MYSTERY OF WALES’ ‘MISSING’ NURSES
We tried to find out if EU medical staff are leaving their jobs in Wales because of Brexit. What we found out instead was surprising
THIS story began as an investigation into whether EU medical staff, on whom our health services depend, were leaving as a result of the Brexit vote.
We wanted to know what effect this was having on the overall workforce levels of the Welsh NHS, which routinely complains of its inability to fill vacancies.
Yet what we publish today is very different. It is an indictment of the chaotic record-keeping of our seven health boards, which use different ways of counting staff. It highlights just how difficult it is for anyone to have a genuine national overview or understanding of the pressures in our hospitals and surgeries.
One way of calculating staff numbers suggests there are 1,200 more nurses than there were four years ago. Another suggests 1,400 fewer. No-one seems, with any absolute certainty, able to explain why they are different.
Last winter was one of the worst on record for the health service.
In January, ambulance staff described the situation as “catastrophic”.
The Royal College of Emergency Medicine in Wales likened A&E departments to “a battlefield”. Unions claimed their members were “in despair”.
Everything pointed to the Welsh NHS lacking the resources to fulfil its job: keeping Wales alive and healthy.
One despairing nurse said in an open resignation letter: “You live with a chronic guilt as you cannot provide the care that you want to give every individual, basic tasks like helping someone wash or eat just cannot be done and it pains me to admit that there have been times I have not been able to help someone.”
There is no question that this matters. There is no reason for seven health boards to keep records in different ways, making it difficult to see the national picture clearly and easily.
Nurses are fundamental to the health service. They are the face of it. Patients may have only one or two interactions with their surgeon over a three-week stay in hospital but will never forget the nurses.
A kind word, a genuine interest and a touch of empathy are the things that stay with people. Our nurses are not in the industry for the money – they are in it because they care.
Over the course of our sevenmonth investigation into nurse staffing numbers, the weather has thawed, the World Cup has come and gone, and I still can’t tell you whether the amount of nurses in the Welsh NHS has increased or decreased.
Our investigation highlights another way in which the creaking IT and HR services that support our frontline health services are not fit for purpose. We have a health service that diverts as much of its resources as it can to keeping us alive. But it means the infrastructure behind that frontline is crumbling.
Please bear with me as I condense dozens of freedom of information requests, hundreds of emails and phone calls as well as one long NHS stats technical briefing into something readable as I hunted for Wales’ missing nurses.
My first step was to send a freedom of information request (FoI) to Shared Services, which is an independent organisation owned and directed by NHS Wales. Among other things, it runs payroll and recruitment for the Welsh health service.
To try and work out the net amount that nursing numbers had gone up and down I asked for:
The total amount of nurses that had joined each health board during the past three years; and the total amount of nurses that had left each health board for the past three years. By comparing the amount leaving with the amount joining we could work out the total number of nurses compared to three years ago. We had used the method a number of times before – including an article last September on EU nurse numbers.
Within 20 days, Shared Services had returned the data and the results were damning. There had been over 900 more nurses leaving the NHS in Wales than joining (5,754 starters compared with 6,728 leavers).
This seems to fit, not only with anecdotal evidence, but with the hard facts like a ward at Swansea’s Singleton Hospital closing last September because not enough nurses could be found to care for patients.
Some health boards had fared worse than others. Aneurin Bevan, for example, had lost more than 200 nurses (net) in just one year.
We prepared the story and approached each health board for comment. This is when things got confusing. A significant number of the health boards disputed the figures and I was called by a senior Shared Services manager to say they could not guarantee accuracy of data. She apologised profusely and said that she would rerun the report and “have it back with us in seven days”.
One week later and true to her word, I did receive the updated figures. Unfortunately only two of the seven health boards had given permission for the numbers to be released. I was therefore told I would have to request the information from each health board separately, “but don’t worry, they are expecting your call, know the situation and it shouldn’t require a full FoI”.
Frustrating. The original figures showed nothing less than a mass exodus of nurses from the Welsh NHS. It is a massive issue and hugely in the public interest.
However it wasn’t just the figure that was shocking, it was also the fact that the organisation responsible for recruitment and paying staff didn’t seem to be able to say how many staff had left the organisation.
Despite these setbacks – we ploughed on.
Despite the assurances that the health boards were expecting my call, when I asked them individually for their nursing leavers and joiners they all said it would require a freedom of information request. Sigh. Really? Was the amount of nurses joining an organisation such an obscure piece of information it required a separate request? Was I naive to think that this information would have been immediately at the fingertips of managers in an organisation?
I therefore fired off another set of FoIs, this time asking for the nursing numbers over four years as well as the amount of bank and agency workers used by the health boards.
Some health boards came back within a few weeks. Some ran right up to the 20 working day deadline. Some waited until they were days from the deadline before asking a clarification question which resets the timer. Some didn’t seem to care at all and sent it back a month after the deadline.
By the time they had all come back, we had left winter, gone through spring and were in May.
Once I looked through the data, however, it was worth the wait.
The new figures were different to the January ones. Instead of losing just over 900 nurses, they showed the Welsh NHS had seen a net loss of over 1,400 full-time equivalent nurses in the past four years (7,226 left compared to 5,773 joined). The headline figures included:
■ ABMU health board saw a net loss of 350 nurses in just four years;
■ Cwm Taf losing 223;
■ Betsi Cadwaladr losing 545;
■ Cardiff and Vale losing 111. The agency figures were just as shocking. Remember, these nurses cost around 50% more than an NHSemployed nurse. To put the issue into context, the Welsh NHS spends £1m every week on paying agency nurses to cover shifts.
There were 3,130 full-time equivalent agency nurses used over four years in the five health boards that recorded the data – 2,000 of these were in Cwm Taf and 613 in ABMU. This is made all the more incredible by the fact that one of the five only started measuring it in 2017.
Those of you who have not drowned in this sea of stats will be thinking “Five health boards? What about the other two?”
Two health boards, Cardiff & Vale and Betsi Cadwaladr, said they did not have the figures “in a format that could respond to your request”.
Betsi Cadwaladr health board even managed to put a figure on how hard it would be to work out how many agency nurses they used.
In response, they said: “We estimate that it would take staff in excess of 5,276 hours to locate and review 63,316 agency invoices for the years in question.
“Therefore, to obtain the data would work out at approximately 5,276 hours at £25 per hour and cost £131,900.”
Just like with the starters and leavers from before, I was stunned that an organisation can’t immediately put a figure on how many agency staff they are using.
Not only that but why are some health boards able to answer the question within two weeks while others came up well short?
Putting aside that anomaly, we now had (what we thought were) indisputable facts.
Namely the Welsh NHS had seen a net loss of over 1,400 nurses and had a dependence on expensive agency nurses to at least the tune of 3,130 full-time staff. It was time to publish.
Brilliant, it may have taken almost five months but finally we were ready to tell the story. It had been worth the wait. On an issue as important as our NHS you need to do everything you can to get it right.
The front page was ready to go and I went to Welsh Government and the health boards for comment. In the main the health boards accepted there were issues with nurses leaving and said they were taking steps. However, when we approached Welsh Government they told us we were wrong.
They presented us with figures which showed that instead of nursing numbers going down, they had in fact increased every year for the past four years.
According to their data, there were actually 1,200 MORE nurses now than in 2014.
This seemed strange. Not only did this seem contrary to what nurses were telling us on the ground but also it contradicted the health boards’ own figures. With mere hours to go before we went to print on the story
I was stunned that an organisation can’t immediately put a figure on how many agency staff they are using WILL HAYWARD
we decided to pull it for now until we could work out the discrepancies.
More frustration. Part of me hoped my figures were wrong so that there would be enough nurses to look after me from the inevitable illness I would suffer from all this stress.
These Welsh Government statistics looked very official. They were drawn from the Electronic Staff Register (ESR) which records NHS staff and seemed to disprove our findings. But that still begged a number of questions:
Why did so many of the health boards accept our findings? Why did data from the health boards vary from the Welsh Government’s by over 3,000 nurses? Why were agency nurse numbers so high if numbers of nurses were increasing? Why were hospital wards closing if numbers were increasing?
I therefore signed up for a technical briefing with the head of statistics for the Welsh NHS.
I will not give you the details of everything that happened in the briefing but the thrust of it was this:
“Each health board collects data in different ways so it is hard to analyse what the data tells us through FoIs.”
According to him, there could be several reasons for the difference in results but the most likely reason was the following:
“While a nurse is being trained they are counted as bank worker. When they are subsequently taken on as a fully qualified nurse they transfer across and are therefore not counted as a new starter.”
This actually made total sense to me. A huge amount of nurses hired in the Welsh NHS are straight out of university and therefore if they are not counted it explains the shortfall in my figures.
I was deflated. However, on the positive side, the NHS, of which I am genuinely proud, was not haemorrhaging nurses.
Just to be sure it did explain the shortfall we decided to check this explanation.
We sent an FoI to each health board asking for the number of “nurse bank workers that have been offered a permanent role in your health board for the period 2014 – December 2017.”
The first health board to come back was Betsi. They had taken on close to 1,000 nurses over the four years from bank which meant instead of being down 500 they were actually up 500 (if they are not actually registering them as starters).
However, after this, the explanations seemed to fall apart. Several health boards, including Cardiff and Vale, said it would be too expensive to work out how many bank workers they had hired.
The ones that did come back didn’t come close to explaining the shortfall.
ABMU had still seen a net loss of 250 nurses, according to our figures.
Aneurin Bevan, who could only supply two years of figures, had only taken on 11 – hardly plugging their 226 net loss.
Hywel Dda went from –100 to +50, but again, this is not even close to making up the 3,000-nurse swing needed to make the Welsh Government’s figures stack up.
We went back to Welsh Government and pointed out their rationale for the huge difference in the health boards’ stats and their own. We also asked for comment on the fact that some health boards didn’t record how many agency staff they were using.
The only response they would give was: “NHS staffing figures are produced independently under the Code of Practice for Official Statistics and are based on the Electronic Staff Register.
“The ESR covers the entire NHS workforce directly employed in Wales.
“The latest figures from the ESR show there are more full-time equivalent nurses working in the NHS in Wales than ever before. Because of the way data is available to health boards, trying to work out an overall figure of nurses from nurse leavers and nurse starters can lead to inaccurate conclusions.”
We are now seven months on and what have we actually learnt?
We probably cannot put an exact figure on how many nurses the NHS has gained/lost. Frankly I don’t think the Welsh Government can with any accuracy either.
But what I feel like I can say with reasonable surety is that the Welsh NHS is in chaos. Not necessarily chaos in the same way as you would describe a disaster area or a war zone. It manages to muddle away day to day. However, seven months of scratching below the surface has revealed a chronic and woeful shortcoming in how they record data and manage their workforce.
You have seven health boards, each with their own way of doing things, which makes comparison across the organisation nigh on impossible.
Why are they not able to quickly say how many nurses they have hired? How is it possible that it would take a health board “over 5,000 hours” to work out how many agency staff it is using?
Why is Shared Services, the department responsible for payroll and recruitment, coming out with totally different figures to the health boards when asked the same question?
In many ways this is a far bigger issue than if nursing numbers have gone up and down.
Over the next decade, our health service is going to face unprecedented pressures. An ageing population, a larger population, scarce resources, less access to EU staff and a broader range of treatments are just some of the obstacles on the horizon.
Yet they are not able to answer basic questions about their workforce.
I must be clear this is not about blaming individuals. The ward manager who has to phone around agencies every morning just to keep enough bodies to run their ward is not to blame. As annoying as I found them during the whole process, neither are the health boards.
The fact is the entire system is creaking. It is like an old town that has grown organically into a big city. There are criss-crossing streets and dead ends that don’t make sense. There is no logic to it. The difference between the city and the NHS is that instead of commuters being late for work, vulnerable people suffer and die.
What you can measure, you can manage, and due to the convoluted structure the NHS cannot accurately measure – so how can it possibly manage?