As the cold nights draw in, another winter crisis looms for the NHS and this time it threatens to be the worst. Regulators say that the health service faces its deepest financial crisis for a generation — according to a recent audit, NHS trusts overspent by almost £1 billion between April and June and are expected to be at least £2 billion in the red by the end of the year. Meanwhile, waiting times are growing, targets are being missed and junior doctors are protesting on the streets about new contracts requiring them to work at weekends for the same pay.
David Cameron once said that his priority could be summed up in three letters — “N-H-S” — but the approaching catastrophe is at least partly of the government’s own making. Although the prime minister hoped to take the politics out of healthcare by protecting its budget, the current crisis is as much about ministerial competence as cash.
Jeremy Hunt, the health secretary, announced last week that he is going to cap the amount agencies can pay temporary NHS staff. The growing dependence on stand-in doctors, nurses and managers cost the health service £3.3 billion last year and accounts for a large part of the overspend. Mr Hunt was right to say that hospitals were being “ripped off” by agencies charging £3,500 for a single doctor’s shift and £1,600 for a nurse. From April the premium paid to temporary workers will have to be less than 55 per cent of the equivalent staff salary. Two days later, Theresa May, the home secretary, said that nurses from outside the EU would have their work visa applications prioritised by immigration officials. It’s a move that has been resisted for years by the Home Office but is now essential to avoid severe staffing shortages this winter. The NHS already relies heavily on foreign nurses, with 8,976 registering to work in the UK so far this year even though it costs £3,000 to recruit each nurse from abroad.
These two announcements were made necessary by a human resources misjudgement rather than a financial black hole. The inconvenient truth that ministers refuse to acknowledge is that the crisis in the NHS is not only caused by the ageing population, rising treatment costs and a growth in survivable but long-term health problems — it is also directly linked to their failure to plan for the kind of workforce required by a modern health service.
Both the eye-watering agency fees and the reliance on foreign recruits are a result of nursing shortages now being felt following the decision to cut training places in the early years of the coalition government. Between 2010 and 2012, the number of nurse training places in England fell by 2,210 and, because the courses typically take three years to complete, it is only now that the impact of that decision is being felt. A difficult situation was compounded by the requirement for hospitals to have more staff on wards — introduced following the Francis Inquiry which found that “inadequate staffing levels, recruitment and training” had contributed to the scandal of poor care and high mortality rates at the Mid-Staffordshire NHS Trust.
Although the number of training places has been increased more recently — 21,205 were funded last year — this is still lower than the number in 2009. There is also a worryingly high drop-out rate for student nurses — the average is 20 per cent, with some courses losing up to 50 per cent of their trainees — at huge cost to the taxpayer. This is mirrored by low retention rates among qualified nurses, with 45 per cent of the workforce now aged 45 or over, a significant increase in the average age of nurses over the past ten years.
The irony is that more people than ever want to go into nursing — the number applying to study the subject rose by more than a third over the past five years. Last year, 52,000 potential students applied for nursing courses — but more than 30,000 of them were turned away because there were not enough places. In every possible way, this is a scandalous waste. It is hard to think of a policy better designed to simultaneously solve the crisis in the NHS, bring down the unemployment benefits bill and help deal with public concerns about immigration than creating more training places for nurses. But ministers cannot see the big picture because they are obsessed to the exclusion of all else on the bottom line.
It costs about £70,000 to train a nurse, so it seems cheaper in the short term to hire one from abroad, on a salary of £23,000 a year, or to use agency staff who do not require a pension or holiday pay. But that’s a false economy. The health service, already groaning under financial pressure, is paying the price for politicians putting short-term advantage above long-term considerations.
One senior figure, who has been involved in commissioning NHS training places, says ministers have failed to understand the impact of their policies on the ground. “There is a double frustration — the failure to plan and the expectation that by announcing ‘we are training more nurses’ the nurses would appear, fully trained, next day to answer the call of government,” he argues.
Dr Sarah Wollaston, the former GP who is now the Conservative chairwoman of the Commons health select committee, says that the NHS has for as long as she can remember suffered from the “yo-yo effect” of poor ministerial planning.
Now hospitals are starting to take matters into their own hands. Lancashire Teaching Hospitals trust, based in Preston, has launched its own nursing degree, in collaboration with the University of Bolton. It is the first in the country to offer nurse student places that are not commissioned by the government quango, Health Education England. Undergraduates will fund their places through loans, rather than NHS bursaries, but will be offered nursing jobs in the hospital to help pay them back. Dr Wollaston thinks such semi-independent courses could be the future. Certainly, in a market where supply and demand have become so catastrophically out of kilter, it is time to question the Department of Health’s monopoly on commissioning the training of doctors and nurses.
As the spending review nears, it is easy for politicians to think that more money will ease all the NHS’s problems. But the real crisis this winter is not a funding gap but a staffing one — which ministers could and should have avoided.