Joyce Rachel 2014

Dr Rachel Joyce is a former Parliamentary Candidate. She has been an NHS doctor for more than twenty years and has worked as both a Medical Director and a Director of Public Health.

The problem

Despite the cries of ‘Tory cuts’ from the opposition and media, only the Conservatives promised and are delivering the £8 billion of extra funding that NHS England said it needed.

Furthermore only the Conservatives have credible plans for an increase in the number of nurses in the NHS between now and 2019, as I described in my article just before the general election.

This additional investment in the NHS and the plans for more nurses does not however mean that the NHS hasn’t got a staffing problem, and that his hasn’t been building up over decades.

There are shortages in hospitals and the community – not because of a shortage of cash, but because services simply can’t recruit to the posts. As a result billions of pounds are being wasted on agency staff, and patients are admitted to hospital not because of acute clinical need but for lack of NHS staff in the community to care for them.

It is also increasingly difficult to retain social care staff due to a lack of career progression, and nursing shortages in nursing homes are putting services under pressure with an ever-increasing reliance on agency staff.

This increases costs for families, the NHS and councils – and affects continuity of care for patients – many of whom will be suffering from dementia, where continuity and person-centred care is so important.

This is not a new problem, but never before have we had such a challenge in terms of an ageing population and an escalating need for care.

The government has temporarily added nurses to the list of ‘shortage occupations’, and under this government Health Education England are training more nurses than ever before.

It has however become not just difficult but expensive to recruit nurses from abroad, and foreign nurses themselves admit they often do not have the right language skills and can have difficulty slotting into the UK health system.

The fact is that if we keep doing workforce planning and training in the same way, we will always end up with the same results.

There is a 40 per cent drop out rate from Britain’s (graduate only) nurse training; a large proportion of the community nursing workforce are due to retire in the next ten years; and for younger staff there is a significant churn with maternity leave and those wanting to come back to work part time.

As far back as I can remember these facts never seem to be adequately taken into account by workforce planners.

The solution

Nurse training and ‘hands on’ care in the NHS and social care could be delivered in a much more flexible and cost effective way, with the introduction of nursing and care apprenticeships and other models of working whilst training.

Earning and learning, accumulating additional competencies and progressing up the career ladder over time, should be the norm.

Some areas are already piloting a health and social care apprenticeship, joining up the training of non-qualified care staff across health and social care sectors, and others a ‘care practitioner’ professional in care homes to address an under-supply of skilled staff.

I believe that these approaches should just be the start of a revolution in the way we train staff. Why can’t these same health and social care staff also have the option to train further whilst working and eventually become ‘fully qualified’ nursing staff?

In the past nurses mostly worked – and earned – as they learned. Very few took the degree route to nursing. State enrolled nurses (SENs) had more practical, hands-on training and academic achievement at O level was often not necessary for entry to the training programme, whilst O levels (but not A levels) were necessary for the three year state registered nurse (SRN) courses.

SENs could also later do a conversion course and become SRNs. These models of training are still flourishing in many parts of the world, but we moved away from this in the 1990s.

In contrast current UK nurse training (which is graduate only) sets a very high academic bar to entry (usually AAA-BBB at A level), and is ‘supernumerary’ over a three year period (although Jeremy Hunt has now required actual delivery of basic care as a key part of training).

The degree-only route to nursing reduces the hands on workforce, deters many from entering the profession, and arguably is to blame for the high drop out rate both during the course and after qualification.

In a recent study, researchers found that the modern degree student nurse does not always see it as their role to do the ‘dirty’ things “like cleaning up blood and faeces” – i.e. basic components of care .

I believe we need to take the best from previous models of nurse training and also adapt to the needs of an ageing population and the corresponding need for more hands on care, by introducing competency-based career progression via apprenticeships and other mixed models of training.

They should be able to progress from workforce entrant through to ‘care assistant’ to ‘care practitioner’ and – for those that want – to enrolled nurse to registered nurse and beyond.

Some nursing degree courses should remain, but those who chose a degree option rather than the work and learn option should pay back their tuition fees if they don’t stay in nursing (at the moment a nursing degree is a free degree course with a grant and perhaps a bursary on top, costing £51,000 per nurse).

Other ways to make a more flexible workforce

The need to adapt training and recruitment and become more flexible is not just a problem in nursing, but also in the allied health professions.

Laudably, Health Education England are ensuring the training of more ‘physician associates’, which should provide a cost effective way help to tackle some front line delivery problems as part of a multi-professional team.

Increasingly we see paramedics not just on ambulances but out in GP practices and in A&E departments, but these career paths aren’t sufficiently flexible or mainstream.

I’d like to see the day when a job currently advertised as ‘intensive care nurse’ would instead be entitled ‘intensive care practitioner’ and could be open to anyone who had the right competencies to deliver the job – whether they first trained via a nursing or a paramedic route, or other.

I’d also like to see the day when the work of the specialist speech therapist looking after stroke patients (an area where there is a severe workforce shortage) could also be entirely done by a nurse or a physiotherapist - or indeed by a former therapy assistant who has undergone a conversion course into a speech and language therapist whilst still working.

They could have additional post-qualification training in the management of the swallowing and speech problems that stroke patients often suffer.

I’d like to see a day where the breakdown in professional barriers to these roles and posts was not just possible, but the norm.


The NHS and care sector needs to be able to adapt to current challenges and be more flexible in the way it trains, recruits and retains its most valuable asset – its staff.

More training whilst working, the introduction of apprenticeships, and the breaking down of professional barriers is a nettle that must be grasped if we are going to be able to continue to provide a flexible and resilient workforce to meet future demands on both the health and social care sectors.

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