Nurses and Midwives: Fees

Andrew Gwynne Excerpts

Monday 23rd March 2015 Westminster Hall

[Andrew Gwynne (Denton and Reddish) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Havard. It is also a pleasure to follow my hon. Friend the Member for Foyle (Mark Durkan). We recently had the pleasure of serving for 13 hours that we will never get back on the Committee for the National Health Service (Amended Duties and Powers) Bill, which my hon. Friend the Member for Eltham (Clive Efford) promoted. It is quite a novelty to speak in a health debate in which hon. Members have actually spoken about health. It feels quite unique after the debates in that Committee.

As is customary, I place on the record my appreciation of and congratulations to the petitioners, who managed to achieve the number of signatures necessary for the debate, and my hon. Friend the Member for Blaydon (Mr Anderson) and the Backbench Business Committee on getting it on the Floor of Westminster Hall today. I also pay tribute to all who work in our national health service, not only the nurses and midwives in particular, but everyone who helps make the NHS the service that it is. We are now only five and a half weeks from the next general election and we are in the last full week of the 2010 to 2015 Parliament. Issues such as the one that we are debating show the direction in which our health service has been heading.

It is totally wrong to impose further charges on nurses and midwives, especially when many are facing a cost of living crisis caused by the Government. Wages are falling and prices rising; this is now set to be the first time in living memory when people will be worse off at the end of a Parliament than they were at the beginning. Yet the Nursing and Midwifery Council wants to increase the burden on the shoulders of registrants. What message does that send to the nurses, midwives and patients whose interests it is there to protect? I think a pretty poor one.

We have all had similar cases, but the hon. Member for Congleton (Fiona Bruce) put her constituent’s very eloquently. I am sure that other Members have such cases to pursue with Ministers, which highlight the issues surrounding the debate. We are talking about not only numbers, but real people, and it is right for such matters to be raised. Taken together with the 1% pay rise—for which, to put it bluntly, nurses had to fight tooth and nail after the Government initially indicated that they would not honour their pledge—the move we are discussing today shows what the Government think of public sector workers. When Labour gets into power, clearly we will have to look carefully at the books, but we absolutely will not do what this Government have done: break every single promise made to NHS staff.

As we have heard throughout the debate, in particular from my hon. Friends the Members for Blaydon, for Easington (Grahame M. Morris) and for Foyle, the Government should have introduced the Law Commission’s draft Bill on the regulation of health and social care professionals, which included some good measures. Had the Government introduced it, it would have enabled the NMC to increase efficiencies and decrease costs. Instead, the Government have been introducing a swathe of delegated legislation to form something of a patchwork quilt of reform. Indeed, I seem to remember, Mr Havard, that you chaired two statutory instrument Committees only last week—

[Mr Dai Havard (in the Chair)]

At the same time.

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[Andrew Gwynne]

At the same time!

I do not understand why the Government could not have found time to introduce the measures in the draft Bill. Even the head of the NMC, Jackie Smith, thinks that the Government have not gone far enough. She has complained that she is fully aware her organisation is not resolving cases quickly enough, but that the legislation as it stands does not allow the NMC to do things any quicker. Likewise, the Royal College of Nursing, the Royal College of Midwives, the Patients Association, the Parliamentary and Health Service Ombudsman, the Care Quality Commission, Unison, Unite and others have voiced their strong support for the draft Law Commission Bill.

In response to the Francis report, the Prime Minister hailed the draft Bill, but then promptly forgot about it. It is simply not a priority for the Government. In response to the draft Bill, they said that they would be

“committed to legislating on this important matter when parliamentary time allows”,

but we have already heard how, towards the end of this Parliament, it has been dubbed the “zombie Parliament”: we have one-line Whip after one-line Whip and we have finished business earlier than the normal moment of interruption on many days. There has been plenty of time to introduce the measures had the Government seen fit to do so. Certainly given the supposed cross-party consensus on the measures, they could have reached the statute book by Dissolution. Judging by the lack of any sort of activity in the House in recent months, the Government have had their chance many times over. Sadly, only a few days of the Parliament now remain.

It looks to me as if the only people opposed to the draft Bill were Ministers. To be fair to the Minister present, whom I like, I do not think that that is through any malice, but that it is rather a result of inertia, or perhaps a lack of attention—I do not know. Let me place clearly on the record, however, that Labour supports reform and simplification of the legal framework for regulation. The draft Bill would enable the regulators to work better together and to share functions and, crucially, to make savings and to keep their costs down. The Government’s failure means that they are now leaving the NMC to force nurses and midwives literally to pay the price.

We went through the same procedure three years ago: the NMC announced that it had to put its fees up; it held the consultation that it is obliged to do; and it promptly increased the fees by one third. In that instance, the consultation showed an overwhelming majority of respondents opposed to the plans. This time it has put the fees up by another fifth, which means, as we have heard from other Members, that the fees will have gone up by £44 in three years, an increase of more than 50% on 2011.

The e-petition has shown the strength of feeling. As my hon. Friend the Member for Blaydon stated, 114,000 signatures is some doing—not many e-petitions make the 100,000 threshold necessary to be considered for a debate in Westminster Hall or in the main Chamber. This e-petition is one of the most modest and reasonable of the ones to meet the criteria, so I genuinely hope that the Minister will consider it in the few days left to him to be accountable to Members of this House of Commons—after Dissolution there will, of course, be no Members of the House of Commons, although the Minister will remain in his post until the formation of a new Government. I want his commitment to give the e-petition the full consideration that it deserves.

I will say a little about the other duties of nurses. Later this year, the NMC will introduce a new process of revalidation for registrants that will place additional requirements on those wishing to stay on the register. It will require significant efforts from registrants. Together with pay restraint lagging well behind increases in the cost of living and an environment of demand, unrest and difficult decisions, it is difficult to see how further increases in the registration fee would not simply demonstrate to nurses that they are not valued. Encouraging staff to leave the NHS is the last thing that we should be doing given the UK’s shortfall in nurses and midwives.

Furthermore, why would new students decide to go into nursing and midwifery when the Government are making life even more difficult for graduates? Nurses have been subjected to an effective cut in their pay of between 8% and 10% since 2010, and the latest move is unacceptable. The Labour party seeks to reverse some of the trends: we are fully committed to a time to care fund, which will pay for 20,000 additional nurses and 3,000 extra midwives, along with 8,000 new doctors and 5,000 extra home care workers over the period of the next Parliament.

I am sympathetic towards the NMC’s complaint that it has no room for manoeuvre when it comes to cutting costs. The real shame here is the lack of reform, but the NMC has £10 million in its reserves. Now that reform is clearly not that far away, perhaps it will consider holding off the fee rise. I understand why it has proposed and gone ahead with that rise, as under current law the fee is almost its sole source of income, and it has a statutory duty of public protection. However, the increase is not reasonable under the circumstances, especially when looked at in the light of the fee bump in 2012.

As far as I am concerned, the blame for this situation lies at the door of the Ministers who could have made changes. The Minister had his chance to introduce the draft Bill in this Parliament, but it will be left to the next Labour Government to make the changes that are so desperately needed.

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[George Freeman]

The Government take recommendations from the Health Committee very seriously—we have done so on a number of issues. It is interesting to quote what the Committee has said on this matter:

“We would urge the NMC to avoid further fee rises and to consider fee reductions for new entrants to the register.”

My point is that it is the NMC’s responsibility to deal with the issue. It is accountable to Parliament, and the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, observes its recommendations closely. However, its internal organisation is a matter for itself.

[Mr Philip Hollobone in the Chair]

[Andrew Gwynne]

The Minister is correct that the NMC is accountable to Parliament, but it has asked for legislative changes, and the legislative programme is largely under the control of Ministers, so why have the Government not acted?

[George Freeman]

It is a fair question, which I will come to, but it has nothing to do with the importance of getting this right; it is merely a matter of the regrettable constraints of parliamentary time. One reason why I very much hope my colleagues and I will be returned in May, Mr Hollobone—I was about to call you Mr Havard; I welcome you to the Chair—is that we will be able to get on with that important reform.

For the benefit of the House, let me finish summarising some of the important information about the NMC. The NMC’s total income for 2013-14 was £65 million. Its fee income was £62 million, which is quite a substantial sum. It received a grant of £1.4 million from the Department of Health and investment income of £1 million. Its expenditure totals £70 million, with £24.18 million, or 34%, going on staff. Its permanent headcount has been going up year on year. The average for the year 2014-15 was 496. The NMC had 521 permanent staff on the payroll in March 2014 and 577 in March 2015. The permanent headcount for March 2016 is projected to be 606. I merely point that out to highlight that the NMC faces some important considerations in driving productivity and efficiency internally to deliver the service it is statutorily required to deliver to its members, who fund it through subscription.

Let me turn now to the relationship between the PSA and the regulations we have introduced. The proposed change will be introduced in the Professional Standards Authority for Health and Social Care (Fees) Regulations 2015—or S.I., 2015, No. 400, with which you will be intimately familiar, Mr Hollobone, as an assiduous observer of these things—which have already been laid in Parliament. The NMC’s council meets this week to decide its policy towards them, so this debate is, again, extremely timely.

The NMC has decided to increase its fees for nurses and midwives from £100 to £120. The rise was effected through the Nursing and Midwifery Council (Fees) (Amendment) Rules Order of Council 2014, which came into force on 1 February. Although the NMC is an independent statutory agency, the Government have made it clear that they expect the NMC council to have clear justification for, and to consider nurses’ and midwives’ financial constraints when making, decisions on fees. I will say a little more in a moment about that and about the importance of the Bill to modernise the NMC’s constitution.

The NMC has consulted its registrants on the proposed fee rise, but I am aware of the strong body of opinion among those who opposed it, and that has been expressed in the debate and in the number of people who have signed the petition. The NMC says that it has not taken its decision lightly and that it has considered the responses to the consultation in detail and carefully listened to the issues raised, and I have no reason to doubt that. However, I remind hon. Members that the NMC’s first duty must be to deliver its core regulatory functions and to fulfil its statutory duties to ensure public protection, and the fee rise must be justified against its core duty.

Let me touch now on the Government grant, which is important. I appreciate that, since the NMC was established in April 2002, there have been a number of increases in its annual registration fee, and I appreciate the impact that that has had on dedicated nurses and midwives working long hours in difficult roles to provide excellent care. That is why, in February 2013—more than 10 years after the increases started in 2002—the Government awarded the NMC a substantial, £20 million grant to ease the pressure.

One purpose of that grant was to allow the NMC to protect nurses and midwives—particularly lower-paid nurses and midwives—from the full impact of a proposed annual registration fee rise. The grant meant that, in 2013, the NMC was able to raise its fee from £76 to £100 and not to £120, as originally intended. With a week before Parliament dissolves, the Government have no plans to give the NMC a further grant to subsidise the 2015 registration fee increase. Given that we continue to have to make tough decisions to put the economy back on track, and that we have given the NMC £20 million, it now needs to work out internally how best to allocate the fee increase, which I should remind hon. Members is equivalent to £3 per member if it is spread equally among them.

I am pleased to say that, as part of the broader package of measures the Government are putting in place to support the lowest-paid workers in the NHS, all the major NHS trade unions accepted the Government’s pay offer on 9 March. It will be implemented from 1 April, giving more than 1 million NHS staff, including most nurses and midwives, a 1% pay rise, without risking front-line jobs or costing the taxpayer more money. That means our lowest paid staff will receive the biggest rise.

I want to update hon. Members on the changes, because they are an important wider consideration against which to view the impact of the fees. For the lowest- paid, the 1% rise will mean an increase of up to 5.6%, or an extra £800 in their pay packets. I have looked at the salary figures, and the average, ending March 2014, for nurses, midwives and health visitors—the people we are talking about—is £31,000. They will get the 1% rise, which is an extra £800.[Official Report, 25 March 2015, Vol. 594, c. 3MC.] Importantly, staff earning between £15,000 and £17,000 will get an extra £200, which is equivalent to 2.3%. Nursing staff earning up to £40,558 who are not at the top of their pay band are still eligible to receive an incremental increase.

Let me take issue with the point that the Government are not looking after the lowest-paid. The pay offer specifically makes sure that the increases the system can afford are targeted at the lowest-paid. Those earning more than £56,000 are more able to cope with the challenges of pay restraint. We are supporting the poorest in the system most, and we are making the highest-paid bear more of the burden. Finally, the bottom pay point will be abolished, seeing the lowest pay rise from £14,300 to £15,000, with about 45,000 on the lowest two pay points benefiting.

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[George Freeman]

I am glad, again, that the hon. Gentleman raises that, because fortunately the Chancellor was able to confirm that the Office for Budget Responsibility has confirmed that finally people in this country are better off, after a very difficult period. I am not going to pretend that it has not been difficult. The reason was that we inherited a chronic legacy of debt, deficit and structural deficit, which was tackled by the previous Government nowhere less than in health care. That created a situation in which, despite a growing economy, we face a huge structural challenge, exacerbated by demographics.

This year there are 1 million more pensioners in the system—1 million more people needing and generating high health demand. I do not hold the Opposition responsible for that. However, the lack of reform and the structural issues at the heart of the health service, which mean that the health structural deficit is growing faster than the general economy, have left us with a challenge. We need to tackle that.

As the hon. Member for Blaydon pointed out, the NMC has stated that there has been a significant rise in its costs, because of fitness-to-practise referrals, which are up more than 100% since 2008-09. Since 2008-09 it has raised its fee by only 63%, making up the bulk of the difference in cost through a programme of efficiencies. Without those it would have had to scale back its fitness-to-practise activity, or generate additional costs earlier. The NMC has provided assurances that it is committed to continuous improvement in carrying out its regulatory functions and will continue to deliver more efficient ways of working to maximise the value of registration fees and to keep them at the lowest level possible while enabling it to fulfil its statutory duty. The NMC is a £70 million-a-year organisation with substantial opportunities to put efficiencies in place, to reduce the cost of the £3 extra cost on its members.

As to the need to update the NMC constitution, the Government have worked with it to make changes to its legislation. We have made good progress with legislative change to reform the way it operates. On 11 December 2014 an order made under section 60 of the Health Act 1999, amending the Nursing and Midwifery Order 2001, came into force. Those changes to the NMC’s governing legislation will enable it to introduce more effective fitness-to-practise processes, while not lessening the public protection it provides.

A key amendment to the NMC’s governing legislation enables it, through its rules, to delegate the decision-making functions currently exercised by its investigating committee to its officers known as case examiners. The intended effect is to speed up and therefore reduce the cost of early-stage fitness-to-practise proceedings, as it will not be necessary to convene the full investigating committee to consider every allegation of impairment of fitness to practise. That should result in financial savings to the NMC as well as greater consistency in decision making. I think we would all welcome that. The rules that bring those changes into effect come into force on 9 March.

The section 60 order has helped the NMC by providing a degree of modernisation of its legislation. However, there is still much to do and that is why we asked the Law Commission in 2011 to review the whole framework of legislation underpinning professional regulation. The report was published last year and we published the Government response in January. I am aware that the decision not to progress a professional regulation Bill to take forward the thinking in the report in the current parliamentary Session was a disappointment to the NMC, as it was to us. We want to move on, but parliamentary time, as you know, Mr Hollobone, is an eternal constraint on Government’s ability to implement. However, that decision provided an opportunity to invest time in getting that important legislative change right, for the benefit of those who will be affected by it. Of course, it will not restrict the NMC’s ability to implement its own internal modernisation and efficiency programme, or to decide how to deal with the internal allocation of its fee obligations to the PSA. It is free to do that.

[Andrew Gwynne]

The Minister will know that a number of the changes and efficiencies that the NMC would like to implement require further legislative change. With those changes, it could free up some of its £10 million reserves, to offset some fee charges. Could we give the NMC some certainty, on a cross-party basis, that, whoever forms the next Government, we will bring in those changes? That would give it the certainty that it could use the reserves to offset the fee increases.

[George Freeman]

I am delighted to confirm that the Government remain committed to introducing primary legislation to address those wider reforms to the system of professional regulation; and it sounds as though, if the hon. Gentleman and I are in our posts then, that may well have cross-party support. That would be an important measure, and our inability to pass it before the end of this Parliament is not a sign of its importance; it is merely a function of the challenge of the availability of parliamentary time.

It is worth pointing out that the performance of the NMC has been challenged and highlighted by a number of bodies, including the Select Committee, but also by some of its members—nurses and midwives. It has had a troubled past with its performance, which is why Ministers commissioned the predecessor body of the Professional Standards Authority, the Council for Healthcare Regulatory Excellence, to undertake a full strategic review in 2012. That review put forward 15 high- level recommendations for improvement in the delivery of the NMC’s regulatory functions, and set an expectation that demonstrable improvements should happen within two years.

In 2014, the NMC commissioned KPMG to undertake an independent review to assess its progress, and KPMG concluded that the NMC had made a substantial number of improvements, which cumulatively placed it in a much stronger position than in 2012. That improvement was recently recognised by the Secretary of State for Health in his oral statement to the House about the Morecambe bay investigation. However, the NMC itself recognises that there is still much more to be done, and so the processes of improvement continue. Ministers have made it clear that we expect the NMC to work towards and ensure compliance with the standards of good regulation, and to continue looking for more efficient ways to work.

Hon. Members on both sides have raised points that I want to deal with. Several mentioned how the fees of part-time nurses are dealt with by the NMC, which is an interesting point. It is not for me to tell the NMC how to deal with it. That is for the NMC to decide, as an independent body, but I should have thought that, on the basis of pure justice and equity, members who do not work full time and therefore do not earn the same as those who do, and who do not generate, even on a pari passu basis, the same level of exposure to the costs or their organisation, would not have to pay the same costs. However, that is of course a matter for the NMC.

The hon. Member for Blaydon raised several questions, including whether the NMC will review its guidelines on fitness to practise, and provide guidance on fitness to practise cases. Those are all matters for the NMC as an independent body, but new legislation means that nurses can pay fees in instalments, and that fees can reflect part-time work.[Official Report, 25 March 2015, Vol. 594, c. 4MC.] The hon. Gentleman made an important point in his speech about part-time nurses.

The hon. Gentleman also spoke about revalidation. The truth is that the majority of the cost of nurse revalidation will fall on the employers that will be responsible for supporting their staff through revalidation. The revalidation drive is an important means of raising professional standards, and it will ensure that the public have faith and confidence that we are raising standards for nurses and midwives.