Education (Student Support) (Amendment) (No. 2) Regulations 2018

Lord Hunt of Kings Heath Excerpts

Monday 21st May 2018 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the Education (Student Support) (Amendment) (No. 2) Regulations 2018 extend the normal student maintenance regime to more categories of nursing students as a replacement for the NHS Bursary Scheme; and calls on Her Majesty’s Government to postpone the introduction of the Regulations until the current review of post-18 education and funding has been completed (SI 2018/443).

Relevant documents: 21st and 25th Reports from the Secondary Legislation Scrutiny Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, the huge pressure which the NHS is under is taking a massive toll on our nursing, midwifery and other health professionals. It has been estimated that the NHS in England has approximately 40,000 nursing vacancies, with a vacancy rate of over 10%. A similar rate applies to midwives, although the RCM estimates it to be higher, to reflect the number of babies being born. The other health professions covered by this regulation are similarly affected. More nurses and midwives are leaving the profession before retirement; one in three nurses is due to retire in the next 10 years. For various reasons, including Brexit, work pressures and the age profile of the nursing profession, the number of nurses and midwives on the NMC register at the end of March 2018 was less than that in March 2017 and significantly less than at the peak in March 2016.

The House of Commons Health and Social Care Committee inquiry found that the nursing workforce in England must be,

“expanded at scale and pace”,

and that,

“future projections of demand for nurses should be based on demographics and other demand factors, rather than on affordability”.

Given this, one would have thought that the Government would do all they could to support and encourage entry to these professions. Instead, they are doing the opposite, reflected in these regulations, by ploughing ahead with their plan to scrap bursaries for yet more students, despite knowing full well the disastrous consequences that will follow.

Two years ago, the Government scrapped the undergraduate bursary. The results were predictable. In 2016, before the abolition, there were more than 47,000 nursing applicants in England. In 2018, the figure fell to about 31,000—a fall of over 15,000. It is clear that this is the reason why we have seen the sharpest ever decline in nursing applications. I have no doubt that the Minister will say that the number of applications is less important than the number of acceptances. I disagree: I want nursing to be seen as a profession where there is hot competition for places because it is such an attractive profession to be in.

No doubt the Government will say that they have committed to create more training places for nurses. They certainly promised an extra 5,000 nursing places and said that nursing bursaries had to be scrapped to make that possible. What has been delivered is a mere 700 fewer students training to be nurses. It is worrying, too, that there has been such a huge drop-off in mature students applying—the extraordinary figure of 42%. The very people we need to apply, who have often brought up a family, are now being denied an opportunity to make a career in nursing or face the consequences of being forced into huge debt.

We know that postgraduate students in particular are more vulnerable to the introduction of fee loans: 64% of postgraduate healthcare students are aged over 25 compared to only 18% of students generally. Women are largely attracted to the healthcare postgraduate route and represent 80% of the course places. There is a higher percentage of ethnic minority students on postgraduate healthcare courses compared to the general population, and the Department for Education equality analysis clearly states that these groups are known to be more debt averse. So introducing loans is likely to undermine recruitment of this cohort and represents yet another missed opportunity to grow the nursing workforce at a time of severe shortage.

The Government claimed in the other place that raising the cap will unlock additional places, but it was the Government themselves who set the cap through their funding of Health Education England. They also say that they can fill some of the gap with nursing apprenticeships. They have promised 1,000 of them, yet only a handful have started the course. This shortfall is not the only problem with overreliance on apprenticeships. A nursing apprentice will take four years to become a registered nurse. Even if there were a miraculous surge in apprenticeships starting this summer, we would not see any qualified nurses on our wards until 2022. Contrast that with an undergraduate nursing course, which can take three years, or postgrad courses referred to in the regulations, which can take two years, which makes them the quickest way to tackle the shortfall in numbers.

Another solution the Government have come up with is nursing associates. But there is clear evidence that using support workers or trainees as replacements for qualified nurses has potentially disastrous consequences for care. I hope that the Minister will confirm that that is not the Government’s intention. The nursing associate is a support role and must not be used as a substitute for registered nurses. Research is clear that diluting and substituting the registered nursing workforce with nursing support workers has ill consequences for many patients.

In pushing ahead with this regulation, Ministers ignore their department’s impact assessment. The DfE’s assessment of the changes to the bursary said that it would disproportionately affect women and ethnic minority students, yet Ministers have pressed ahead. Then the department found that the change could make women, older students and students with lower incomes less likely to participate. Again, Ministers pressed ahead.

This is not just a matter of fairness or even just about the benefit of having a diverse working population. In fact, older nursing graduates, to take the nursing profession in particular, are more likely to stay longer in the NHS and are more likely to choose areas such as mental health or learning disability nursing, which are facing such severe staff shortages. Nearly two-thirds of postgraduate nursing students are over 25, more than a quarter are from minority ethnic groups and 80% are women, so the impact of today’s regulations will surely be even worse than the previous cuts.

I welcome the golden hellos to postgrad students in specific hard-to-recruit disciplines, but the Government need to do much more to financially support postgraduate students.

Even if the Government are determined to make the change, there are good reasons not to make it now. This policy would move postgraduate nursing students over to the main student finance system, which means dealing with the Student Loans Company. There is every reason to believe that that company may not be ready. In recent weeks, the Government have been dealing with an error made by the company that has led to 793 nurses being hit with unexpected demands to repay accidental overpayments they were unaware of. I do not know whether the Minister has seen the recent NAO report on the company, but that also gives great pause for thought about whether it is able to accept this new responsibility. It strikes me that, before embarking on these regulations, we have the flagship review of higher education. The Government could have allowed that review to take account of this matter, rather than going ahead with the change today.

My final point is about student finances in general, and the impact on the Government. How many postgraduate students affected by this policy will repay any or all of their additional loan? How is this financially sustainable? Or is it just another example of what the Treasury Select Committee called a “fiscal illusion”—in this case, a student financial system that allows the Government to pretend that they have made a saving when all they are doing is passing the Bill to the next generation?

It is little wonder that the devolved nations have retained the NHS bursary system. We in England should do the same. I beg to move.

[Baroness Walmsley (LD)]

My Lords, like the noble Lord, Lord Hunt of Kings Heath, we, too, oppose the introduction of these regulations—and for very similar reasons. It always makes sense to make policy based on evidence and on the advice of experts. This is what the Government have failed to do in relation to the funding of student nurses. The removal of the bursaries for undergraduate nurses has already considerably reduced the number of applicants, and the number of those taking up a place was 705 lower last year than the year before. Given the 40,000 nurse vacancies that the noble Lord mentioned, this is a serious matter for patient safety, as pointed out by the Care Quality Commission. I accept that these are only one year’s figures, but I believe that, before upsetting the apple cart even further, the Government should postpone removing bursaries from postgraduate nurse trainees and other important groups until we have clear evidence of the effect on the number of undergraduate student nurses.

If we want to increase the number of registered nurses quickly, which we need to do, it makes more sense to support the two-year postgraduate route, not put it at risk by removing those bursaries, too—because this is the quickest way to get more nurses. Most suppliers of the two-year courses indicate that capacity could be increased by 50% given the right financial support, yet the Government are planning to deter applicants by removing the bursary. This does not make sense. Instead, the Government are focusing on the two four-year routes into nursing, yet the apprenticeship route is not providing the expected 1,000 extra nurses per year. The most recent data tells us that there are only 30 apprentice nurses—hardly a success. Will the Government look into the barriers that are preventing NHS employers taking on apprentices? It could be the 60% cut in funding for further professional development, which has affected the number of those who would like to become training assessors and mentors for student nurses and apprentices.

Nursing associates have a role both as assistants to registered nurses and as users of an alternative four-year route into nursing—but, again, it takes a long time and these associates, as the noble Lord, Lord Hunt, said, should not while training ever be seen as substitutes for fully qualified nurses. So why are the Government planning to deter applicants for the rapid postgraduate route, where 64% are over 25, where they are predominantly women and where they are more diverse than the general student population? In a career such as nursing it would be advantageous to attract people with a little more life experience than the average 18 year-old.

Also, we know that older women and ethnic minority students are more debt averse, as well as already having a student debt of up to £50,000 from their first degree. Therefore, it is vital to look at how this fast route into nursing could be supported. The RCN tells us that, if the fees were paid and a modest bursary towards living costs provided, the total would be less than the average annual premium paid by trusts over a single year for a full-time agency nurse. This is short-termism of the worst kind.

While the Government carry out their review of post-18 education, they might benefit from looking at the measures introduced in Wales by Kirsty Williams AM, the Liberal Democrat Minister in the Welsh Government responsible for medical education. Her conversations with students revealed that the main concern and deterrent was not fees but living costs. Therefore, she has introduced the equivalent of the minimum wage for students during their course. This method of student funding should be carefully considered by the Government while carrying out their review, particularly for nursing students, who have more contact time than other students because of their clinical placement and therefore less time to get a part-time job to support themselves. Will the Government please consider this sensible idea?

The House of Commons Select Committee on Health and Social Care stated that the nursing workforce should be expanded at scale and pace to avoid dangerous levels of vacancies. It should be based on need and demand rather than affordability. It is up to the Government to say how the money will be raised, but from these Benches we recommend some sort of hypothecated taxation or a reformed national insurance scheme which is truly progressive and demonstrates intergenerational fairness. The Liberal Democrats are also in favour of restoring the bursaries for undergraduate student nurses and we are against these new regulations, which would remove the bursary from postgraduate nursing students and other important health professional courses.

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[Lord O'Shaughnessy]

That is quite right. That is fully funded clinical placements—just for the sake of clarity. I thank the noble Baroness.

There is understandable concern among noble Lords, which has been expressed previously in this House, about the new system of financial support, but I want to be clear that we are giving the group of postgraduate students that we are discussing access to undergraduate maintenance and tuition fee loans, just as we do with postgraduate teachers. This represents a more generous package of support than the postgraduate master’s loan. We are also making available additional funding for childcare, travel to clinical placements and exceptional hardship funding to ensure that the students are fully supported and are able to complete their studies.

Furthermore, as many noble Lords have mentioned and as the noble Lord, Lord Hunt, and the noble Baroness, Lady Watkins, welcomed, in the debate on the regulations in the other place on 9 May, my honourable friend the Minister of State for Health set out a range of additional support that we are investigating for postgraduate nursing students. This includes specific incentives such as “golden hellos” for postgraduates who go to work in mental health—where the noble Lord, Lord Willis, was quite right that we need to attract more nursing and where there has been a shortfall—the area of learning disability and community nursing. The Government have announced £10 million to support such incentives and we are considering how this should be best delivered.

Many noble Lords have expressed concern about the drop in number of undergraduate applications to nursing courses. We acknowledge that early indications from the latest UCAS data, published in April, show that the number of students applying to study nursing has decreased from this point in the cycle last year. However, that cycle is not yet over, so we need to apply some caution.

It is also worth noting, as noble Lords have pointed out, that there is a distinction between the decline in number of applications and that in the number of students starting their courses. That was exemplified last year, which showed a 23% drop in the number of applications compared to a 3% decline in the number of acceptances. That is regrettable, but it was still the second-highest number of acceptances on record. Several noble Lords have expressed their desire for further information on how this develops. I can confirm that my department has committed to publish an update in autumn 2018 following the close of the 2017-18 application cycle.

As the noble Baroness, Lady Watkins, pointed out, there is a global challenge to recruit more nurses. We are working hard to make nursing as attractive a profession as possible. As a result of constructive dialogue over recent months, NHS Employers and the relevant trade unions began a consultation exercise on a three-year pay deal for NHS staff employed under the Agenda for Change contract. Under the plan, the starting salary of a nurse will rise to £24,907 by 2021, not only rewarding current staff for the incredible work they do but sending a clear signal to the country about how much nurses are valued.

We are boosting the attractiveness of the profession in a number of other ways, too. Nearly 4,500 nurses have started the return to practice programme and 3,000 have completed it. Across the country, NHS trusts are developing arrangements for flexible working and there is a concerted effort to tackle workplace bullying through an NHS-wide call to action. Our homes for staff programme is supporting NHS trusts to dispose of surplus land to help up to 3,000 nurses and other staff access affordable housing. I hope that gives the noble Lord, Lord Clark, some concrete examples to back up the warm words we use about supporting the nursing profession.

Several noble Lords have touched on new routes into nursing, which the Government are prioritising. The most significant innovation in this area was the announcement of a new nursing associate role in November 2016. Health Education England has already trained 2,000 nursing associates in a pilot programme and is planning to train up to 5,000 in 2018, with up to 7,500 nursing associates trained through the apprenticeship route in 2019. As well as creating a much-needed new role in its own right—I emphasise “in its own right”, as it is an augmentation to the nursing and other professions—nursing associate training offers an alternative route to becoming a registered nurse. We expect this “earn and learn” approach to be more attractive to older students, a concern which many noble Lords have raised.

To support this career path, Health Education England is developing a shortened nurse degree apprenticeship to facilitate transition from nurse associate to registered nurse, which will also automatically recognise the prior learning and experience gained in the nursing associate role. For the first time, apprentices will be able to work their way up from entry-level health work through to advanced clinical practice in nursing.

Several noble Lords expressed their concern about the apprenticeship route and the figure of only 30 nurses. The official data has been delayed and we believe that the figure is more like 250. We will be able to confirm that. It is a better start but, clearly, not yet the target that we want to reach. However, we believe that this stepped approach through the nursing associate role, giving the opportunities for a pause after two years and then to go on for two years, ought to be more attractive to employers than the current four-year commitment. This development of the nursing associate route therefore provides for a better use of the apprenticeship route.

I want to address a couple of what are perhaps misconceptions. The figure of 40,000 vacancies is used often in this House. I might be pedantic and disagree with that number—the quantum is just about right—but it is important to say that these are not empty places. They are being filled by agency and bank staff. Part of the reason for that is that people want flexibility and more pay, two of the things that we are trying to address so that we can provide more permanent contracts for those people who currently work flexibly.

The noble Lord, Lord Clark, and the noble Baroness, Lady Garden, talked about EU staff. I hope your Lordships will agree that I miss no opportunity to say from this Dispatch Box how much we value those staff and that they have just as much right to apply for settled status as anyone else in this country, provided they fit the criteria. However, it is worth pointing out that there are more EEA staff in the NHS than there were in June 2016. The one category where the figure is lower is in nursing and midwifery but the reason for that was the introduction of a more stringent language test. We are dealing with that issue, which I hope will mean that we continue to see an increase in EEA staff working in our NHS.

The noble Lord, Lord Willis, asked specific questions about the apprenticeship levy. I will need to write to him on that issue having consulted my colleagues in the Department for Education.

Turning quickly to the second point of the Motion, several noble Lords, including the noble Lord, Lord Hunt, the noble Baronesses, Lady Walmsley, Lady Watkins and Lady Garden, and others said that we should postpone the introduction of the reforms until the post-18 education and funding review has been completed. As noble Lords know, the Prime Minister launched the review earlier this year to ensure that we have a better system of higher education support that works for everyone. Many aspects of the current system work well and, as was set out in the terms of reference for the review, there are important principles that the Government believe should remain in future. One of those is that sharing the cost between taxpayers and graduates is the right approach, as I rehearsed earlier in my speech.

I take the point made by the noble Baroness, Lady Walmsley, about looking at the Welsh example. I have looked at it myself and I am sure it is something that the review would want to consider. However, it is important that we do not prejudice the work of the expert panel established to support the review or prejudge its outcomes. The fact of the review should not delay these healthcare education reforms, not least because they predate the launch of the review by some distance and already apply to the vast majority of nursing students. We believe it would do more harm than good to further delay these reforms, although it is worth underlining that any relevant reforms stemming from the review will apply equally to this group of student nurses.

In conclusion, I recognise the well-motivated concerns expressed by noble Lords during this debate. However, I hope I have been able to demonstrate that the student finance reforms that this Government have introduced have allowed both the removal of the artificial cap on nurse training places and the largest expansion of student nursing places in a single year ever seen. These two facts are not coincidental; they are inextricably linked. The latter is possible only because of the former and they form part of a wider set of workforce reforms designed to expand, train and reward our nursing profession better so that we can continue to deliver the high standards of NHS care that patients demand. On that basis, I hope the noble Lord, Lord Hunt, will feel able to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to all noble Lords who have spoken in this debate, particularly the noble Baroness, Lady Watkins, who returned early from the WHO to take part in it.

I am left, though, with huge concerns and a real puzzlement as to the Government’s approach. As the noble Lord, Lord Willis, said, faced with this huge crisis in nursing in particular but also among the other professions covered by the regulation, the Government, without any evidence base, seem to be setting out a plan to discourage older women and people from black and minority ethnic groups from entering nursing, midwifery and other professions. In the breakdown of postgraduate healthcare students, the statistics show clearly that 64% are over the age of 25, women are largely attracted to this route and there is a higher percentage of minority ethnic students. We also know from the Department for Education’s own analysis that those groups are known to be more debt-averse. So the consequence is bound to be a negative impact on the very group of people we probably most need to come into the nursing profession.

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[Baroness Walmsley]

I would add that the Browne recommendations had no cap at all.

[Lord Hunt of Kings Heath]

My Lords, I would pray in aid my noble friend Lord Adonis, who sadly is not here tonight, and take the Minister back to the original intent of the loans that we introduced.

The Minister does not seem to have responded at all to the issue that, essentially, we are transferring this debt to future generations. At some point, the fact that so little of the loans is being paid back will have to be confronted. The Minister justifies increasing the number of places now on the basis that at some time in the future some Government are going to be faced with a massive problem. So not only are we discouraging some of the most important people that we want from coming into the profession, but we are also engaging in the most extraordinary financial trickery to justify current expenditure.

The Minister mentioned apprenticeships and associates. Of course we should welcome apprenticeships, and I welcome the associate profession, which is a good thing. However, the problem is that we know what the health service gets up to. We know that directors of nurses do not have as much influence on boards as they need, and that NHS trusts up and down the country will substitute associates for qualified general nurses whenever they can. Given the debacle of the whole apprenticeship approach, in putting all our eggs into that basket we are very much risking the future of this profession.

My noble friend Lord Puttnam talked about the problem that it takes a long time to recover from a situation of drastic shortage, and my noble friend Lord Clark talked about some of the implications. When you see a car crash about to happen, you usually attempt to stop it. I see this policy as putting the foot on the accelerator, leading to an inevitable crisis.

However, this was debated in the other place. I see no purpose in prolonging the debate. I hope that, under the auspices of the review of student finance, the Government will start to think again. I beg leave to withdraw the Motion.

Motion withdrawn.