Think tank calls for healthcare workers’ student loans to be written off amid NHS dropout crisis

New analysis published today by the Nuffield Trust lays bare the scale of losses caused by clinical staff dropping out of training and opting out of careers in the NHS. High leaver rates among nurses and other clinical staff, both during training and early into their careers, are putting the NHS under severe strain and costing the taxpayer. This should be tackled urgently through initiatives including a scheme that gradually writes off their student debt over ten years, the think tank says.  

The Nuffield Trust’s calculations draw on over 190,000 student records and represent the most comprehensive look to date at attrition rates across the clinical career pathway – in training, post qualification and into the first few years of work. They reveal that one in eight nursing students dropped out during training, one in nine midwives do not join their profession after graduating and around one in five nurses have left NHS hospital and community settings within two years of joining. The analysis also looks at the medical workforce, finding that two training posts are required to get one full-time GP due to high rates of attrition and part-time work. 

The authors argue that losses from the pipeline of qualification and work represent a huge cost inefficiency, with the typical nurse costing around £64,600 to complete training. To shore up the domestically trained NHS workforce, which in nursing has seen new joiners drop by almost a third in two years, the Nuffield Trust examines strategies used in other countries, including tie-in initiatives to keep staff in the NHS, paid training placements and a loans forgiveness scheme. 

The Nuffield Trust concludes that loans forgiveness should be immediately made available to the 28,000 nurses, midwives and allied health professionals (AHPs) joining eligible public services each year. Such a scheme would gradually write off outstanding student debt - currently averaging around £48,000 per nurse - reducing it by 30% after three years of service, 70% after seven years and writing it off completely after ten years, in recognition of workers’ contribution to public services. The proposal is outlined in detail in an accompanying paper jointly authored by Dr Billy Palmer of the Nuffield Trust, Dr Gavan Conlon of London Economics and Dr John Cater CBE, a leading University Vice-Chancellor. 

The authors argue that such a scheme would increase the number of applications to clinical education courses, reduce attrition during training and grow participation in NHS, social care and other eligible services. It would be expected to cost around £230 million per year for nursing, midwifery and AHP graduates, which the authors note is less than the amount to be saved by Treasury through the incoming changes to the student loan repayment scheme. The scheme could be expanded to doctors at a cost of around £170 million per year.   

The Nuffield Trust report suggests that fixing leaks in the domestic staff pipeline would have an immediate impact on the number of clinicians joining the NHS. Current proposals contained in the government’s NHS Long Term Workforce Plan largely focus on increasing the number of training places.   

The Nuffield Trust’s data analysis of attrition in training and prior to starting work found:  

1. Well over twice the proportion of nursing and radiography students did not gain their intended degree (13%) compared to physiotherapy students (5%).   

2. Around one in nine midwifery graduates (11%) and one in seven occupational therapy graduates (15%) do not immediately join their respective profession. 

3. For every two GP training places filled, only one full-time practitioner joins the GP workforce.  

4. The proportion of doctors taking a pause in training after their foundation years doubled between 2011 and 2021, from 34% to 70%, and around one in six of those taking a break are not returning to finish training.  

The analysis of attrition in the early career phase found:  

5. 18% of nurses have left the NHS within the first two years of employment. This is around twice the level seen for midwives (10%).  

6. Fewer than three in five doctors in ‘core training’ remained in NHS hospital and community services in England eight years later, with half of this attrition seen in the first two years.  

The Nuffield Trust analysis also revealed that 6,325 fewer new nurses with a UK nationality joined NHS hospital and community services in the year to March 2022 compared with the two years before that (a fall of 32%). The Nuffield Trust says this rapid and significant fall will need to be monitored to see if it is a one-off drop or part of a wider trend. Existing figures show that more than four in 10 nurses and doctors joining NHS England hospital and community services were from overseas in the year to June 2022.  

Nuffield Trust Senior Fellow and report author Dr Billy Palmer said: 

“These high dropout rates are in nobody’s interest: they’re wasteful for the taxpayer, often distressing for the students and staff who leave, stressful for the staff left behind, and ultimately erode the NHS’s ability to deliver safe and high-quality care.  
 
“Simply ploughing more staff into training without thinking either about why they leave, or what might tempt them to stay, is enormously short-sighted. The government’s plans to increase clinical training places must be accompanied by a realistic plan to encourage staff to stay and reward them for doing so.  
 
“Our proposal to write off student debt is affordable, credible and could be implemented straight away. Policymakers need to seize this opportunity and begin to stem the unacceptable levels of attrition in the NHS workforce.”