Government urged to wipe student nurse debt to curb attrition

A new analysis published today by the Nuffield Trust has laid bare the scale of staff and student attrition, and has called for radical reform to try and curb the number of nurses withdrawing from courses.

Looking at more than 190,000 student records across the UK, the Nuffield Trust has put together a comprehensive overview of attrition rates across clinical pathways, including in training, post-qualification and into the first few years of work.

It found that, between 2014 and 2020, one in eight nursing students dropped out before finishing their degree in both England and Wales, compared with one in six in Scotland and one in 26 in Northern Ireland.

Meanwhile, it revealed that one in 14 UK nursing graduates do not begin a career as a nurse after graduating, compared to one in nine midwifery graduates.

“Our proposal to write off student debt is affordable, credible and could be implemented straight away”

Billy Palmer

The think tank’s analysis of attrition in the early career phase found that one in five nurses in England leave NHS hospital and community settings within two years. This is broadly twice the level seen for midwives.

It noted that the annual leaving rate in the first two years remained the same until five years from joining the NHS, but after that it flattened out.

The report argued that fixing leaks in the domestic staff pipeline would have an immediate impact on the number of clinicians in the NHS.

As such, the Nuffield Trust has called on the government to implement “bold policy making” to try and curb attrition rates in nurse training and in the early career stages.

A policy which authors of the report concluded was the most compelling, and argued should be an immediate priority for the current government, was a loans forgiveness scheme which would eventually wipe nurses’ student debt.

They said that the scheme, which was outlined in an accompanying paper to the report, should be made available to the roughly 28,000 nurses, midwives and allied health professionals (AHPs) joining eligible public services each year.

The policy involves gradually writing off outstanding student debt – which currently averages around £48,000 per nurse – over a set number of years in exchange for staying in a public sector health service.

For example, debt could be reduced by 30% after three years of service, 70% after seven years and written off completely after 10 years, in recognition of workers’ contribution to public sector services.

Report author and Nuffield Trust senior fellow, Dr Billy Palmer, said: “These high drop-out 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.”

Dr Palmer noted that government targets to increase clinical training places, as outlined in the NHS Long Term Workforce Plan, “must be accompanied by a realistic plan to encourage staff to stay and reward them for doing so”.

He added: “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.”

The loans forgiveness scheme is expected to cost around £230m per year for nursing, midwifery and allied health professional graduates in England, according to the Nuffield Trust’s analysis.

It explained that this was still less than the amount expected to be saved by the Treasury under the incoming changes to the student loan repayment scheme – which will see the repayment threshold drop and an increase in the time it will take for debt to be cleared.

The think tank argued in its report that a loans forgiveness 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.

During a press briefing on the proposal, Dr Palmer told Nursing Times that a loans forgiveness scheme could also widen participation onto nursing courses.

He said: “One of the advances here is an inclusion and equality aspect, because we know that [there is] a link between socioeconomic status and willingness to take on debt.”

The Nuffield Trust also put forward a series of other recommendations to tackle attrition rates, which were directed at the government and national bodies responsible for delivering nurse education.

This included calling on the government to formally evaluate models being used across the world and in the UK to improve participation on clinical training courses, including an independent review of degree apprenticeships, such as those in place for nurses.

Dr Palmer said: “There’s some very appealing aspects of the apprenticeship model we hear that it probably has lower levels of retention [issues].

“The purpose is to try to offer a more inclusive route into these different professions, but it’s fairly poorly understood about what some of the challenges and barriers are to rolling it out and actually getting some of those benefits to fruition.”

Meanwhile, the think tank also called on those commissioning nursing courses to ensure that education, training and placements were consistently achieving their intended outcomes while also not burdening providers.

In addition, it called for any inequalities in career advancement opportunities across the different professions to be urgently addressed.

Dr Palmer warned that there were inconsistencies in pay progressions between NHS professions, and that nurses often suffered the most.

He said: “Nurses in particular clearly have fewer opportunities for pay progression moving up the banding pay structure within the NHS, and yet they also have some of the highest levels of attrition across all clinical professions.

“That’s something that really needs to be looked at – are we making sure that the pay frameworks are providing the pay progression opportunities…in the NHS to keep people in these public services.”

The Department of Health and Social Care was contacted for comment.