Speaker1: [00:00:00] Care in these places is completely inappropriate. That system is broken, too burnt out and just can't do it anymore. They're not going to survive. What's going wrong is affecting our public and our population primarily. 40 years' experience and you're still in the same pay band. We've seen adverts for corridor care nurse. It's an amazing profession. It's amazing job. Funding, it's money. Seven out of ten of those told us that they were considering leaving.

Speaker2: [00:00:31] Voices of Care. The healthcare podcast.

Speaker3: [00:00:35] Patricia, welcome to Voices of Care. So good of you to come and join us today.

Speaker1: [00:00:39] Thank you. It's great to be here.

Speaker3: [00:00:40] Well, it's a time, I think is it four years since you've been acting in this role? I remember seeing you back then, talking about your enthusiasm and advocating, I think, for fair pay and staffing, safe staffing levels. Same story four years later, is it?

Speaker1: [00:00:58] Sadly it is, and probably more of, to be perfectly honest, the last four years haven't seen really any improvements. If anything, things have deteriorated. In different ways, but certainly things are still the same, but sadly, possibly a bit worse.

Speaker3: [00:01:13] Well, the RCN has been on record as saying we're now facing a nursing crisis, and the chances of a grand government plans happening are not going to be very high unless we solve that. Can you paint what that picture looks like? It's a number of factors, I think, that have come together.

Speaker1: [00:01:29] Yeah. I think what we can see across both the NHS and social care are real problems, problems for patients and the population, residents, etc. people who need services. Primarily, and we have to put them in the centre of all of this, what's going wrong is affecting our public and our population primarily. But for nursing, what we've seen is increasing number of students leaving, nursing, being a student. We've seen fewer people wanting to become nurses. We've seen more of our experienced registered nurses leaving, burnt out and just can't do it anymore. We see patients in corridors being cared for in inappropriate places across all of our services. It isn't just in acute hospitals, in mental health, in the community. It's the same, you know, wherever you are. So for us, the crisis and a number of factors all coming together at this point in time is having an impact across the board, both on the public and, of course, on our profession.

Speaker3: [00:02:35] Yeah, the corridor care. Obviously, you spoke about it earlier this year and produced reports around it. That's not isolated or regional. It seems to be almost systemic.

Speaker1: [00:02:45] Absolutely. And that's probably one of our biggest concerns, that it is normalised now. It is almost an acceptable way of managing patients. We've seen adverts for corridor care nurse and even doctors, you know, to care for patients. And once that becomes normalised, we've got a really big issue because what the public have to know and what our members tell us is care in these places is completely inappropriate. It's unsafe, it's unsavoury. We hear of patients who are having, you know, really undignified treatments given in a open space. But it really is the sign of a system in crisis when you've got that happening on a regular basis. We probably saw it in the past, and I recall over my time working at the RCN at different conferences, for example, talking about care being given in corridors or in cupboards and converted cupboards. But it was perhaps seasonal in a few places. Now it is almost universal. It's almost everywhere, all of the year. And as I said before, we shouldn't just see this as a problem of acute hospitals. This is the same in the community. It just manifests itself in a different way, where patients wait too long to see a community nurse or the community nurse is trying to see way too many patients in a day and can't and can't get to do it. It's the same in mental health services. We've got patients staying in emergency departments way too long, waiting for a bed to get into a mental health service. So it's affecting all services.

Speaker3: [00:04:37] And I guess part of that is obviously it puts pressure on obviously the workforce, their own sense of being valued, and value isn't quantifiable, but something that is, of course, to be paid what you're worth. And fair pay is an element of this crisis. I think as we're recording here at the beginning of May, we're still waiting for the pay award announcement.

Speaker1: [00:05:00] We are for the NHS. We are still waiting. And this government promised to do the right thing and to publish the reports and make their recommendations, and pay earlier because this is a pattern that we've got into of late payment. So members should have had a pay rise on the 1st of April. We've got no sign of even what that pay rise is going to be, let alone it being paid. And we think the system is broken. The system for nursing pay is broken. We've been calling for direct negotiations for nursing because even with these delays, we're not going to get what we need. We can tell we're not going to get what we need to help contribute to solving the crisis for nursing.

Speaker3: [00:05:45] And I mean, we don't know what the figures are, but I mean, I know in December '24, 2.8% was mentioned. Your response, I think, probably privately wasn't printable, but publicly it was not an endorsement. And I think the context for this, I think I'm a big fan of putting context around this. I think I mean, the Health Foundation have recently, literally this month, talked about average pay in the NHS being 8 or 9% lower in real terms than it was 15 years ago. I think for nurses, it's something almost like 24%.

Speaker1: [00:06:16] Yeah, it's over 20%. And that for us is why we're saying it's not just about this cost of living rise. It's not just about what the pay review body says. That system is broken. It's failing nursing and has failed nursing for a long time now. We need direct negotiations in order to be able to negotiate the things that are going to work for nursing, and some of that is more complex than the percentage pay rise per year. Some of it is about redressing some of the imbalance that is in the system, so that some of our lower grade, we've got lots of our members who start their career as a band 5. That's the lowest band for a registered nurse, and they end their career 40 years later in the same band. 40 years' experience and you're still in the same pay band. It can't be right. And we're the only profession within the NHS to whom that happens. And when it comes to our members who are black and brown, even more so, they are absolutely locked to the bottom of our pay scale.

Speaker3: [00:07:22] Well, 40 years you've talked about we're at a seminal moment. We've had Lord Darzi's report, we've got a ten-year plan. And the RCN have been on record when you met the health secretary not too long ago, and you were saying that big changes, NHS England abolished going back to the centre, a ten-year plan, that this could be an opportunity for hope in very brief terms. Is there some hope in the ten-year plan that you think should materialise? Perhaps this would be one item.

Speaker1: [00:07:54] So yes, I mean we have to hope and we have to keep trying to influence to ensure that all of the changes, the aspirations of the ten year plan that we know about, the shift to community, a focus on public health and prevention, all of those are the right things to be thinking about. But nursing has to be part of the solution, where the biggest part of the workforce, where the people that deliver most of the care and have got the opportunity or the opportunities to do even more of that in the prevention field, etc.. So we need to see that nursing is front, left and centre of that plan, to really have a hope that the plan will deliver what the government aspires through it. At the moment, we remain, I think, dubious as to whether it's going to deliver. We wait to see but unless nursing's at the centre, we can be very clear. The plan won't work.

Speaker3: [00:08:50] I'd like to just focus a little bit around the ten-year plan and the shift, the left shift to the community, because that's quite important. People's perceptions around nursing tend to associate them with acute settings. Looking at community first, what are your thoughts? Because over the last decade or so, we've seen quite a significant fall in the number of health visitors, district nurses, school nurses. I think the projections are on current trends, the numbers will be halved by 2029.

Speaker1: [00:09:21] Yeah. And those are the sort of things that need to be redressed because without more community nurses, without more health visitors and school nurses, we're not going to be able to shift the services from the hospital to the community and really focus on prevention. And there's been an aspiration for many times and many years to do this. But to really do it, they're going to have to really think through who do we need to be doing those things? And we're very clear. It's nurses, and that focus on general practice is another element of the plan. And at the moment, we would say that that system is broken too. That general practice nurses are not seen for what they're doing and what they're contributing to the system. As that gets revamped and we can see hope that the negotiations are looking at a different way of managing contracts, but that needs to include a shift in the way nursing is treated through that. It needs to recognise that nurses in general practice need to be paid the same as their colleagues in the NHS, and they need the same pay terms and conditions and the same opportunities that other nurses have as well.

Speaker3: [00:10:36] And remarkably, I think the numbers show that in GP practices, 30% of nurses didn't get a pay rise, which is quite remarkable.

Speaker1: [00:10:44] None at all. None at all. When in the last couple of years, there have been promises around 6% and various things which have come through the increase to the GP contract. So it is really disappointing that that is not being passed through. And they're an older workforce typically. But we are seeing increasingly people not going into that as a workplace and people leaving. So, a real risk in general practice, they won't be able to deliver without nurses either.

Speaker3: [00:11:15] One more question around the NHS ten-year plan, NHS transformation. You alluded to certain groups, minorities not having the same opportunities. I was struck by the NHS staff survey this year, and I want to talk to you about the culture that's going to need to be shifted as well within the NHS. I think the numbers show 35% of your members or nurses are experiencing bullying and harassment, and 14% discrimination. So that's going to be something that's profoundly going to need to change.

Speaker1: [00:11:51] Oh, absolutely. It's heartbreaking to read those sorts of stats.

Speaker3: [00:11:55] Shock waves, I think you said you were saying.

Speaker1: [00:11:58] Yeah, it is. It's shock waves. But on a very personal level, having been a nurse for over 40 years, it's an amazing profession. It's an amazing job. And they're amazing people. And to think that on a daily basis, you're going to work, and very regularly, you're finding yourself being abused by patients or discriminated against by your colleagues or patients. We can't expect people... That has a massive impact on them, on morale, but also on their health. So these fundamentals need to be addressed by the NHS. We have staff going to work when they're sick, huge numbers going to work when they're sick, because they know the impact of them being off sick because there aren't enough staff already. So these things have to be addressed. And one of the ways of doing that is to ensure you've got enough people in the workplace, because patients are frustrated because they've waited too long. They take that out on the people that are there in front of them. So it's a vicious cycle. Without the investment in nurses, having enough staff, then actually a lot of these problems will not get resolved.

Speaker3: [00:13:05] Well, thank you for your candour there. Let's move to social care. That's got its own new milestone potential, Casey commission. But before we look at that, the role of nursing in social care is well established. And if you can paint the picture, nursing is fundamental to how the social care system actually delivers.

Speaker1: [00:13:28] Yeah. Both in people's homes and in social care settings, residential and nursing homes, etc.. And the role that nursing plays is partly keeping people out of hospital and out of healthcare settings, as well as helping them to get back into their own homes or back into residential care, where we've got highly skilled people doing very advanced skilled care to support people to live in their own homes. But we've seen a significant drop again in the number of nurses, registered nurses working in social care, filling the places there. And that has an impact on the patients and the residents. Without enough staff, the care that those patients receive, residents receive is not going to be up to standard. So the NHS and social care systems need to work much more closely together. They are one system. It's absolutely vital that our older people, in the main, who are living, needing social care services, have got access to high-quality expert services to prevent their health deteriorating and requiring hospital or other services.

Speaker3: [00:14:48] And I mean, I was struck, again, from what you've said there, that I think the number of registered nurses over the last decade or so has dropped by 35%, according to Skills for Care. We were very fortunate to have Professor Deborah Sturdy as one of our guests, who spoke so passionately about the role of nursing in social care. So the other issue is, of course, the turnover rate among nurses is so much higher. So what would the RCN like to see when the Casey Commission eventually reports to turn that around, because your members are clearly doing a huge job, but under tremendous pressure in that context?

Speaker1: [00:15:23] So I think the first thing I would say about the Casey review is it's a shame it's been kicked down the road again.

Speaker3: [00:15:31] They haven't had any meetings yet.

Speaker1: [00:15:31] It's just one after... We have one review into social care after another. Always long-term, always kicked down the road and then never implemented. So there's a real fear for us. Number one, we've got a three-year wait. And number two, will it actually be implemented? At the root of all of this is funding. It's money. And whatever the system is, more money has to be available to go into social care. We are living longer, we have higher needs, and we just have to accept that. We are going to have to ensure that there is funding into local authorities, as the current system stands, to enable them to fund the care that patients need. And part of that will be having to address the reality that people working in social care also need to be able to receive good levels of pay, good terms and conditions, good levels of support and access to ongoing development in order to be able to live as safe, and high-quality care. So the funding model has to include addressing the elephant in the room, which is a lot of our social care colleagues get paid and treated even worse than our staff do in the NHS. And then we also know that we have people relying on overseas recruitment, both in the NHS and in social care. And colleagues from overseas often get treated yet worse again.

Speaker3: [00:17:02] Well, that's a perfect place to actually develop that discussion because looking at solutions now, the funding and pay, all of these things that you've called for, are going to take time. Right now, of course, care needs to be delivered. And addressing this recruitment retention crisis in nursing. I wanted to get your views because you said you mentioned it earlier. There's been a collapse, if that's the right word, in the number of applications, patients for student degrees and the long term workforce plan, which I know Mr. Streeting is looking to review, is predicated on a remarkable increase in the number of nurses over the next decade.

Speaker1: [00:17:44] Absolutely. So since 2021, which was a bit of a peak, presumably caused by Covid, when everyone was very excited on what nurses do. We have seen a significant fall off of the number of people applying to become registered nurses, to go to university to train. But alongside that, we also see that 21% of those that start their course don't finish their course, and huge numbers of those that qualify and register and start leave within the first five years of their registration. So the signs are not good that the education system is working well for us. So it has to be addressed when you've got... We did a recent survey of our student members. Seven out of ten of those told us that they were considering leaving their course because of financial reasons. So we can see again that money is definitely an issue. There's other things that need to happen, but certainly money is something that needs to be addressed.

Speaker3: [00:18:49] Now that's a remarkable number, as the plan assumes a 92% increase in the number of nurses over the next decade. You're saying seven out of ten are considering leaving? 21% don't complete the degree. And it seems like a huge amount of waste because it costs something like £60-£65,000, according to the Nuffield report, to train a nurse. And that's going to have a knock-on effect. I guess that's also had an impact on the fact that we've had to rely on international workforce to cover that gap.

Speaker1: [00:19:20] Absolutely, absolutely. The plan to fill all the gaps that we did have. So we had around 40,000 vacancies in the NHS for registered nurses. Previously, the plan to fill those gaps was not actually to invest in growing our own, it was to recruit from internationally, from overseas and so a lot of the gaps have been filled. We are now at about 27,500, so we can't deny, but it's still a large gap. But that gap has largely been filled by international recruits. A cheap, quick fix, not a long-term solution. And what we need, and it's very clear what we need, is a long-term solution that doesn't take staff from countries that actually, in many cases, need them even more than we do in reality and actually then will move through. Many stay for a long time, but many are not here for that long. We actually need to be able to grow our own. It's not the right policy to be relying on international national recruitment to fill our educated nurse places.

Speaker3: [00:20:29] And there's an additional pressure because the work that you've done at the RCN, I think, unbelievably, is 67% increase in the last few years of people who leave within five years of qualifying, 43% within ten years. So the actual nursing workforce, its demography and its experience levels.

Speaker1: [00:20:52] They are really changing. Really changing. And we have to address recruitment. We have to address retention because if you are going to recruit more, if they come into a workplace that has no staff and is dysfunctional and they're surrounded by inexperienced colleagues, then they're not going to survive. And we think that's part of what's happening.

Speaker3: [00:21:20] Interesting.

Speaker1: [00:21:20] As people have moved on and chosen to retire or leave earlier, change profession, which we've never really seen before, we've seen an increase in the number of people leaving nursing well before they retire. So we're losing experience. It's one of the contributing factors that, as you're coming out, you're not surrounded by expertise and experience.

Speaker3: [00:21:43] To support your own career.

Speaker1: [00:21:44] To support your own career. And you're thrown in at the deep end. And that's a scary place to be, because at the end of the day, the majority of nurses are talking about people's lives every day. Not, you know, whether you're counting a few beans here or there. It's serious stuff that they're doing, they're safety critical, and it's scary if you're not supported. So we have to address the retention issue if we're going to address the recruitment issue. Pay is a significant factor in the retention issue, alongside ensuring we've got the right culture, the right number of people with the right skills in the right place who are valued for doing what they're doing.

Speaker3: [00:22:22] Well, let's go to the recruitment point because we are going to, as you say, have to grow our own. That's the right policy for many different reasons. And you've talked about the leaky bucket, people leaving the training and studying. I think 70% saying it's for financial reasons. Can you expand upon that? Because you've come up very recently with a very radical plan to reverse that, if you could share that.

Speaker1: [00:22:48] Yeah. So, a few years ago, the government removed the bursary. So, until that point, nurses, if you were studying nursing, you didn't have to pay. You didn't have to pay the fees and the tutor fees. And so when they removed the bursary, you did. So immediately, people started accruing debt. So you have to pay the same way as others do.

Speaker3: [00:23:13] So 25/26 it's £9500, something like that.

Speaker1: [00:23:17] And three years of that or four years of that, depending on what program you're doing. So that's significant. But on top of that, it is difficult for student nurses to actually work. A lot of students work alongside.

Speaker3: [00:23:29] Yes. Of course.

Speaker1: [00:23:30] Or through the summer, etc., for students, not possible. Their courses are longer. They don't have a long break in the summer.

Speaker3: [00:23:37] And lots of clinical work.

Speaker1: [00:23:38] They actually are doing clinical work in the same time. So, trying to work alongside that, some of them do. But to be honest, that's a tough gig to expect to work alongside a full-time education programme as well as clinical hours.

Speaker3: [00:23:51] And then that leads to, I think, the average £48,000 of student debt. And you're now saying it should be forgiven.

Speaker1: [00:23:59] We absolutely have the... we had a study done for us to look at the cost of actually forgiving that debt if people pay back by other means, staying in the NHS or other public services. And what that has demonstrated is that nurses are likely to stay longer in the NHS or public services, 7 to 10 years longer, if their debt is forgiven. So it's a significant impact. That's many, many more years out of individuals and collectively many years more a service in reply to this policy change. So we would really, really urge the government to be thinking about this as a serious option to consider what would make nursing more attractive to come into, but also would encourage people to stay longer.

Speaker3: [00:24:57] And how does how are you proposing that that work? So the longer... Certain percentages are forgiven, if they stay for a certain period of time within the NHS, etc..

Speaker1: [00:25:07] Our proposal would be that if you stay for three years, you get 30% written off, forgiven. If you stay for seven years, you get 70% of it written off or forgiven. And if you stay for ten years or more that you get the whole thing written off so that you can see an added value in being a registered nurse. And actually financially at the beginning, you can see if you are accruing debt, it's not that part of the debt that you're going to have to pay.

Speaker3: [00:25:38] And I think you did the study with, I think, London Economics. And they found that if this does work, I think 65,000 extra years of nursing. And you'd potentially add, is it over £1 billion of value add?

Speaker1: [00:25:52] Every year, every of the extra years that people stay would add around £1 billion back to the economy. And the cost is probably around £200,000 a year. So we're not talking about a bad investment and we're not talking about losing money. We're talking about gaining money, essentially, by this policy.

Speaker3: [00:26:19] And I think that if we don't do it, the cost of inaction. I think the report mentioned on current projections, you could over the next few years, the end of Parliament, is it 32,000 nursing cohorts, members of cohorts, actually leave?

Speaker1: [00:26:34] Leave? Yes. And that's how it is now. And we've got a genuine concern that it's going to get worse, that the numbers leaving will increase. Both through the student years, but also when they stop because there's no sign of at the moment of anything changing. So, whilst it may feel like a drastic policy change for us, it feels like a no-brainer. It just feels like it makes financial sense as well as it makes healthcare sense and nursing sense.

Speaker3: [00:27:08] And since you've published the proposals, how have they been received in terms of the sector and policymakers, I guess would be the most important.

Speaker1: [00:27:16] There is some interest definitely. One of my colleagues was meeting last week with Department of Health and Social Care around that to explore it further. So we are certainly continuing to push that this is a viable option to contribute to solving one of the problems of nursing and healthcare.

Speaker3: [00:27:38] And alongside that, obviously the role of apprenticeships. And this was quite fundamental in the long-term workforce plan published in 2023. Big increase in the use of apprenticeships. Where does that sit in? Does that help in addressing this issue? Will it solve the problem?

Speaker1: [00:27:55] Well, there's no doubt that apprenticeships can really help contribute to nursing. When the bursary was removed, the big drop in the numbers that came in was of more mature people, second career people for whom either they've already got a debt from a first degree, or they've got other commitments that they can't afford to go into that world of taking on student debt. So, apprenticeships do offer an alternative. Most definitely. But it's tough. That's another tough way of doing it to work alongside trying to do a degree apprenticeship program. But it is an option. But until the government solves some of the apprenticeship model funding model problems, the levy and the way the levy works for employers, currently, many employers don't see it as being a really attractive option for them to be able to invest significantly in. So there are other barriers to apprenticeships that need to be unlocked. And again, they shouldn't be insurmountable. It should be doable to unlock those. But we would absolutely not want to see a two-tier system where people who can't afford it only have the option of an apprenticeship. We absolutely believe that a traditional university based degree program, alongside other colleagues and other peers, to enable you to study to be a nurse should be a viable option for anybody who wants to be able to take that.

Speaker3: [00:29:33] Well, we're hoping that the government is listening to the podcast and your submissions. One final question, if I may. The transformation in the NHS and social care that's promised in the Commission and ten year plan will require the RCN has said on record to make sure that nursing remains at the centre of that and we don't lose national leaders. We've been privileged together with yourself and others. Many nurse leaders to join Voices of Care. Nurses and their ability to lead, and the leadership provided by nursing, is going to be so important over the next few years. Can you perhaps give your thoughts on 40 years of experience, of how we ensure we encourage that expertise.

Speaker1: [00:30:11] Well, I think actually quite a lot of the things that we've talked about contribute to leaders wanting to stay in the system and wanting to be around. I think there's a real concern at the moment around some of the changes we're seeing at NHSE in the integrated care boards and systems around us, losing nursing expertise and nursing leadership. And we would really urge the government to think carefully. We have over 3000 members working in ICBs. We have hundreds of members that work in NHS. These are not bean counter people. These are clinicians who are offering expertise, clinical expertise into commissioning decisions, quality decisions, safeguarding decisions, all things to lead the NHS and social care systems, all expertise that is absolutely needed alongside ensuring that senior experienced expert clinicians at consultant nurse level, at advanced practice level, etc. are paid to do what they are right to do and employed to do. And that that's recognised as being a huge contribution to what services patients can receive.

Speaker3: [00:31:32] Well, on that note, and that call to action, Patricia Marquis, thank you so much for coming in and sharing your wisdom with us.

Speaker1: [00:31:38] It's been a pleasure, thank you.

Speaker3: [00:31:39] Likewise, if you enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on the health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us, and I look forward to seeing you on the next episode.

Speaker2: [00:31:59] Voices of Care, the healthcare podcast.