Jef Smith discusses the role of nurses in residential homes and takes a look at why nurses are in such short supply in the care sector.

When considering the care industry in the UK, it is easy to feel that nursing homes should surely be a booming sector. The elderly population, from which care services of all sorts draw most of their customers, is steadily increasing. Higher numbers of people are suffering from long term health conditions towards the end of life. These are precisely the sorts of illness and disability which, while not needing intensive medical or hospital care, do significantly benefit from readily available support from qualified nurses. Providing expert nursing in a sympathetic non-clinical setting is exactly what nursing homes can do well. In theory, there is growing demand and a larger clientele from which to draw residents.

Yet, despite this theoretically encouraging market background, barely a quarter of care homes — less than 5000 across the whole of England — provide on-site nursing. Furthermore, the quality of care they offer often leaves much to be desired. In its latest State of Care report, the Care Quality Commission (CQC) presents statistics on its quality ratings for various types of homes which reveal that 45% of nursing homes needed to improve while 10% were actually graded as Inadequate. The comparative figures for homes without nursing were 30% and 6%, which clearly puts nursing homes at a serious disadvantage.

For reasons which are interesting to explore but which CQC hesitates to spell out in detail, small nursing homes do significantly better than their larger counterparts in the grading stakes, with figures of no more than 7% for Requires Improvement and 4% for Inadequate, a total of 11%. This contrasts sharply with the record of the somewhat bigger homes, where the two lower ratings accounted for 52% of homes of medium size, and 46% those considered large.

This finding is broadly consistent with the equivalent for homes without nursing and confirms a long-term trend of a general correlation between good care and small size. Despite this, there is a strong tendency for newly opening homes to have a hundred places or more, presumably because profitability occupies a larger place than quality in the motives of providers and their financers.

The problem of recruiting nurses

One major issue holding back anyone contemplating opening a new nursing home, or indeed anyone running an existing one, is the seriously inadequate supply of nurses. Personnel planning is of course a complex process — there are many uncertain factors and timescales are long — but it is still difficult to ignore that the need for nurses has been badly underestimated, and the strategies put in place to respond to the resulting crisis have proven inadequate.

In the short term, it is difficult to see the supply of nurses trained in the UK improving significantly. The Secretary of State for Health claims that there will be an extra 20,000 nursing posts by 2020, but he proposes to fund these from replacing the current bursaries during training with a system of loans similar to those of university students. The Royal College of Nursing (RCN) pointed out that student nurses’ heavy involvement in clinical practice largely precludes them from taking on other income-generating employment during their training years. The result, RCN and other nursing organisations conclude, could well be to depress, not stimulate, nurse recruitment.

The profession has suffered serious blows to both its morale and its image over recent years. The fallout from the Winterbourne View scandal and related incidents has caused lasting damage.

Winterbourne View was variously described as a hospital and a care home; in fact, it was a sort of hybrid, and its nurse employees brought shame on both types of setting. The hospital and residential care sectors are often fishing for staff in the same pool, not least for qualified nurses, and homes, providers’ organisations like the Registered Nursing Home Association (RNHA), and the National Care Alliance often find it difficult to compete. The fact that the hierarchy of management is much shallower in the care homes context can of course be seen as a plus point, but opportunities for continuing education and career development are relatively limited outside the NHS.

Great job satisfaction

Nevertheless, for all its drawbacks, nurses who work in social care often pay tribute to the immense job satisfaction they receive. They welcome both the freedom to innovate which membership of a small team in a home provides, as well as the opportunities to reach a position of real authority at a relatively early stage of one’s career. The contacts with the wider community, the non-institutional setting compared with acute sector wards, and the way in which long term contacts with service users can be developed and sustained are all cited as reasons for preferring a home to a hospital as a workplace.

The issue of pay cannot, of course, be ignored, and here again social care struggles to keep pace with better resourced hospital services. In its 2015 workforce survey, Skills for Care presented data which “shows that nurses [in social care settings] are paid less than their NHS counterparts which may be contributing to their higher than average turnover rates”; the average salary is below £25,000, which is certainly not competitive, and turnover is over 30%, which also compares poorly with the hospital sector.

This situation may be eased a little by the Government’s current review of the rate paid to independent providers for nursing services, the results of which are promised for the spring of 2016, but homes will still face enormous cost pressures. These include substantial increases in regulatory fees, the continued squeeze on local authorities, which gives little scope for increased fee levels for contracted places, the introduction in April of the National Living Wage, and incessant pressures to drive up quality leading to greater overheads.

Overseas recruitment

For a wide range of reasons, therefore, the managers of homes with nursing face considerable difficulties in recruiting qualified nurses. What has come to be regarded as the almost routine solution is to turn to foreign-educated staff to fill the gap left by the faults in the domestic supply chain. This has resulted in 37% of nurses employed in homes having a non-British nationality, and the age profile of the nursing workforce — 44% are 50 or over — suggests that overseas recruitment will remain an important tool for the foreseeable future.

Here, however, the profession and its managers run into the problem of public and political attitudes to immigration. In April 2015, Skills for Care warned that the sector’s heavy reliance on workers from outside Europe made them very vulnerable to changes to or the enforcement of UK and EU employment law. It quoted as an example the fact that nurses who began work before August 2011 would have to be earning £35,000 by August 2016 to get permission to remain in this country.

Anxiety about tighter limits to overseas recruitment of nurses led a consortium of organisations including CQC, RCN, Skills for Care, and various provider bodies to write a joint letter to the UK Migration Advisory Committee (MAC) in September 2015 calling for action to ease the regulations, which they saw as adding to their staffing woes. As Des Kelly of the National Care Forum (NCF) commented at the time: “Nurses play a vital role in adult social care and yet the recruitment of nurses in care settings has become increasingly more difficult... The demand for trained nurses currently exceeds the available supply and the gap will not be bridged for some time.”

This plea did not go entirely unheard. In October, the Government announced that nurses would be added to the so-called “shortage occupation list”, which enables overseas applicants for nursing posts to be prioritised for immigration. The concession, however, is only an interim measure and the MAC has been requested to review the change and present further evidence early in 2016.

The care sector’s situation in relation to recruiting nurses, one of its most important resources, remains perilously vulnerable. Nurses play a unique part in the structure of care for older people, but it is a role which is far from fully developed or even properly recognised. The pressures over nurse recruitment and retention form a major threat not only within the care sector, but to health and care services as a whole. Given the financial and quality pressures on the NHS generally and on acute hospitals in particular, and the ways in which a strong cohort of nurses in the care sector can help ease these pressures, it seems self-defeating not to make comprehensive use of this valuable resource.

Last reviewed 10 February 2016