Bribing healthcare students with long term debt relief won’t stop them leaving

For every five nurse training places in England, only three full-time nurses join the NHS.

Jim is an Associate Editor at Wonkhe

That’s a worrying stat that is contributing to an understaffed health service under ever-greater strain – especially when you add to it the high numbers of medical professionals leaving the NHS early in their careers in general.

To try to address this “attrition” problem – which has been around at various alarming rates for as long as I can remember – the Nuffield Trust has published Waste not, want not: Strategies to improve the supply of clinical staff to the NHS – setting out the scale of NHS attrition, and suggesting a 10-point plan to improve retention.

The signature proposal that’s caught the headlines is to gradually write off clinicians’ student debt over 10 years – a model for which has been worked up by London Economics for Edge Hill University.

It’s not a terrible idea – but it’s not at all clear that that should be the priority if there really is £230m to spend on each cohort.

A quoted 2018 report from Health Education England, for example, identified financial, academic, workload and placement factors as the most commonly cited reasons for considering leaving – none of which would be addressed by writing off student debt.

Another report based on a survey from Health Education England in 2022 found two in five student nurses and three in five student midwives saying they’d considered leaving – citing the placement experience, stress, a lack of support and doubts over their own ability as the major factors. Long term debt relief doesn’t feel like it would help there either.

The killer stat on attrition is probably that drop-out rates were highest in the first year of study, and lowest in the third year – a finding that is consistent across all subjects – albeit that 8 per cent of nursing students left in the first year, compared with 4 per cent of physios.

And while the reasons for not joining the NHS after graduation are mixed – many are in private settings, some in related NHS jobs and so on – a quite low proportion of nursing students who graduate go on to begin their career outside of nursing, and then tend to stay on for at least a couple of years.

When they do start to leave, it’s a lack of progression, poor flexibility and underutilisation of their skills that lures them out. And for medics, who are increasingly taking a pause before they start their two-year foundation programme, it’s with workload, stress, feeling overwhelmed and placement experience that pop up again as core concerns – with one in six reporting bullying and/or harassment by other staff in their training post.

We might have expected the report to have a run at solutions for the recurring problems here – a lot of which seem to be about what it’s like to be in a stretched work-based learning setting. It’s certainly the case that most providers struggle to exercise real quality control over a regime characterised by inadequate national policy over financial support, and a distinct shortage of placements (and support for students on them) that significantly restricts the influence that a provider can have over the resultant experience.

Instead with no real explanation, the big idea is financial tie-in – in effect a loan forgiveness bribe that we might assume the authors think will cause a struggling student to grit their teeth and bear it all in exchange for full debt relief ten years later, without even addressing the repayment rate that new joiners face in that first decade.

To be fair, there are nine other ideas in the ten point plan – national bodies are for example told to correct some of the “inaccurate and negative perceptions” of clinical training and careers, but if anything the problem seems to be that they’re not sufficiently warned about how difficult it will all be.

There’s a helpful recommendation on developing – in partnership with universities, the Council of Deans of Health and the Medical Schools Council – formal conditions on the quality, success and balance of placements.

That might help, but it feels like we’ve seen that sort of thing before – it’s the practical levers that can be pulled either by providers or students themselves when they’re not being met that are likely to matter more.

What strikes me more than anything is that this is the sort of area where, at least in England, OfS ought to be sounding the alarm over the stats (at least for nursing and midwifery) and then coordinating interrogation and action in conjunction with the HEE and the Council of the Deans of Health.

Because if it’s the case that the ability of the providers it regulates to impact the quality of the experience students get on placement is limited, we need to know why and what might help for all sort of other work-based learning too.

Alas, the complexity of the national relationships, OfS’ apparent lack of interest in subject-based improvement below (or near) its baselines, and a regulatory model which seems distinctly incurious about the causes of poor student experience beyond APP work pretty much renders that a non-starter.

One response to “Bribing healthcare students with long term debt relief won’t stop them leaving

  1. Good analysis.

    I wonder about financial incentives. I’m from Scotland, where students get free education and a £10,000 bursary, but which has the highest drop out rate. Is it that because they are getting it for (less than) nothing, they are less likely to stick?
    Or are they starting because of the bursary?

    Sure, the practice side is still heavy, without as many staff in health as needed. But I do wonder about the incentivising and the counter intuitives.

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