Topic analysis: Local accountability for workforce supply and retention

How we collected evidence

We reviewed legislation, guidance and plans at a national level to identify where roles and responsibilities have been allocated and clarified. We'll continue to monitor these documents to identify any significant changes.

What we learnt

The Health and Care Act (2022) requires the government to publish a report at least every 5 years describing the system in place for assessing and meeting the workforce needs of the health service in England. They have not yet clarified these roles and responsibilities since the Act became law in 2022.

The NHS Long Term Workforce Plan didn’t set clear roles and responsibilities for workforce decision-makers or include any measurable objectives, outcomes or success indicators. Without clear roles and parameters, it’s hard to conceptualise how this plan will be delivered. We continue to make the case for clear roles, responsibilities and delivery plans.

Neither government or ICS leaders have set out how they will:

• increase nursing staff numbers through undergraduate and postgraduate routes 
• resolve the financial pressures on students (including the cost of living) 
• incentivise more people to join the profession when working conditions are so challenging, and when nursing pay, terms and conditions remain unresolved 

We’re concerned that this level of ambition cannot be delivered unless significant capacity issues are identified, understood and resolved. This includes challenges with clinical placements, the capacity of the educator workforce and the availability of existing staff to support nursing students on placement.

There’s heavy emphasis on growing the number of nursing associates to 64,000 by 2036. We also see this in local recruitment campaigns and workforce plans. There’s no reference to understanding the scope of the role, or how (or whether) this has been considered in parallel to projections for registered nurses. Registered nurses should not be substituted with support staff – evidence shows that patient safety can only be upheld when there are enough registered nurses.

We’re concerned that increasing the number of nursing associates will have significant implications for social care and could risk inappropriate substitution of registered nurses across the entire workforce. This is unsafe for patients and for nursing associates. Employers should provide additional detail and assurances that the workforce is protected from inappropriate substitution.

Integrated Care System leaders should:

• Provide clear roles, responsibilities and commitments for workforce planning and supply within their Integrated Care System (ICS), to ensure transparency and accountability for workforce decision-making.
• Champion the need for national decision-makers to set clear roles and responsibilities for workforce plan delivery, so that ICS leaders can be clear on what actions fall within their remit.
• Make sure there is a nurse at executive level within their governance structure to provide professional, strategic and operational guidance to corporate boards and commissioners on nurse staffing (see the RCN Workforce Standards).

Services providers should:

Use the RCN Workforce Standards to support a safe and effective nursing workforce, and ensure nurse leaders are involved in workforce planning, setting staffing establishments and developing individuals within their workforce.

The relevant RCN Workforce Standards are:

• Ensure they have the right numbers of registered nurses with the right knowledge, skills and experience, in the right place at the right time to provide safe and effective nursing care to patients. 
• Have governance arrangements in place that are sufficiently robust to provide assurance that nurse staffing is adequate to provide safe and effective care for patients and clients. 
• Decisions and accountability relating to the nurse staffing level rests with the corporate board. Executive nurses are responsible for the information and advice they provide to the board. Other board members or members of a senior management team such as HR Directors may share this responsibility in some organisations. The board collectively is accountable for the decisions they make and the action they do or do not take in response to this information and advice. The board should collectively agree the operating framework for Executive nurses are responsible for setting nursing workforce establishment and staffing levels.