Nurses and Midwives: Fees

Alan Meale Excerpts

Monday 23rd March 2015 Westminster Hall

[Mr Anderson]

That is central to the discussion. I have been struck by the fact that nurses who are relatively well paid and work full time will have to pay exactly the same registration fee as those who work short hours. That may make things quite comfortable for the NMC’s bureaucracy, because the organisation will know exactly how much money it will have, but it does nothing for people who are worried about where the next pay packet is going to come from. My hon. Friend is right to say that it is a real problem.

[Sir Alan Meale (Mansfield) (Lab)]

From my hon. Friend’s contribution to the debate so far, it is clear that a poll tax model has been adopted in respect of the gathering of funds for the Professional Standards Authority. Doctors and dentists will be paying the same fee as nurses. Does he not think that that is quite unfair, given the wage structure in the national health service?

[Mr Anderson]

That seems unfair to me, as it does to the nurses. As I will try to bring out in the debate, the important thing is not only the money that people are paying—for some, that is a real issue—but the value for money that they receive. Two years ago, the Government had to step in and give the NMC £20 million to prevent a fee increase. Of course, the nurses and midwives welcomed that, but it means that the taxpayer is subsidising the NMC because it has failed to do its job properly. My hon. Friend is right to say that there is an imbalance in what it is doing.

[Sir Alan Meale]

It is about not only the position but the numbers. There are far more nurses and midwives than doctors and dentists. The fee increase is disproportionate and quite unfair.

[Mr Anderson]

The fee increase is disproportionate, but the numbers of disciplinary and fitness-to-practise cases are also disproportionate. As we will hear, the number of nurses facing fitness-to-practise issues is grossly more than the number of doctors facing such cases. That means there is less money to spend on education and training to increase registration standards for nurses, which is what we all want.

Nurses lose at every level through the way in which the system is run. The review was not just about people saying, “Please don’t make me pay more money”; it was about, “Can we have a root and branch investigation into how this organisation is run? Can we make it run better? Can we make it run in everyone’s interest?”

--- Later in debate ---

[Mr Anderson]

My hon. Friend is obviously reading my mind, because that is the point that I was going to come on to next. She is absolutely correct that part-time workers, who are mainly women, are being hit disproportionately because they are in part-time work, and there could well be equality issues around that.

The decision to increase fees will have a catastrophic impact on nurses’ and midwives’ future decisions, which will have a direct result on work force planning and patient care. At present, 30% of nurses and midwives in practice have protected pension rights, so they are eligible to retire at 55 with their full pension. Many do that, and, after a brief period of absence, return to part-time practice. That has gone on for decades and is something that the health service has welcomed and plans for.

I have been told by many people who work in nursing and midwifery that it would not be economic for them to return to work after they retire if registration fees rise and continue to do so. That was borne out by the Unison survey, which found that 51% of respondents would not return to practice if fees increased. That would be a double whammy for the health service. We would lose people with experience who were prepared to come back to work part time; they will not do that because of that block put in front of them.

We already have a chronic shortage of supply of nurses and midwives in the UK, which is made worse by the Government’s decision to cut the number of nurses and midwives in training. That shortage is demonstrated by the increasing numbers being recruited from Europe. A reduction in those returning to practice will have a devastating impact on patient care. It is essential that service and staff implications are taken into account by the NMC and the Government. Without that, it will be impossible for the NHS to plan its work force properly.

On revalidation, the NMC ignored the heavy opposition it received and decided to go ahead with its proposal to increase fees regardless. For any nurse or midwife whose registration payment is due by the end of February 2015 or later, the new fee applies. The bodies and unions sought reassurance from the regulator that fees would not increase further, but the NMC has offered no guarantees about coming years.

Later this year, the NMC will introduce a new revalidation process for registrants, which will place additional requirements on those who wish to stay on the register and continue to work. I support the work on revalidation, and I know colleagues on the Health Committee have been critical of the failure to move faster on that, but many nurses and midwives are concerned that those changes could result in further fee increases. It is not clear what the cost impact will be.

[Sir Alan Meale]

The papers that I have read make it clear that the NMC gathers most of the PSA’s funds, yet it seems to have little say in its budget. Does my hon. Friend agree that that is probably the main reason for the re-evaluation?

[Mr Anderson]

Absolutely. I will come on to discuss the PSA before I sit down, which my hon. Friend will be glad to hear will not be long now.

Professional bodies and trade unions are working hard with the NMC to ensure that the development and introduction of the new process is as successful as possible and that lessons are learnt from the pilot sites. That process will be extensive and require significant efforts from registrants, but it surely cannot lead to further unjustifiable fee increases for hard-working midwives and nurses.

The NMC could take measures to prevent future fee rises for registrants, but it is not the only one that should beheld responsible. The Government could have taken measures to reduce further fee increases, but they chose not to.

First, the NMC has the most unwieldy legislation of all regulators despite being the largest. By contrast, the General Medical Council and the Health and Care Professions Council have more flexible legislation, which allows them to be more efficient and cost-effective. That prompts the question: why should midwives and nurses be treated differently from doctors and occupational therapists?

In April 2014, the Law Commission published a draft regulation of health and social care professionals Bill, which included reforms that would have helped the NMC keep costs down. If implemented, the draft Bill would offer the NMC the opportunity to speed its processes up and give it flexibility to amend rules without having to seek Parliament’s permission.

The Mid Staffordshire NHS Foundation Trust public inquiry called for regulators to focus on promoting safe, compassionate care, rather than intervening only after patients have suffered harm. The draft Bill would have allowed the NMC to focus more resources on education, effective registration and promoting professional standards, which would have done exactly what the inquiry called for. Currently, it is impossible for the nine health regulators to work together: there are nine different pieces of legislation, nine different codes of conduct and nine different fitness-to-practise procedures. It is not clear to me why we are treating health workers differently when the main objective of all health regulators is surely the same—public protection.

The draft Bill would enable and require regulators to co-operate more closely with each other, which would ensure consistency. It would help the NMC and all the regulators to keep their costs down collectively. However, this Government failed to include it in the Queen’s Speech, which meant it could not be debated or passed into law. It would be interesting to hear from the Minister what he thinks of that decision.

Registrants should not be punished for the Government’s failure in that respect. Likewise, the NMC should not use it to justify or push through any future fee increases. The NMC has joined representatives of patients’ groups, nursing and midwifery professional bodies, and trade unions to call on politicians, such as us here today, to commit to introducing the draft Bill to reform health care and its professional regulation.

In addition, following a review in 2010, the Government decided that the Professional Standards Authority, the body responsible for the oversight of the health professions’ regulators, would no longer continue to be funded by the Government and the devolved Administrations. Instead, the review recommended that the PSA should be funded through a compulsory levy or fee on the regulatory bodies that it oversees. So, rather than consult on whether there should be a levy or on who should pay it, the Government decided to consult on how the PSA levy on the regulatory bodies should be calculated. Rather than saying, “Should we do it?” they said, “How will we pay for it?”

Professional bodies and trade unions quite rightly argued against this levy; it is another hammer blow for the people working in the service. However, their concerns were ignored by the Government who, in their response to the consultation, decided to determine the fee based on the number of registrants that a regulator has. Again, this unduly disadvantages the NMC, which will bear a disproportionate amount of the cost because, as I said earlier, it is the largest regulator in the world. Based on the current size of the NMC’s register, the first £1.7 million levy to the PSA equates to £2.50 per registrant. The upcoming fee rise has already resulted in 12.5% of this additional sum effectively going straight to fund an external organisation, which is doing nothing to protect the public or to help to educate or protect the staff working in the service.

Because the NMC has no other source of income, these costs will almost inevitably be passed on to registrants, who include some of the lowest-paid professionals regulated by the health regulators. As I said before, approximately 90% of the NMC’s registrants are women, so the PSA levy will have an adverse impact on equality, as the hon. Member for South Down said. Also, many NMC registrants work in part-time roles, and so frequently they are not high-income earners. If the NMC is forced to increase the annual registration fee in order to pay the PSA, which in some respects it already has, that will have an impact on equality, as those in this group will be financially worse off. The poorest will pay the most, which is not unusual under this Government.

Over the years, all the NMC’s efforts have been directed at dealing with fitness-to-practise cases. This has had a detrimental impact on the level of service provided by the NMC to its registrants. For example, the NMC has failed to provide effective and up-to-date guidance on key issues, and there has been a lack of professional advice to registrants who have queries or concerns about how to interpret the requirements of or guidance on the code of conduct. Given the overwhelming, and appropriate, focus of professional regulation on public protection, and the diminution in professional advice, it could be argued that it is unfair to expect registrants to continue to bear the sole financial burden of the NMC’s professional regulation activities.

Furthermore, if the body overseeing the regulators is funded by the regulators, the public will lack confidence. Consequently, the funding arrangement for the PSA, which is based entirely on registrant funding, is flawed. At a time of ongoing financial austerity, the additional bureaucracy is undesirable, particularly when there are already existing mechanisms to scrutinise and hold regulators to account, for example, the annual accountability hearing by the Health Committee, which enables the people in this building to scrutinise what the regulators are getting up to.

For these reasons, I urge the Government not to implement the levy on the nine health regulators, and for the Government and the devolved Administrations to continue to fund the PSA until it is included in the draft Law Commission Bill.

It is appalling that the NMC decided to increase its fees despite the heavy opposition from hard-working nurses and midwives. It is tough enough to be a nurse or midwife without having to be penalised for coming to work. They are working in an increasingly difficult environment, which has been made worse by public sector cuts, chronic understaffing and continued pay restraint that means their pay is lagging well behind cost of living increases. If the NMC’s fees continue to increase, it will result in nurses leaving the profession, exacerbating existing problems in the health system, which is already struggling to cope.

To ensure that future fee increases are not made, it is essential that the following steps are taken. First, the NMC should undertake a full review of all fitness-to-practise referrals that do not proceed to a full hearing, and use that information to sit down with the employers and trade unions to ensure that all referrals to the NMC are in the interest of patient safety and public protection, and not just an excuse for employers to carry out internal disciplinary procedures. That would have a positive impact by reducing the number of referrals and the overall cost thereof.

Secondly, the NMC should shift resources into promoting awareness and the development of guidance that would help registrants to understand better how to act within the NMC’s code of conduct in their practice. That would help to reduce the number of fitness-to-practise referrals, which would be a win-win for everybody concerned.

Thirdly, the NMC should consider a reduced fee for new registrants, part-time workers and those nearing retirement age, to reflect better registrants’ income throughout their careers. There should be a phased fee for all concerned.

Fourthly, the Government should not implement the PSA levy on regulators and should continue to fund it centrally, at least until it is included in the draft Law Commission Bill.

Finally, the draft Law Commission Bill must be given adequate parliamentary time by the next Government to be debated and passed, to enable the NMC and other health regulators to reduce costs, in the interests of all concerned.

We count on nurses and midwives every day.

--- Later in debate ---

[Grahame M. Morris]

I agree wholeheartedly. All across the country—certainly in my area—efforts are made, and have been made consistently, to recruit good quality staff. Often recruitment is done overseas, with adverts being placed in newspapers in countries that train good quality nurses and midwives, but have a surplus. It often strikes me as bizarre that although we have a reservoir of women returners, we not making it as easy as possible for them to return. Doing that would be in the interests of the service and of the country. It would be a false economy to continue doing what we are doing.

[Sir Alan Meale]

I am here today because my sister is a midwife and has been a nurse all her adult life. This is not just about times of restraint and restrictions on pay; there has also been a thorough re-grading of the whole nursing and midwifery system throughout the UK, which has already re-graded many nurses to lower grades than previously. They are experiencing a double whammy, and this is the third time they have been hit with a fee rise. We should not approve it.

[Grahame M. Morris]

I am grateful for my hon. Friend’s intervention. That is another excellent point, well made. Pressures are being placed on the NMC, including increases in its costs, that are placing a greater strain and burden on nurses and midwives. The Government have to recognise that. I know that my hon. Friend the Member for Blaydon has reservations about whether the Government supporting the NMC with one-off grants would impact on its impartiality. I do not think that should necessarily follow. We should recognise the considerable pressures being placed on it financially, not least those arising out of public concerns and the recommendations of the Francis report. We want the public to be confident that the profession is properly regulated and that the fitness-to-practise procedures are operating properly and effectively. However, I agree with my hon. Friend. There was a ministerial statement last Thursday regarding untoward practices highlighted in a report, including bullying of staff and so on, in a hospital in east London—I think it was the Barts Health Trust. If fitness-to-practise referrals are being used by employers in that way, it is reprehensible and is adding to the strains and pressures on the NMC.

The latest fee increases are being imposed on nurses and midwives who were extensively consulted about them. My hon. Friend mentioned the overwhelming numbers: 96%—many of us would be over the moon to have that as a vote of confidence in the general election—voted against those recommendations. However, it seems that the consultation served little purpose, other than to antagonise nurses and midwives, because the Nursing and Midwifery Council has, apparently, taken little or no regard of the views of NHS staff and has pressed ahead with the fee increase.

The Nursing and Midwifery Council has also failed to provide any assurances that the latest increase will not be followed up by further increases in coming years. As my hon. Friend the Member for Mansfield (Sir Alan Meale) mentioned earlier, if we are to encourage people to come back into the profession, they have to know that the regulator has a reasonable, cost-effective process in place. The Nursing and Midwifery Council stated in evidence to the Health Committee last year that it had introduced an

“annual formal review of the fee level”,

so it is not necessarily an ongoing commitment. However, we have to ask: why has there been such a huge increase, of more than 50%, in a relatively short period?

Clearly the Nursing and Midwifery Council must meet its statutory obligations. We would expect that as Members of Parliament—and the public would certainly expect that—for maintaining professional standards. Certainly more needs to be done to remove the constraints it faces through the fitness-to-practise process—a number of hon. Members have highlighted that—which is too costly. Seventy-seven per cent of the Nursing and Midwifery Council’s income of more than £70 million is being spent investigating less than 1% of the nurses and midwives on the register. That is an incredible sum of money, and I find it difficult to comprehend how that can be an efficient use of resources.

The Nursing and Midwifery Council is making progress—I recognise that, and certainly the Committee recognised it, although it said it thought the progress was “fragile”. The NMC recognises past failures—not least in IT systems—and is seeking to overcome some of them, but it is clear that further improvement is required. An assessment by the Professional Standards Authority for Health and Social Care—the organisation that oversees all the professional regulators—has found that the Nursing and Midwifery Council is failing to meet seven of the 24 standards of good regulation. By any measure, I would suggest that there is still a long way to go in bringing it up to standard. Of those seven failures, two relate to fitness to practise.

While it is important that improvements continue to be made, it is wrong to expect nurses and midwives to bear the burden of the costs by themselves, particularly when we have seen the value of their pay fall in real terms over the life of this Parliament. The Government cannot sit idly by and allow continual increases in fees without taking action or giving some guidance. We hear Ministers time and again praising the hard work and dedication of nurses, and I hope the Minister will do that at the conclusion of the debate. Nurses do an amazing job in the most difficult circumstances, but when it comes to pay, pensions or professional fees, the kind words of Ministers seem to be rarely followed up by practical action that would help NHS staff.

In conclusion, I hope the Minister will say what steps he is taking to support the Nursing and Midwifery Council to ensure that it can continue to drive through the improvements we all want to see without having to increase the fees and the cost of employment for nurses and midwives. I also hope that he will address the points made by my hon. and right hon. Friends on the need to speedily bring forward the law commissioners’ sensible and well thought out proposals on the NMC. I would be interested if he could explain why they have not been brought forward before now.