Exclusive: RCN chief says reforms needed to stabilise nursing

Nurses “won’t wait forever” for the government to make necessary changes on pay and terms and conditions, the chief executive and general secretary of the Royal College of Nursing (RCN) has warned.

In her first interview with Nursing Times since being appointed, Professor Nicola Ranger made clear that the crisis in nursing “is not sorted”.

She set out what actions the RCN wants to see from the new Labour government in the coming months to tackle it.

“We do want to give this government a bit of a chance, but our members won't wait forever"

Nicola Ranger

In May this year, Professor Ranger stepped up to lead the RCN on an acting basis after Pat Cullen unexpectedly announced her resignation to stand in the general election.

Professor Ranger was then appointed substantively in July, just days after Labour won the general election by a landslide.

Nurses felt “a sense of optimism” around having a new government, after 14 years of Conservative rule, and were “hoping it’s going to be different”, she explained.

Soon after Labour came into power, Lord Ara Darzi was commissioned to conduct an independent review of the NHS in England.

The review, published in September, concluded that the NHS was in a “critical condition”.

Professor Ranger said she was “very pleased” with Lord Darzi’s assessment.

“I think it really focused in on what our members already see, which is, despite their best efforts, a failing NHS,” she added.

In response to the Darzi review, the government pledged to undertake the biggest reimagining of the NHS since its inception.

It promised major reforms, including moving care from hospitals into the community, shifting services from analogue to digital and changing focus from sickness to prevention.

Professor Ranger noted that nurses were “absolutely key to every single one of those ambitions”.

Yet, she aired concerns about the ongoing decline in public health and community nurses, who she said would all be essential to making these goals a reality.

“We think the ambitions are right, they’re focusing on the right things, but none of it will be possible without nurses, not one bit,” she added.

The same month that these reforms were pledged for the NHS, members of the RCN in England rejected the government’s pay offer for 2024-25.

In a ballot that received a record turnout, two-thirds of members voted against the 5.5% award for Agenda for Change (AfC) staff.

Professor Ranger said nurses were now  “raising their voices”. She noted that the RCN had the highest turnout in a pay ballot compared to other health unions and was also the only union to reject the offer.

“What that says, or should say to the government, is nursing is not sorted [and] you’ve got to listen to us,” she said.

“We no longer believe that nurses are a band 5 profession"

Nicola Ranger

The RCN pledged to use the ballot result to kickstart a conversation with the government on restoring nurse pay.

Professor Ranger confirmed that conversations had begun and that she had met with the health and social care secretary, Wes Streeting, last month. “We made our feelings known very clearly,” she explained.

Pressed on whether further strike action by the RCN could be on the cards, if the government is unwilling to negotiate, Professor Ranger said: “We do want to give this government a bit of a chance, but our members won't wait forever.

"We’ve been clear about what we expect, so we will wait and see… how much we’ve been listened to.”

The RCN has several criticisms about how the NHS pay awards are delivered in England, including that government delays in recent years to the pay review body process mean nurses have had to wait longer than they should for their wage uplifts.

Meanwhile, Professor Ranger also made clear that an annual pay increase alone cannot resolve the challenges currently facing nurses.

She said: “We don’t believe that a percentage pay rise is enough anymore.

"It’s got to be a bundle of things that get reformed in order for us to properly get nursing back on its feet.”

Nurses make up almost a third of all AfC staff working in the NHS, with nearly half (43%) of them working at band 5. However, the RCN position is that this needs to change.

Professor Ranger said: “We are the only profession that could start as a band 5 and retire as a band 5.

"I don’t know any other discipline as part of the Agenda for Change that will do that.”

When AfC was first introduced in 2004, nurses “felt a lot happier with where they were on their pay grade”, said Professor Ranger.

But nursing has evolved considerably in the last 20 years and is now a degree educated and safety-critical profession.

As such, questions have been raised about whether the AfC system recognises nursing roles for what they are today.

Over the last year, the RCN has been calling for newly registered nurses to progress to band 6 after a period of preceptorship.

The union has argued that both paramedics and midwives have been afforded this opportunity and that it was an injustice that nurses did not have the same offer.

Professor Ranger said: “We no longer believe that nurses are a band 5 profession.

"The paramedics had a Treasury-funded progression from band 5 to 6 in 2016 and we want exactly the same for nurses.”

A more radical proposal, put forward by the RCN under the previous Conservative government last year, was to consider introducing a separate pay spine for nurses.

The government consulted on the proposal earlier this year, but the outcome was never published. While the RCN favoured the idea, it faced immense backlash from other health unions.

Asked whether the RCN would be continuing to push for the separate pay spine under the new government, Professor Ranger said the focus would remain, for now, on lifting nurses to a band 6 after preceptorship.

She added: “What I would like to see is, if we're genuinely a safety critical profession, what a pay structure can look like that genuinely rewards people financially.”

While improving nurse pay remains a priority, there are many other problems facing the profession that need to be addressed, including the fact that interest in pursuing a career in nursing has dropped.

An analysis published last month by the RCN found that there had been a 19% decrease in the number of acceptances onto pre-registration nursing courses between 2020 and 2023.

These figures have come while healthcare organisations position themselves to try and achieve the ambitious goals set out in the NHS Long Term Workforce Plan.

Published under the previous Conservative government, the plan pledged to increase the number of nurses by 170,000-190,000 by 2036-37.

When asked if these ambitions could be achieved in the current nursing recruitment climate, Professor Ranger replied: “Absolutely not. Not a dicky bird’s hope.”

She added: “The whole point of that NHS workforce plan was to increase the number of pre-registration nurses, and actually it has gone down.

"We are just not attracting, at this moment, people into the profession.”

Professor Ranger warned that people “genuinely cannot afford” to study nursing.

She criticised the removal of the nursing bursary in 2017, which caused a large drop in applications to nursing courses in the years immediately after.

"Taking away the bursary, and everything that went with it, has been a mistake,” she said.

"What is no compromise is that nursing has to be degree educated"

Nicola Ranger

“It was taken away to open up a free market [and] it’s done the complete opposite of that.”

To remedy the crisis, the RCN has been calling for a loan forgiveness scheme for nurses, where nurses can have their tuition fees wiped after working in the NHS for a certain number of years.

A YouGov poll published earlier this year found that three quarters (76%) of the public would support this policy.

Professor Ranger said: “I think our whole system has got to be rethought with regard to student numbers.

"It’s not working for students, it’s not working for universities and it’s not working for the patients.”

Meanwhile, the NHS Long Term Workforce Plan has committed to increasing the number of students coming through via degree apprenticeships, so that by 2031-32 they will provide 22% of all training for NHS staff.

Last year, the RCN warned that focusing on apprenticeships was the “wrong move” and that nursing deserved its place in the university system as an undergraduate or postgraduate degree.

Professor Ranger’s position is that there are “advantages and disadvantages” to both undergraduate programmes and degree apprenticeships.

However, she argued that one thing that cannot be diminished is nursing has “got to be a degree”.

She added: “Whether it's an apprenticeship or an undergraduate programme, what is no compromise is that nursing has to be degree educated.

"And sadly, I still hear people questioning whether you need to have a degree to be a nurse.

"You absolutely do for the very reasons that [I’ve] said earlier, that [nurses are] safety critical.”

While the RCN intends to closely monitor the government over the coming months on whether it delivers changes for nurses, the college also has its own work to do.

Last month marked two years since Bruce Carr KC’s damning review into the culture at the RCN, which uncovered issues of bullying, misogyny and a lack of diversity within the college’s governing council.

Nursing Times pressed Professor Ranger on whether the culture at the RCN had changed since 2022.

She said: “I started at the aftermath of the Carr Review, I think we’ve worked really hard to get our governance in the right place.”

Professor Ranger argued that the RCN’s strength was that it was “vigilant and aware” of the challenges it faces.

“By getting it out in the open, I think [we] really took the opportunity to think about what needs to be different, and I think we’re making real strides with that," she said.

Earlier this year, the RCN launched a new five-year strategy for becoming more inclusive, diverse and equitable both internally and in the work it does for its members.

Professor Ranger said the strategy would try to ensure that the RCN was “an organisation that lives those values”.

She added: “Are we perfect? Absolutely not.

"But I think part of the issue is being able to agree there are challenges and put very robust processes in place to be able to address them, all of which I feel we competently have [done].”