We need more nurses, but this is not the way to get them

Conservative promises on nursing student numbers are not realistic – both the capacity of existing training providers and ongoing low levels of nursing applications suggest that wider investment would be needed.

There’s been a problem with recruiting nursing students in England since 2016. For this and other reasons the NHS will need more than 43,000 new nurses by next year, according to the Nursing Times. Conservative proposals have already been slated for including existing nurses in the total promised – but the higher education parts of the proposal are equally ridiculous.

The pledge

In 2016 the student bursary was removed and fees were levied for the first time. Couple these changes with an ongoing decline in mature student applications (a large number of mature student applications are for nursing courses) and the figures make for depressing reading – 66,190 people applied to study nursing in the UK via UCAS in 2016 – by 2018 this had dropped to 50,805.

So a Conservative manifesto promise of:

50,000 more nurses, with students receiving a £5,000-£8,000 annual maintenance grant every year during their course to help with their cost of living – and they won’t have to pay it back. Everyone will receive at least £5,000 with further funding in regions or disciplines that are struggling to recruit – such as mental health – and help with their childcare costs.”

…initially looks like something we should welcome. Figures within that 50,000 have been widely briefed to the press – of 50,000 new nurses, 14,000 will be recruited from undergraduate nursing training. There’s also 5,000 via the degree apprenticeship route, and – somewhat alarmingly – 19,000 existing nurses that Conservatives hope they can encourage to stay. The bursaries and childcare support should be attractive, though there is no suggestion that tuition fees will drop.

The numbers

Let’s take these figures at face value, and assume that the intention is to recruit 14,000 new undergraduate nursing students at English providers by the possible end of the next parliament (by 2023-24) – it’s too late to change (September) recruitment numbers for this academic year so I’ll assume 3,500 new places in each of four years. We should note that there may also be plans – that I’m not able to model – to expand postgraduate conversion routes.

In the 2019 UCAS cycle 28,120 applicants had a place to study nursing 28 days after A level results. This is a very slight drop from the 2018 end of cycle figure (28,540 acceptances) and maintains a recruitment level of around 28,000 since 2015 – so the acceptance rate has risen from around 50 per cent to just under 60 per cent.

For entry direct to a three year degree course, candidates are likely to need at least three A levels – usually between three Bs and three Cs, usually including science subjects. I note this because nursing is a demanding course – nursing applicants cannot just be rustled up. The acceptance rate of 60 per cent is relatively high, suggesting the majority of suitable candidates from the existing application pool are finding places.

Nursing students in England study at one of 62 schools of nursing attached to a university. The largest is at Anglia Ruskin, which had 2,970 first degree students enrolled in 2017-18, and saw 735 of these qualify last year. It has gradually been growing in recent years, and competition (as spoken eloquently of by the rise in the acceptance rate) has played a part.

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So, to meet the projected intake of extra nurses we would need the equivalent of a new nursing school the size of the one at Anglia Ruskin each year for the next four years. To run a school of that size would need something in the region of 200 members of academic staff – even if we take the more likely route of expanding existing schools this is not simply a matter of slipping a few more students into already full class rooms.

Where would the students come from? The hope is that the return of the bursary offer and the addition of childcare support would attract those who had been put off in earlier years. We’re still in the demographic dip, and although the numbers of UK 18 year olds will rise over the next few years it may not be fast enough to expand the pool of applicants.

The timing

A nursing course is three years long – students starting their course in the autumn of 2020 would not expect to be qualified to practice until the summer of 2023. So if there’s an ambition to meet the 50,000 target by the end of the next parliament (2023-24) the 14,000 I’ve been sharing out over four years will have to be recruited in two. Or more than 14,000 – as currently a quarter of all nursing students drop out (a rate that has stayed the same since 2006!).

This turns a rate of expansion that felt hugely challenging into one that stretches the bounds of credibility. Two nursing schools the size of Anglia Ruskin would be needed each year for the next two years (or if you prefer, more than 112 nurses in each existing nursing school… including the five that have less than 200 each) – and around four hundred new academic nursing posts (that would, ironically, take existing nurses away from practice.)

As nursing is a vocational programme that involves a lot of time on the ward, hospitals would also need investment in training capacity. This is an impact that has simply not been mentioned – the figures in the costings document don’t even cover 50,000 nurses salaries at a basic rate.

So the chances of hitting this new 50,000 new nurses target is slim. There is systemic investment that needs to happen before students hit the labs and the wards, there is an ongoing drop in applications that needs to be addressed. The bursaries may be part of it, but the experiences of nurses on the ward – attrition from the career of nursing is worryingly high – must be worth examining too.