Mounting pressures on the UK’s healthcare services are never far from the headlines, but growing concerns over a crippling shortage of nurses have focused attention this month on universities’ efforts to train the next generation of NHS staff.

With staffing losses now running at 10 per cent each year in England, some 3,000 more nurses left the health service than joined it in 2016-17, according to data published by NHS Digital. The figures have prompted industry leaders, including experts at the Royal College of Nursing, to call for an urgent review of what has gone wrong with a healthcare system said to be in crisis.

Despite a push for more places in training institutions, the number of nurses due to graduate in three years’ time “still won’t match up to the number of those leaving”, said Stephanie Aiken, deputy director of nursing at the RCN. “We’ve got 40,000 vacancies and an ageing workforce. If all the nurses who are eligible to retire do so in that time, we have got a massive problem on our hands.”

The abolition of NHS bursaries in 2017 and the shift towards nursing undergraduates paying for their courses using standard £9,250 tuition fee loans is one of several external factors contributing to the current recruitment problems, according to Sarah Green, head of nursing and midwifery at the University of the West of England.

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Meanwhile, nursing pay levels are also said to have fallen by 14 per cent in real terms since 2010, according to RCN figures, making it an increasingly unattractive career path for many prospective students.

Edge Hill University in Lancashire is one of the largest providers for nursing degrees in England, with about 1,600 student nurses currently but, while acceptance rates remain high, the institution has experienced a “substantial drop” in applications this year.

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“There was a time when we were attracting probably 7,500 applications, looking to take 500-550 students each year. That figure has gone down to probably more like 5,000 applications and it will go down again this year,” explained John Cater, Edge Hill’s vice-chancellor.

Since legislation was passed in 2013 requiring that nurses of all disciplines must be taught to degree level, putting an end to three-year diplomas previously available in England, universities have had an especially important role to play in the state of British healthcare.

Between 2010 and 2016, the number of applicants to nursing courses in the UK ranged between 61,800 and 67,400 a year, according to Ucas. In 2017 – the year that the funding model changed in England and NHS bursaries were scrapped in favour of standard tuition fee loans – this figure fell to 54,985.

The data, released by Ucas last month, also show vast regional differences. Recruitment was up in the North East but down in London and the South West, where overcrowded and understaffed hospitals feature regularly on news bulletins as politicians shake their heads.

For the most part, universities have responded to the drop in applications by increasing the proportion of prospective students that they accept, and many institutions find that their most popular nursing courses are still oversubscribed. Midwifery at Edge Hill, for instance, currently has 512 applications for about 20 places next year.

But there were still 270 fewer acceptances in the UK last year than in 2016 – representing a huge blow to efforts to reduce NHS shortages by the government, which promised to provide 10,000 new nursing degree places by freeing up cash from the student loan system.

Most strikingly, mature students are increasingly being put off enrolling. Last year, while the number of English 18-year-olds being accepted on to nursing courses increased by 11 per cent, there was a 13 per cent drop in acceptances from those aged between 21 and 25, and a 6 per cent drop among those aged 26 and over. This means that, for the first time since 2008, more English 18-year-olds were accepted on to nursing courses than 21- to 25-year-olds; and this is something that could have big consequences for retention in the healthcare sector, according to the RCN’s Dr Aiken.

“Nursing in recent times has attracted a more mature student whereas now we are seeing the cohort change so that there are more school-leavers coming in,” she explained. “That’s significant because we do not know if that will have an impact on retention and attrition.

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“If you come into nursing with life experiences it may be that you are more able to manage and cope with some of what you’re exposed to on nursing courses. Mature students bring something different to the workforce.”

While it is “too early” to know the true impact of the bursary abolition, experienced nurses such as Dr Aiken point to the loss of funding support as an important factor.

“Our members tell us they could not have afforded to come into nursing without it,” she said. “Many mature students already have caring responsibilities and therefore could not afford to fund themselves through university on top of that, regardless of the long hours expected of nurses working on placement during their degrees.”

Alistair Fitt, chair of Universities UK’s health education and research policy network, and vice-chancellor of Oxford Brookes University, a large provider of nursing degrees, said that while it was “not surprising” to see that the scrapping of bursaries has resulted in “some hesitations”, it was all too easy to blame the changes for the fall in applications, when in fact the system had been “unsustainable”.

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“Falling applications has some relation to the end of bursaries, I think, but the bursary system had to end,” he said. “Under the old workforce planning system, the amount of money available for training was being pushed down year after year so strategically a change had to happen or universities would just not have not been able to afford it any more.”

For Professor Fitt, “the real problem that’s been exposed by the NHS digital figures is the poor staff conditions and low morale in the NHS”.

Dr Cater, meanwhile, sees the current crisis as the result of the government’s decision to cut recruitment targets for nursing programmes by 16 per cent in 2012.

“The consequence of that was that, in 2016, when that cohort graduated, fewer nurses were going into the NHS system, creating a trough,” he said. “We have taken on more students this year, but actually we will not have an output of those nurses until 2020-21.”

So what are the possible solutions? Some suggest better advertising, promoting nursing as a worthy and potentially well-paid career path. But, aside from the expense, there are potential problems with this model, according to Dr Cater.

“The more that you advertise, sometimes the more you can give that impression of a crisis,” he said. “So rather than being held as an aspiration, the job becomes something the state is trying to force people into. We’ve spent an absolute fortune on advertising for teachers and it hasn’t really worked.”

Rather, many argue that better communication is needed to help convince prospective students – young and old – that tuition fee loans are affordable and that there are several options for career advancement within healthcare.

“A lot of our students didn’t necessarily understand the changes to the bursary apart from ‘we now have to self-fund’,” explained Margaret Rowe, dean of the School of Health and Society at the University of Salford, which made headlines last year for dropping the word “nursing” from its title completely as part of a new marketing strategy.

Ms Rowe said that her department had seen a “dramatic” reduction in application numbers across all non-medical health courses in the past year, with some courses suffering a fall of 35 per cent or more.

“Of course they don’t have to repay [a student loan] until they start earning at a certain level – at most entry levels it would only be £5 a month,” she said. “But one of the things we have been working on is to improve our marketing materials to reflect that.”

Once again, mature students in particular have been impacted by the loss of bursaries at Salford, Ms Rowe said, “because they are the ones who already have commitments and don’t like the idea of taking on debt”.

For universities such as Salford and UWE, a key part of efforts to attract more students and improve the quality of training comes by working with clinical partners to provide well-supported work placements – a compulsory aspect of nursing training that accounts for 50 per cent of learning – although “the ongoing stability of this funding is uncertain”, said Ms Green.

The introduction of individual funding support not dissimilar to the “bargaining” seen by teacher training providers is another strategy that could help to draw in more mature and part-time students in particular. “Something that healthcare trusts could think about more seriously is telling students to study, take the loan, and then offer to pay it off once they’ve worked for them for a few years,” suggested Professor Fitt. “That to me seems cheaper than what they are doing now which is trotting off around the world at great expense to recruit nurses from other countries.”

Professor Fitt said that, overall, he was “upbeat that if we all work hard enough this problem will solve itself”.

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“We will increase the supply of nurses by the extra 10,000 that the government wants us to, but the government has to start sending the right message and supporting our campaigns,” he said.

rachael.pells@timeshighereducation.com