Nursing is the single largest profession in the health service and is integral to the functioning of the NHS. While there has been welcome progress against the government’s commitment for 50,000 more nurses by March 2024, with some 24,190 more in 31 months, over half of the target is yet to be achieved.
Meanwhile, the current shortages are substantial. While headline nursing vacancy figures (over 46,800 in June 2022) do not reflect the contribution of temporary staff who fill many vacant posts, we previously estimated that – given vacancies and absences – some 17,000 posts were unfilled on a given day, although this shortfall will vary over time.
Yet in the last year, we have seen record numbers both joining the UK nursing register (around 48,400 in the year to March 2022) and joining the NHS in England (over 44,500 in the year to June 2022). With the taps being turned to full and the level not rising as required, it is perhaps timely to reflect on the rate at which the health service is losing nurses (Figure 1). Encouraging existing nursing staff to stay in the NHS, and reducing the leaver rate, are hoped to contribute in the region of 7,000 of the 50,000 target.
How many nurses are leaving the NHS?
In the year to June 2022, 40,365 NHS nurses in England left active service – equivalent to one in nine. Across the decade for which data are available, this is a peak in absolute terms (6,100 more leavers than the previous peak five years prior) and relative to the size of the workforce, with a leaver rate of 11.5% (Figure 2).
The trend on nurses leaving the NHS is perhaps even more stark in Scotland. For the most recent year available (to March 2022), some 7,470 nurses left, representing a leaver rate of 10.6%, or one in nine nurses. Across the decade for which Scottish trend data are available, this is the highest level in terms of absolute number of leavers and relative to the size of the workforce, with the previous peak – in the year to March 2018 – of around 5,020 leavers (nearly 2,450 fewer than recent levels) equivalent to a rate of 7.7% (2.9 percentage points lower). We were not able to identify any corresponding data for Wales or Northern Ireland.
The picture is not consistent within countries either. For England, rates of nurses leaving active service range from one in eight in the South West (12.3%) to one in nine in the North West and in the North East and Yorkshire (both 10.9%) in the year to June 2022. Detailed data – which includes those moving between organisations as well as leaving the NHS – reveals more notable differences across individual employers (Figure 3).
There are also differences by type of NHS provider. The highest average nurse leaver rates – at one in six nurses in the year to June 2022 – appear to be in community provider trusts (16.8%), which provide services such as district nursing and community physiotherapy, followed by care trusts (one in seven, 14.7%), which provide closer health and social care services particularly for the elderly. The lowest average reported rates were in non-specialist acute trusts, at one in eight nurses – from 11.8% for small acute to 12.4% for multi-service acute (note that two trusts were removed from the analysis due to data issues).
There are also differences by characteristic of nurse. A number of reports, including by the Nuffield Trust and the Institute for Fiscal Studies, have noted that compared to British nurses, EU-nationals were more likely to leave the NHS, while those reporting a nationality other than British or EU are less likely to leave.
How many are leaving the profession across the UK countries?
The rates of nurses, midwives and nursing associates leaving the professional register also increased substantially in the last year. In the year to March 2022, over 27,100 (some 3.6%) of these staff left the register. This pattern is apparent across all four countries of the UK, with rates highest since the first round of a new revalidation process for Nursing and Midwifery Council (NMC) registrants (Figure 4).
When breaking the leaver rates down by country of training, around 3.7% of nurses, midwives and nursing associates who trained in the UK left the register in the year to March 2022, compared to 7.9% of those who trained in the EU/EEA and 1.6% of those trained elsewhere overseas. Overall, staff trained overseas accounted for the vast majority (nine-tenths) in the growth in nurse numbers in the last year, with a net increase of 2,070 more UK-trained nurses, midwives and nursing associates compared to 19,564 for overseas.
Why are nurses leaving?
Information on reasons for leaving is, regrettably, limited. In particular, the most prominent data on leavers in NHS hospital and community services is typically only published as an aggregate for all staff groups, includes staff moving within – as well as from – the NHS, and has lots of missing information. This is particularly problematic given the Department of Health and Social Care itself accepts there is significant complexity in the reasons for leaving:
"Retention is the most significant area of uncertainty across the [50,000 nurses] programme. It is also the area of greatest complexity, with a multitude of contributory factors. Some of these, such as working conditions, are within the control of the NHS. Others, such as the attractiveness of outside careers, are not."
Department of Health and Social Care, 50,000 Nurses Programme: delivery update, 7 March 2022
Within the data covering all staff, retirement is the most commonly given reason. But work-life balance is now the second most common reason for leaving a role (nearly 6,900 across all staff in the three months to June 2022) and numbers citing this reason are now nearly four times higher than a decade ago. Not only this, but the numbers leaving due to health reasons (around 1,800) have also nearly quadrupled, and those who left due to a promotion (over 5,600) or to undertake further training and education (nearly 1,000) have more than tripled.
A survey capturing the views of those considering leaving found that feeling undervalued, being under too much pressure, or feeling exhausted were the most common reasons. These nurses also cited low staffing levels as one of the main reasons for considering or planning to leave, highlighting the risk of self-perpetuating downward spirals.
A further survey of nurses actually leaving their register in the year to December 2021 suggested that – as in previous years – retirement (43% citing this as one of their top three reasons for leaving), personal circumstances (22%) and too much pressure (18%) were the most common reasons why. This latter factor perhaps tallies with a one-off data release, which suggests that across voluntary resignations in the year to March 2021, work-life balance was a more common reason in nursing (31%) compared to other groups.
The survey of leavers from the register also found that negative workplace culture was an important factor, with 13% citing this as one of their top three reasons. Certainly, findings from the 2021 NHS staff survey reiterate the problem, with one in 10 (10%) nursing staff reporting that they experienced discrimination at work. Not only this, but 22% of nurses experienced bullying, harassment or abuse from fellow colleagues in the previous 12 months.
Previous sickness absence and the state of wider economic conditions may also be key factors. Novel analysis of individual staffing records suggests that nurse leaver rates, in particular, are associated with recent sickness. For example, a nurse or midwife who missed three days of work for mental health reasons was 27% more likely to leave three months later than a peer with no absences. The research also found that a 1 percentage point increase in regional unemployment was associated with a 2.1% reduction in the probability of a nurse or midwife leaving.
To leave a mark
While we have focused on retention, this must not be considered in isolation. To optimally manage the nursing workforce, the NHS would need to balance the inflows, such as newly qualified clinicians and overseas recruits, to the outflows – such as those retiring or leaving for roles outside the NHS – while also accounting for the need to expand the workforce. However, this critical equation is often not adding up.
It is important to note that reducing leaver rates is not just a numbers game. Doing so would likely be good for staff as it may reflect improved wellbeing at work, good for the NHS on which the burden of recruiting replacements falls, and good for patients who may benefit from the retention of experienced and knowledgeable staff. For these reasons, we have previously implored that “leaders at every level need to urgently understand – and act on – the reasons why staff have left and intend to leave”.
About this analysis
In this analysis, carried out exclusively for the BBC, Billy Palmer and Lucina Rolewicz draw on recently published data to assess rates of, and reasons for, nurses leaving the NHS. The authors are due to be involved in a larger research collaboration evaluating the programme of work around the 50,000 additional nurse commitment. This analysis is not part of that evaluation, which has yet to commence, and does not pre-empt the findings of that research.