Ageing workforce, inadequate recruitment and poor retention
The UK nursing and midwifery workforce is ageing, and this is already having a considerable impact on services. In 2001, the largest midwifery age group in England was 35 to 39 years and in Northern Ireland 40 to 44 years; in 2012, this rose to 45 to 49 years and 50 to 54 years, respectively (Royal College of Midwives (RCM), 2014). According to the Royal College of Nursing's 2011 Labour Market Review, one in three UK-based nurses are aged 50 or older. This ageing population has been predicted as a major contributor to a reduction in the nursing workforce (Centre for Workforce Intelligence, 2011; RCN, 2011; 2013). One of the proposed solutions includes delaying retirement. This might be a short-term strategy, but if it is not backed up by appropriate training and recruitment drives, the benefits will be short-lived and the issue will only become worse down the line, when a larger wave of nurses and midwives retire.
A substantial (and much needed) recruitment drive has taken place for health visitors, which pledged an extra 4200 health visitors by 2015 (Department of Health, 2011). However, this is believed to have had a direct impact on other specialties, as this has targeted a shrinking pool of nurses and midwives (likely the result of a combination of budget cuts, a substantial reduction in training, retirement, and job dissatisfaction).
School nursing services have been particularly affected by this drive. It meant that, locally, priority was often given to health visitor training and services over school nursing (House of Commons Education Committee, 2014), affecting staff morale.
Relying on agency work to plug gaps in the midwifery and nursing workforce is costly and inefficient. Moreover, money spent on temporary health-care staff has increased in recent years (from £2.1 billion in 2012–2013 to £2.6 billion in 2013–2014) (House of Commons Committee of Public Accounts, 2015).
Overseas recruitment drives have been put forward as a solution to nursing and midwifery shortages. With a large number of NHS organisations reporting qualified nursing workforce supply shortages (Health Education England (HEE), 2014a), many are looking to recruit abroad. However, while this may temporarily boost numbers it does not offer a sustainable solution.
Investment in training needs to be backed up by good retention. To achieve this it is important to ensure that midwifery, health visiting and school nursing careers offer attractive opportunities and rewarding working conditions. This can also help encourage health professionals to return to practice, which can provide a short-term boost in qualified staff.
A combination of adequate training, recruitment and retention strategies should look to answer these issues in both the short and long-term. If planning the midwifery, health visiting and school nursing workforce is not just a numbers game (HEE, 2014b), the number of staff members remains essential to be able to deliver safe care.
Caseload/staffing levels
The latest NHS workforce statistics for these three professions in England are (Health and Social Care Information Centre, 2014):
Staffing levels are an issue across the three professions. For example, an RCM report shows that the number of midwives is inadequate, even if there has been an increase in the number of staff members. In 2012, there were nearly 130 000 more births than the midwifery service is staffed for (RCM, 2014). Even if the number of births has dropped slightly, there would remain a shortfall in the midwifery service. According to the RCM (2014): ‘The end of the baby boom, if that is what we are seeing, does not mean the end of the need for more midwives.’
Increasing complex needs also have an impact on midwives', health visitors' and school nurses' workload, meaning that an increasing number of staff members is needed to deliver safe care.
The CPHVA's (2014) recent school nursing figures show that in England the average school pupil has 12 minutes per year of school nurse time. In many areas a critical point has been reached, leaving children, young people and their families at risk. At a Nursing and Midwifery Council (NMC) hearing for misconduct following the tragic suicide of a young person, the school nurse involved (who has been cleared of all charges) had her caseload acknowledged by both the coroner and the NMC council panel as ‘heavy’, ‘busy’ and ‘ridiculous’ (BBC, 2014).
Fong (2014) calls for the setting of a minimum standard for caseload size in school nursing, while the Institute of Health Visiting (2014) has called for a government commitment to a maximum ratio of 1:250 health visitors to families.
Fair pay
A healthy step towards fair pay for frontline staff would go a long way in making midwives, health visitors and school nurses feel valued, and would help with recruitment and increase retention.
NHS staff members have suffered a pay freeze, which has lasted several years. The Government's decision to withhold the recommended 1% consolidated pay rise last year led to midwives striking for the first time, alongside nurses and other NHS employees.
Despite proposals early this year by the Government to honour this rise (RCN, 2015), much still needs to be done to achieve fair pay in a context of severe understaffing, increased pressures and rising living costs. Commenting on the 1% pay rise, Cathy Warwick (2014), CEO of the RCM said it: ‘still lags way behind the rising cost of living and will see our members earning the same in 2016 as they did in 2013.’ However, on 25 February, members of the RCM voted in favour of accepting the 1% pay rise for NHS staff that was negotiated the previous month (RCM, 2015).
Training and CPD
In this context of increased pressures for midwives, health visitors and school nurses, it is essential that they are well equipped and supported to carry out their work. Yet, ambitious recruitment drives such as the Health Visitor Implementation Plan, need to be backed up by appropriate training, and cutting corners could be damaging to the profession and put staff and those in their care at risk.
For school nurses, the number of available training places needs to be increased to ensure skilled members of staff are available, while also taking into consideration this need for support beyond the specialist community public health nursing (SCPHN) qualification.
The widespread cuts in the health sector have had an impact on the availability of training and CPD. Yet, all three professions would benefit from targeted training on specific areas of need, such as delivering tier one mental health care. Investing in training and CPD can help them tackle issues early on, and help make important savings in the long term.
Giving midwives, health visitors and school nurses the tools and capacity to address current priorities
Addressing the above issues would help midwives, health visitors and school nurses to improve the quality of their care, including better continuity in care and cooperation between services.
Continuity in care is particularly an issue antenatally. Warwick (2013) said: ‘It is also ironic that, despite the evidence of the benefits of continuity of carer, when women are asked, the lack of continuity stands out. In a recent survey, half the women said that they never or hardly ever saw the same midwife twice in the antenatal period and three quarters had not met the person caring for them in labour beforehand … Knowing that continuity leads to better outcomes, how can we let this situation continue?’
Improvements in staff training and ratios would also equip nurses and midwives to efficiently deliver on current priorities, such as mental health. For example, child and adolescent mental health services (CAMHS) have been facing difficult cuts, with 59 out of 98 local authorities in England having cut or frozen their CAMHS budgets since 2010/2011 (YoungMinds, 2014). Currently, many school nurses, despite very tight resources, huge caseloads and a lack of mental health training, are being expected to step in and provide the mental health care that these children and young people desperately need but cannot access elsewhere. Yet, early intervention can help prevent mental health problems from escalating.
With increased capacity and skills, staff in all three professions could support governmental commitments, such as tackling female genital mutilation (Home Office, 2014). Continuity among the professions would also enable midwives, health visitors and school nurses to increase their commitment to, and delivery of, prevention and health promotion. Public health priorities such as breastfeeding promotion and obesity prevention can be effectively tackled if health professionals are giving consistent messages at every stage of the life course. To achieve this, it is necessary for a more joined-up approach among health professionals from conception through to adulthood.
Conclusions
As long as midwives, health visitors and school nurses only have capacity to fire-fight and their services are not properly invested in, we will not be able to benefit from the long-term changes they can bring to a population's health and wellbeing, and thereby a reduction in the economical burden of ill health.
With a general election coming up, BJM, JHV and BJSN are together urging the next government to address the issues we have highlighted to ensure the long-term health and wellbeing of the next generations.
We need a government with enough courage and vision to see beyond its 5-year mandate, because serious and substantial investment, not lip service, is needed to bring sustainable change. Anything short of this would have disastrous consequences on the health of the population and generations to come.