Winter planning 2023-24

The Royal College of Nursing (RCN) is the world’s largest professional organisation and trade union for nursing staff, with members in the NHS, independent and voluntary sectors. RCN Scotland promotes patient and nursing interests by campaigning on issues that affect our members, shaping national health policies, representing members on practice and employment issues and providing members with learning and development opportunities. With over 48,000 members in Scotland, we are the voice of nursing. 

The staffing crisis facing Scotland’s health and care services has never been more apparent with the winter just passed being recognised as the worst on record for NHS services. Staff shortages are impacting on the quality and safety of care across all services and Audit Scotland has identified workforce capacity as the biggest risk to NHS recovery. Scotland simply doesn’t have the nursing workforce it needs and action to tackle this workforce crisis, and therefore support winter resilience, has not been sufficient.

It is important to note that over the last few years, pressures in the health and care systems have not let up over the summer. The system is under huge amounts of sustained pressure and action to tackle this must focus on addressing workforce shortages in a sustainable way.

The latest NHS Scotland workforce statistics show over 4,000 registered nurse posts across Scotland remained vacant at the end of March. This equates to 8.5% of posts. There has also been a decrease of 558 WTE nursing and midwifery staff in post in the past year. Meanwhile in care homes for older people, the latest available data shows that 64% of services had nursing vacancies in December 2021 compared with 48% the previous year - this represents a 16% increase in nursing vacancies at a time when pressure on the system has never been higher.

To fill the gaps in the nursing workforce, the use of staff from agencies has increased dramatically, rising to the equivalent of 1,741 WTE nursing and midwifery staff in 2022/23, up from 1,018 WTE in 2021/22. The cost in 2022/23 was a staggering £169.7m, up 91% from £88.8m the previous year. To put this in perspective, the agency spend two years ago was £39.3m. Total spend on bank and agency staff combined was £447m in 2022/23, up 39% on the previous year. While some investment in agency nursing will always be needed to cover unexpected events and ensure safe patient care, it is not the solution to the current workforce crisis and this level of spend is unsustainable.

The Scottish Government Winter Resilience Overview focused on international recruitment to boost the NHS workforce over Winter 2022-23, with a target to recruit up to 750 additional nurses, midwives and allied health professionals from overseas. While the Scottish Government has announced that this target has been exceeded, as of June 2023, less than 300 of these new internationally recruited staff were actually in post. Our internationally recruited nurses are, and always have been, invaluable to our health and care services. However, the numbers are small in the context of our workforce crisis and the process of recruitment and induction is not speedy. Against the background of a global nurse shortage, the Scottish Government’s focus must be on efforts to stop our experienced staff leaving and making nursing an attractive and rewarding career choice.

In RCN Scotland’s 'The Nursing Workforce in Scotland' Report, published in May, we highlight how expanding our nursing workforce must involve sustainable domestic recruitment and retention of our existing highly skilled and dedicated nursing staff. The report’s recommendations set out how the RCN believes these objectives can be achieved, including the need for the new Nursing and Midwifery Taskforce to deliver timely, sustainable and funded changes to address persistently high nursing vacancies. The Taskforce must look at how Scotland can retain experienced nursing staff, develop new routes into the profession and ensure nursing is a career of choice once again.

The Health and Care (Staffing) (Scotland) Act, passed over 4 years ago, is due to come into force in April 2024. This groundbreaking legislation will only make a long-term positive difference if services have the nursing establishment they need. The high levels of nursing vacancies in health and social care need to be addressed as a matter of urgency ahead of implementation and an accurate, transparent baseline must be published before April 2024 to enable trend data to emerge over time.

In November 2022, RCN members in Scotland took the historic step of voting in favour of strike action to take a stand for their patients and their profession. Subsequent negotiations resulted in a pay offer that was narrowly accepted by members and secured the commitment to the Nursing and Midwifery Taskforce and a review of the Agenda for Change Framework. While RCN members voted in March to accept the Scottish government’s NHS pay offer by a narrow majority, a significant minority of members voted to reject the offer, a demonstration of their continued frustration and concern about the nursing workforce crisis facing Scotland’s NHS. The chronic staff shortages and low morale that led to the strike mandate are still very real and we are clear that the Scottish Government must live up to its promise to reform Agenda for Change to support recruitment and retention and recognise the clinical skills and expertise of nursing staff. Further improvements to pay, terms and conditions are needed in the years ahead and the Scottish Government must work with the Scottish Terms and Conditions Committee (STAC) to secure a mechanism for the future determination of Agenda for Change pay, well in advance of this winter.

Lack of capacity in the community health and social care sectors were key factors, with delayed discharges preventing the effective flow of patients within hospitals and a lack of preventative support in communities resulting in more people being admitted to hospital. The critical situation across Scotland’s hospitals will not be solved until the social care and community sectors have the right numbers of staff, with the right skills, in the right place.

Community nursing teams are under extreme pressure, with over 1,400 nursing vacancies in community settings – this equates to 11% of posts. The vacancy rate for registered nurses in district nursing is 10%.

Complex health care needs are increasingly being met within a social care environment which means that the skills and availability of the nursing workforce employed within social care settings is becoming ever more important. Yet there are over 1,400 fewer registered nurses in care homes for adults than in 2012, a 27% decrease. The clinical skill, contribution and impact of registered nurses in community, social care and primary care services must be recognised.

Action to increase the number of registered nurses in these settings must be prioritised over large-scale structural reform. We share the desire to improve the quality and consistency of social care and community health services across Scotland. However, it is entirely unclear how the current National Care Service Bill will achieve this or address the serious challenges within a sector that is in crisis. Ultimately improving the quality and consistency of services cannot be achieved without increasing investment, tackling the workforce crisis and recognising (and resourcing) the increasing need to deliver complex clinical care within community and care home settings. Services must have the right numbers of staff, with the right skills, in the right place and that needs to start with increased investment and improving pay, terms and conditions and career pathways within the sector.

Thousands of registered nurses are missing from teams across Scotland, impacting on the safety and quality of patient care and putting even more pressure on staff who are already working extra unpaid hours to cover gaps and going home feeling that they are unable to provide the quality of care they want.

The latest annual report from the Nursing and Midwifery (NMC) register shows that the number of nurses leaving the register in Scotland increased again over the past year. Concerningly, it also reported that, after retirement, concern for their physical or mental health was the most common reason for leaving the register. Meanwhile the latest NHS workforce data shows that the sickness absence rate increased from 5.7% in 2022 to 6.2% in 2023 and the turnover rate increased from 9.1% in 2022 to 10.4% in 2023.

Too many nursing staff are leaving the profession, across all career stages, from newly registered nurses leaving after only a few years in nursing, to those choosing to retire earlier than previously intended. For every nurse who leaves the profession, valuable experience and expertise are lost. Our members have told us clearly that feeling undervalued, concerns about low staffing levels and workplace pressures are key reasons for wanting to leave nursing.

In addition to addressing the fundamental issues of safe staffing and fair pay, Scotland urgently needs a nursing retention strategy that covers a range of areas including:

- Career progression and development, included protected time for learning
- Health at work, including a focus on addressing the poorer health outcomes faced by nursing staff and a focus on adequate time and facilities for breaks
- Flexible working opportunities throughout an individual’s career
- Support for nurses in the early stages of their career
- Improve employer engagement and communication with staff
- Increase nursing student retention so that more students complete their degree course.

These issues are included within the scope of the work being taken forward by the Nursing and Midwifery Taskforce and we are calling for the Taskforce to develop, and the Scottish Government and employers to implement, a detailed retention strategy.

As the nursing workforce of the future, we are also calling on the Scottish Government to ensure nursing students have adequate financial support to allow them to prioritise their education, cope with the rising cost of living and complete their studies without falling into financial hardship. Given persistently high levels of nursing vacancies, and high attrition rates from nursing courses, a fair financial package has never been more important to encourage more people to take the undergraduate degree route into a nursing career and grow the domestic nursing workforce. A recent RCN survey of nursing students found that 74% said financial concerns are having a high or very high impact on their mental health, and 48% on their physical health, while 66% have considered dropping out of their course due to financial concerns. We’re calling on the Scottish government to improve financial support to show that nursing is truly a valued profession. This must include a cost-of-living increase to the nursing student bursary, and associated allowances, with regular review to ensure the bursary increases in line with the cost of living.

As discussed above, nursing workforce shortages are impacting on the quality and safety of care across all services – in acute hospitals, GP surgeries, care homes and communities. Responses to an RCN survey last year from members in Scotland highlighted that nearly 70% of staff felt that patient care was compromised on their last shift due to staffing shortages and only 16% agreed that they had enough time to provide the level of care they would have liked.

In May, RCN Scotland held a roundtable event where members met with MSPs and senior nurse leaders to discuss the action needed to tackle these challenges. Members shared the challenges of working in an environment where staff shortages have become the norm. They talked about the impact on patients and residents and on themselves and colleagues, highlighting the moral injury caused by being unable to provide safe and effective care.

The treatment of patients in inappropriate areas such as corridors and waiting rooms is increasingly common and, during the roundtable discussion, some members shared difficult stories about their experiences of care in inappropriate settings and the damaging impact on patient safety and dignity. We know this issue goes far beyond the doors of emergency departments, with nursing staff across many acute settings desperately struggling as they are forced to provide patient care in corridors and other inappropriate locations. This current situation is completely unacceptable for nurses and patients. No patient should ever have to suffer the risk or indignity of being cared for in such a way – and it cannot be allowed to continue to become normal practice in today’s NHS.

Long-term solutions to Scotland’s staffing crisis are needed, with proper workforce planning based on increasing population need.

The Nursing and Midwifery Taskforce, and the Review of Agenda for Change, are key opportunities to tackle, in a sustainable way, Scotland’s nursing workforce crisis. The Scottish Government must continue to prioritise these important initiatives and ensure that they deliver for Scotland’s nurses and those they care for.