NHS: Specialist Services in Remote Areas

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 11th December 2018 Lords Chamber

[Lord O'Shaughnessy]

There are a number of schemes, as the noble Baroness points out. As well as the travel costs scheme, there is the low-income scheme. They are designed to help people with those kinds of costs. I do not have the specific numbers about take-up, but I shall certainly write to her with those.

[Lord Clark of Windermere (Lab)]

The Minister is correct to highlight the building of new hospitals, but these are no good if you cannot attract staff to them. Can he comment on the pilot scheme in west Cumbria which is training senior nurses to undertake the work of some junior doctors? How successful has that been, and how many students will take part in the second year of the course, which starts in January? What plans do the Government have to increase the number of staff right across the health service?

[Lord O'Shaughnessy]

I shall look at the scheme the noble Lord mentions and would be delighted to follow up with him directly on that. We need more staff; we have more NHS staff than we did in 2010, but nevertheless we need more GPs and nurses. Of course, we also need to diversify the workforce in new ways. One of the most exciting innovations in the workforce sphere recently is the creation of several thousand nursing associate posts to support nurses and doctors in a range of settings.

Domestic Abuse: General Practitioner Charges

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 15th November 2018 Lords Chamber

[Lord O’Shaughnessy]

I join the noble Baroness in condemning this type of crime, and it is disturbing that violence against older victims has risen. That is precisely the reason the Government have asked the Law Commission to look at the issue and bring forward suggestions on how to give the authorities greater powers to clamp down on those who perpetrate such crimes.

[Lord Clark of Windermere (Lab)]

My Lords, is the Minister concerned that the treatment of these abuse issues is under serious threat, given that many surgeries in the north of England no longer have a single permanent doctor?

[Lord O’Shaughnessy]

I do not think that it is an issue of staffing per se, because it is not only doctors but other healthcare professionals who are able to provide letters of this kind. The evidence that has been gathered through consultation and indeed through the progress of the secure tenancies Bill is that the charges for these letters act as a barrier. That is the issue we are trying to address.

NHS: Staff

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 13th November 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty's Government what plans they have to ensure that British citizens are recruited and trained to staff the National Health Service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Department of Health and Social Care is working with a range of partners to improve the recruitment and retention of staff required to deliver safe and effective NHS services. In England, we are increasing domestic doctor training places by 25%, there are now more than 52,000 nurses in training, and we have made more funding available to universities. Furthermore, we are increasing midwifery training places by 3,000 over the next four years.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer, which is a little disappointing. I remind him that there are currently 100,000 vacancies in the National Health Service. There is a shortage of doctors, nurses, physiotherapists and radiographers, and I could go on. There is a shortage throughout the service, and it is no good the Government telling us what their aspirations are. In the light of the Chancellor’s Budget Statement, in which he concealed that there is to be a £1 billion cut for the NHS in the year beginning in 2019, will the Minister explain how the cut in funding for the training of nurses, doctors and other members of staff coincides with the aspirations he has told us about? And please, do not give any excuses whatever about the pension miscalculation.

[Lord O'Shaughnessy]

We agree that there is a need for more staff, and indeed there are more NHS staff than ever. I can tell the noble Lord that we are increasing doctor, nurse and midwife training places, and more GPs than ever started training in the NHS this year. With an ageing and growing population, we absolutely recognise the need for more doctors, nurses, midwives and many other professions. The Budget made no changes to health spending.

Health: Flu Vaccines

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 23rd October 2018 Lords Chamber

[Lord O’Shaughnessy]

I take my noble friend’s point very seriously. It is worth stating that the reason for moving to this new vaccine is precisely because it is more effective. Unfortunately, the response rates for the vaccine that was used in the over-65s last year were not as high as hoped. Indeed, there were quite a number of admissions to intensive care units of that age group. That is the reason for moving to the vaccine, but because it is the first year it has been available, it has been necessary, because of global demand, to stagger the delivery, as I said. GPs and pharmacies were informed of this staggering of deliveries at the beginning of the year. I can tell my noble friend that 8.2 million doses have already been ordered for this age group, of which 4.9 million have already been delivered, against around 7.6 million used last year. So there is adequate supply, and it will be delivered to all GPs and pharmacies as necessary to meet the demand by the end of November, so that by the beginning of December anybody who wants that vaccination should be able to access it.

[Lord Clark of Windermere (Lab)]

My Lords, does the Minister appreciate that by delaying the availability of a vaccine for the over-65s, the Department of Health is increasing the risk of that group of people contracting flu? Can he explain to the House why it has taken the decision not to have it available until early December?

[Lord O’Shaughnessy]

I am very happy to tell the House: it was on the advice of the Joint Committee on Vaccination and Immunisation, which is precisely where we get expert advice on how to act. The reason for moving to this new vaccine is the one I set out. The reason that the delivery is staggered, but to be completed by the end of November, is because it is from December into January that we have the peak of influenza in this country. The Deputy Chief Medical Officer said:

“Based on many years of surveillance in the UK it is highly unusual for widespread community flu activity to become significant or substantial before the start of September”.


It is on that clinical advice that this decision has been taken.

NHS: Staffing

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 10th October 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to ensure that the National Health Service has sufficient staff following Brexit.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, my department is working with Health Education England, NHS England, the royal colleges and others to make sure that the NHS is able to recruit and retain the staff it needs. Furthermore, we are working with NHS and social care employers to make sure that the 167,000 EU nationals working in health and care can access the EU settlement scheme, which will safeguard their rights to live and work in the United Kingdom.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer. Earlier this year he pleased the House by announcing that NHS staff who had worked in the NHS for more than five years would be allowed to remain in Britain under the settled case arrangements. Can he advise the House whether, following the Prime Minister’s statement on immigration at the Tory party conference, that remains the case?

[Lord O'Shaughnessy]

Yes, it is absolutely the case that anybody from the EU who is living and working in this country, not just in NHS and social care, before exit day—or December 2020, the end of the withdrawal period—will be able to apply for settled status. Indeed, if they have not lived here for five years, they will be able to apply for what is called pre-settlement status and then apply after five years.

NHS and Social Care Services: Parity of Esteem

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 5th July 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right to point out that there are differences between the two workforces: clearly the NHS has a largely publicly employed workforce and social care has a largely privately employed one, so there will inevitably be some differences in form. We need to make sure that those workforces work together and are as attractive as one another, which is why finding a sustainable funding solution is so important so that those private contractors have the ability to pay what is necessary to attract the right staff.

[Lord Clark of Windermere (Lab)]

My Lords, the NHS proves that, with determined leadership, democracy can deliver long-lasting benefits to society. Will the Minister join me in paying tribute to those parliamentarians—in spite of them all being Labour—who, over 70 years ago, time and again traipsed through the Lobbies to bring about the National Health Service?

[Lord O'Shaughnessy]

Well, they say that success has many parents and we should pay tribute to the Liberal MP William Beveridge, the Conservative Health Minister Henry Willink, and the Labour Health Minister Nye Bevan in the founding of the NHS. It is important to point out that the Conservative Party has been in power for 43 of the NHS’s 70 years and it has thrived under our leadership.

Nursing and Midwifery (Amendment) Order 2018

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Monday 25th June 2018 Lords Chamber

[Lord Clark of Windermere]

May I press the Minister a little further on the training costs? Is he saying that all students on the nursing associate courses will be apprentices and that no student on the nursing associate course will pay towards the cost of that course?

[Lord O’Shaughnessy]

I thank the noble Lord for that question. My understanding is that the nursing associate is a two-year apprenticeship that provides a level 5 qualification. Therefore, there is currently a consultation about the nature of the role—the balance between work and training and so on—but obviously if it counts as an apprenticeship any organisation providing it can draw down on the apprenticeship levy fund to pay for those training costs. Whether it is in theory possible to train through an alternative route that would involve the paying of fees is something I will need to investigate and write to the noble Lord about. Of course, I will put that letter in the Library. The funding is there and the NHS is paying it. It is not necessarily drawing it down at the moment; this is an opportunity for us, with a course that is tailor-made for apprenticeships, to take advantage of that money to fund the courses.

I hope I have been able to answer noble Lords’ questions. This is an exciting moment in the development of the workforce. It provides an extra gear to the workforce to provide for the ever more complex care needs of our population. This is a good step forward. We are moving quickly and I look forward to working with noble Lords in the coming months to make sure we can put this course and its regulation on a statutory footing, attract many thousands of people into it and welcome a new profession into the health and care family. On that basis I commend the order to the House.

National Health Service: Assaults on Staff

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 20th June 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government how many attacks on NHS staff were reported in 2016-17 and 2015-16.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Government are committed to taking action against those who abuse or attack NHS staff. In 2015-16, NHS organisations, which are responsible for protecting their staff, reported 70,555 physical assaults. Of those, 52,704 were due to patients’ conditions or treatments they were receiving. Data has not been collected for 2016-17. We are reviewing with the NHS how in future information about assaults and abuse of NHS staff can help trusts promote best practice.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer. Can I give him a little help with the updated figures? Has he seen the figures produced by the Health Service Journal and Unison which show a 10% increase in violence against NHS staff in the latest year? That is just unacceptable. Why did the Government in November 2017 abolish NHS Protect, which had the responsibility to protect NHS staff against violence? I know that it was replaced and that its staff, but not its functions, were transferred to the NHS Counter Fraud Authority, which focuses on fraud and protection of buildings. Will the Minister confirm that there is now no body responsible for the safety of NHS staff? I am drawn to the conclusion that this Government value property more than people.

Long-term Plan for the NHS

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

We have in this debate just started the lively conversation that we will be having on taxation in the next few months. Clearly there are a number of ideas; they have been voiced by Members on the Liberal Democrat and Labour Benches as well as those on my Benches and the Cross Benches. We know that there are a number of ways that this could be done; the Prime Minister has shown incredible leadership to admit that this is necessary. These are very difficult decisions: in polls, people say that they want to pay more tax but when it comes to the crunch they often feel slightly differently. True leadership is being able to take us through that situation, and that is what the Prime Minister is showing.

[Lord Clark of Windermere (Lab)]

I thank the Minister for taking the trouble to repeat the Statement made yesterday in the other place. Of course we welcome the money, but let us not get carried away. Every health trust charity believes that the increase needs to be at least 4%. Secondly, this still leaves only one country in the G7 paying less towards healthcare than we are.

May I ask the Minister three very brief questions? I saw a report saying that the training costs of doctors and nurses were not included in these figures. Is that correct? Secondly, when we pursue the Government’s concept, which is right, of bringing the NHS and social care together, hence delaying the plan, will the extra costs of social care come out of the 3.4%? Finally, when it is discovered that there is no exit bonus when we leave the EU, will the Government guarantee that that shortfall will be made up from elsewhere?

[Lord O'Shaughnessy]

The noble Lord mentions the figure of 4%. I have looked at a number of think tank reports and their assumptions on what is required. They make some very cautious assumptions of the productivity improvements that the NHS is making, based on historical performance. The improvements in productivity over the last five years are very healthy—in fact, in the last year the NHS became more productive at a rate of 1.8%. If you add that to the 3.4%, that gives an increase of more than 5% in terms of bang for your buck. It is incumbent on us during this process not only to put in more money but to make sure that we are driving those productivity gains that we have seen in the last five years. If that then gives a 5% effective increase in funding, that is what we will need to deal with the long-term pressures that the noble Lord has quite rightly highlighted.

On the three questions, there is an explicit commitment to deliver this workforce strategy that the NHS comes up with as part of its plan. On the extra costs of social care, we clearly need a social care settlement that delivers the funding for those rather than their being covered by the NHS. That is what we mean about the commitment not to create extra pressures. As I have said, the funding will come from three sources—whatever the mix, the funding will be there.

NHS: Winter 2017-18

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 18th April 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what assessment they have made of the effectiveness of their plans for the NHS in dealing with the pressures during the winter of 2017-18.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, last year the NHS started planning earlier than ever before to support delivery during the challenging winter months. Despite the NHS being extremely busy, with challenging weather conditions and flu rates at their highest level for several years, hard-working A&E staff treated more than 55,300 people within four hours per day between December and March—that is 700 more a day on average than the year before. A review of winter performance by NHS Improvement and NHS England will be published this summer.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer. Of course, we are all very thankful indeed that we have got through the worst days of the winter, and we are grateful that new plans were put in place. However, I think we all know that we got through only due to the dedication and commitment of the staff in the health service at every level, and that we face dire shortages in every sector of the health service. Is the Minister aware, for example, that 800 student nurses in 20 universities have had their grants or loans cut off or reduced due to administrative errors by the Student Loans Company, and that many of them now face financial distress, with the prospect of no or reduced support for the foreseeable future? Does the Minister accept that that is preposterous when there is such a shortage? Will he therefore step in and try to sort that out, so that no student nurses suffer?

[Lord O’Shaughnessy]

I join the noble Lord in paying tribute to the dedication of staff who have taken us through what has been the worst winter for eight years. I was not aware of the particular issue he raised; I am glad he has raised it and brought it to me. I shall take it back to the department immediately after Questions to make sure that we get to the bottom of what is going on and try to fix it urgently.

NHS: Staff Pay

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 21st March 2018 Lords Chamber

[Lord O’Shaughnessy]

I thank the noble Baroness for her welcome for the Statement. We, along with all Members of the House, value NHS staff and this is a proper recompense after what have undoubtedly been difficult years for them. Regarding what this means for funding for charitable and social care staff—I did not address the point when the noble Baroness, Lady Jolly, asked me about it—we will obviously make sure that any staffing issues, including salaries, are part of the Green Paper discussions. They will clearly have to take into account the higher pay that is coming down the stream for these staff.

[Lord Clark of Windermere (Lab)]

My Lords, of course we welcome this, but I must say that the Minister was selling it a bit hard when he said that the Government have managed the National Health Service well when they have made cuts in training which have exacerbated the situation.

My question is a simple one. The Minister has said that the Treasury will meet all the costs. Is that an absolute assurance? I ask that because many local hospital care trusts have found that there are hidden costs. For example, the Government are pushing apprenticeships, but what they never mention is that it is the local care trust which has to pay the university thousands of pounds a year for the apprenticeship training. Will everything be covered in this pay rise?

[Lord O’Shaughnessy]

I thank the noble Lord for giving me the opportunity to provide that confirmation. In the 2017 Autumn Budget we set aside in the reserves £800 million a year, which will fund the first year of the Agenda for Change pay deal, and obviously if the members of the NHS trade unions accept the agreement, that funding will be released. The Chancellor will also provide the additional funding required to fulfil his commitment through the 2018 Autumn Budget and make available £4.2 billion over three years to fund the deal. I hope that gives the clarity the noble Lord and others seek.

Nurses: Training

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 7th March 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what specific proposals they have to increase the number of fully trained nurses working in the National Health Service and the associated care services.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, there are record numbers of nurses working in the NHS in England, including 13,900 more acute, elderly and general nurses. To increase the future supply of registered nurses, the Government are funding over 5,000 more student nursing places for those entering training each year from September 2018. We are opening up new training opportunities to increase the number of professionally qualified nursing staff across the health and social care workforce through the apprenticeship route.

[Lord Clark of Windermere (Lab)]

I thank the noble Lord for his reply, but I do not think the Government really grasp the seriousness of the shortage of nurses. In the last two years, 33% fewer students came forward. We have a shortage of 40,000 nurses and it will take years to put that right. Can I make a suggestion to him? The best and quickest way to increase the number of trained nurses is for the Government to drop their opposition to the bursary scheme for postgraduate students. These two-year courses are cheaper; it would cost the average funder £33,500 for the two-year course, which is half as much as the average trust would pay simply to employ an agency nurse for a year to fill the gaps. Why will the Government not follow that route?

[Lord O'Shaughnessy]

My Lords, we take very seriously the need to train more nurses. There are 52,000 nurses in training and, as I have said, there is a commitment to increase the number of training places by 25%, which is obviously how we get to a long-term solution. On the issue that the noble Lord has raised about postgraduate bursaries, the policy intention is to bring these courses in line with other courses. I know that this is an issue of great concern. The Royal College of Nursing has expressed its concerns and we take those seriously. I also know that the regulations have been prayed against in the other place; they are also being looked at in the Secondary Legislation Scrutiny Committee and we await its report. I reassure him that the issue is being considered and we will respond once the committee has reported.

NHS: Charitable Donations

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 22nd February 2018 Lords Chamber

[Lord O’Shaughnessy]

I reassure my noble friend that I am not trying to make an ageist point. The point I was trying to make is that the majority of healthcare costs in a lifetime occur at two points in life: in younger children and in older age. We effectively have an insurance system where we pay through our tax and use the care when it is needed. The concern is that at a point in life when people might be vulnerable and not have support around them, and not necessarily know what is required in complex care, having had the facts about one piece of care they may feel that they should not be creating a burden on society by asking for more care. I do not think that is the right approach.

[Lord Clark of Windermere (Lab)]

My Lords, will the Minister make it quite clear—loud and clear—that virtually every hospital trust has its own charity and indeed that many individual wards have one?

[Lord O’Shaughnessy]

That is precisely the point. Any of us who have spent time in hospital will know that those charities are well advertised. As I say, they have £400 million of income, which I think makes them second only to cancer research in terms of income for health charities. I agree that they are a real asset to our health system.

NHS: Winter Crisis

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 7th February 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what assessment they have made of the effectiveness of their planning for the winter crisis in the National Health Service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, planning for winter started earlier than ever before to ensure that robust plans were in place to support NHS delivery during the challenging winter months. Despite the NHS being extremely busy and flu rates being at the highest level for years, hard-working staff treated more than 55,000 people within four hours every day in December—more than 1,200 more than last year. NHS England and NHS Improvement will publish their review of winter by summer 2018.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply. As he knows, NHS spending has risen by an average of 4% each year in real terms since its inception in 1948. Since this Government took over in 2010, that 4% increase has fallen to an average of between 1% and 1.5% in real terms. Can the Government not accept that some of their meanness is one of the major causes for the crisis the NHS finds itself in?

[Lord O'Shaughnessy]

I totally reject the accusation of meanness. If noble Lords look at the spending on the NHS, not only has it gone up in real terms every year while a massive fiscal retrenchment has had to take place to deal with £150 billion of borrowing bequeathed by the previous Government, but it now accounts for the highest percentage share of public spending that has ever been in place. We have found the money in difficult circumstances. We all agree that more is needed. More was found in the Budget; I am sure more will be found in the future.

NHS: Nurse Retention

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 17th January 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord is quite wrong to say that it is an unappreciated profession; nurses are deeply appreciated by everybody in this country, and that includes members of the Government.

Of course we want to reduce the number of nurses leaving the profession. It is important to point out that the number is down on two years ago, which was the peak in both number and proportion, and that the number of nurses has risen over that period. The noble Lord mentioned the pay cap. He will know, I hope, that in the Budget the Chancellor announced that he would be funding pay increases above the pay cap for nurses and other professionals on the Agenda for Change contracts, which is extremely welcome. We know that pay matters.

The noble Lord is right to focus on under-40s; that was an area that concerned me. The programme whereby we are promising to deliver 3,000 social homes for nurses is an important part of retaining staff, because we know how important housing costs are, particularly in the south of England.

Finally, we have been around the issue of bursaries a number of times, and there is no evidence that their introduction will make a long-term impact on our ability to recruit the nurses we need. Indeed, we are increasing the number of nurse training places from next year by a further 5,000.

[Lord Clark of Windermere (Lab)]

My Lords, the Minister has yet again repeated that there are 11,700 extra nurses on the ward, and compounded that by saying that there are more trained nurses in Britain than there were in 2010. Yet a Written Answer to me of just 10 days ago shows that we currently have 317,980 nurses, which is fewer than there were in 2010. Can he square that circle—or is he talking not about nurses but about nursing assistants?

[Lord O’Shaughnessy]

On the specific and most recent workforce data—if we are going to get into the specifics of nurses only—in May 2010 there were 273,071 nurses and in September 2017 there were 275,356, so that is an increase. I shall certainly look into the figures with which I wrote to the noble Lord. Of course, I intend always to be truthful. I am reading from the latest workforce stats.

As for nurses on wards, the noble Lord will know that the number has gone up. An important response to the scandal of Mid Staffordshire and the Francis report was to increase nurse numbers. We know that that has a consequence for other professions—I have talked about that quite openly—and in mental health and district nursing. That is why we want to increase the number of nurses in those areas.

NHS: Winter Funding

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 11th January 2018 Lords Chamber

[Lord O’Shaughnessy]

I would hope that the noble Baroness would welcome the money that was set aside in the Budget. It is important to point out that in addition to that £337 million, half of which has gone to support plans that were already in place and being actioned before the Budget, there was a further £100 million to support A&E streaming, which is also a way of taking pressure off emergency services. That has had an impact, so I do not accept the accusation that the money came too late, and indeed there is still money in the pot as services come under pressure.

As regards the future, the noble Baroness will know that it was also announced in the most recent Budget that another £2.8 billion would be allocated to the NHS to help it get through the next few years. We know that the pressures are increasing because of the ageing population. The idea of that money is precisely to help the NHS get back on target on A&E waits as well as referral to treatment.

[Lord Clark of Windermere (Lab)]

My Lords—

--- Later in debate ---

[Lord O'Shaughnessy]

I thank my noble friend for pointing out the fact that no Government have funded the NHS like this one. Indeed, the proportion of public spending taken up by NHS spending has been increasing in the last seven years, contrary to the views held by those opposite. On the impact of adult social care, my noble friend speaks with great wisdom. We know that money invested in the social care sector has a big impact. It already has, as he pointed out. That is why it is meaningful that the department has taken on full control over social care policies so we can push ahead with integration, which, as we know, is the right way to solve these problems.

[Lord Clark of Windermere]

My Lords, it is a question not only of money, but of planning and training staff. Did the Minister see yesterday that the head of chemotherapy at Churchill Hospital, Oxford, said that cancer treatment and chemotherapy were being delayed and curtailed because of the lack of trained nurses? Yet the Prime Minister denies this. Who are we to believe?

[Lord O'Shaughnessy]

I think that the trust has been clear that there are not going to be delays. If the noble Lord is talking about the story on the front page of the Times yesterday, the trust has subsequently been clear that it will not delay or curtail its treatments. We know that more nurses are required. That is why, as I am sure he will be pleased to know, there have been around 11,700 more nurses on wards in the last seven years.

Agency Nurses

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 10th January 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 27 November 2017 (HL3070), what assessment they have made of the operation of the “break glass clause” in the supply of agency nurses to hospital trusts from off-framework agencies.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, significant progress has been made in reducing agency staffing in the NHS. In 2016-17, the NHS spent £700 million less on agency staff than in the previous financial year. The “break glass” clause is one of a number of measures introduced to support patient safety while we seek to reduce the use of agency staff. Since a peak in April 2016, the number of nursing shifts procured from off-framework agencies has more than halved.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer on this very complicated issue. However, does he recall his Answer to my Written Question of Monday in which he confirmed that the incoming Conservative-led Government in 2010 cut the number of nurses virtually every year, sometimes in excess of 10,000, with the result that we have fewer nurses working in the health service today than in 2010? That is the cause of our reliance on agency nurses, which costs the NHS billions of pounds. This cannot continue, so will the Minister use his influence to try to ensure a proper workforce plan for the NHS so that we have sufficient staff to meet the needs and demands of the British people?

[Lord O'Shaughnessy]

The noble Lord is quite right that we need sufficient staff. He will know that when the Government came to office in 2010 difficult decisions needed to be made about the funding of all public services, because of the economic situation at the time. It is worth pointing out that, since that time, there are over 10,000 more nurses on wards, which is obviously particularly important at this time of year. In terms of the future figures, I hope he will be aware that there will be an increase in the number of training places for nursing—£5,000 a year. Indeed, Health Education England, which is responsible for workforce planning, will deliver a long-term plan to make sure that we can tackle this issue, which has been a long-standing problem for the NHS.

Nurses and Midwives: Numbers

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree with the noble Baroness that there is a need for more nurses. That is why we are introducing more training places and new routes into nursing, such as the nursing apprenticeship. I know that she is particularly concerned about EU national nurses and health visitors. I think noble Lords will be reassured that between June 2016 and June 2017, there was an overall 5% increase in the total number of staff from the EU within the NHS, which is welcome. The one area, as I said, that has fallen marginally—by about 162 in practice—is in nursing and health visitors. That was significantly due to the new language test that was introduced. That is something that the NMC is looking at to make sure we are getting nurses capable of practising in this country to come here.

[Lord Clark of Windermere (Lab)]

My Lords, as the Minister knows, citizens of the EU who have spent five years working in the UK can avail themselves of the opportunity to apply for a right to remain permanently in the UK. That is now unclear. Will he announce that those who have been granted the permanent right to remain in Britain as EU citizens will be entitled to stay and work here? That would be a good way to start building confidence.

[Lord O'Shaughnessy]

My Lords, the rules as they are apply, so those who are eligible to apply for a right to remain can do so. We are talking about providing a path for those who are not yet at that point, now or in the future, to achieve settled status to provide the kind of certainty that we know. I understand that this causes some people to pause for thought about whether they should stay.

Nurses: Tuition Fees

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 29th November 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government whether they will write off the tuition fees of nurses who spend a number of years working in the NHS or related public care services.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, there are currently no plans in place to write off tuition fee loans for nurses who take up work in the NHS. Substantial financial support is available for nurses in training. With the increase in the student loan repayment threshold introduced by the Department for Education, from April 2018 a newly qualified nurse will not pay back their loan on earnings up to £25,000 a year.

[Lord Clark of Windermere (Lab)]

My Lords, when we have a shortage of 40,000 nurses, when the Government’s introduction of tuition fees has resulted in fewer nurses entering training, and on the very day it is announced that we are having to import 5,500 nurses from India, is it not crucial that we incentivise everything we can to get British students into nursing? Would my proposal about working in the NHS not help that?

[Lord O'Shaughnessy]

My Lords, nurse training places have been discussed a number of times in this House. I am sure noble Lords will be keen to know that, while there has been a small percentage drop-off in places year on year, the numbers recruited this year are comparable to 2014-15. That is common with the introduction of tuition fees for other courses and we would expect it to rebound. In the long run, the intention is to grow more of our own nurses and to recruit from the United Kingdom, which is why there will be an increase of 25% in the number of clinically funded training places for nurses—5,000 extra—from 2018-19 onwards.

NHS: Deficit

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 22nd November 2017 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord waits patiently. I pay tribute to the quality of the report and we have already accepted some of the ideas set out in it. Now that the Budget is over and the Treasury can turn its mind to additional things, we will be responding to the report very soon.

[Lord Clark of Windermere (Lab)]

My Lords, in his Budget Statement today, the Chancellor referred to the fact that he was establishing a working party of the department and the unions to look at salaries in the NHS, but he was a bit vague when it came to the funding of the outcome. Can the Minister give an assurance that the Government will fund whatever is agreed by the department?

[Lord O’Shaughnessy]

The Chancellor has confirmed that he will fund an Agenda for Change, as it is known, pay deal on the condition that the pay award enables improved NHS productivity and is justified on recruitment and retention grounds.

NHS: Winter Staffing Levels

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 26th October 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to increase staffing levels in the National Health Service to meet anticipated demand during the forthcoming winter period.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, providing appropriate staffing over winter is essential. NHS England and NHS Improvement have worked together to make sure that every major consultant-led emergency department has a robust plan to meet demand. This includes necessary staffing levels. In addition, the department has provided £100 million to relieve pressure on urgent and emergency care specifically to allow primary care streaming and improve patient flow in A&E departments.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply. Those are soothing words, but I am afraid not really matched by the reality on the ground. It is clear that we face a dire prospect this winter on account of the Government’s poor labour planning over the years they have been in power. We know that we are 40,000 nurses short, GP numbers are tumbling and adult social care staff numbers have fallen from 70,000 to 48,000 in four years. Last year, 45% of the consultant posts advertised were not able to be filled. We really are in a very difficult position.

I ask the Minister a very specific question: is it true that the Government have given the go-ahead for vulnerable patients who are not fit to be discharged to their home to be discharged to third parties? They will be allocated to homes where the hosts have no medical expertise and for which they will get paid £1,000 a month.

[Lord Clark of Windermere]

This is my final question. Will the Government not listen to medical opinion and drop this preposterous scheme?

[Lord O’Shaughnessy]

The noble Lord knows that winter is always a more difficult time for the NHS. I hope he also knows that there are 11,000 more nurses on wards than there were in 2010. Indeed, I was looking at the data on doctors. There has been a 30% uplift in emergency doctors in that time as well. So there are more staff in the NHS—but, of course, there is much more need for winter preparedness. The NHS feels that it is better prepared than ever for winter.

On the issue that the noble Lord refers to—I assume he is talking about the story in the press today—that is, I stress, a local pilot that is being explored. I do not think it is even under way. It is being proposed by a local doctor—indeed, an emergency registrar. For it to go ahead, it is clear that any such pilot would have to abide by the very strict rules that exist on safety, safeguarding quality and so on for any care setting. The head of Age UK said that any new innovation—I think we want to encourage innovation—needs to pass the mum or grandma test. I think that is a very reasonable test to apply to something such as this.

Medical Examiners and Death Certification

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 18th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight this point. Medical examiners are not involved in stillbirths, because the cause of death is before the point of birth. However, there is clearly a need for the involvement of coroners. I will look into the detail of that. I can tell the noble Baroness that the Government are taking the issue of stillbirths seriously. A new perinatal mortality review tool is looking at that and it is integrated into the learning from deaths scheme now going on in the NHS.

[Lord Clark of Windermere (Lab)]

My Lords, this is a very welcome initiative, but in view of the incredible shortage of medical staff in the NHS, is the Minister confident that there are sufficient staff to cover it? Are the Government looking at other ways of making staff available—for example, people may be brought back from retirement—to handle it in the initial years?

[Lord O'Shaughnessy]

That is a very good question because we are talking about a greater workload. The pilots and the early adopters have demonstrated that it is possible to do this with existing staff loads. As it is rolled out across the country, there may be a need for additional staff. I reassure the noble Lord, and indeed others including bereaved families, that any staff who are used will be registered practitioners and would be regulated by the GMC.

Health and Social Care

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 12th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The CQC report, which I am sure the noble Lord has looked at, talks about agencies and indeed nursing home providers deregistering. It also talks about the ones that are registering. There is a fairly consistent turnover in the number of those, so it is about balance. There is a similar number of providers within the market—again, with slightly fewer residential nursing and slightly more domiciliary to reflect the kind of balances of care that we have discussed.

[Lord Clark of Windermere (Lab)]

My Lords, as the figures today show that the number of registered nurses in Britain is actually falling, and bearing in mind that the existence of care beds depends upon nurses, will the Minister answer the Question that I asked earlier this week and give us a progress report on the number of students who entered nursing courses at universities this September, so that we can make a judgment on the current position?

[Lord O'Shaughnessy]

I think the noble Lord is referring to the King’s Fund report on nursing. It is important to stress that there are still greater numbers of nurses overall compared to 2010; indeed, over 11,000 more on wards. There are some particular shortages in mental health and community nursing, which have been alluded to before. In terms of the nursing numbers, he will know, because we have discussed this before, that there is a ratio of about 2:1 in the numbers of applications for nursing places. I do not have a more recent update than that. My expectation therefore is that that was the position going into September. I shall certainly write to him with the details. I emphasise that this increase in the number of training places, with funded clinical placements, is designed to address the issue that we have about the need for more nurses as we have a growing and ageing population.

National Health Service

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 10th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The NHS is seeing more people than ever—I think that some 1,500 more people a day are being seen in A&E. A lot more people are going through the service. The truth is that there are a number of factors: there are factors around lifestyle and around ageing. The point is that we have to change. At the heart of this Question is the comment made by the chief inspector about our not having new models of care. We need to change the way in which we provide care. That means integrated care, with much more of it based in the community. That means us all taking difficult political decisions about how care is configured so that it meets changing needs related to obesity and ageing.

[Lord Clark of Windermere (Lab)]

My Lords, a major problem facing the NHS is the drastic shortage of nurses. As the Government have changed the funding of nurse training at universities and as those universities now have their students in place, can the Minister give us any figures on the number of nurses in training in this current year?

[Lord O'Shaughnessy]

I know that the noble Lord has been concerned about this issue. I hope that he heard my right honourable friend the Secretary of State announce last week not only an increase in the number of nursing associate places, where qualification is through an apprenticeship route, but a 25% increase in the number of degree training places and funding for the clinical placements that they involve.

Older Persons: Care and Human Rights

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 11th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I certainly pay tribute, as the noble Lord does in the foreword of the report, to the growing trend towards strengthening the protection of older persons’ human rights. He is also right to highlight today and in the report that there are still widespread negative stereotypes. The Government are proud to lead the world in tackling age discrimination, and we published in February a strategy called Fuller Working Lives on that purpose. We are taking many actions to fulfil the requests in his report; one particular one that I would focus on from a health perspective is the fact that, by 2020, all medical curricula will include training for geriatrics, so there will be that additional support throughout the entire NHS.

[Lord Clark of Windermere (Lab)]

My Lords, I, too, congratulate my noble friend on producing such a brilliant report. One theme running right through the report is that ageism, like sexism and racism, is simply wrong. Does the Minister agree with that? In his response to the report, will he make it clear that the Government will not support ageism in general legislation or in any rules affecting this House?

[Lord O'Shaughnessy]

Rules affecting this House will, of course, be decided by its Members, who are probably the least likely group in the entire country to be ageist. The noble Lord is quite right to highlight this incredibly serious point. Any form of negative stereotyping or discrimination is, of course, wrong. I mentioned a couple of things that the Government are already doing and a lot is going on to counter any kind of discrimination. This Government have got more older workers into employment and are tackling the discrimination in the workplace that, unfortunately, still takes place.

NHS: Working Conditions

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 5th July 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what proposals they have to improve working conditions for NHS staff.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, the Government are improving working conditions for NHS staff by recruiting record numbers of doctors and nurses over recent months. Furthermore, we are helping trusts to become employers of choice through more flexible working, improving staff health and well-being, and tackling bullying of and violence against NHS staff.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply, but it indicates to me that the Government are still in a state of denial. He talks about recruiting extra nurses. Has he seen the report last week that showed that for the first time ever there were more nurses leaving the profession than joining it? How does that stack up with his assertion that they are recruiting more nurses? Does he not accept that it is only on account of the dedication and commitment of all NHS staff, including doctors, nurses and ancillary staff, who on occasion work in appalling conditions, that the service is as good as it is? Why do the Government, as a first step, as a gesture, lift the pay cap so that the nurses and the doctors can have a salary that they deserve?

NHS: Shared Business Services

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 27th June 2017 Lords Chamber

[Lord O'Shaughnessy]

To date, the cost of dealing with this problem is around £6 million. Clearly there is a contractual relationship between NHS SBS and various bits of the NHS. It needs to be established clearly, independently and objectively where the culpability lies for any incurrence of costs, both with the problem in the first instance and in dealing with it. Once that has been established, costs will be fairly and correctly apportioned to whoever caused the problem in the first place.

[Lord Clark of Windermere (Lab)]

Has the Minister seen the reports that managers moved many of the documents out of sight and actually destroyed many of them? If that is the case, it is very serious. If it were a wholly private company, its directors would be suspended pending investigation. If it is the case that documents were deliberately destroyed, will the most serious action be taken against the directors of that company?

[Lord O'Shaughnessy]

Clearly, if there were such an incidence, the noble Lord is quite right that it would be dealt with very strongly—but it is important to point out that there has not been evidence that that has happened. Documents were destroyed that sat within SBS, but they were not part of the backlog and they conformed, as we understand it, to the protocols around destroying old papers when they have gone past a certain time limit. So there is no evidence that what the noble Lord described has happened in this instance—but, as he points out, if it had happened it would be of the utmost seriousness.

Brexit: Nursing Staff

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 27th June 2017 Lords Chamber

[Lord O'Shaughnessy]

I reiterate the point that the Prime Minister made yesterday about the welcome, and indeed the offer of settled status, not just to nurses but to any other EU citizens and workers in the country. It is absolutely not the case that they are unwelcome—quite the opposite. They are as valued as much as any other person working in the health service. The noble Baroness mentioned housing, and she is right, of course, that housing is a huge issue for everybody. Indeed, one thing that I want to look at in the next few years is how we can take surplus land that sits within the NHS and make sure that some of it is used to provide the kind of key-worker housing that nurses, doctors and, indeed, other members of the public sector can use, so that they are able to come into the service and support our hospitals.

[Lord Clark of Windermere (Lab)]

My Lords—

--- Later in debate ---

[Lord O'Shaughnessy]

I completely agree with my noble friend, who speaks from experience. It is important not to peddle a myth of unwelcomeness, when it is clearly the case that nobody has said that they are unwelcome. No one in government has said that they are unwelcome; nor has the BMA, the RCN, or anyone else for that matter. They are valued as highly as any other member of the medical profession.

[Lord Clark of Windermere]

My Lords, does the Minister accept that any fall-off in the number of nurses and doctors from the EC poses a real risk to the health service? Does he accept that, while the number of nurses in training may be increasing now, the Government were wrong in the coalition period after 2010 to cut the number of nurses in training in the UK?

[Lord O'Shaughnessy]

The critical point is to have enough nurses and, indeed, enough medical staff. Of course, where they come from is going to be dictated by various circumstances. As I have discussed already, language controls have been introduced in order to focus on patient safety. We do need to increase the number of nurses in the health sector. That has happened since 2010. There has been an increase. There are more in training. But clearly there need to be more as we have a growing and ageing population.

Education (Student Fees, Awards and Support)(Amendment) Regulations 2017

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 27th April 2017 Lords Chamber

[Lord O'Shaughnessy]

I am not going to speculate on the impact of that. What I can tell the noble Lord is that, despite the scare stories that numbers will have been affected, there have been more EU-based nurses in the past year. That is the point that I wish to get across.

The real issue at stake is whether the number of staff in the NHS is increasing to meet the growing demands on it, and here the Government have a strong record. Over the past year, the NHS has seen record numbers of staff working in it. The most recent monthly workforce statistics show that, since May 2010, there are now over 33,000 more professionally qualified full-time equivalent staff in NHS trusts and clinical commissioning groups, including over 4,000 more nurses.

Health Education England’s Return to Practice campaign has resulted in 2,000 nurses ready to enter employment and more than 900 nurses back on the front line since 2014. There has been a 15% increase in the number of nurse training places since 2013, plus the introduction of up to 1,000 new nursing apprenticeships and the creation of nursing associate roles—the kind of non-graduate nursing roles that my noble friend Lord Forsyth pointed out as being such a crucial part of the mix. These all form part of our plan to provide an additional 40,000 domestically trained nurses for the NHS. These new and additional routes into the nursing profession will allow thousands of people from all backgrounds to pursue careers in the health and care sectors and, critically, allow NHS employers to grow their own workforce.

I will end as I began. I believe that this regret Motion is misguided. The extension of the loan-based system to nursing and midwifery training is a natural development of reforms that have received cross-party support, successfully expanded higher education, dramatically improved the participation of disadvantaged groups and provided a fairer distribution of the costs of funding higher education.

Despite the pessimism of some, the decision by the British people to leave the European Union, which this party respects, has not had a material impact on the workforce. Furthermore, and paid for in part by the resources freed up by our changes to student finance, this Government have put in place a series of programmes that have successfully increased the number of staff in the NHS and provided more training places than ever, allowing us better to grow our own workforce among UK residents.

The true source of regret is that the Opposition have used this opportunity to run scare stories about both the impact of sensible funding changes we have made and the impact of leaving the European Union on the NHS workforce. I urge all Members of this House to vote against the Motion.

[Lord Clark of Windermere]

My Lords, I have listened very carefully to the Minister. I wanted to be persuaded; I am not persuaded. I believe that the Government are taking a big risk. They have gambled before. It may not be known, but in 2011, 2012 and 2013, they reduced the number of nurses in training because they thought we had sufficient. As a result, several thousand nurses were short-trained in those three years, because the Government got the figures wrong. I believe that they have got the figures wrong again. It is a big risk that we do not need to take. It is unfair on the nurse’s career, but, most of all, it is unfair to potential patients in the National Health Service. I want to test the opinion of the House.

Healthcare: Spending

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Tuesday 4th April 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government whether they will increase spending on healthcare as a percentage of gross domestic product to be in line with the G7 average.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, since 2010 health spend has increased in real terms and is broadly in line with the EU average. This Government are giving the NHS an additional £10 billion above-inflation increase in its annual funding by 2021. We have now gone beyond that, with £425 million of new capital spending for the NHS announced at the spring Budget, and we have pledged to provide further capital at the autumn Budget.

--- Later in debate ---

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer, which goes a long way towards explaining why the NHS is at breaking point. Our hospitals and GPs’ surgeries are full, social care is on its knees and staff are working in impossible conditions. Those are not my words; they are the words of the BMC, which knows what it is talking about. My Question is not about Europe; it is about the G7. First, will the Minister confirm that as a country we are next to the bottom of the G7 nations in health spend? Secondly, why will the Government not commit us to meeting the average of the G7 countries, which would go a long way towards reviving our wonderful National Health Service?

[Lord O'Shaughnessy]

The noble Lord makes the point that the NHS is operating in challenging conditions, not least because of rising demand and expectations. Notwithstanding that, there is a huge improvement in performance. More operations are being performed, there are more diagnostic tests, more people are starting cancer treatment, and people say that they have never been more satisfied with the quality and dignity of care that they are receiving. Those are the points that we need to bear in mind when we talk about the fantastic work that NHS staff do.

National Health Service: Nurses

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Wednesday 22nd February 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to eradicate the shortage of trained nurses in the National Health Service and care sector.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, this Government have undertaken work to increase the number of trained nurses. We now have a record number of nurses working in the NHS. By increasing the number of training places for both new nurses and nurses returning to practice, we continue to support the growth of our nursing workforce in the health and care sectors.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply but I cannot share his wing-and-a-prayer approach to the drastic shortage of nurses we face. Bearing in mind that the NHS alone is short of 24,000 nurses, and the 23% reduction in nursing applications as of this autumn, does the Minister not agree that they should reinstate the bursary scheme at university for nurses, or at least promise nurses who qualify and spend a number of years working in the health service that they will have their tuition fees reimbursed?

[Lord O'Shaughnessy]

I am sorry that the noble Lord takes such a negative view of the changes we are making. There are actually 6,500 more full-time equivalent nurses and health visitors than there were in 2010. There has been a 15% increase in the number of training places and of course, through our reforms which he just mentioned, we are taking the cap off the amount of training places that can be offered.

Mental Health: Children’s Services

Debate between Lord Clark of Windermere and Lord O'Shaughnessy

Thursday 19th January 2017 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords, might I press the Minister a little further on his very last sentence, when he referred to the increased availability of nursing? I know that he is aware that there is a projected 20% drop in nurse training at this stage but, for specialist nurse training, especially mental health nurse training, the drop is even larger than 20%.

[Lord O'Shaughnessy]

This is something that we had the opportunity to discuss yesterday. I am aware of the concerns on this issue. The reforms are designed to take the cap off the number of places, making more places available. In the last year, something like 37,000 applicants were turned away from nursing places, which is clearly not something that we want. When there is a change in regime, clearly there may be an impact on numbers in the first year—as there have been when tuition fees have been introduced in the past—but historically that has tended to rebound.