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Interesting; on the one hand, one could dismiss this as an 'in other news, water is wet'-type of study, but such evidence is probably very helpful in the overall debate around healthcare funding.

Another factor not mentioned here but which might be relevant, is that as long as nursing is undervalued (particularly economically, but in less tangible ways too) to the extent that the system is short of nurses, it is unlikely that employers would able to choose pick and choose better nurses from those available, and/or remove bad ones. It seems obvious from an organisational perspective that nurse > no nurse, but there's a direct link (in my experience) between the quality of care patients receive, and the attitude/experience/quality of the individual nursing staff.

One lesson might well be that the relative pay gap between senior nurses and senior doctors is too big - i.e. senior doctors should be paid less / we should employ fewer doctors and more nurses. But that's probably a very very hard thing to actually do politically both in terms of internal hospital/NHS politics and national politics.

There are strongly entrenched interests in the NHS which I suspect constrain relative pay between professions and grades much more tightly than they constrain absolute pay numbers.

In the US I typically receive very poor care from people with the title "Nurse Practitioner" who are usually hired for the exact purpose of getting people to do doctor-like work for cheaper. They are ok at dealing with very normal conditions like the flu/cold, acute non-critical injuries, etc. (which you honestly don't even need to get care for anyway) but not good at dealing with issues outside of that
Probably a better approach would be less pay for better quality of life jobs* which would still require more doctors and slightly more overall pay.

Also a lot more nurses; since with the baby boomer generation in and entering retirement the need isn't going to go down relative to historic levels.

* Edit:

By better quality of life I mean things like having a 4 x 8 hour shifts with each having about 2 hours of overlap for review of records, passing down, and filling out post shift paperwork. Yes nurses would need similar shifts, the overlap also gives time for the transfer of knowledge, in the process of getting it entered/updated in the health record systems.

I didn't see "shortage" being used in this article. The industry may be attempting to get by with fewer workers to keep costs down.
Nurses in the UK are relatively poorly paid: https://nursingnotes.co.uk/agenda-for-change-pay-scales-2019.... They start at Band 5, which is about 24,000 pounds annually. That’s about $30,000 per year for a job that requires a three-year university education. (Somewhere between an ADN and BSN in the US.) London gets a 20% or so bump, so let’s say $36,000. A VA nurse in NYC starts at more than double that, over $78,000: https://www.va.gov/OHRM/Pay/2019/LPS/NY.xls.
It's too crude to compare salaries like that.

That said, it's true that nursing is relatively under-paid in the UK. Part of that however is because the state is the largest employer of nurses which keeps wages down but that in turn keeps the cost of healthcare down.

When your state only provides a minority of nursing then it has to pay higher wages to compete with the profit-driven sector.

But it's crude to say "Nurses make less than half than in the US", because so do software developers, but no-one's saying "think of the devs!".

Why is it too crude to compare those salaries? The gulf between 30k and 78k is enormous. The UK nurse certainly isn't making up all, or even most, of that difference in government benefits.
You can become a degree registered nurse in the U.K. in four years via an apprenticeship without paying anything for it out of pocket[1]. Obviously the sensible thing to do is move to the US immediately after qualifying but good luck getting paid and trained at the same time in the US.

[1]https://www.gov.uk/government/publications/nursing-degree-ap...

There are thousands of Portuguese nurses who emigrated to the UK, since that 'low' salary is still much higher than what they would be paid here. Now Portugal has a shortage of nurses too.

I believe the immigration wave started after austerity measures were implemented in both countries.

You can find the original study here (open access): https://qualitysafety.bmj.com/node/156220.full

Abstract:

Background- Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nurse staffing and staff–patient interactions.

Setting- Six wards at two English National Health Service hospitals.

Methods- We observed 238 hours of care (n=270 patients). Staff–patient interactions were rated using the Quality of Interactions Schedule. RN, healthcare assistant (HCA) and patient numbers were used to calculate patient-to-staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as ‘negative’ quality, rate at which patients experienced interactions and total amount of time patients spent interacting with staff per observed hour.

Results- 10% of the 3076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (p=0.035, OR of 2.82 for ≥8 patients/RN compared with >6 to <8 patients/RN). A similar pattern was observed for HCA staffing but the relationship was not significant (p=0.056). When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels.

Conclusion- Low RN staffing levels are associated with changes in quality and quantity of staff–patient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff–patient interactions. Beneficial effects from adding assistant staff are likely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution.

So obviously this comes down to cost.

> in the aftermath of austerity and with not enough staff to go round

Pay more, get more nurses.

Or you can trade-off nurses for less-good health care.

- - - -

Just to show an "existence proof" of an alternate universe, there are two totally free hospitals in India. They have no billing desk because they do not bill.

So how is it funded?

The people who work there and who support them financially believe that they are literally working for God. It is as if a Christian was volunteering to work at hospitals established by Jesus.

https://en.wikipedia.org/wiki/Sri_Sathya_Sai_Super_Specialit...

> The Sri Sathya Sai Institutes of Higher Medical Sciences also popularly known as Super Specialty Hospitals are tertiary health care hospitals established by Sri Sathya Sai Baba to provide patient care facilities to all irrespective of caste, class, creed, gender, religion or nationality totally free of charge.

> So how is it funded?

Actually it's funded by the billions of dollars donated to his charitable trust.

> Just to show an "existence proof" of an alternate universe, there are two totally free hospitals in India. They have no billing desk because they do not bill.

That's not an alt universe, that's just free healthcare, just like in the UK, Fiji, New Zealand, and numerous other nations.

I'm not sure what point you're making, and I don't want to be disagreeable, but I would point out that those nations' healthcare systems are paid for by taxes, not charitable donations.

To me it seems impressive and wonderful that people have been inspired to contribute billions of dollars to support health care and clean drinking water and other charitable good works.

It beggars belief that such a topic is even up for debate.

We're at such a state of technological advancement now in a place like the UK that we're essentially post scarcity. We need very few people any more to provide the basic building blocks of life.

In such a scenario, what we should be doing is taking advantage of that fact to distribute labour more appropriately - more hospital work, more social work, more housing, etcetera.

Instead what we have is seemingly some sort of race to put half the population on retail/delivery/general grunt work to please the whims of the other half, who don't actually end up happy because they're working their arse off and generally stressed by the lack of 'life infrastructure' as well.

How has this gone so wrong?

Except we aren't "post scarcity", not in the slightest.

There is a limit to the number of people who are both able and willing to become nurses. Nursing is not just "looking after people in a hospital" - it's a highly skilled job which also entails a very high level of stress, and which nowadays requires a degree level qualification in the subject. The number of people able to do this job, including surviving the stress levels it entails over a whole career, is relatively limited.

There's also another aspect to it - historically, a large number of women who nowadays would train to become doctors (assuming they stay within the healthcare sector) were effectively barred by either explicit or implicit sex discrimination so went into nursing instead. That largely doesn't happen today, at least for those educated in the UK.

More pay might move the number willing upwards (especially for those who are already qualified but not working as nurses for whatever reason - full time parents, those taking other work etc) but the structural problem of "how many people are able to do it" will probably never go away.

>historically, a large number of women who nowadays would train to become doctors were effectively barred by either explicit or implicit sex discrimination so went into nursing instead.

Exactly: if you're smart enough to be an RN, and willing to get that much education, why not go farther with your education and become a doctor, so you can get paid many times what you'd get as a nurse?

Tech wise I believe we //can// be there: if there were the political will we could do this with existing technology.
"Suppose that, at a given moment, a certain number of people are engaged in the manufacture of pins. They make as many pins as the world needs, working (say) eight hours a day. Someone makes an invention by which the same number of men can make twice as many pins: pins are already so cheap that hardly any more will be bought at a lower price. In a sensible world, everybody concerned in the manufacturing of pins would take to working four hours instead of eight, and everything else would go on as before. But in the actual world this would be thought demoralizing. The men still work eight hours, there are too many pins, some employers go bankrupt, and half the men previously concerned in making pins are thrown out of work. There is, in the end, just as much leisure as on the other plan, but half the men are totally idle while half are still overworked.

-- Russell, Bertrand, In Praise of Idleness (1932) http://www.zpub.com/notes/idle.html

My wife is an RN. She thinks that credentialism is definitely an issue (escalating requirements are pushing non-bachelors RNs out of the market and reducing the scope of work that assistants can do). However, it's also true that nurses who make mistakes kill people (or fail to keep them alive). You can train almost anyone for a retail or delivery job in a few days, and the consequences of gross incompetence are modest.

Personally I think we need to dramatically reduce credentialism in health care, but we have to be willing to tolerate the occasional horror story that seems like it could be fixed by more education.

Funny, as a patient I prefer the opposite. Higher educated nurses tend to play doctor, but I can't trust their opinion because they aren't real doctors. It comes at the cost of them listening poorly, for they carry the confidence of their degree.
>but we have to be willing to tolerate the occasional horror story that seems like it could be fixed by more education.

That's a complete non-starter in this day and age though. "Just one life" and all that crap. It's simply not possible to float the idea that taking on more risk (by employing less trained nurses) in order to bring some benefit to society (more nurse-hours available) may have an overall net benefit to society without be labeled a baby murderer.

> You can train almost anyone for a retail or delivery job in a few days, and the consequences of gross incompetence are modest.

And we train taxi drivers, and even lorry drivers, in a few days

You can't really "distribute labor" in the sense you mean, as if people were units you allocate regardless of their own will. At best you can offer incentives to take up caring positions, but there are barriers. Nursing and hospital work is high stress and high skill, while social work is low paid and frustrating. Even basic caring is generally distasteful work, like senior care or group home work with autistic or handicapped children.

People generally aren't going to rush to those kind of careers. Nursing is an exception, but it's a very demanding stressful line of work, where you have to filter out a lot of people to avoid serious, life threatening mistakes.

The successive governments have been utterly idiotic about it too for a long time, even recently cutting nursing bursaries, constantly freezing pay, while simultaneously claiming for the last two decades we need mass immigration for the nursing shortage.

Scrap the high income cap on national insurance contributions and pay for the nurses!

The issue is that the definition of essentials is constantly increasing.

100 years ago a person with a failing heart might say "I have everything I need in my life" and die without getting a transplant.

That won't happen today.

People keep producing more because they want more.

"How has this gone so wrong?"

Hindsight? Care to take a crack at the complex socioeconomic issues that will exist in 50 years arising from technology, infrastructure and social dynamics that haven't been invented yet?

So you have a basis for this assertion behind hand waving? If companies didn’t need those folks, they wouldn’t hire them. They hire them, because automation technology is nowhere even approaching good enough to maintain our quality of life without extensive human labor. It’s as simple as that.
In Poland by the end of 2020 half of the nurses will be eligible to retire.

Not to mention that Poland already has low number of nurses for its population.

If you want to study how bad it can be keep an eye on Poland.

Better pay and recruitment might help move the needle on the number of nurses in the short to medium term, but long term, the demographic time-bomb in western countries means they will never have enough nurses to care for their entire aged population in the manner they do now. So either a lot of people are going to get sick and die without anybody to care for them, or, one way or another, nursing and healthcare is going to have to change to become more efficient. That will mean it becomes a lot more impersonal, with much greater use of mechanisation, automation and robotics.

I don't see this as being entirely a bad thing. While nurses and other caregivers can be an important source of human contact for the sick and elderly, caring and being cared for by another person can be an emotionally and physically fraught and draining process. If we can build automated systems that allow baseline physical and hygienic needs to be met, even for the frailest and sickest people, I think that had to be good for the mental health of both those needing care, as it will reduce their sense of being a burden, and on the caregivers themselves, as they will be able to focus on the most important quality-of-life issues instead of being stuck on a treadmill of providing basic care.

I would assume pay rates are relatively locked in and restricted under the government health care program in the UK. Not sure if there's a general Nurses union, but much like police, they may be legally unable to unionize or strike.
You can look at healthcare as a cost or as a benefit.

If you look at it as a cost, you will attempt to minimize it.

If you look at it as a benefit, you will attempt to maximize it.

The State looks at healthcare as a cost to be minimized. The State does not get sick or need healthcare.

Likewise, employers also look at healthcare as a cost to be minimized, but they do have some motivation to provide better quality insurance if they wish to attract employees.

Only you, the potential patient, really care about the benefits side of healthcare, and the quality of healthcare.

Health insurance has been screwed up by having the State and/or employers provide it for decades. What is required is for people to be able to purchase health insurance themselves just like they do any other kind of insurance. That would be a start anyway.

Obviously? It’s like saying “reducing the number of hole diggers on your staff reduces the number of holes they dug.” Almost all care in hospitals is provided by nurses, doctors function like high level executives who drop in for a few minutes every day to look at the dashboards.
At least give me a diff-in-diff, guys.

To be fair, they acknowledge their limitations and the fact that they can't make a causal interpretation. (Bad hospitals -> nurses leave?) But why the hell design the study this way?

How would you design it otherwise? An interventional study would presumably be ideal, but probably impossible to achieve.
Too few nurses and too many share buybacks.
The UK has free public health care but maybe introducing a price for a doctors or hospital visit would help lessen this problem?

One could introduce a fee of say 20 pound pr. visit. Something that is low enough that anyone in UK could pay it but also high enough to remind people that what they are consuming is finite resource.

The NHS charges by time, not by money. People 'pay' by waiting. Rich people waiting the same time as poor people pay more in money terms because their time is more valuable. The queue is managed via clinical need as assessed by professionals.

That breaks when people can pay in real money. Since the system is supply constrained all that does is reserve scarce medical resources for those with money rather than those with the most need. It allows rich people to jump the queue - just like the 'VIP' lane at a theme park.

Queue jumping in the UK was always frowned upon. The ultimate social faux-pas. That seems to be weakening in recent years and the 'time as money' system is weakening with it.

>Something that is low enough that anyone in UK could pay it //

The problem is with such things that they're regressive taxes. Rich people can still afford to go to the doctors when they have a sniffle but poor people will re-consider even when they have a life-threatening illness because £20 is a months food bills for the poor person.

There are considerable numbers of people who cannot afford £20 for a visit. So, for those people we'd need to implement a bureaucracy to give them free healthcare, and the cost of that would eliminate any potential benefits it would have.

There's no evidence it would work. There's some evidence it wouldn't work.

Don't forget this study was done in in-patient settings: those patients were actually ill and needed treatment.

£20 for some people is a lot though. That is definitely not something that 'anyone' could just pay when they wanted. You'd be hurting the most vulnerable people.
We already have a charge for prescriptions. The vulnerable get them free because if they didn't they wouldn't pay for it.

This would necessarily have to function identically.

Or, you treat people who are abusing the system with the treatment they really need: mental heath support.

If there aren't enough nurses for the sick people, we need more nurses. We can't control the number of sick people by excluding the poor.

What happens with Brexit, with all the health care workers from the Continent?

Do they have to go home?

Special rules to allow them to stay?

There's never too few nurses, there's only not enough money to pay for "enough" nurses
There is no shortage, my gf just finished nursing school and can't find a job and many of her peers are in the same boat.

Hospitals don't want to hire nurses because it loses them money. They only care about staying at the federally-mandated minimum staffing ratio, which they can skirt by only staffing adequate numbers when the oversight agencies come around. Seems like this is happening in every industry - CS appears to not want to hire either unless they absolutely are forced to fill a void. They'd rather just have one person do the work of two people since that person won't be able to find a job elsewhere anyway.

This article is about the UK where the NHS has been chronically underfunded for the last decade.
Nurses are on the Shortage Occupation List so the UK government (the one with the hostile environment for immigration) wants immigrant nurses.

https://www.gov.uk/guidance/immigration-rules/immigration-ru...