasnot been made available. Therefore, assumptions are based on UKCC pressreleases with differing information. Other countries, such as Canada, havedeveloped their professional register as a central element in nurse workforceanalysis and planning but in the UK we have failed to develop this vital tool. Otherkey sources are the four National Boards. They, and the UKCC, are due for re-organisation in 2002. This means that in the short term data provision from thesesources is unlikely to improve. Despite the announcements of NHS workforceplanning initiatives in the UK countries, it remains impossible to develop a completeand coherent UK national overview of the UK nursing labour market necessary toinform and test policy intervention. This situation is unlikely to improve in theforeseeable future without co-ordinated action by the various stakeholders.


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Ten key issues have been identified where it is not possible to make an accuratedetermination of trends or of the impact of current policy interventions, and wherethere is scope to improve the information base. If there are no improvements in theinformation base at these crucial pressure points, workforce planning will continueto be assumption driven, rather than evidence based.

Box 1: Mind the information gap - growing the workforce- ten things we need to know

1 We do not have accurate UK-wide attrition rates during pre-reg nursing andmidwifery education.

2 We do not know with any accuracy how many newly qualified nurses andmidwives take up employment in the NHS or elsewhere.

3 We have little published evidence of the actual retirement behaviour of nurses;a vital issue as so many are in the 50 plus age group.

4 We have no accurate knowledge of how many of the growing number ofoverseas registrants are actually working in the UK, or where they are based.

5 We have only scant information on the ‘cross border’ flows of nurses betweenthe four UK countries - this is likely to become a growing issue with devolvedgovernment and diverging health policies in the four countries.

6 We have no recent detailed information on the actual number of ‘re-entrants’who stay working in the NHS after refresher training, where they are working,and the hours they work.

7 We do not have consistent or complete information on vacancy rates acrossthe four countries to assess the impact of shortages.

8 We do not have complete data on flows of joiners and leavers in the NHS toassess with any accuracy the current sources of recruits and destinations ofnurses leaving the NHS.

9 We have only scant information about the dimensions of the growing non-NHSnursing labour market and the ‘flows’ of nurses between the NHS and othernursing employment.

10 We do not have UK-wide information about the ethnic composition of the UKnursing population or workforce, to enable any assessment for potential torecruit, or to monitor equal opportunities in employment.


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Table 2: Assuming the best or worst? - meeting the headline target for 2004Interventions to achieve NHSstaffing increase target 2000-2004

Degree of accuracy/ Likelyimpact 2000-2004

Possible changes 2002-2004

Positive NegativeIntervention:Improve retention

Unquantifiable. OMEwastage data showed nosignificant improvementover 1999-2001.Assume steady wastage rateof 8.7%

Could improve if:a) Agenda for Change isimplemented and givesa more responsivecareer/pay structureb) flexible retirementpackage encouragesmore nurses to stay on inNHSc) Improving WorkingLives/ flexible hoursimproves retentiond) economic recessionmeans more nursesparticipate in paidemployment

Could be negativelyaffected if:a) delays in Agenda forChangeb) increase in retirementrates

Intervention:New intakes

Intake to NHS in England ofbetween 59,200 and 66,070over 2000-2004 (higherfigure assumes attainment ofDH target for reducedattrition)Parameters defined withreasonable accuracy.Not possible to achieve anyother significant changebefore 2004 the 2001 intakewill be the 2004 ‘newnurses’.

Could increase if:a) other improvementsin student attritionb) increase in % ofnewly qualified’ takingup NHS employment

Could reduce if:a) attrition rates during

pre-reg do notimprove

b) completion, but non-registration ratesincrease

c) more newregistrants opt fornon-NHSemployment

Intervention:Returners

Assumption of 29,000 Could increase if:a) increased success inrecruiting fromdiminishing poolb) economic recessionmeans more nursesparticipate in paidemployment

Could reduce if:a) diminishing pool

means that those leftare less inclined tore-enter NHS

b) “Re-entry”experience does notlive up toexpectations andnurses move to non-NHS or non nursingroles

Intervention:International recruitment

Assumption of 24,250.Could vary widely,depending on accuracy ofUKCC data, recruitmentactivity over next threeyears, numbers actuallyentering UK and working inNHS.

No accurate data on numbersworking in NHS. UKCCinformation suggests rapidupward trend in applicationsand registrants from abroad.Open to rapid policyintervention (BUT new Codeof Practice places newconstraints?)

Could be maintained orincreased from currenthigh level by continuedhigh level of co-ordinated recruitmentactivity.

More registrants arefrom countries wherework permit required toenter UK; suggests moreare entering and workingin UK.

a) target could beadversely affected ifrecruits do not stay to endof contract period, or donot renew short contractsb) entry of USA or otherrecruiting countries intoEnglish speakinginternational labourmarkets could make itmore difficult for UK torecruitc) strict compliance withnew Code will mean thatsome recent main sourcecountries are no longeracceptable targetsd) any delays inprocessing applicationsfrom non EU nursescould build in a time lag

Source: QMC/RCN


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Behind the headlines: the real workforce challenge for theNHS

The analysis above suggests that the NHS Plan staffing targets for nurses inEngland could be met, if international recruitment continues at a high level, andgiven the assumptions made in the absence of hard evidence.

There is a danger in focusing exclusively only on nursing numbers, in any planningexercise. Firstly, it does not give sufficient attention to the need to determine if thenumbers are based on a realistic estimate of service activity, or of any significantshifts in staff mix. The Scottish approach has some transparency on this issue, butthe targets in England do not. Secondly, there is a widely acknowledged need to‘integrate’ workforce planning across professions and between work groups, but thishas not yet been implemented.

The NHS Plan in England says nothing about how the numbers of health careassistants and other non-professionally qualified nursing staff will change. Healthcare assistants are one of the fastest growing staff groups in the NHS, yet they arelargely invisible in the NHS Plan. The NHS Plan also makes a clear commitment toexamining changes in roles of health professionals and skill mix, which could havesignificant implications for staffing levels. The Department of Health is supporting arange of NHS pilot sites where new and innovative roles are being introduced inhealth care teams24. If these initiatives are implemented more widely, there wouldbe significant implications for the mix of staff and mix of required skills. Theemphasis on integrating workforce planning which underpins the new approach toNHS staffing needs to be made more transparent, and the staffing implications ofany changes in skill mix will have to be factored into future planning scenarios.

Whilst the staffing growth up to 2004 will assist in meeting planned growth inservices, we would argue that it is vital to focus beyond the short-term attainment of anotional staffing target. It is necessary to validate the appropriateness of the target,refine it, and to address issues of longer-term sustainability of staffing growth, and ofappropriateness of staff mix and utilisation.

It is not clear how the staffing target of 20,000 was derived, nor what skills these20,000 should have, or where they should be deployed. Analysis in this report willshow that there are stubborn shortages in some geographical regions andspecialties that have continued, despite policy intervention. Setting the nationaltarget figure has concentrated minds, focused an overall resource allocation effort,and stimulated the delivery of significant additional central financial resources tounderpin recruitment, retention and return efforts. But fine tuning is now required totarget better the additional resources to the regions (for example, London) and thespecialties that continue to display high levels of staffing shortfall.

A staffing target presented in terms of headcount rather than whole time equivalentalso has major limitations. Headcount may be a simpler and easier political goal toaim for than a whole time equivalent indicator. However, without an estimate of wteit is unclear what the actual effect on staffing growth will be, in terms of the increasein availability of nursing hours, and it is difficult to compare the costs and benefits ofdifferent policy interventions. For example, what are the relative merits of devotingmore resources to increasing new intakes from pre-registration (who will mainlyinitially work full time) or to returners (many of whom will work part time)?


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It is time to move beyond a sterile numbers game, debating if the 2004 targets inEngland will be met. Unless there are unforeseen circumstances, and given acontinuation of the current high levels of effort and of resource allocation, the targetwill be met. Indeed it is unlikely that the government would have given such a highpolitical prominence to the target if it had not first assessed its capacity to meet it. Webelieve that there are now more important questions to address – is the nursestaffing target sufficient, is it being met cost effectively, and can the required longer-term staffing growth be sustained in the face of demographic and economicchallenges?

In terms of long-term sustainability of staffing growth, it is clear that the combinedeffect of several of the retention and return strategies will be to further increase theaverage age of the workforce, with diminishing returns if more ‘older’ nurses chooseto work less than full-time. The current policy interventions to meet increased staffingtargets are largely a reaction to planning failures in the mid-1990s. Behind theheadline figures aimed at meeting these short-term targets, a longer term and equallychallenging scenario is being played out. Demographic change and the ageing of theprofession cannot be prevented, it has to be addressed†. Current levels of reliance oninternational recruitment may not be sustainable, both on ethical grounds and in theface of increasing competition in English speaking international nursing labourmarkets.

Beyond the 2004 target date, from mid decade onward, increasing numbers ofnurses and midwives will enter the age groups when they can and will retire.Meeting the 2004 target could prove to be the relatively easy part. Sustainingstaffing growth and improving staff utilisation from mid decade onwards will be thenext real test of planning and of government.

† The previous RCN Nursing Labour Market Review (Making up the Difference), published inDecember 2000, explored demographic trends and implications in detail.


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Chapter 2: Students - the future nursingworkforceThis chapter reviews the trends in intakes to pre-registration nursing and midwiferyeducation, and assesses the likely number of nurses and midwives completing pre-registration education. Its main purpose is to analyse the overall contribution thatcan be expected from ‘new’ nurses and midwives becoming eligible to register andenter the workforce for the first time.The NHS Plan set a target of an extra 20,000 ‘qualified’ nurses for the NHS inEngland by 2004, with projections25 published by the Department of Health showinga more ambitious increase – by 27,000 – in the numbers of NHS nursing staffbetween 2004/2005 and 2009/2010 (Table 3)26.Table 3: Nursing staff forecast for the NHS in England (headcount)

Staff in post Change1999/00 310,1422000/01 316,750 6,6082001/02 321,214 4,4642002/03 325,678 4,4642003/04 330,142 4,4642004/05 335,199 5,0572009/10 356,887 21,688

Source: Department of HealthIn Scotland, nurse staffing forecasts are made over the shorter term but with moredetail and transparency. Figures from the year 2000 Student Nurse Intake Planning(SNIP 2001) exercise revise upwards estimates made in the previous year’sexercise, forecasting an overall increase in demand for qualified staff of around 700by 2004/2005 (Table 4). Most of this increase is expected in the first year(2000/2001) of the projection27.Table 4: Forecast change in demand for nurses and midwives, Scotland

1999/00 baseline 2000/01 2004/05Adult 38795 39373 39541Paediatrics 1811 1884 1983Mental health 8083 8055 8236Learning disabilities 2517 2429 2154Midwifery 3463 3416 3455Total 54669 55157 55369Source: SNIP 2001

Achieving an increase in the number of nursing and midwifery students is one of thekey ways of meeting the forecast growth in demand. More students will have to beattracted into nursing and midwifery programmes if the targets in England andScotland are to be met. The NHS Plan expects that, in England, 5,500 morenurses, midwives and health visitors will be in training each year by 2004, thantoday. SNIP 2000 recommends increasing intakes to nurse and midwife training inScotland to 2,900, some 3% higher than the number of places contracted for lastyear.There are a number of initiatives designed to increase the number of applicants for,and intakes to, education. However, a recent report by the National Audit Office28

comments, “there are indications that many of the institutions are beginning toreach full capacity. Investment in teaching and placement staff and in teachingaccommodation, and more innovative approaches to identifying and using practiceplacements … are necessary if the expansion in the numbers proposed in the NHSPlan are to be met.”


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This chapter looks at current numbers and recent trends in the in-trainingpopulation, applications and intakes to training, discontinuations and completions. Itfocuses on England and Scotland, where the national boards have publishedfigures for 2000-2001. Figures for Northern Ireland and Wales are not yet available.

Student populationIn Spring 2000 there were about 60,000 pre-registration nursing students in GreatBritain. These numbers had increased rapidly since the mid-1990s when they werearound 40,000. This growth has continued in 2000-2001 with 49,600 students intraining in England and 7,800 in Scotland and 3,000 in Wales at the end of March(Table 5). This suggests a total UK in-training population of around 62,000. But, inEngland - which accounts for 80% of the in-training population - the rate of growthhas halved from 14% in 1999-2000 to 7% in 2000-2001. The rate of growth hasalso halved in Wales, from 7% to 3%.

Table 5: Pre-registration nursing - in-training populations by country at 31 March 1995 to 2001*1995 1996 1997 1998 1999 2000 2001

England 32445 32531 34699 38390 40544 46421 49605N. I. 1569 1408 1447 1349 1326 1374 n.a.Scotland 5608 5830 5933 6110 6499 7027 7789Wales 2360 1987 2013 2478 2757 2947 3039TOTAL 41982 41756 44092 48327 51126 57769 Est.

62,000Source: national boards. *Table excludes students on conversion courses

Similarly, the in-training population of midwifery students in England has grown (to3,963 in March 2001) but only by around a hundred compared with nearly 200 inthe previous year. In Wales (144) and Scotland (606) the numbers in midwiferytraining have remained almost unchanged.

Applicants and intakes to educationDuring the early 1990s, the numbers of students in training were falling as NHSfunded commissions for pre-registration nursing and midwifery training werereduced in line with the outcomes of the annual commissioning exercises in eachcountry of the UK. As a result, the number of entrants to pre-registration nursingprogrammes fell by 5,400 (26%) between 1989/90 and 1994/95. But, from 1995/96onward, enrolments began to recover (Table 6) and, by 1997/98 had returned totheir 1989/90 levels. Figures for 1999/2000 revealed an increase of more than2,000 (12%) in the intake to pre-registration nursing courses in England. The latestfigures show further growth in 2000/01, but an increase of less than 360. This is thesmallest rise since the turnaround in student numbers began. The ENB annualreport notes that two higher education institutions that previously had intakes inMarch, have moved them to April/May. Consequently, these intakes are notincluded in this year’s figures. Despite this, there appears to have been a genuineslowdown in enrolments on pre-registration nursing programmes in England.Figures from NMAS show that the number of valid applications from places on fulllength pre-registration diploma nursing and midwifery programmes in England haveincreased from 18,800 in 1997/98 to 35,000 in 1999/2000†. This applications dataalso points to slowing growth in student numbers. Most of the increase camebetween 1997/8 and 1998/9; the rate of growth in applications slowed sharply in theyear ending September 2000, and the number of applicants accepted actuallyreduced slightly (to 14,819).

† Each applicant can apply to more than one institution.


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In Scotland the number of applications for places on diploma programmes (adultbranch) have reduced by 13% (377) since 1998/9 despite a 10% rise in the numberof places available.Table 6: Entries to pre-registration nursing programmes, 1989/90 to 2000/01

England N. I. Scotland Wales1989/90 15797 815 2837 9931990/91 15514 697 2779 10101991/92 16864 627 2146 7121992/93 15921 642 2348 9451993/94 13325 528 2317 8711994/95 11608 466 2230 7241995/96 12620 476 2209 6691996/97 14604 452 2386 8511997/98 16930 459 2367 1160

1998/99 16905 471 2600 1017

1999/00 19247 502 2675 1091

2000/01 19604 n.a. 3036 1122

Source: national boards (excludes conversion courses)The intake in Scotland exceeded 3,000 for the first time, growing by 13% over theprevious year’s intake. Within this total, commencements on the three-year diplomacourse increased (by 12%) from 2,295 to 2,604. However, the overall growth rate isslightly exaggerated as it reflects the fact that one institution moved its spring 2000intake from March to April. In Wales intakes also grew (by just under 3%) continuingthe recovery after dropping in the late 1990s.Figures from UCAS show that there were over 28,600 applications for places onnursing degree courses starting in 2001/2002. This is 12% more than in theprevious year and compares with around 20,000 applications in 1996. UCAS reportthat 3,096 had accepted places on programmes starting in autumn 2001, up 15.6%on last year29.In midwifery there are two routes to qualification. An 18-month post-registrationprogramme for those already qualified as nurses and a three-year programme forthose without nursing qualifications. Intakes to three-year programmes have grownfast, particularly in England, over the last ten years and exceeded 1,000 for the firsttime in 2000/01 (Table 7). But, these increases have to be offset against the similardecline in entries to the 18-month programme. Consequently, entries to allprogrammes leading to qualification as a midwife only increased by 66 in England,and by 6 in Wales, while in Scotland the intake actually fell slightly.The key message from the available evidence on applications and entries to nurseand midwifery education is that the second half of the 1990s has witnessed asignificant and substantial turnaround. Applications to pre-registration nursing andmidwifery have grown, and the numbers of students has expanded. However, themost recently available data suggests a slow down in growth.Increasing the numbers of places available and the number of applicants isimportant. But the supply of newly qualified nurses and midwives eligible foremployment depends on several other factors. These include: how many of thesestudents successfully complete their programmes, how many of these join theprofessional Register, how many of those who join the Register actually remain inthe UK and, how many of these enter and stay in nursing employment, in the NHSor elsewhere.


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Table 7: Entries leading to qualification as a midwife, 1989/90 to 2000/01England Scotland Wales N.I. Total

18 mth 3 year 18 mth 3 year 18 mth 3 year 18 mth1990/91 2371 125 444 0 98 0 0 30381991/92 2015 255 378 0 64 10 0 27221992/93 1687 525 192 180 85 15 64 27481993/94 1194 454 127 173 75 14 35 20721994/95 696 589 76 169 50 12 25 16171995/96 1018 654 80 168 41 17 29 20071996/97 967 744 79 189 55 12 30 20761997/98 914 856 90 171 63 12 30 21361998/99 849 862 68 183 42* 12 30 20651999/00 860 948 73 191 71 13 n.a >21562000/01 780 1094 51 206 76 14 n.a >2221

Source: National Boards. * In Wales, 1998/9, a further 19 students started midwifery BScprogrammes. The programme length is not stated in WNB statistics

DiscontinuationsEstablishing the level of attrition (described variously as ‘wastage’, ‘drop out’ or,more accurately as ‘discontinuation’), from nursing and midwifery education iscomplex. There are no agreed definitions or standards and there is no commondata set. In England, the Department of Health’s Human Resources PerformanceFramework introduced targets for reduction. In particular, for the 2000-01 intake‘non-completions’ were targeted not to exceed 13% for nursing and midwifery. TheNAO criticised the use of a single national target that is not tailored to the individualcircumstances of each institution. A survey of higher education institutions by theNAO reported attrition rates for diploma students starting in 1996-97 ranging from5% to 37% across universities in England. They comment that the usefulness of anational target depends on having a nationally consistent definition of ‘attrition’ andthat the impact of widening entry gates will be a factor in interpreting rates in thefuture.

Academic failure and personal circumstances (including financial pressure) arecited as the two main causes of non-completion30. The effect of the recent increasein the student bursary (September 2001), and other measures to address attrition,should be apparent next year. There are no clear trends in the attrition rates forEngland. These have fluctuated from year to year (Table 8) but in 2000/01 werehigher than the 13% target. What is also apparent from these figures is that theattrition rates for those on degree programmes are lower than on the diplomaprogramme. In Scotland, discontinuations from first level training have alsoincreased, reaching 23% of commencements and 10% of in-training population. In2000/01 discontinuations from three-year diploma courses were at their highest forsix years (657, or 25%) (these figures include transfers between branches). Thenumber and rate of discontinuations in Wales is also up, rising to 237, representing21% of intake (or 8% of in-training population) of pre-registration programmes.

Table 9 shows (for England) the end of first year outcome for students commencingnursing diploma programmes in each of the three most recent years. This shows anincrease in both the number and proportion of students discontinuing or interruptingtheir first year of pre-registration nursing diploma education.

Overall, there were 3,225 discontinuations from pre-registration diploma and degree(nursing) programmes in 2000/2001 (England) (that is, discontinuations at anystage, not just year one). This amounts to approximately 16.5% of the intake and


15

6.5% of the in-training population (at 31 March). The ‘discontinuation’ rates(expressed as a proportion of the 2000/01 entries) are highest for students in thechildren’s nursing branch (Table10). Degree programmes continue to have a lowerdiscontinuation rate than diploma programmes (5% and 7% of the in-trainingpopulation respectively). However, the increase in discontinuation rates affectedboth types of programme.Table 8: Pre-registration nursing - discontinuations in relation to entries and in-trainingpopulations, 1998/99 to 2000/01 (England)*

DiscontinuationsDiscontinuations as %

in-trainingDiscontinuations as %

year entriesdegree diploma degree diploma degree diploma

2000/01 248 2977 5.0 6.7 12.4 16.91999/00 175 2490 4.2 5.9 10.5 14.61998/99 169 2368 4.7 6.4 13.7 17.6Source: ENB annual reports. *The figures in this table relate to students who discontinued theirprogramme in the given financial year although they may not have commenced within that year

Table 9: Nursing diploma programmes - cohort analysis for the first year intake for 1998/1999,1999/2000 and 2000/2001, EnglandCohort 1998/99 1999/2000 2000/2001Entries relating to first registration (ie 1st year of programme) 13,119 16,506 16,610Resumptions & transfers 231 202 343Total in year 1 13,350 16,708 16,953Discontinued during year 1 407 491 569Interrupted during year 1 109 155 175Total leavers during year 1 516 646 744Total leavers during year 1 as % of total in year 3.9% 3.9% 4.4%Completed 15 7 0Still in system at end of year 1 (initial entries less totalleavers less completers)

12,588 16,055 16,209

Source Data from ENB annual reports

Table 10: Discontinuations from pre-registration nurse training by branch, 2000-2001 (England)

BranchStudents

intraining

Pre-regentries

Pre-regdiscontin-

uations

As % intraining

As %entries

Adult 32358 12458 2052 6.3 16.5Mentalhealth

8222 3093 499 6.1 16.1

Learningdisability

2029 845 133 6.6 15.7

Children’s 5198 1887 351 6.7 18.6Commonfoundation

1798 1321 190 10.6 14.4

Source: ENB


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CompletionsThe effect of increased intakes to training is apparent in the numbers of studentscompleting their programmes and becoming eligible for entry on the professionalregister. In England the total number of nurses eligible to register had fallen for fiveyears in a row. In 2000-2001 they increased (by 2.6%) to more than 15,385(including 2,666 enrolled nurse conversions), although still well short of the 21,000completing in 1995-96 (Table 11). In Scotland the number of completions from‘1992’ diploma courses fell by 100 (6%), and overall completions (including degreecourses and conversions) increased by 25, or about 1%.

Table 11: Completions - nurses and midwives eligible for registrationEngland Scotland*

Nurses Midwives Nurses Midwives1995/96 20938 1328 1373 2121996/97 18026 1278 1517 1951997/98 16109 1272 1384 2041998/99 15807 1343 1470 1851999/00 14988 1291 1582 1912000/01 15385 1405 1481 189

Source: National boards. *Nurse figures for Scotland are for three-year diploma courses leading toqualifications on parts 12-15 of the Register. They exclude conversion courses. As a result, almost16,000 newly qualified (excluding conversions in Scotland) nurses and midwives were, in theory,available to join the Register for the first time in 2000-2001.

SummaryThis year’s figures from the ENB were hailed by ministers as evidence that ‘thecorner’ had been turned on nurse training in England. But the latest figures werebeing compared with the intakes and in-training populations of four years ago. Amore detailed examination shows that in England:

• the student population is growing but the rate of growth has slowed down

• despite growth in the number of applications for degree courses, the total intaketo nurse education saw only a minimal increase in 2000-2001

• discontinuations show a small increase, although not too much should be readinto a single year’s figures

• completions have increased significantly and newly qualified nurses will help theNHS to meet planned targets

• if the most recent trends continue, and if growth in intake was to stagnate then itis likely that the total of newly qualified staff will make a smaller contributionthan projected to the longer-term target of projected growth in the NHS nursingworkforce in England in 2004-2010.

In Scotland, in the last year, there has been growth in the intake to nurse education,a reduction in the intake to midwifery, and a reduction in the number of newlyqualified nurses eligible to join the Register for the first time.


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Chapter 3: The pool of registered nursesThis chapter examines the dimensions of the ‘pool’ of registered nurses andmidwives. Newly qualified practitioners must register with the UK Central Council forNursing, Midwifery and Health Visiting (UKCC) if they are to practise legally in theUK. The registered population is therefore the ‘pool’ from which the NHS and otheremployers must recruit qualified nursing and midwifery staff. Monitoring key flowsand changes in the registered population provides important clues as to the state ofthe nursing labour market. Having fallen by around 6,000 through much of the1990s, new entries to the Register from education in the UK have increased in thelast two years, reflecting the rising intakes to pre-registration education. The recentfurther growth in intakes means that new entries are set to rise over the next threeyears. There has also been continued sustained growth in the number andsignificance of entrants to the UK Register who are trained abroad. Despite thesetrends, the overall picture is of a total registered population of nurses whichcontinues to age, with significant implications for policy and planning as largenumbers reach retirement age.

Entries to the Register from trainingOver the last decade, the annual number of initial entries to the Register fromeducation and training in the UK reduced by around 6,000 up to 1998, and hassince increased by about 3,000 up to 2000/2001. This initial decline andsubsequent partial reversal to growth reflects similar trends in the number ofentrants to pre-registration nursing and midwifery education. In 1990/91 there were18,980 new entrants from education and training in the UK (Table 12). In 1998/99there were 12,974, nearly a third fewer31. Latest data suggest that by 2000/2001this figure will have increased to 15,433 initial entrants32.

Although the largest numerical fall has been in the number of entrants fromeducation and training in England (which reduced by 2,285 between 1990/91 and2000/2001), proportionately the largest reduction has been in Northern Ireland(42%). The decline has been partly a result of the reduction in the number ofeducation and training places available, but may also reflect a more competitivelabour market and changing career expectations. The apparent decline of 7% ininitial entries in Scotland for 2000-2001 does not equate to a similar decline in thelevel of completions in pre-registration education. There was a slight dip in entriesto pre-registration education in 1997/98, which could indicate more completedstudents were delaying registration, or, as anecdotal reports suggest, more final-year student nurses and midwives from Scottish colleges and universities are beingrecruited by English employers (and therefore register for the first time in England).

The figures for the last four years suggest that the trend has begun to reverse33. In1998/99 the number of initial entrants from education and training in the UKincreased by 7% (890) over its 1997/98 level. This growth has continued. In1999/2000 there was an 8% increase, and provisional data for 2000/2001 suggestsa further 10% rise.

These overall increases, which tend to be similar to the rises in intakes to pre-registration education three years earlier, mask widely varying changes across theRegister. For example, in 1999/2000 the intakes to children’s nursing (parts 8 and15) and to mental health nursing (parts 3 and 13) rose by 20% and 10%respectively, while intakes to learning disabilities nursing (parts 5 and 14) grew byless than 3%.


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Table 12: Initial entries to the UKCC effective Register from pre-registration nursing andmidwifery training in the UK, 1990/91 to 2000/01*, by country

England N.I. Scotland Wales UK total1990/91 14786 659 2537 998 189801991/92 14184 726 2513 846 182691992/93 13931 717 2485 936 180691993/94 13992 707 2334 915 179481994/95 13997 585 2060 769 174111995/96 13527 581 1920 842 168701996/97 11208 492 1802 708 142101997/98 9416 437 1688 541 120821998/99 10184 421 1789 580 129741999/00 11048 363 1909 715 140352000/01 12501 379 1771 782 15433Source: UKCC annual reports; 2000/2001 figure from UKCC press release 85/200.* Unpublisheddata for 2001 supplied by UKCC

The number of new entrants to the Register in 2000/2001 reflects the outcome ofdecisions on the number of places for education and training commissioned in1997/98, actual enrolments and the subsequent survival and success of thosestudents. Comparing enrolments in pre-registration education and actualregistrations three years later for England only (Table 13) provides another, albeitcrude, measure of the outcomes from education and training.

The figures should be interpreted with caution because (a) nurses do notnecessarily Register in the year they qualify; (b) the ‘academic’ year and the UKCC‘registration’ year do not necessarily coincide; and (c) there will be some crossborder flow between the four UK countries, with some nurses first registering in aUK country different from that in which they trained.

In previous years, overall attrition rate data suggests that around 21% of studentswho enter pre-registration nurse education and training did not register three yearslater. However, analysis of ENB and UKCC data from the last two years suggeststhat this attrition rate may have increased to 28% or more. Department of Healthprojections34 assume that a marked improvement can be achieved in reducingattrition rates, with a performance target for England of an attrition rate “coming outof training” of 13% for 2000/01 and 2001/02 (i.e. the Department assumes a“survival rate” of 87% available to enter the Register). However not all students whocomplete their course will register, so a comparable overall attrition rate, includingnon-registrants could be around 85%. On the basis of published data up to 2001,Table 13 shows the likely numbers completing and entering the Register undereach of the three different attrition rates. On the basis of these projections we canassume that the number of new admissions to the Register from education andtraining in England can be projected to increase over the five-year period1999/2000 to 2003/2004 by between 65,700 (assumes a continuation of highcurrent attrition rate) and 73,400 (assumes ambitious target of reduced attrition ismet and sustained). In terms of meeting NHS targets, not all new admissions to theregister will be working in the NHS.


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Table 13: England only, pre-registration nursing and midwifery intakes to training and forecastentry to Register, 1999/2000 to 2003/2004, under three different ‘survival’ rates.Year ofentry totraining

Students startingpre-registration

programmes

UKCCregistration

year

Initial entries to the Register fromtraining in the UK – nursing*

(72%) (79%) (85%)1996/97 15344 1999/00 11048 11048 110481997/98 17786 2000/01 12501 12501 125011998/99 17767 2001/02 12792 14036 151021999/00 20195 2002/03 14540 15954 171662000/01 20698 2003/04 14902 16351 17593

Total 1999/00 to 2003/04= 65783 OR 69890 OR 73410

Source: ENB and UKCC annual reports, UKCC figure for 2000/2001 is provisional.* Assumessurvival rate of 72% (current) or 79%,( based on recent trends) or 85% (adjusted from Departmentof Health projection of 13% attrition “coming out of training”)

Entries to the register from overseasThe second source of entries to the Register are those who trained abroad. TheDepartment of Health in England has made it clear that international recruitment willbe part of the solution to meeting its staffing targets: “We shall build on oursuccesses in recruiting staff, particularly nursing staff, from abroad to help us, in theshort term at least to deliver the extra staff we need to deliver the NHS Plan”35. Ithas set up “a network of international recruitment co-ordinators… to speed up therecruitment process”36. The crucial contribution of international recruitment tomeeting NHS Plan targets has already been highlighted in this report.

Data from the UKCC register can be used to assess trends in, and the relativeimportance of, inflow of non-UK nurses.† The key indicator is the level of initialadmissions to the UKCC Register of nurses and midwives originally trained andregistered outside the UK. In the year up to March 2000, a total of 7,383 initialentrants were admitted from all overseas sources. The three most important sourcecountries in that year, were (in declining order of importance) South Africa, Australiaand the Philippines. Provisional data from the UKCC for the year ending March2001, report a further increase to 8,40337, from non-EU sources only, suggesting atotal overseas intake of around 9,700 for the year 2000-2001. The UKCC reportsthat in 2000/2001, the three most important source countries, in declining order ofsignificance were the Philippines, South Africa and Australia.

In the early 1990s, overseas registrants accounted for about one in ten newadmissions to the UK Register. By 1999/2000 this figure had increased to one inthree new admissions; the provisional data from the UKCC suggests that by 2000-2001 this figure had risen further to nearly four out of ten.

† There are limitations in using UKCC data to monitor the inflow of nurses to the UK, because itregisters intent to work in the UK, rather than actually working. Overseas nurses may be registered,but not move to the UK, or they may move to the UK but not take up employment in nursing.


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Table 14: Non UK and UK initial admissions to the UKCC Register, and non-UK as a % of allinitial admissionsYear Non UK

admissionsUK

admissionsNon-UK admissions as % of all

initial admissions1993/94 2121 17948 111994/95 2452 17411 121995/96 2762 16870 141996/97 3774 14210 211997/98 4300 12082 261998/99 4891 12974 281999/00 7383 14035 352000/01 9,700* 15433? ?

Source: UKCC. *‘Overseas trained nurses apply to the UK in record numbers.’ UKCC News, website,dated 4 June 2001 - www.ukcc.org.uk/cms/content/home/search.asp. This press statement quotes afigure for 2000-2001 of 7,705. The UKCC subsequently increased their estimate for 2000-2001 to8,403 from non EU sources only, (press statement on 14 August 2001 -www.ukcc.org.uk/cms/content/home/search.asp).

The UKCC has predicted a further “very large increase in overseas registrations” in2001-200238. Many of these new registrants will be Filipino nurses already in theUK and working through their adaptation period. The recent increases in overseasadmissions to the Register reflect the move of the NHS and other employerstowards active and targeted overseas recruitment. Previously there had been a‘natural’ level of inflow, reflecting the motivations and situation of individual nurses.However, employers and recruitment agencies are now actively recruiting fromspecific countries, aiming to recruit ‘batches’ of 20, 50 or 100 nurses. Many of thesenurses are being recruited on fixed-term contracts of one or two years, linked to theprovision of a work permit.

We know little about how many of these nurses are currently in the UK, or what theyare doing. The UKCC figures must be interpreted cautiously since an individual canregister without working in, or even residing in, the UK. Unpublished data from theUKCC showed that 17,674 of those on the Register in February 1999 had trainedabroad and currently reported a UK postcode39. This figure is likely to have grownsignificantly in the last three years with the marked increase in inflow. One third(9,228) of those on the Register in February 1999, who had trained abroad, alsoreported an overseas address40.

There are no statistics on the total number of nurses and midwives actually inemployment in the UK who trained and qualified overseas, but there do appear tobe significant variations in the geographical distribution of overseas registrants. InFebruary 1999, practitioners who trained abroad represented approximately 3%41 ofthe registered population resident in the UK42. The importance of London as a basefor many overseas nurses was highlighted by the data that showed that one in threeof all UKCC registrants in inner London (31%) was from overseas, compared withthe average figure throughout England of 3.5%.

Given the emphasis on meeting the NHS Plan targets, and the increasingglobalisation of labour markets, it is likely that we will continue to witness historicallyhigh levels of inflow of internationally recruited nurses, at least over the next coupleof years. DH guidance43 to trusts on recruiting overseas issued in 1999 advised thatprime consideration should be given to countries in the EU. Recruitment activitysince then, as indicated by UKCC registrations, shows that the opposite hashappened. Growth in overseas registrants has been accounted for by an increasein non-EU registrants, whilst the number of registrants from countries of theEuropean Economic Area (EEA) has reduced.


21

The 1999 guidance identified areas, such as the Philippines, where there werereported to be surpluses of nurses. It also urged employers to adopt a morecautious approach to recruitment in some source countries, such as South Africaand the Caribbean, because of the potentially damaging impact on the homecountry’s health services. In practice, the issuance of the guidance did not endrecruitment from South Africa and the West Indies. This was at least partly becausethe guidance did not prevent recruitment agencies and private sector employersfrom continuing to recruit. The Department has recognised the limitations of the1999 guidance, and in October 2001 published a new Code of Practice aimed bothat NHS employers and recruitment agencies44.

It is too early to judge what the impact of this ‘tougher’ guidance will be, but theCode emphasises that international recruitment is “a sound and legitimatecontribution to the development of the NHS workforce”. Despite the markedincrease in overseas registrants noted above, the preface to the Code states thatinternational recruitment is only “a small but significant part of the initiatives” to meetstaffing growth targets.

LeaversThe UK population of registered nurses and midwives is declining because thenumber of leavers exceeds the numbers of new entrants. Between 1990 and 2000almost 170,000 practitioners left the Register. This number grew from a little over10,000 per annum (1.6% of the registered population at the start of the year) in1991/92 to a peak of 27,173 (4%) in 1997/98. In 1999/2000 21,118 practitioners leftthe Register. Little is known about why people fail to renew their registration or therelative importance of different causes (death, ill health, retirement, emigration etc).

The registered population – trends and characteristicsIn March 2000 there were 634,529 qualified nurses, midwives and health visitorsregistered with the UKCC. Around 9.8% of registrants are men, a little over 1%more than ten years ago. The population of registered nurses grew through the late1980s and early 1990s at about 2% per annum, to reach a high of 648,200 in 1997.But in recent years there has been a net reduction in the registered population. Inthe three years between 1996/97 and 1999/2000 the registered population fell bymore than 13,000 (or about 2% of the population). Provisional data from the UKCCsuggest that there has been a further fall of 2,479 between March 2000 and March2001.

The headline UK rate can also mask significant variations between the four UKcountries. In the years up to 1999/2000 Northern Ireland and England experiencedproportionately larger falls in the resident registered population than in Wales. TheUKCC provisionally reports a 7% reduction in new registrants in Scotland in2000/200145.

The ‘registered’ population represents the theoretical pool from which the NHS andother employers recruit qualified staff. In practice the pool is smaller than theregistered total. There are two main reasons for this.

First, over 25,000 (4%) of those on the Register are resident overseas. These arenurses and midwives who qualified in the UK and are currently living abroad. TheUKCC issues verification documents to regulatory authorities abroad to confirmindividual registrations with the UKCC. Outflow of UK nurses to other countries hasincreased in recent years, as measured by the number of verifications that theUKCC issues to regulatory bodies in other countries. However this outflow has notbeen at the same pace of increase, or to the same level as that of inflow.


22

In 1999/2000 a total of 5,083 verification documents were issued. This is anincrease over recent years, but remains lower than in the late 1980s. Outflowappears to be linked primarily to moves of nurses to other developed countries.Some of these countries, such as Australia46, Ireland47 and Canada48 are alsoexperiencing or projecting demographic related nursing shortages. It is alsonoticeable that UK nursing journals are carrying more job advertisements from USemployers. A recent US study49 predicts that, with a combination of rising demand,an ageing workforce and falling intakes to training, the USA could have a shortfall ofover a million registered nurses within ten years. Whilst there are currently entryrestrictions on nurses moving to the USA to take up employment, US health careemployers are lobbying for these restrictions to be waived. If this occurs there islikely to be increased activity by US employers in international nursing labourmarkets, both in competition with the UK in third countries, and in direct recruitmentin the UK.

Second, some of those on the Register have already retired from nursing andmidwifery work. A key shift in the nursing and midwifery population in recent yearshas been the ageing profile. In 1991 one in four (26%) of all practitioners on theRegister were aged under 30; by 2000 only one in eight (13%) were under 30. Atthe same time, the number of practitioners aged over 55 has grown from 70,596(9%) to 78,115 (12%). Over the next five years the number of practitioners over 55is likely to approach 100,000. Nurses who joined the NHS Pension Scheme beforeMarch 1995 - as many of these will have done – have special retirement rightsenabling them to retire, with full benefits, at age 55. And so, many will no longer bein nursing employment although their registration may not lapse for two or threeyears.The significance of this age-shift is threefold:1. Older practitioners may leave the Register faster than newly qualified nurses

and midwives can replace them. On average, more than 20,000 practitionershave left the Register in each of the last five years. Whilst the age profile ofthese leavers is not known, unpublished analysis by the UKCC is reported tohave found that the ‘peak years for leaving the Register are 35 to 39 and 60 to6450.

2. Fewer of the ‘older’ nurses who remain on the Register actually participate inthe nursing labour market. The UKCC’s midwives intention to practise statisticsshow that less than a fifth of the 33,852 midwives who intend practising in2000/2001 were aged over 50 compared with more than a third of those on theRegister.

3. Those older nurses who do participate are less likely to work full time. Surveysof registered nurses have shown that the proportion working full time (in theNHS) falls from around 80% at age 25-29 to 63% at 50-5451.

SummaryEntries to the Register from education in the UK fell by a third – to 13,000 - duringthe early and mid-1990s. Since 1998/99 there has been a reversal in this decline,and intakes have risen, although more slowly on some parts of the Register thanothers.

Nurses who trained abroad have become an established source of new entrants tothe professional Register. The highest ever number – 8,403 plus EU registrants –registered in 2000/2001, representing about 40% of new additions. UKCC pressstatements suggest this number will increase further in 2001/2002. However, theUK may increasingly have to compete in international nursing labour markets withthe USA and other countries which are also experiencing nursing shortages.


23

Despite increased entries from education and from overseas, the overall populationon the Register is still declining. Between 1990 and 2000, 170,000 practitioners leftthe Register, with over 21,000 going in 1999/2000 alone. This largely reflects theageing of the population - only 1 in 8 of those on the Register are under 30 todaycompared with 1 in 4 less than ten years ago. More than 73,000 are aged between50 and 55 and can expect to withdraw from the nursing workforce in the next five toten years.


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Chapter 4: Registered nurses and the widernursing and midwifery workforceThis chapter moves forward from examining the ‘pool’ of potential working nursesand midwives to assessing trends in the nursing and midwifery workforce. In theperiod between 1990 and 1998 the overall number of registered nurses andmidwives employed in the NHS remained static, but there were marked increases inthe numbers employed as GP practice nurses and in private sector hospitals,nursing homes and clinics. In general, the net growth in nursing employment in the1990s occurred outside the NHS.Since 1998 the implementation of NHS strategies for nursing and human resources,and NHS modernisation plans, have symbolised a fundamental policy shift in theNHS. Workforce planning, and effective approaches to recruitment, retention andmotivation of NHS nurses and midwives are now acknowledged as core elementsof a ‘modernised’ health service. Achieving health gain targets depends, in part, onachieving plans to increase NHS nurse numbers throughout the UK. This is placingincreasing emphasis on attracting more applicants to nurse education, encouragingreturners to nursing employment, and improving retention through improvedpay/career structures, flexible working practices and retirement options. Morecontroversially, it also appears to be reliant on recruitment of nurses from abroad.

The NHS workforceThere were 440,810 nursing staff employed by the NHS in England in September200052. Of these, 72% (316,750) were registered nurses, midwives and healthvisitors. Around a third of NHS nurses work part time. As a result, the whole-timeequivalent number of registered staff in the workforce was 256,280. A further35,690 (wte) registered nurses were employed by the NHS in Scotland and 17,670(wte) in Wales (Table 15). This brings the total (wte) number of registered nurses inthe NHS for Great Britain to approximately 309,640. Adding in data for NorthernIreland, for March 2001, gives an overall UK estimate of approximately 321,148qualified nurses and 115,470 unqualified nursing staff.

Table 15: Nursing staff (whole-time equivalent) employed by the NHS in 2000/01 (UK)*England Scotland Wales N.I. Total

Qualified 256,280 35,690 17,670 11,508 321,148Unqualified 89,830 15,530 6,560 3,550 115,470Total 346,180 51,230 24,230 15,058 436,618

Source: DH Statistical Bulletin 2001/3; Health Departments Evidence to Review Body 2001.*Figures are rounded. Figures are for September 2000; figure for Scotland for 2000 is provisional.Excludes agency staff. Northern Ireland figure is March 2001, provided by HRIS, DHSSPSNI.

Taking 1997 as the base, the number (wte) of registered nursing staff employed bythe NHS in England has increased by 10,270 or about 4%. Most of this increasecame in the period 1998-2000 (Table 16). Provisional data for 2001, reported in arecent press release, suggests that there will have been a further increase of10,000 (headcount) or “over 7000” (WTE) over the period 2000-200153.

In Scotland the change in the numbers of registered nurses up to 2000 has beenless pronounced, with a reduction in non-registered nursing and midwifery staff(Table 17). In Wales, the growth in employment of registered nurses has beengreater than in England. In Northern Ireland there was a slight reduction over 1997-2000 but data for 2001 points to a more significant increase in the number ofregistered nurses in the last 12 months.


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Table 16: Whole-time equivalent number of nursing and midwifery staff employed by the NHS inEngland, 1997 to 2000*

1997 1998 1999 2000 % change1996-2000

Qualified 246,010 247,240 250,650 256,280 4.2%Unqualified &HCAs

101,960 105,290 108,850 112,970 10.8%

Learners 2,250 2,080 1,880 1,970 -12.4%Others 590 430 490 70 -88%TOTAL 350,810 355,050 361,870 371,290 5.8%

Source: DH Statistical Bulletin 2001/3. * The total figures may differ from that presented in othertables because of differing definitions of staff without professional qualifications

Table 17: Whole-time equivalent number of nursing and midwifery staff employed by the NHS inScotland, Wales and Northern Ireland 1997 to 2000*

1997 1998 1999 2000 % change1997-2000

ScotlandQualified 35240 34490 35590 35690 1.3Unqualified 16230 15820 15760 15530 -4.3TOTAL 51470 51980 51350 51230 -0.4WalesQualified 16720 16670 16920 17670 5.7Unqualified 6570 6920 6960 6560 -0.2TOTAL 23290 23590 23890 24230 4.0Northern IrelandQualified 11450 11190 11210 11340 -1.0Unqualified 3250 3340 3420 3490 7.0TOTAL 14710 14530 14630 14820 0.7

Source: Scotland and Wales: Table 1, Health Departments Written Evidence to Review Body, 2000.*Excludes learners. Figures are rounded. Scotland data for 2000 is provisional; Scotland datafrom 1998 onward is based on new occupation codes and may not be directly comparable withprevious years. Northern Ireland: Figures are for March, figures are rounded. HRIS, DHSSPSNI.

VacanciesThe level of unfilled, or vacant posts, is used as an indicator of recruitment andretention difficulties. It is difficult to determine actual trends in NHS nursing andmidwifery vacancies because of discontinuities in monitoring vacancy levels overthe last five years.

The NHS Staff Vacancies Survey in March 2001 covered all NHS trusts in England.It asked for details on vacancies that trusts had been actively trying to fill but whichhad lasted for three months or more as at 31 March 2001. The survey reported atotal of 9,020 qualified nursing, midwifery and health visiting posts had been vacantfor three months (Table 18). This represented a slight overall reduction in threemonth vacancy levels with the rate reducing from 3.9% in March 2000 to 3.4% inMarch 2001. The actual reduction in vacant posts achieved over the periodbetween March 2000 and March 2001 was 1,090.

Vacancies by specialty varied between 1.7% in community learning disabilities and3.9% in ‘other psychiatry’. All specialties of nursing had a fall in the vacancy rateover the period 2000-2001, except for district nurses and health visitors. Thereduction from 2000 to 2001 came after a significant increase the previous year, upfrom 2.8% to 3.9% at the national level. Although most vacancy rates fell in 2000-2001, the 2001 rates in all specialties remain at, or above, their 1999 level.


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Vacancy by region varied between 1.6% in Trent and 6.5% in London (Table 19).All regions of England except the North West had a fall in the vacancy rate forqualified nurses, and all specialties of nursing had a fall in the vacancy rate, exceptfor district nurses and health visitors.

Whilst remaining below the average figure, the upward trend of vacancies in districtnursing and health visiting may become a particular cause for concern. These aretwo of the specialties with the oldest age profiles, and are crucial to plans todevelop primary care and better services for older people and children.

Table 18: Three-monthly vacancy rate by main specialty, qualified nurses, midwives and healthvisitors, March 1999 to March 2001 (England)

3-month vacancy rate (%)Work area 1999 2000 2001Acute, elderly & general 3.5 4.6 3.7Paediatrics 3.6 4.4 3.6Learning difficulty 2.1 3.4 2.7Psychiatry 2.2 4.0 3.6Midwives 2.3 2.8 2.6District nurses 0.7 1.3 2.3Health visitors 0.9 1.9 2.2Others 1.7 2.4 3.1Total 2.8 3.9 3.4

Source: Department of Health, March 2001 NHS Staff Vacancies Survey

The three-month vacancy level in London and the South East continues to be wellabove the national average. Within regions there are also significant variations. Thehighest overall vacancy rate was in Bromley in London, which reported a vacancyrate of 10.9%. Some London specialties have even bigger challenges to face.Camden and Islington reported a vacancy rate of 25% for community psychiatryposts, and Barking and Havering reported a rate of 20% in paediatrics.

The March 2001 survey did not collect figures on total vacancies. But if the ratio ofthree month to total vacancies remained the same as in 1999, then a reasonableestimate of total vacancies for March 2001 in England is approximately 19,600 wte.

Data from ISD54 on vacancies for qualified nurses and midwives in the NHS inScotland over the period 1996 to 2000 showed a reduction in the vacancy rate –falling from 3.7% in 1996 to 2.6% in 2000, with the three-month vacancy rateremaining more-or-less unchanged, fluctuating between 1% and 0.7% (April 2000).More recent data, for March 200155 show an increase in the overall vacancy rate to3.6% for all qualified nursing staff, but with a three-month rate of 0.5%. Comparabledetailed and up-to-date figures are not available for Northern Ireland and Wales. Arecent report suggests that there are 400-450 total vacancies in the NHS inNorthern Ireland56.


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Table 19: Three-month vacancy rates by region, qualified nurses, midwives and health visitors,March 2001

Region Three-month vacancy rate March 2001(%)

Eastern 3.0London 6.5Northern&Yorkshire

2.1

North West 2.4South East 4.5South West 2.3Trent 1.6West Midlands 3.0TOTAL 3.4

Source: Department of Health, March 2001 NHS Staff Vacancies Survey

TurnoverTurnover gives some indication of job mobility in nursing. It is also factored in as ameasure of NHS trust ‘performance’, as higher staff retention is regarded as anindicator of ‘good’ HR practice. However, official figures on the numbers of nursesand midwives changing jobs within the NHS or leaving the NHS for nursing or non-nursing jobs are no longer published in all four UK countries. The only national (GB)figures are those provided by the OME since 1996, as part of its annual survey forthe Pay Review Body.

These data show small year-on-year fluctuations in turnover between 12.6% and13.8% with significant variations by country (Table 20) and region. For example, inMarch 2001, turnover was reported to be 20.2% in the ‘Inner’ and 21.6% in the‘Outer’ London weighting zones, compared with 11.2% in the West Midlands and11.1% in the North West. The data also suggested a wastage rate (that is, leaversexcluding transfers to other NHS trusts) of 8.3%57. Although the survey collects dataon where leavers went to, more than half are shown as ‘other’ or ‘don’t know’. Itmay be unwise to place much reliance on the distinction between those changingjobs within the NHS (turnover) and those leaving the NHS (wastage).

Table 20: Turnover of registered nursing staff from NHS trusts in the years ending March 1996 toMarch 2001

England Scotland Wales GB*

1996 n.a. n.a. n.a. 13.81997 n.a. n.a. n.a. 12.61998 13.6 8.6 8.7 13.11999 13.5 8.1 9.1 12.92000 13.0 n.a 5.5 12.62001 13.5 10.4 8.6 12.7

Source: pay review body reports. Survey results, unmatched samples. * GB 2000 excludes Scotland

The OME survey also reported that wastage rose ‘sharply’ for district nurses and forhealth visitors between 2000 and 2001, and that these two groups now had thehighest wastage rates of any registered staff. (The age profile of these two groupsis older than for most other specialties and it is likely that a higher proportion ofturnover is accounted for by retirals).

ReturnersQualified practitioners returning to paid nursing employment have been the target ofan ongoing series of linked ‘return to practice’ (RTP) campaigns in England. From 1


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April 2001 health care professionals returning to the NHS have received at least£1,000 income to support them whilst they are retraining (midwives will receive£1,500), with further assistance available for childcare, travel etc. The Governmenthas claimed that, as a result of the campaigns, over 7,500 qualified nurses havereturned to work in the NHS in England between February 1999 and March 2001,and that a further 1,300 had returned between April and September 200158. Manyreturners appear to be working part time - of 9,671 nurses, midwives and healthvisitors who were monitored by the Department of Health as having returned topractice in NHS between February 1999 and October 2001, only 3960 (41%) werereported to be full time59.

There is no recent detailed analysis of the regional variation in the impact of RTPinitiatives. Data from 1999 showed that at that time the impact of the RTPcampaigns has been uneven60. The London region, which accounted for over athird of vacancies, had only 12% of the enquiries and 11% of the returners. Incontrast, Trent had 5% of the vacancies but 14% of the returners.

The OME Workforce Survey reported that ‘re-entrants’ filled approximately 0.8% ofregistered nursing staff posts in the year to 31 March 2001 in England. Thisrepresented about 6% of all ‘new’ staff (excluding transfers within the NHS), andappears to be at a reduced rate compared to the previous year61.

The NHS Executive conducted a survey of potential nurse returners in 199962. Thissurvey found that flexible hours and refresher courses were most likely to enablepotential returners to rejoin the profession. An emphasis on flexible working hours iscentral to the Department of Health’s ‘Working Lives’ campaign63 and has beengiven further prominence in the NHS Plan.

The National Assembly for Wales has announced a financial package similar to thatin England to support nurses and midwives on RTP courses, and has reported that160 people were on RTP courses in 200164.

Health care assistantsGiven the increasing emphasis on determining skill mix in the nursing workforceand on broadening out ‘entry gates’ to the nursing profession, it is surprising howlittle data is available on health care assistants working in care environmentsalongside registered nurses. Whilst there is information on numbers entering andcompleting NVQ/SVQ training, this does not tell us how many are subsequentlymaking use of this qualification in the NHS or in other health care sectors.

Health care assistants (HCAs) comprise a relatively small, but growing componentin the wider nursing and midwifery workforce in the NHS. Compared with what isknown about the labour market for registered nurses and midwives, there is onlyminimal data on the numbers (and nothing on the flows) of health care assistants.Neither the NHS Plan nor subsequent published documents give details of plannedchanges in HCA numbers.

Current figures for England (drawn from the September 2000 NHS census) showthat the NHS employs 27,500 HCAs, representing about 3% of all non-medical staff.Figures for Wales are difficult to interpret because HCAs are counted with ‘othersupport staff’ (these numbers are declining). In Scotland the numbers appear to besmall. According to ISD there were 54 wte HCAs in post at the end of March 2000compared with 37.5 in September 1999. Information from surveys conducted onbehalf of the National Training Organisations concerned with the care sectorsuggest that there has been a rising trend of registrations for care and relatedNVQs/SVQs65. It is not possible to identify how many of these workers qualify andsubsequently take up NHS employment.


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In England the number of HCAs has increased by 10,000 over five years, risingfrom 13,000 wte to 23,100 wte in 2000. Much (17%) of that growth came between1999 and 2000. Qualified nurse numbers grew by about the same amount – but thiswas only a 4% change compared to a 76% increase in the number of HCAs. Howmuch of this growth is real, and how much is due to re-classification of staff alreadyin employment (for example, as nursing auxiliaries), is not known. As in nursing, theHCA workforce has an ageing profile (Table 21). In 1996 40% were under 35; thishas reduced to 34% while 10% are aged 55 or over.

Table 21: Age profile of HCA’s in EnglandAge profile (%) <25 25-34 35-44 45-54 55-64 65+ Unknown1996 15.3 24.3 24.1 23.3 8.3 0.1 4.62000 11.7 22.1 25.9 23.6 9.7 0.1 6.8Source: Department of Health

GP practice nursesIn addition to those registered nurses working in NHS hospital and communityhealth services, 12,511 registered nurses (wte) were employed as practice nursesin England, Wales and Scotland in 1999. In England the number of practice nurseshas grown by nearly 40% during the 1990s. In Scotland the number has almostdoubled, and in Wales there has been an increase of two thirds over the periodfrom 1990 to 1999 (Table 22). In Scotland, the latest SNIP report forecasts furtherincreases (up to 190) in the numbers of practice nurses over the next five years66.

Table 22: Number (wte) of practice nurses, by country, 1990 to 2000England Scotland Wales GB total

1990 7738 584 418 87401991 8776 647 524 99471992 9121 695 519 103351993 9605 748 552 109051994 9099 768 582 104491995 9740 808 622 111701996 9820 875 637 113321997 10080 901 642 116231998 10360 968 665 119931999 10690 1123 698 125112000 10710 n.a n.a n.aSource: Health Statistics Wales 1999, Scottish Health Statistics 1999, and DH bulletin 2000/11

The non-NHS sectorNon-NHS nursingNurses are employed in several sectors outside the NHS. These include: nursingand residential homes; independent hospitals and clinics; independent hospices;nursing agencies; and public sector services (prison service, defence medicalservice, higher education, police service, local authorities). An accurate anddetailed identification of how many nurses are employed in these sectors is notcurrently possible. The sparse information that is available is contained in disparatesources, uses a variety of definitions and is prone to double-counting.

Independent sector

Independent care homes are the largest employers of nurses outside the NHS.Laing and Buisson67 estimate that, in the year 2000, these homes employed some55,300 wte nurses. In England the number (wte) of registered nurses employed innursing homes more than trebled between 1985 and 1995 when it reached 42,428.


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Over the same ten-year period the number (wte) of registered nurses employed inindependent hospitals and clinics grew by more than 20%, from 6,660 to 8,037.Between 1995 and 1999, employment in these two sectors has risen by nearly 9%(4,360) in England (Table 23).

Table 23: Number (wte) of registered nurses employed in private hospitals, homes and clinics, 1990to 2000 (GB)

England Wales Scotland1990 37311 1683 29051991 41356 2044 33361992 46533 2416 39661993 48545 2652 46311994 50465 2525 47851995 50470 2678 61361996 50810 n.a. 53591997 51230 n.a. 50001998 n.a. n.a. 50451999 54830 n.a. 48922000 n.a. n.a. 4728Source: Health Statistics Wales 1999, Scottish Health Statistics 2000, and DH bulletin 2001/3.

Laing and Buisson report difficulties in recruiting and retaining qualified nursing staffin the care home sector across England, especially in the south. They expect theabolition of the distinction between nursing and residential homes when the CareStandards Act takes effect in April 2002, together with the introduction of ‘free’nursing care from October 2001 for people in care homes, to have a major impacton staffing. They suggest that the hours of nursing input that the NHS will be willingto pay for when it takes over responsibility for funding assessed nursing care needs,will be lower than the current levels. This could mean a ‘very substantial reductionin the number of nurses working in care homes’. Laing and Buisson project atransfer of more than 10,000 wte nurses out of the independent care home sectorand into the NHS over the period up to 2010. Other recent developments, such asthe “concordat” between the Department of Health in England and private/voluntaryhealth sectors68 could see a trend in the opposite direction.

Scotland saw rapid growth in this sector during the early 1990s, with employmentrising from 2,905 (wte) in 1990 to 6,136 in 1995. Since then, numbers have fallensharply, dropping by 22% in five years. SNIP 2000 cites evidence of immediaterecruitment and retention problems in Scotland’s registered nursing homes with tenhealth boards reporting staff shortages. The forecast is for an additional 210 adultgeneral nurses for nursing homes and 116 for other non-NHS sectors (Table 24).

Table 24 Scotland: forecast demand for registered nurses outside the NHS1999/2000 base 2004/05 Change

Adult general 6809 7135 +326Paediatrics 47 58 +11Mental health 1650 1806 +156Learning disabilities 1065 1026 -39

Source: SNIP 2000

Nursing agencies

There are an estimated 1,050 agency branches in the UK, representing about 750nursing agencies. But there are few data available on the numbers of nursesemployed through them. Part of the problem is that many of these nurses areregistered with more than one agency and others have NHS jobs as well asundertaking agency work, so it is prone to double-counting69. The Audit


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Commission70 estimated in 2001 that around 43,000 registered nurses work, atleast some of the time, for agencies in England and Wales.

Expenditure on agency nurses by the NHS has increased significantly since 1996.In 2000/2001 the NHS (in GB) spent £460 million on agency nurses compared with£264 million in 1998/99 and £190 million in 1997-98. The estimate for 2001/02 is£570 million71 Figures for England alone highlight a 25% increase in agency spendbetween 1999/2000 and 2000/01, from £360 million to £447 million72. While part ofthis increase reflects higher costs charged by agencies, it also suggests increasedusage and growing employment (recognising of course that many agency nursesalso have substantive NHS contracts and that nursing agencies provide staff tosectors other than the NHS) 73.

As part of a strategy to reduce dependency on agency nurses, the Department ofHealth has launched NHS Professionals, an in-house NHS-led ‘agency’ in Englandthat is expected to become the primary supplier of temporary staff in the NHS.However, it is too early to judge the extent to which nurses will switch from agencyto NHS Professionals employment.

The overall message from these figures is that between three and four times asmany nurses work in the NHS as in all other forms of nursing employment. Most ofthe growth in nursing employment over the last ten years has occurred in thevarious non-NHS sectors. While the numbers of nurses and midwives employed inthe NHS has grown by a few percentage points, mainly in the last two years, thenumbers working in the independent sector almost doubled and there wassignificant growth in general practice.

An ageing workforceThe nursing workforce is ageing. Figures for England show that in 1996 40% ofNHS nurses, midwives and health visitors were under 35. By 2000 the proportionunder 35 had dropped to 32% (in Scotland it was 21% in 1998). At the same timethe proportion over 45, that is, within ten years of retirement, has increased from27% to over 30% (Table 25).Table 25: Age profiles - NHS (England and the UKCC Register)

NHS 1996 % NHS 2000 % UKCC 1999/2000 %Under 25 6.0 4.2 2.925-34 34.3 27.6 24.635-44 28.9 34.3 35.645-54 21.2 23.5 24.555-64 5.9 6.7 11.065+ <1.0 <1.0 1.4Unknown 3.7 3.7 <0.1Source: DH bulletin 2001/3; UKCC annual report (DH data is for wte, UKCC data is headcount)

Recent figures from the Department of Health indicate that 50,000 NHS nurses areaged over 50 and that between four and five thousand nurses retire each year –equivalent to between 1.3% and 1.6% of the staff in post in September 199974.One in five nurses, midwives and health visitors on the Register are aged 50 yearsor older. But, the age profile of those working in the NHS appears to be relativelyyounger than the total population on the Register. In 2000, less than 8% of NHSnurses were aged 55 or over compared with 12% of those on the Register.This difference is explained by: the withdrawal of older nurses from employment;the withdrawal of older nurses from NHS employment; and, the older age profile ofnurses working in some of the non-NHS sectors, particularly nursing homes andpractice nursing. Survey evidence suggests that 12% of practice nurses and 19% of


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those working in nursing and residential homes, were aged 55 or over75. Thesesectors are likely to experience more pressure in the short term. As a consequence,the NHS may experience greater competition from non-NHS employers as theyseek to replace retirees.Within the NHS there are important differences by area of work. In particular,community staff nurses, health visitors and district nurses had older age profilesthan hospital-based staff when these data were last published by the NHS in 1996(Table 26). For example, more than three-quarters of sick children’s nurses areaged under 45 compared with only half of health visitors. More recently, a survey bythe Audit Commission found that 27% of district nurses were aged 50 or over and,almost half intended to retire before age 6076.Table 26: NHS nursing, midwifery and health visiting staff % age distribution (England, 1996)*

<45 45-49 50-54 55+RSCN 78 7 5 3Midwives 67 12 9 6Health visitors 50 19 17 12District nurses 53 18 15 10Acute, elderly & general nursing 70 9 7 4Psychiatric nursing 67 13 8 5Learning difficulties nursing 65 12 8 5Community nursing 55 15 13 11

Source: Department of Health, Non-medical workforce census, 1996. * Rows do not sum to 100%because of ‘unknown’.

There have been recent policy-led attempts in England to encourage more nursesto stay on in NHS employment up to, and beyond, their potential retirement date. InJuly 2000 a Health Service Circular77 was issued on flexible retirement, whichhighlighted the implications of the ageing of the NHS workforce. It summarised theoptions within the NHS pension scheme open to employers to encourage morenurses to stay on at work. More recently it has been reported that the NHSPensions Agency is drawing up proposals to ‘modernise’ the pension scheme fornurses and midwives with a view to improving retention of older nurses andencouraging more returners78.

EthnicityImproving the recruitment of ethnic minorities into nursing and midwifery is a policypriority for the NHS. Little information is available on the ethnic composition of thenursing workforce. Until the mid-1990s, no national data were routinely collected.Data from the 1995 non-medical workforce census showed that the majority (89%)of registered nursing, midwifery and health visiting staff in the NHS (England) wereWhite. This figure has reduced marginally, to 86%, in 2000, with 4.8% Black and1.7% Asian.

Importantly, the figures for 1995 show that the proportion of Black nurses rose withage. For example, 6% of those aged 45-54 and 9% of those aged 55 and over wereBlack compared with less than 1% of those under 25 and only 2% of those aged25-34. Black, Asian and ‘other’ applications to pre-registration nursing andmidwifery education increased by 2,680, and numbers accepted by 300, in 200079.Nevertheless , NAMS report that only 12% of Black, Asian and other applicants areaccepted†. This suggests that the proportion of nurses coming from ethnicminorities is unlikely to change significantly in the near future.

† NAMS report that White applicants make up just under half of all applications, and more than threequarters of accepted applicants.


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Participation rates

By combining data from the UKCC Register with what can be pieced together aboutthe numbers in employment, it is possible to provide a crude estimate ofparticipation in nursing employment and, crucially, the size of the non-nursing pool.In order to gauge participation rates using the Register, figures on the numbers inemployment – which are usually expressed in whole-time equivalents – have to beconverted into headcount figures. Wherever headcount figures are not available,they have been estimated using official data sources80.

Table 27 shows best estimates of the numbers of registered nurses in employmentin the UK, which total approximately 487,750. In addition, RCN survey evidencesuggests that a further 4% of nurses work in other sectors (defence medicalservices, agency nursing, occupational health etc). This brings the sum total ofregistered nurses employed in the UK to about 518,670.

Table 27: Employment of registered nurses, midwives and health visitors, 2000*

NHSnursing

GPpracticenursing

Nursinghomes,

independenthospitals and

clinics

Other Total

England 256280 10710 54830 n.a. 321280Scotland 35600 1123 4728 n.a. 41451Wales 16920 698 2410 n.a. 20028NI 11500 100 1425 n.a. 13025Total (wte) 320300 12631 63393 n.a. 395784TOTAL (heads) 395430 21410 82330 19500 518670

Buchan and Seccombe, 2000, updated . * Note: non NHS data for N.Ireland is 1999.

There were 634,529 nurses registered with the UKCC in 2000. Of these, a total of25,381 were recorded as having an address abroad (a further 12,437 had no knownpostcode). Subtracting 25,381 from the total on the Register gives a “not more than”figure of approximately 609,000 to use as the total potential ‘pool’ of registrants. If518,670 are in employment, this implies a participation rate in UK nursingemployment of approximately 85%. Comparing participation rates in nursing overtime is particularly difficult because studies have used slightly differing methods andfigures. But, the evidence would suggest that it has increased over time – fromaround 68% ten years ago81.

What is more, 30,330 of these registrants are aged 60 or over. Adjusting for doublecounting between these two groups, the potential population from which employerscan recruit is approximately 579,000. If 518,670 registrants are employed asnurses, midwives and health visitors, then the potential pool from which employerscould recruit is probably no more than 61,000. Compared to even one year ago,there has been a reduction in this pool of about 10,000, due to the effect of returnerrecruitment campaigns and the impact of ageing on the pool. This estimated pool iscomparatively small – representing about 10% of practitioners on the Register agedunder 60 and living in the UK.

There is also a wider and undefined ‘pool’ which comprises those individuals withnursing and midwifery qualifications who are currently not on the register andtherefore not eligible to practice, but who could become eligible through refreshertraining. Recent estimates by the Department of Health, using UKCC datasuggested that there were about 160,000 nurses in England aged under 60, andwith effective registration who were not working in the NHS (as noted above, manywill have been working in other paid employment), and a further 106,00 who had lettheir registration lapse82.


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In general, the smaller the size of the pool of non-practising registered practitioners,and the more there are attempts to encourage non-registered practitioners to re-enter this pool, the more challenging will be recruiting from the pool. Not all of thosein the pool will be able or will want to return to nursing. The NHS Executive’s returnto nursing survey (1999)83 found that only 1 in 5 respondents intended to return tothe profession, 1 in 5 indicated that they would not return and the remainder saidthey were unsure.

SummaryThe NHS employed about 321,000 (wte) registered nurses, midwives and healthvisitors in the UK in 2000. These numbers have been increasing in each of the fourUK countries over the last three years, but at varying rates. In England, growth inregistered nurse staffing in the NHS over the period 1997-2000 was about 4%, andpreliminary reports from the Department of Health suggest further staffing growth of“over 7000” wte in 2000-2001.

Shortages, as indicated by the existence of long-term vacancies, continue to be aproblem. In England, there were nearly 9,200 (wte) long-term vacancies in the NHSat 31 March 2001. The number of these ‘hard to fill’ posts has reduced slightly fromthe previous year, but remains higher than in 1999.

Each year about 13% of nurses and midwives change jobs, or leave the NHSaltogether. There are marked regional variations in this figure - turnover in InnerLondon being twice the national average.

The rapid growth of the non-NHS nursing labour market in recent years may betailing off. Recent data from Scotland indicates a downturn in nurse employment inprivate hospitals, homes and clinics. However, whilst market analysis suggests thatthe introduction of the Care Standards Act in England in 2002 could lead to asignificant reduction in the number of nurses working in the independent care homesector, other developments such as the ‘concordat’ between the NHS and private/voluntary sectors could stimulate increased demand for nurses in non-NHS sectors.The number of practice nurses has continued to grow, reaching over 12,000 at theturn of the century. It is difficult to establish how many nurses in total are working innon-NHS sectors. Best estimates suggest the figure is around 100,000(headcount).

The nursing workforce is also continuing to ‘age’. More than 30% of NHS nursesand midwives in England are aged over 45; and roughly 1.5% of staff in post retireeach year. The age profile of nurses in non-NHS sectors is older. The NHS maytherefore experience greater competition as these employers seek to replace thosewho retire in the next five to ten years.

Participation of registered UKCC practitioners in the nursing workforce is high ataround 85%. The pool of non-working nurses that employers might recruit from iscomparatively small. Estimates suggest that it may be no more than 61,000. Wecan expect that at least 1 in 5 of these do not intend to return to the NHS.

There have been recent increases in the number of nurses employed in the NHS,and a slight reduction in long-term vacancies. These short-term headline gainsshould not be allowed to draw attention away from the growing challenge over thenext five to ten years, of replacing retirees from an ageing workforce, whilstparticipation rates in employment are already high.


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References and notes 1 Queen Margaret University College/Royal College of Nursing (2000). Making up the Difference: AReview of the UK Nursing Labour Market in 2000. RCN, London.2 Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine(2001), Nineteenth report on Nursing Staff, Midwives and Health Visitors. Stationery Office, London,cm 5345.3 Department of Health (2001) Investment and Reform for NHS Staff- Taking Forward the NHS PlanDH, London.4 “Dearth of skilled staff is biggest threat to NHS plan” Health Service Journal, 9 August, page 9.5 Department of Health (2001) Review for 2002. Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine. DH, London.6 Wanless D (2000) Securing our Future Health: Taking a Long Term View. Interim Report.November. Public Enquiry Unit, HM Treasury, London; p183.7 Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine(2001), Nineteenth report on Nursing Staff, Midwives and Health Visitors. Stationery Office, London,cm 5345, Appendix E.8 Audit Commission (2001) Review of National Findings: Accident and Emergency. AuditCommission, London.9 Department of Health (2000) A Health Service of all the Talents. DH, London.10 Scottish Integrated Workforce Planning Group (SIWPG) (2001) Planning Together. ScottishExecutive, Edinburgh, forthcoming.11 Health Department, Scottish Executive (2001) Facing the Future: Report of the 19th November 2001Convention on Recruitment and Retention in Nursing and Midwifery. Scottish Executive, Edinburgh.12 For a detailed review of the UK’s nursing labour market in the 1990s see: Buchan J, Seccombe I andSmith G (1998) Nurses Work: An Analysis of the UK Nursing Labour Market. Ashgate, Aldershot.13 Department of Health (2001). More NHS Nurses, More NHS Beds. Press Release 2001/0614, 12December, 2001.14 i)UKCC News, 4 June 2001. Overseas trained nurses apply to UK in record numbers. ii)UKCC News, 15 August . Massive Rise in recruitment from Philippines.UKCC data related to i) suggests that there were 1,291 registrants from EEA countries, and 6,414 fromnon EEA countries. The figure from ii) was 8,403 for non EEA only- adding EEA registrants (1,291)gives a total of approx. 9,700.15 Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine(2001) Nineteenth report on Nursing Staff, Midwives and Health Visitors. Stationery Office, London,cm 5345. Appendix E,. No detailed data is available on “stability rate” which would be a moreaccurate indicator of retention.16 Two assumptions are made here. First that the NHS Plan’s promise that there will be 5,500 morenurses in training in 2004 implies a straight-line increase from the current intake level. Secondly, thatthe attrition rate is constant across the years.17 Department of Health (2001)Review for 2002: Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine. DH, London, para 2.27.18 Department of Health (2001). More NHS Nurses, More NHS Beds. Press Release 2001/0614, 12December, 2001.19 Written Parliamentary Answer, 30 November 2001,16398. Parliamentary Monitor.20 The OME survey for the Review Body in 2001 reported that “re-entrants” accounted for 1,693(WTE) of a total of 29,918 “joiners” taking up registered nursing employment in the NHS in Englandand Wales - about 6% of total. However the utility of the survey as a source of information onreturners is severely constrained because many “joiners” (over 5,000) were from unknown sources.21 NHS Executive (1999) Return to Nursing Survey.22 Department of Health (2001) Review for 2002: Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine. DH, London, para 2.40.23 Department of Health (2001) Code of Practice for NHS Employers involved in internationalrecruitment of healthcare professionals (foreword) DH, London.24 Department of Health/ NHS Executive. (2001).Changing Workforce Programme. DH, June.25 DH, February 2001, Investment and reform for NHS staff – taking forward the NHS Plan.26 It is understood that these targets include practice nurses.


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27 This overall figure disguises a continuing fall in demand for learning disabilities nurses.28 National Audit Office (2001) Educating and Training the Future Health Professional Workforce inEngland. NAO, London , March.29 UCAS press release, 10 October 2001.30 National Audit Office (2001) Educating and Training the Future Health Professional Workforce inEngland. NAO, London , March.31 Initial entries to part 10 are separately identified in UKCC reports from 1995/96 onward. The numberof initial entrants has grown from 485 (2.8% of all entrants) in that year to 641 (5%). Most entrants topart 10 continue to be ‘subsequent’ entrants, that is, via the 18-month shortened course for thosealready on another part of the register.32 UKCC Big rise in overseas applications. UKCC News, website, dated 4 May, 2001.(http://www.ukcc.org.uk/cms/content/home/search.asp)33 Except in Northern Ireland where 351 diploma students qualified in October 1999 and 350 areexpected to qualify in September 2000. NI Assembly, written answers, 17 January and 30 June 2000.34 Department of Health (2001) Review for 2002: Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine. DH, London, para 2.18.35 Department of Health (2001) Investment and Reform for NHS Staff - Taking Forward the NHS Plan.Para. 3.26. DH, London.36 Department of Health (2001) NHS Emergency Pressures: Making Progress. DH, London, p15.37UKCC. More countries providing more nurses and midwives. UKCC Press statement, dated 14August 2001. (http://www.ukcc.org.uk/cms/content/home/search.asp)38 UKCC. Overseas trained nurses apply to the UK in record numbers. UKCC News, website, dated 4June 2001 (http://www.ukcc.org.uk/cms/content/home/search.asp). This press statement quotes a figurefor 2000-2001 of 7,705, and states that “this financial year this figure is expected almost to double.” Ifdoubled, this would suggest a figure of around 15,500 for 2001-2002. The UKCC subsequentlyincreased their estimate for 2000-2001 to 8,403 from non EU sources only, (press statement on 14August - (http://www.ukcc.org.uk/cms/content/home/search.asp).39 Buchan J , O’May F (1999) Globalization and Healthcare Labour Markets: A Case Study from theUnited Kingdom. Human Resources for Health Development Journal, 3 (3), 199-209.(www.moph.go.th/ops/hrdj/ ).40 Buchan J (2000) Trends in recruitment of overseas nurses, Employing Nurses & Midwives, March2000, p14. These nurses may have been accepted on to the Register but have not come to the UK or,have come and then returned abroad.41 The proportion resident in the UK may be higher – details on the Register are incomplete for 8% ofoverseas registrants.42 Postcode information for 1999 showed that overseas registrants make up 1% of the registeredpopulation in Wales, 1.2% in Northern Ireland and 1.4% in Scotland, compared with 3.5% in England.The largest concentrations of overseas registrants are in central London, where 31% are from overseas.However, postcode information should be used cautiously. Some postcode information may reflecttemporary initial addresses or addresses of recruitment agencies.43 Department of Health (1999) Guidance on International Recruitment. DH, London.44 Department of Health (2001) Code of Practice for NHS Employers involved in internationalrecruitment of healthcare professionals. DH, London.45 UKCC News, 4 May 2001.46 In Australia there is an estimated shortfall of 5,000 out of a total workforce of 250,000. NursingTimes, 3 August 2000.47 Department of Health and Children (2000) The Nursing and Midwifery Resource- Report of theSteering Group. Dublin, September.48 Health Canada (2000) Nursing Strategy for Canada. Health Canada, Ottawa. See also Ryten E(1997) ‘A statistical picture of the past, present and future of registered nurses in Canada’ CanadianNurses Association, Ottawa.49 Buerhaus P, Staiger D and Auerbach D (2000) ‘Implications of an ageing registered nurseworkforce’. Journal of the American Medical Association, 283(22), 2948-54.50 UKCC Press Statement, 18 June 2001.51 Buchan J (1999) ‘The greying of the UK nursing workforce: implications for employment policy andpractice’. Journal of Advanced Nursing, 33(9) 818-826.52 These figures exclude learners (mostly on post-registration training courses) and Project 2000students.


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53 Department of Health (2001) More NHS Nurses, More NHS Beds. Press Release 2001/0614, 12December, 2001.54 These figures show that, at 31 March 2000, the NHSiS had 874 wte vacancies for qualified nurses.This represented 2.6% of establishment. But these figures do not include returns for two trusts (FifePrimary Care and Borders Primary Care).55 ISD, October 2001. ISD (M) 36 data.56 Information provided by IAU, Department of Health, Social Services and Public Safety, October2001.57 Note that these figures are based on varying responses to the annual survey. Comparison of thematched samples shows slightly varying figures, but the same overall trends.58 Department of Health (2001) Review for 2002: Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine, DH, London, para 2.27.59 Written Answer, 30 November 2001, 16398.60 Queen Margaret University College/Royal College of Nursing (2000) Making up the Difference: AReview of the UK Nursing Labour Market in 2000. RCN, London.61 Review Body for Nursing Staff, Midwives and Health Visitors. (Eighteenth Report) Appendix E.Note that one third of joiners in each year were recorded as ‘other’ or ‘don’t know’.62 NHS Executive (1999) Return to Nursing Survey.63 Department of Health (1999) Working lives. DH, London.64 Department of Health (2001) Review for 2002: Written Evidence from the Health Departments forGreat Britain, Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied toMedicine, DH, London, para 7.35.65 Improvement and Development Agency (2000) Quarterly Monitoring of Care Sector NVQs/SVQs.66 Student Nurse and Midwife Numbers, The Report of the Reference Group on Student Nurse IntakePlanning, Scottish Executive Health Department, Edinburgh, 2001.67 Laing and Buisson. Flexible Staffing Services in UK Health and care markets 2001. Laing andBuisson Publications, May 2001.68 Department of Health/ Independent Healthcare Association (2001) A Concordat with the Private andVoluntary Health Care Provider Sector.69 Smith G and Seccombe I (1997) Mapping and quantifying the non-NHS nursing labour market.RCN, Employment Brief 9/97.70 Audit Commission (2001) Brief Encounters: Getting the best from temporary nursing staff. AuditCommission, London.71 Figures are taken from successive Review Body reports.72Akid, M (2002) NHS spending on agency nurses reached record levels. Nursing Times, January 10,2002.73 The only other published data available show the wte agency nurse use by the NHS in Scotland.These figures fluctuate year-on-year but peaked in 1998 at 341 – a 41% rise on 1997. Source: ISD(1999), ‘Agency Nursing Staff’, Health Briefing 99/07.74 Department of Health, HSC 2000/022, Flexible Retirement. DH, London.75 Buchan J (1999) ‘The greying of the UK nursing workforce: implications for employment policy andpractice’. Journal of Advanced Nursing, 33 (9) 818-826.76 Audit Commission (1999) First Assessment: a review of district nursing services in England andWales. Audit Commission, London.77 HSC 2000/22.78 “Pensions scheme will help returners” Nursing Standard, September 19, 2001, page 6.79 Nursing and Midwifery Admissions Service, Statistical Report, 2000.80 The most recently available figures for England and Scotland suggest that the wte is 0.81 for NHSnurses, 0.59 for GP practice nurses and 0.77 for non-NHS nurses. Where figures have had to beestimated, for example, to project the non-NHS nurse population in Wales, they are based on changesin bed numbers or extrapolated from actual trends in other countries.81 Buchan J, Seccombe I and Smith G (1998) Nurses Work: An Analysis of the UK Nursing LabourMarket. Ashgate, Aldershot.82 Written Answer, 30 November 2001,16388.83 NHS Executive (1999) Return to Nursing Survey.

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