Nurses and Midwives: Fees

Ann McKechin Excerpts

Monday 23rd March 2015 Westminster Hall

[Mr Anderson]

That is the core of the debate. I am concerned about the fact that more and more cases are being referred. It appears that there has been a failure on the part of hospital management or health management in general, who are, in some cases, referring nurses and midwives to the NMC instead of using their own disciplinary procedures. They are giving away their responsibilities, and in doing so they are adding to the cost and the work load of the NMC, which should be dealing with other issues of equal importance.

Believe it or not, the NMC is the world’s largest regulator, with 670,000 nurses and midwives on its register. It is in the unique position of having a guaranteed income of £71 million a year. What other business or organisation has such a luxury nowadays? The NMC’s primary purpose is to protect patients and the public in the UK through effective and proportionate regulation of nurses and midwives. It is required to set and promote standards of education and practice, maintain a register of people who meet those standards, and take action when a nurse or midwife’s fitness to practise is called into question. By doing so, the NMC seeks to promote public confidence in nurses and midwives, and in the regulation thereof. However, the fee rise has done little or nothing to raise the confidence of the nurses and midwives whom the NMC regulates. Many, including some in my own constituency, feel that when they voiced their opposition to the fee increase, they were opposed or—even more worryingly—completely ignored.

For a nurse or midwife to practise in the UK, they must be on the register. They have no choice. It is illegal to work as a nurse or a midwife in the UK without being on the NMC’s register. To join and to stay on the NMC’s register, all nurses and midwives must pay the annual registration fee.

[Ann McKechin (Glasgow North) (Lab)]

I congratulate my hon. Friend on securing the debate, especially as I tried for about three months last year to secure a debate on this subject. Does he agree that, particularly given the 60% increase in the fee over the past few years, the fact that there is no fee reduction for nurses and midwives who work part time is becoming a much greater concern and is discouraging people from coming back to work part time?

[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.

--- Later in debate ---

[Mr Anderson]

I am happy to say that, although I do not completely agree with my hon. Friend. A review would allow us to have a discussion and get people involved. If the Government are too involved, some people will worry whether the NMC will lose the independence of which it should be proud, if it is running properly. I have no problem in principle with the Government helping out in any way they can, because that is part and parcel of ensuring that nurses are able to do the job that we and the public want.

The fee increase was significant because nurses and midwives have been subjected to a Government-imposed pay freeze while, outside in the real world, everyday items and household bills are increasing dramatically. As we know, figures from the Labour party and others show that people are £1,600 a year worse off than they were five years ago. It is a double whammy, to put it mildly, for hard-working nurses and midwives to be told, “You are going to be worse off—and by the way, why don’t you pay more for your registration?”

In May 2014, the NMC consulted again on increasing the fee from £100 to £120, an increase of almost 60% in two years. The Government could have offered another bail-out to allow the NMC more time to address the challenges it faces from fitness-to-practise cases, but they chose not to. The proposed annual registration fee increase was heavily opposed by all the professional bodies and trade unions that represent the views of registrants. Ninety-nine per cent. of respondents to the Unison survey opposed the proposed increase to £120 a year. In the RCN survey, the same proportion of respondents disagreed with the proposed fee rise. The anger felt by registrants is demonstrated by the e-petition condemning the proposed fee increase, which was signed by almost 114,000 people. Their feelings are reasonable and understandable.

I will now address the NMC’s poor financial management, which was highlighted in the 2011 report. The fee increase was felt to be inappropriate because it placed too big a burden on individual nurses and midwives to make up for the NMC’s poor management. The £20 million grant from the Department of Health was meant to contribute to the cost of clearing the backlog of historical fitness-to-practise cases. Despite that help, some 50 cases have been outstanding for three years or longer. The issue was reinforced by the report, and 50 cases have been on the books for the three or four years since then. In 2009, the NMC had a relatively small number of such cases, and had it taken appropriate action at that stage, there would never have been the need to increase the registration fee to such a level.

The NMC’s consultation paper on registration fees recognised that the key driver of increasing costs is the massive increase in fitness-to-practise referrals. Since 2008, the number of fitness-to-practise referrals has increased by 133%. The NMC holds two and a half times as many hearings as all the other regulators combined. Last year, the NMC spent £55 million of its £71 million budget on fitness-to-practise issues, which means that 77% of its budget is spent on fewer than 1% of registrants. In comparison, the General Medical Council, which my hon. Friend the Member for Mansfield mentioned, spent only 56% of its resources on fitness-to-practise cases involving registered doctors in 2013-14. The people who helped me to secure this debate support my contention that the NMC model is unsustainable and detrimental to the majority of registrants.

Employers are the largest group making fitness-to-practise referrals. In 2012-13, however, 40% of fitness-to-practise referrals were closed during the initial assessment. Employers were making referrals that were not fit to be heard but that had to be heard, and the cost of those hearings comes directly out of the purses and wallets of nurses and midwives. It has been suggested to me that, following the Mid Staffordshire NHS Foundation Trust public inquiry, employers have become increasingly risk- averse and are using the fitness-to-practise referral process instead of internal processes and procedures to address performance and disciplinary issues. Instead of taking cases on themselves, employers are referring them to the NMC at unsustainable cost.

Inappropriate referrals block the system and add to costs, which is why it is important that the NMC assesses whether it is appropriate for employers to refer so many cases. The NMC could do that by including employers in reviewing the reasons for the dramatic increase in referrals since 2008. Is there a crisis? Is there a problem? Is there something wrong with the practice? If employers sit around the table with the NMC, perhaps they will get to the bottom of the situation.

The NMC should also take a more proactive approach to the promotion of education and standards as part of a preventive measure that could contribute to reducing the number of fitness-to-practise cases referred to the regulator. There should be an equally strong commitment to public protection, because that will prevent harm in the first place.

I have a quote from a full-time officer from Unison about his experience in dealing with NMC cases:

“The NMC pursue allegations against registrants that have little or nothing to do with patient safety and could not be said to have a public interest element. Despite the recommendations of the Law Commission review and its apparent endorsement by the NMC and the Department of Health, the NMC continues to bring cases relating solely to inter-employee and other issues wholly unrelated to their nursing practice. In addition the NMC insists on taking any cases with an apparent ‘public interest’ to a full hearing or meeting even where the registrant wishes to be voluntarily removed from the register. The lack of any clear definition of what is meant by the public interest makes the issue wholly subjective.

At a recent NMC hearing an NMC panel decided that a registrant’s apparent failure to approve staff applications for flexible working amounted to serious professional misconduct and was a public interest issue! This hearing lasted 10 days and probably cost well in excess of £30,000. It is absurd that nurses and midwives should be asked to foot the bill for such folly with ever increasing registration fees.”

That is the experience on the front line—that is what people are paying £120 a year for.

In an attempt to convey the affordability of the proposed fee increases, the NMC consultation paper compared subscription fees for professional bodies and those of trade unions with the NMC. However, that is not valid comparison. Unlike the NMC, trade unions and professional bodies are organisations that nurses and midwives can join voluntarily.

I would be delighted if the Government said that we could have a closed shop for trade unions and professional bodies. I am sure that you would agree, Mr Havard, but I have got a feeling that they may not be keen. Come 8 May, the next Government will be led by that wonderful gentleman, my right hon. Friend the Member for Doncaster North (Edward Miliband), but I have a feeling that he also might not be too keen on closed shops in the health service or anywhere else. However, that is what we have got with the NMC.

I understand why that is the way it is, but for the NMC to pretend that, somehow, a comparison can be made with joining trade unions is completely unfair. It would be much more suitable to compare the NMC’s registration fees with Health and Care Professions Council registration fees. Under “Agenda for Change”, both regulate professionals in similar pay bands, but when we compare a nurse at the top of band 5 with an occupational therapist on the same band, we see that the nurse would pay £120 a year in registration fees while the OT would spend £80. That goes back to the point raised earlier about why on earth part-time workers and those on different bands should pay the same subscriptions.

Although the NMC recognised the economic difficulties nurses and midwives face in its consultation paper, it proposed the fee increase regardless. Effectively, it ignored the reality of how those people are struggling.

[Ann McKechin]

I was astonished to find that the NMC has not instigated any efficiency programme to try to control costs and those of tribunal hearings in particular—even things such as booking hotels and accommodation for tribunal members—to try to ensure the most efficient cost basis, given current restrictions. Does my hon. Friend agree that, given that the NMC has a captive audience, it needs to spend more time showing that it is getting maximum efficiency for its costs?

[Mr Anderson]

My hon. Friend makes a valid point, which again comes back to what the review can look into: whether members are getting value for money. That is what we are talking about here. The NMC might think, “If we need more money, we can get it because they have got no option other than to pay.” It can hold people to ransom and, unfortunately, that is what it is surely doing. That is clear, because it has ignored the legitimate claims of those who have said, “Please, give us some relief here.” It appears that those people were told, “We’re going to ignore you, anyway.”

During a time of continued pay restraint for hard-working nurses and midwives and ever-increasing costs of essentials such as child care, household bills and everyday items, the proposed fee increase left many registrants feeling that that was yet another attack on their standard of living.

Standardised Packaging (Tobacco Products)

Ann McKechin Excerpts

Wednesday 21st January 2015 Commons Chamber

[Ann McKechin (Glasgow North) (Lab)]

There are now only a few weeks until Parliament dissolves, but tonight I want to urge the Government, even at this eleventh hour, to do something that can save hundreds, if not thousands, of people across the country from a premature death. They still just have the time to undertake one major reform that they promised long ago: the introduction of plain packaging for cigarettes. However, despite almost three years of consultations and reviews and clear evidence both at home and abroad to support regulation there has been a deafening silence for over eight months. Why is the Prime Minister prevaricating? I hope the Minister can answer that question this evening and show her resolve to be serious about this nation’s public health.

We have debated this issue many times but the need for tonight’s debate is simple: plain packaging works. Too many people suffer from diseases brought on by smoking and too many young people are still picking up the habit for the issue to be ignored until after the election.

Sadly, my own city, Glasgow, has one of the worst records for smoking-related premature deaths in the country. Of those who take up smoking, only about half will manage to stop before they die, and two thirds of current smokers started before they were 18 years old, so the early teenage years are the key period to hook people into the habit.

The cost to patients, their families and our NHS is still too high despite the considerable improvements in treatments and drugs over recent years. In Glasgow, according to the latest Scottish Public Health Observatory’s tobacco control profile there were over 1,900 deaths from lung cancer in 2012 alone and almost 47,000 smoking-attributable hospital admissions over that year. Almost 28% of the city’s population smokes against the Scottish national average of 23%. Even a small percentage drop in those figures would make a really big difference to a lot of people, save lives and alleviate the pressure on our health services.

Successive Governments over recent years have put in place a range of measures to assist public health. Duty on cigarettes has been routinely increased in Budgets above the prevailing rate of inflation and this has undoubtedly made a significant difference. However, the impact is clearly plateauing and there is evidence that in the poorest communities in particular the rise of the black market in cigarettes could be acting as a block on further smoking reduction.

Increasingly, non-economic measures need to be introduced to further limit the habit, the most obvious being the ban on smoking in public places. It was not without controversy when introduced, but with Scotland taking the lead it has transformed our communities, reducing overall smoking levels. It has been of benefit to workers and non-smokers alike, but if we are honest the smoking ban has also led to more people switching their drinking, and in turn smoking, habits to a domestic setting, rather than necessarily quitting.

Cessation services via GPs and local councils have become better organised and more comprehensive. The Local Government Association in England is producing a new report this weekend on cessation services, but has informed me that councils are committed to spending over £140 million in England on cessation services this year, and this is undoubtedly a sound investment.

The Government are to be commended for taking forward the legislation introduced by the previous Labour Government to prohibit the display of tobacco products at the point of sale, with all shops being subject to the ban by April this year. This, along with the ban on public advertising, has helped to change perspectives about the normality of smoking.

We know that children and young teenagers can be influenced by a complex range of factors and we must do more to protect them against the harm that smoking brings. Attractive colours and packaging have a strong influence on young people, and tobacco companies have not been slow to find other, indirect ways of promoting their products. In a presentation to an industry conference back in 2006, Imperial Tobacco’s then global brand director, Geoff Good, acknowledged that the tobacco advertising ban had

“effectively banned us from promoting all tobacco products”,

but noted that

“the marketing team have to become more creative…We therefore decided to look at pack design.”

In fact, the industry was even happy to admit this in its response to the Government’s consultation on the future of tobacco controls. Philip Morris stated in its response that

“packaging is an important means…of communicating to consumers about what brands are on sale and in particular the goodwill associated with our trademarks, indicating brand value and quality…placing trademarks on packaged goods is thus at the heart of commercial expression”.

I struggle to imagine what the good will of a cigarette might actually amount to, but there is no doubt that the industry has exerted enormous pressure to stop this move.

It is no coincidence that the colours and graphics used on these packs are designed to attract new and younger users, and research shows that this increased emphasis has had an effect. Between 2002 and 2006, there was an increase in the proportion of young people aware of new pack design from 11% in 2002 to 18% in 2006. As the Minister is well aware, the systematic review commissioned by her own Government of 37 different studies provided evidence of the impacts of plain packaging. Each of the 19 studies that examined perceptions of attractiveness found that standard plain packets were rated as less attractive than branded packs. The studies also showed that the awareness of health risks was higher with standard packaging. Younger respondents were more likely to perceive that standard packs would discourage the take-up of smoking. All those findings back up the case that such a change would have an impact on young teenagers who were tempted to smoke.

In Australia, where plain packaging legislation was introduced in 2012, smoking rates have fallen dramatically. Daily smoking levels are at an historic low of 12.8%, and the average number of cigarettes smoked is now just 96 per week, compared with 111 in 2010. Fewer young people in Australia are trying cigarettes, and those who do so start at a higher age than in the past. Opposition to plain packaging among the public has also fallen steeply since the legislation came into force.

Some have argued that such a move will open the doors to a massive black market, and I note that that allegation has been reported in The Daily Telegraph in the past week. However, the main driver of black markets is economic: the difference between the actual value of the good and the price set for the consumer. It should not be beyond the wit of the authorities to devise a form of unique marking to stem counterfeit products. As the Minister will be aware, Sir Cyril Chantler stated in his report last year that he had found

“no convincing evidence to suggest that standardised packaging would increase the illicit market”.

The Trading Standards Institute has helpfully advised me today that, having reviewed the proposed regulations, it understands that standardised packs will retain the same security features as those found on existing tobacco packaging. It is the institute’s professional view that standardised packs would provide no new challenges in terms of detecting illicit products.

We know from what has occurred in Australia that tobacco companies have been forceful in pursuing their opposition at every step of the way. On the day that the Australian Government passed their legislation, Philip Morris and a number of other producers immediately launched a lawsuit to challenge the law. That challenge was rejected by the Australian domestic courts in 2012, but Philip Morris was not prepared to give up. In addition to taking the domestic action, it rearranged its assets in order to become a Hong Kong investor and use the 1993 bilateral trade agreement between the two countries to initiate an investor dispute arbitration. That case is due to be heard next month in Singapore, behind closed doors.

In addition, the company helped to finance a separate World Trade Organisation action brought against Australia by five tobacco-producing states. Australia refused each of those countries’ first requests, as allowed under WTO rules, but Ukraine made a second request in September 2012, which led to the establishment and composition of a dispute panel. The panel was composed in May 2014, but no report has been adopted and this matter is still outstanding. Similar industry pressure in New Zealand led by British American Tobacco has led to a long postponement, despite the fact that the legislation was introduced in its Parliament more than a year ago.

Using the same ISDS dispute procedure that the UK Government are so keen to support in the current EU-US negotiations on the Transatlantic Trade and Investment Partnership—TTIP—Philip Morris is suing tiny Uruguay over its decision to increase the size of health warnings on cigarette packets from 50% of the cover to 80%. We now await the outcome of this David and Goliath struggle, but it does raise the question as to why our Government are not more questioning of the possible impact of investor-state dispute settlement clauses on our public health policy, given the lengths that the tobacco industry is clearly prepared to take.

We need the UK to be brave—to face up to the industry giants and act in the interests of the public we serve. The Minister will be aware that the Scottish Government have sensibly agreed that legislation should be brought in throughout the UK at the same time and have given their assent to regulations being brought in by this Government covering Scotland, too. I want her assurance tonight that she will act on this agreement to give the boost to public health that is so needed in my city.

Over the past few years there have been several well-supported public campaigns calling on MPs to act, and recent polling has shown that a majority of the public are in favour of this proposal.

[Sir George Young (North West Hampshire) (Con)]

The hon. Lady will be aware that a range of views may be held among Government Members, but may I assure her that within my party there is a strong body of opinion supporting what she is saying and joining her in urging the Government to take action?

[Ann McKechin]

I am grateful to the right hon. Gentleman for his support tonight. This matter should, I hope, elicit cross-party support, because the health of our young people is a key issue that all of us should be deeply concerned about.

[Mark Lazarowicz (Edinburgh North and Leith) (Lab/Co-op)]

I am grateful to my hon. Friend for making a powerful speech tonight. May I take her back to an earlier point at the beginning of her speech and highlight the fact that if this measure is not introduced by the Government soon, it will be delayed until probably after the summer, as a result of which, indirectly, thousands of lives will be lost?

[Ann McKechin]

Yes. As I have said before, half those who take up smoking will not be able to stop, and we know that every week hundreds of teenagers across the UK take up the smoking habit. So every week that we delay has a direct health impact in our local communities.

The Minister’s own review, the Chantler review, concluded when it reported in early April last year that branded packaging plays an important role in encouraging young people to smoke and in consolidating the habit, irrespective of the intentions of the tobacco industry and that the body of evidence showed that plain packaging is very likely to lead to a modest but important reduction over time on the take-up and prevalence of smoking. The Minister is already on the public record as accepting that standardised packaging is

“very likely to have a positive impact on public health”—[Official Report, 3 April 2014; Vol. 578, c. 1018.]

and as wanting to proceed as swiftly as possible. I have no reason to doubt her intentions, but time is running out.

The Prime Minister must allow Parliament to vote on plain packaging regulations before the election. He must heed the advice of health professionals, 4,000 of whom signed an open letter to The Guardian demanding urgent action, and ignore the protestations of his Australian spin doctor Lynton Crosby, whose tobacco industry links are said to have scuppered the push for plain packaging in 2012 when the Government pushed the issue into the long grass. Too many people are needlessly dying prematurely because of smoking and too many young people are still being hooked.

[Paul Burstow (Sutton and Cheam) (LD)]

This is a very important debate. As the chair of the all-party group on smoking and health, may I say to the hon. Lady that what we need to hear from the Minister tonight is that the Government write-around has started and that the regulations will be laid, so that we can have a vote?

[Ann McKechin]

The right hon. Gentleman is right about that, because these regulations, which need to be laid by the end of this month if they are to be approved in time by the Joint Committee on Statutory Instruments and the Secondary Legislation Scrutiny Committee. That is why we need to use the precious time that we have in this Parliament between now and the end of March to save lives and reduce the burden on the national health service. I hope the Prime Minister, his Government and the Minister who responds will listen to that call and start to act on behalf of everyone.

Tobacco Packaging

Ann McKechin Excerpts

Friday 12th July 2013 Commons Chamber

[Anna Soubry]

Absolutely. One of the problems in this debate is that unfortunately it has been called plain packaging. It is far from plain. As, in effect, the Government would be in control of what goes on to the cigarette packet, there is provision to make it as complicated as possible, with a variety of colours, watermarks, holograms and so on. Far from being a counterfeiter’s dream, it would be a counterfeiter’s nightmare.

[Ann McKechin (Glasgow North) (Lab)]

The Minister said that this is a joint consultation with the devolved authorities. Can she confirm whether Scottish Government Ministers were happy to hit the pause button for an undefined time period?

[Anna Soubry]

I have been very pleased to have a number of discussions with colleagues north of the border and in Wales. It is a pleasure, as always, to continue to work with them.