The Care Association Alliance recently attended a workshop arranged by the Centre for Workforce Intelligence (CFWI) that aimed to collate evidence for the Migration Advisory Committee (MAC) on whether to add nurses to the Shortage Occupation List (SOL) on a long term basis. One important revelation during this meeting was that when the Home Office asked the MAC to look into the nursing shortage in 2014 they were specifically directed to review the potential shortage in the NHS and not to consider other areas. Hence, any evidence from the social sector submitted to this consultation was ignored. The deadline for the current consultation is 31st December 2015 and I urge all Care Associations to submit their response as a matter of urgency in order for the evidence to be given due consideration. Over the course of this paper, I will endeavour to provide evidence highlighting the level of nursing shortage currently experienced in social care and examine how this is affecting our sector, along with explaining why permanent entry onto the SOL will make a significant difference to the shortage.
- The Number of nurses available to employers is likely to significantly drop over the next three years due to the low number of nurse graduate placements commissioned over previous years.
- EU nurse recruitment levels are likely to drop by upto 80% over the next two years due to language requirements being introduced by the NMC.
- There are currently around 24,000 full time vacancies for nurses within the health and social care system.
- In social care the nursing population is much older than in the rest of the healthcare system and Skills for Care predict that 25,000 nurses will retire from within social care over the next 25 years.
- Permanent Leave to remain rules make the UK one of the least competitive countries for attracting potential skilled migrants. Adding nurses to the Shortage Occupation List would alleviate this.
- The only organisation in the UK that does not recognise the developing chasm in the nursing workforce population is the Home Office, based on advice received from the Migration Advisory Committee.
- 1. Why does the Shortage Occupation List matter?
This is one of the main questions asked by the MAC; why will permanently retaining nurses on the SOL make a difference? There are two main reasons why the SOL status will help alleviate the shortage of nurses. Firstly, over the past year a large number of applications to bring nurses into the UK have been turned down, which would otherwise have led to a nurse entering the register. According to CFWI data almost 3,000 applications to bring in nurses from outside the EU were turned down over the previous year due to the immigration cap. Had nurses been on the SOL these applications would not have been refused and this would have led to several thousand extra nurses entering the UK workforce.
The second benefit of permanent entry onto the SOL has recently been highlighted in a large number of press articles. These have pointed out the limiting requirement for nurses to earn over £35,000 (approximately a Band 8 nursing rate) in order to attain Permanent Leave to Remain after April 2016. Under the new rules, any nurse must earn this amount in order to stay in the UK for more than 6 years, otherwise they will be forced to return home. This inability to settle in our country as permanent residents makes nursing positions in the UK highly unattractive to potential migrants. Being on the SOL will help alleviate this situation as highlighted in the quote below, which is taken from the statement of intent from the Home Office[i].
“The SOL is subject to revision and updating from time to time. However, you will be eligible to benefit from the SOL exemption if, when you apply for settlement, you are being sponsored under Tier 2 (General) to undertake employment in a job which has been removed from the SOL while you were being sponsored to do that job. If you have at one time been sponsored to undertake employment in a SOL job but subsequently changed occupation and are not in a SOL job when you apply for settlement, you will not benefit from the exemption.”[ii]
In plain English this means that any nurses who enter the country whilst the occupation is on the “Shortage Occupation List” will be able to achieve permanent residency even if the job is subsequently removed from SOL.
We are not the only country suffering a shortage of nurses, which only increases levels of competition within the global market. Due to comparatively lower immigration constraints, The United States and Australia are the preferred destinations for nurses from India and the Philippines, our two main sources of foreign nurses[iii]. Both of these countries are making immigration easier for overseas nurses and are actively enticing these individuals to emigrate to their countries. While harsh laws in the UK currently state that nurses will be asked to leave after 6 years, comparably in Australia nurses from overseas are offered a permanent place in the country after having worked for only 1 year in their public health service. Adding nurses to the SOL will allow them to settle permanently in our country without earning a Band 8 pay rate. Furthermore, it will send a strong message to overseas nurses that they are a valuable part of our healthcare economy and not a seemingly unwanted burden that needs to be sent home when we have finished making use of their skills.
- 2. Demand for nurses
One of the key questions being considered by the MAC is what the level of demand is for nurses within the UK in both health and social care. However, this figure is extremely hard to pin down due to the number of providers responsible for staffing the huge number of locations utilised by the health and social care system. A recent report by Christie’siii shows a total nursing workforce in the UK of 655,000 registered nurses. Of these 354,000 work within the NHS, 242,000 work in private healthcare with the remaining 50,000 working in social care. Whilst vacancy rates are not collected for private healthcare establishments, rates for NHS and social care employers are published. Data gathered from skills for care shows a 9% vacancy rate for nursing positions in social care and from NHS employers a 7% vacancy rate within the NHS. This equates to a total of 24,000 FTE positions currently unfilled. Significantly, this data only accounts for two thirds of nursing employment and could be much higher if the nursing shortage is also felt within the private healthcare system.
The lack of full time positions being filled is partially compensated for by utilising temporary staff. The cost of this has been highlighted in a number of high profile newspaper articles[iv] and the NHS has recently introduced rules to try and cap the amount paid to nursing agencies.[v] The spiralling cost of this reliance on temporary staffing has been recognised at a national level and ministers have taken first steps to try and reduce spend within the NHS. For social care providers however there is no nationally recognised cap and this, coupled with ever increasing competition for agency staff from the NHS, acts to increase costs even further for social care employers that are short of nurses. Such reliance on temporary staff to fill rostered hours has led to an increase in spend on agency staff in the largest care home groups of almost 55% over the past two years.iii
As an employer, we have experienced permanent, full time nurses leaving their positions to become an “agency” nurse. A significant attraction into agency work is the ability for nurses to sign up with multiple agencies, many of which offer much higher wages. The Christie and Co. report supports a rate of pay at approximately £30 per hour. An individual is then able to accept or decline as many shifts as they wish, allowing for greater control over their working hours and lifestyle. There is such an acute shortage of nursing staff that many nurses can chose to work full time in a ‘temporary’ capacity, often earning significantly more than they would in a permanent nursing position. This means that nurses who would usually be employed on a permanent, full time contract are instead opting for agency work, further exacerbating the shortage of permanent employees.
Analysis of immigration into the UK reveals one of the key changes in demand that occurred last year. This was the refusal of applications for a Certificate of Sponsorship for nurses. In order to obtain a work permit for a nurse, an employer must first apply for a “Restricted Certificate of Sponsorship”. Currently only a limited number of these are allowed through the immigration system each month. In 2015, for the first time, a large number of the Certificates of Sponsorship that employers applied for to get nurses into the country were refused due to the national limit of immigration being reached[vi]. This suggests that the demand for nurses from outside the EEA is growing and cannot be met by the current immigration rules.
The final factor that will lead to an increased demand for nurses is the demographics of the nursing workforce. Across both health and social care, 37% of nurses working today are over the age of 50. In the social care workforce this is even more extreme. The 2015 report on nurses in social care[vii] states that “In terms of age there are some interesting issues to consider”. Chart 4 [shown below]shows that over 72% of nurses working in adult social care are aged 40 or over, while 44% (or just over 2 in 5) are aged 50 or over. Given this age breakdown, the sector should expect to lose close to half its nursing workforce to retirement in the next 10 to 15 years.”[viii] Consequently, social care will need to recruit almost 25,000 nurses in the next 10 to 15 years. This places worrying levels of pressure on the social care nursing workforce.
- 3. Supply
For many years, the UK health and social care system has heavily depended on international recruitment of professional staff. While 11% of NHS staff currently employed are from overseas, this figure increases significantly for nurses where 18% are from overseas. This can be seen even more obviously within social care, where 37% of the total nursing workforce are from outside the UK. Over the last ten years 20% of all nurses entering the UK register have been from overseas, and this figure was much higher in the 10 years prior to this.iii While Non_EU recruitment has fallen away, over the past 10 years EU recruitment has increased by 351% to around 7,000 nurses last year alone, demonstrating the continuing dependence of the UK on foreign trained nurses. This increase in EU recruitment has been in direct contrast to the picture in recruitment from outside the EU, which has dropped from a high of around 10,000 nurses ten years ago to only a few hundred last year.vi
Over the past decade there has been an almost inexplicable decrease in the training of UK nurses which can only be due to lack of understanding of nurse demand. This has meant that we had c. 20,000 nurses finishing training in 2014/15. This will be 18,000 in 2015/16 and fall to a low of 17,000 in 2016/17. Health Education England has recognised the shortage and commissioned an additional 1,000 nurse places, or a 9% increase[ix] starting in 2015/16. However there will be a 4 year lag and we will not see UK nurse graduate levels reach 2014/15 levels until 2018/19. This means that unless there is significant immigration of nurses to shore up low UK graduate levels the nursing shortage is only going to get worse over the next few years.
The main reason that the health and social care system in the UK is not in meltdown is a large and ever increasing introduction of EU nurses to the UK workforce, reaching a high of 7,000 last year alone. This is under significant threat next year, however, due to changes in the registration criteria being introduced by the Nursing and Midwifery Council[x]. In 2016 there will be a new requirement for all EU staff to prove competence in English language before entering the UK register. This will add an extra bureaucratic step to entering the nursing profession, slowing recruitment, but will also significantly affect incoming numbers of nurses. When a similar requirement was introduced for non-EU nurses in February 2007, numbers of incoming nurses dropped from 5,000 to just under 1,000 in two years, a drop of over 80%. If a similar decline is seen in EU nurses then this may well lead to new nurse numbers decreasing to levels not seen for 20 years.
Overseas recruitment from outside the EU is in a much worse situation. New immigration systems and increased requirements in English language have seen immigration levels dropping from 14,000 in 2003/04 to 800 in 2013/14. Non-EU immigration has been further hit by changes to rules for “permanent leave to remain” that were introduced by the home office in 2011.i In contrast to the British approach many other countries that recruit internationally are removing barriers from entering the country. Australia for example are allowing foreign nationals to combine scores from multiple English language tests in order to achieve entry to their register and are even offering accelerated permanent residency to nurses that work in their publicly funded nursing workforce. Unless the UK radically shifts its’ approach to foreign immigration of nurses, we are unlikely to attract them in large numbers and the current shortage being faced will become drastically worse.
When collectively analysing the three sources of nurses into the UK, we are likely to see a significantly reduced number of nurses available to the health and social care sector over the next few years. This can be observed in the graph below, which shows the number of entrants to the nurse register if the expected decrease in EU/EEA nurses occurs and there is no significant increase in overseas recruitment. The graph also illustrates the effect of the known lower number of nurses graduating over the next few years.
- 4. Migration Advisory Committee stance on nursing shortage.
The Migration Advisory Committee (MAC) utilises a “top down methodology” to assess whether there is a shortage in any given occupation. These are:
- Percentage change in median pay, compared to 12 months previously.
- Percentage change in median pay, compared to 36 months previously.
- Return to occupation levels.
- Change in median vacancy duration.
- Vacancies/ claimant count
- Percentage change of claimant count compared to one year ago.
- Percentage change of employment level compared to one year ago.
- Percentage change of median paid hours worked compared to three years previously
- Change in new hires compared to one year ago.
- Skill-shortage vacancies/ of total vacancies.
- Skill-shortage/ hard to fill vacancies.
- Skill-shortage vacancies/employment.
Each of these measures is compared against a benchmark value that applies across all jobs within the UK. In order to achieve “shortage status” the occupation must appear over the benchmark figures in 6 out of 12 categories.
This approach to staffing may be effective in an open market where recruits are easy to train and readily available. However, there are some serious drawbacks when applying this to nurses. Applying the MAC model when analysing the nurse shortages is extremely unlikely to ever result in a recommendation to place nurses on the SOL. These are highlighted below for each of the 12 factors, where applicable.
- Pay levels for nurses are strongly controlled by government and unions. 54% of all nurses are employed within the National Health Service and pay increases are agreed in a negotiation between the Royal College of Nursing and Department of Health. This negotiation is driven by the political ideals of the party in charge of Government and the state of government finances. The shortage of any given workforce is not often a key factor in setting pay rates across the NHS. In addition, the finances of all publicly funded bodies, and around 60% of all social care providers, are dictated by government. Even if employers were able to increase pay rates for nurses, (which NHS bodies cannot do under the Agenda for Change agreement) there is no subsequent increase in income to pay for this rise in cost, making any increase extremely costly to any independent body that wishes to do so. Having said this, however, nurse pay rates went up by 3% in 2014 in social care establishments, significantly above the 1% within Agenda for Change. This increase would have come straight out of profit margins for many of these employers as there were real term decreases in the income from local authorities.
- See above regarding pay rates for nurses.
- Return to occupation is currently being proactively explored by Health Education England. However the numbers available to return and the requirement for those with a long term lack of practice to carry out a 2 year university course make this an extremely difficult challenge.
- Vacancies within healthcare are very often under-represented. Most employers will advertise for a single vacancy for a registered nurse, rather than multiple vacancies at once. As a consequence, adverts are more likely to run constantly rather than for specific time periods. In addition, many organisations (both publicly and privately) utilise agencies for employment purposes. This will mean that individual vacancies may not be advertised on the open market or may be hidden behind the agency name. Therefore analysis of which organisation posted the advert is almost impossible.
- Vacancies within healthcare are often under-represented. Most employers will advertise for a single vacancy for a registered nurse. If there is one applicant for this position then one nurse will be employed, whereas if there are 10 then 10 will be employed. This is primarily driven by fear of regulation. If a care-home or NHS trust were to advertise that they had 10 nurse vacancies it may be seen as a reason to take action against that employer as they are unable to maintain safe staffing levels. If there is only one advertised vacancy then this is much less likely to be held against an organisation. Further, in a social care context existing nursing staff are much more likely to be asked to work increased hours, allowing for a certain amount of “flex” within the existing workforce.
- No comment
- Percentage change of employment level. This is extremely hard to calculate as nurses must continue to practice to be part of the professional register and therefore it is not possible to have “unemployed nurses”.
- Percentage change in median paid hours worked. This is not possible to alter within the nursing Agenda for Change framework that the NHS works under, without paying for overtime hours. Additional hours required are extremely expensive and are either avoided through use of external agencies or staff are allocated local “bank” shifts by NHS professionals. An individual is likely to be working the required number of hours within a full time position and then picking up extra temporary shifts, often with a different employer. This makes it almost impossible to calculate a true number of hours worked within the sector.
- Change in new hires – This is completely controlled by a government grant. This is one of the worst managed aspects of
workforce planning in the country and has led to the current shortage experienced in the UK. There has been a very poor understanding of demand within the UK for nursing staff and this remains the case moving forward. Unfortunately the limit is imposed on the country and our sector by central funding bodies. There is no possible way to increase this number, if extra nurses are required. Hence, the number of university placements commissioned will bare almost no relation to demand for nurses. Finally, any new changes implemented will take 4 years to become visible and therefore judging the number of new hires into the sector on a yearly basis is meaningless. The only exception to this is the ability to recruit overseas nurses, which has been increasing significantly for EU/EEA nurses and recommendations from the MAC has stopped employers from being able to recruit in larger numbers from outside the EU/EEA.
- Skill-shortage vacancies are defined as not being able to find suitably qualified recruits to meet staffing requirements. As all nurses are required to hold a relevant qualification and be part of a registered workforce this does not seem a relevant factor. In addition the most recent Employer Skills Survey highlights professionals within social care an emerging pocket suffering from skills deficiency.
- No comment
- No comment
The country is currently in the grip of a significant nursing shortage. This is costing the NHS and private sector billions of pounds per year in temporary nursing staff costs. Nursing Homes around the country are changing registration and becoming residential care homes. The individuals whom they cared for are being kept in hospital wards, leading to ever increasing bed-blocking figures within the acute sector. The recent Frances Report stated that significant increases in nurse levels were required to improve care levels. Additionally, the Care Quality Commission in their “state of care” report[xi] stated that the nursing shortage was having a significant impact on quality of care across both the NHS and Social Care. The only body in the UK that concludes that there is no shortage of nurses in the UK is the Home Office, a lone voice that is based on an analysis of evidence presented by the Migration Advisory Committee. By not including nurses on the SOL an already dwindling supply of nurses will be reduced to crisis point.
For The Care Association Alliance
[i] STATEMENT OF INTENT: CHANGES TO TIER 1, TIER 2 AND TIER 5 OF THE POINTS BASED SYSTEM; OVERSEAS DOMESTIC WORKERS; AND VISITORS, published February 2012
[iii] The UK Nursing Workforce Crisis or Opportunity, Christie and Co. 2015
[vi] MAC call for evidence, Partial review of the SOL: Nurses. Centre For Workforce Intelligence 26 November 2015.
[viii] Registered Nurses in Social Care, Skills for care, 2015.
[ix] Health Education England National Workforce Plan, 2014-15