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The great mystery of Wales' missing nurses

Posted on 24/07/2018 by

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Try as we might, we can't find them


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.

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 our 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 seven-month 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 supports 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 that 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.

Asking the question

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.

What is a freedom of information request?

The Freedom of Information Act provides public access to information held by public authorities.

It does this in two ways:

  • public authorities are obliged to publish certain information about their activities; and

  • members of the public are entitled to request information from public authorities.

The act covers any recorded information that is held by a public authority in Wales.

Public authorities include government departments, local authorities, the NHS, state schools and police forces. However, the cct does not necessarily cover every organisation that receives public money

Recorded information includes printed documents, computer files, letters, emails, photographs, and sound or video recordings.

Anyone can make a freedom of information request – they do not have to be UK citizens, or resident in the UK. Freedom of information requests can also be made by organisations, for example a newspaper, a campaign group, or a company.

Under the Act, most public authorities may take up to 20 working days to respond, counting the first working day after the request is received as the first day.

To try and work out the net amount that nursing numbers had gone up and down I asked shared services for:

  • The total amount of nurses that had joined each health board during the last three years and;
  • The total amount of nurses that had left each health board for the last three years.

By comparing the amount leaving with the amount joining we could work out the total nurses compared to three years ago. We had used the method a number of times before - including a piece last September on EU nurse numbers.

Within 20 days Shared Services had returned the data and the results were worrying. There had been over 900 more nurses leaving the NHS in Wales than joining (5,754 starters compared to 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 over 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 that they couldn’t guarantee accuracy of data.

She apologised profusely and said 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”.

I am not going to lie, the words I muttered to myself would not have been suitable for TV before 9pm. The original figures showed nothing less than a mass exodus of nurses from the Welsh NHS. It is 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.

Round two

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.


Really? Was the amount of nursing 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 Foi’s, 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.

What is an agency nurse?

An agency nurse is a qualified nurse who is not employed directly by the health board.

They are hired in from and agency to fill gaps in the contracted workforce.

They typically cost around 50% more than full-time nurses employed by 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 last four year (7,226 left compared to 5773 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 a NHS employed 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?”.

Well you are right to think that. Two health boards, Cardiff & Vale and Betsi Cadwaladr said they did not have the figures “in a format that could respond to your request”.

Incredibly, 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 £25.00 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 healthboards able to answer the question within two weeks whereas others would need a crack team of statisticians working with infinite monkeys on typewriters to the tune of £131,900 to answer the same question?

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.

Round three

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 healthboards for comment. In the main the healthboards 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 healthboards own figures. With mere hours to go before we went to print on the story we decided to pull the story for now until we could work out the discrepancies.

My language at this point would have made Malcolm Tucker from The Thick of It blush.

Part of me hoped that my figures were wrong so that there would be enough nurses to look after me from the inevitable tumour I would have from all this stress.

Stories of how our NHS inspires and struggles

Technical briefing

These Welsh Government stats 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 out findings?
  • Why did data from the health board vary from the Welsh Government’s by over 3,000 nurses?
  • Why were agency nurses 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 stats for the Welsh NHS.

I will not give you the details of everything that happened in the stats 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 Foi’s.”

According to the briefing, 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 am not going to lie, I was a bit deflated. When you have worked on something for six months you always hope it will come to something. However on the positive side the NHS, which I am genuinely proud, of 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 nurses 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”

So where does that leave us?

We are now seven months on and what have we actually learnt?

We probably can not 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 healthboards 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 aging 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 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?

Source: WalesOnline