Nurses and Midwives: Fees

David Anderson Excerpts

Monday 23rd March 2015 Westminster Hall

[Mr David Anderson (Blaydon) (Lab)]

I beg to move,

That this House has considered the e-petition relating to proposed increase in fees for nurses and midwives.

It is a great privilege to serve under your chairmanship today, Mr Havard. I thank hon. Members for coming to this serious debate, and I thank my colleagues on the Backbench Business Committee for agreeing to it. I also thank the various trade unions and representative organisations in the national health service that have provided support and given me background material for the debate.

I start by reading out the petition and thanking Mr Stephen Iwasyk and the other 113,795 people who signed it, demonstrating their interest and concern about this vital issue. The petition states:

“We would like the Government to Review the Nursing and Midwifery Council (NMC) with regard to the fees charged to registered nurses and midwives, and the processes through which those fees are decided. The Nursing and Midwifery Council (NMC) recently discussed a further increase in registration fees for Nurses and Midwives from £100 to £120. The fees were increased 2 years ago from 76 to 100 following a consultation that was overwhelmingly against the rise. The NMC are, of course, obliged to consult before any further rise. However 96%+ of individuals voted against the rise last time. The Health Committee in their report earlier that year said ‘We would urge the NMC to avoid further fee rises and to consider fee reductions for new entrants to the register.’ Approximately 670,000+ Nurses and Midwives contribute £67+ Million annually to the NMC. Please sign the petition to encourage a review of the NMC and the charging of annual fees to Nurses and Midwives.”

I am grateful for the opportunity to debate an important issue that faces many of our constituents who are nurses and midwives. The petition, which had reached 113,796 signatures by the time it closed in February, relates to the proposal of the Nursing and Midwifery Council to increase registration fees for all 670,000 nurses and midwives by almost 60% in two years. The e-petition opposed the proposed fee increase and called for a general review of the NMC, and a review of the charging of annual fees to nurses and midwives.

[Ms Margaret Ritchie (South Down) (SDLP)]

I congratulate my hon. Friend on securing the debate. Does he agree that there is an urgent need for the Government to enter discussions with the Nursing and Midwifery Council with a view to reducing fees, in order to sustain the profession and keep people in it?

[Mr Anderson]

That is absolutely what the debate is about. I will point out some glaring worries that have been described to me about the capability and the effectiveness of the NMC. It is not that people do not want to pay a subscription fee; people are forced to pay a fee to be registered, and if they do not pay it, they cannot work. If they cannot work, obviously, they will not make money. The question is whether they get value for money. I am pleased that my hon. Friend the Member for Easington (Grahame M. Morris) is here, and I hope that he will talk about the findings of the Select Committee on Health, which published a report a couple of years ago that was—to put it mildly—quite critical of the NMC.

I will provide some background about what the NMC stands for, what its objectives are and why it proposed a fee increase. I will explain why the NMC fee increase was so strongly opposed by the overwhelming majority of nurses and midwives. The reasons for that opposition included the NMC’s historically poor financial oversight and management, which was highlighted in a damning report by the Council for Healthcare Regulatory Excellence in July 2012. The council criticised the NMC’s lack of focus on preventive measures to reduce fitness-to-practise referrals, the real-terms pay cut imposed by the coalition Government on hard-working nurses and midwives and the catastrophic impact that a fee increase would have on workplace planning. Finally, I will talk about the impact of future fee increases on nurses and midwives and on the care that patients will receive.

Despite heavy opposition from professional bodies and trade unions representing registrants’ views, the NMC chose to increase fees, effective from the end of last month. I want to talk about how fees could be reduced, which comes back to the point made by the hon. Member for South Down (Ms Ritchie).

[Grahame M. Morris (Easington) (Lab)]

I congratulate my hon. Friend on securing the debate, and I congratulate those who supported the petition. Does he agree that one of the fundamental problems is that the Nursing and Midwifery Council is spending a disproportionate amount of its budget—about 75%—on 1% of the register through the fitness-to-practise cases? There must be a more cost-effective way for it to carry out its obligations.

[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.

[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?”

[Grahame M. Morris]

There is a valid point about nurses and midwives who are returners and working part time. This burden is falling on the profession at a time when wages have been cut in real terms by between 8% and 10% over the past five years because of the Government’s failure to implement the recommendations of the pay review body. This is a double travesty.

[Mr Anderson]

My hon. Friend is right. He will not be surprised to learn that I share his view. The Government are treating nurses and other public sector workers appallingly. At the same time as saying, “We will give you no pay rise,” the Government are saying, “We want 60% more off you, and if you don’t pay it, you won’t be able to work.” As my hon. Friend the Member for Mansfield (Sir Alan Meale) said, these people are being pole-axed.

To join and stay on the register, all nurses and midwives must pay the annual registration fee. The fee is tied to their employment contract, which often stipulates that anyone who fails to pay the fee will face disciplinary action by their employer and a temporary lapse from the register. Since the NMC was established under the Nursing and Midwifery Order 2001 on 1 April 2002, there have been a number of increases in the annual registration fee. Historically, nurses joined the register for life and there was no annual fee increase. The order changed that, however. In 2004 the NMC annual registration fee was £43, which increased to £76 in August 2007.

In 2011, the Council for Healthcare Regulatory Excellence was tasked with investigating the NMC. It published a damning report that criticised the NMC’s lack of leadership, poor communication, inadequate governance and poor financial management. A new chairman and chief executive were appointed and, critically, the NMC accepted the report’s findings in full—the NMC accepted that it was not doing what it was supposed to have been doing as well as it should have been doing it.

In May 2012, the NMC indicated its intent to consult on a 58% fee rise from £76 to £120 a year. Following pressure from Unison, the Royal College of Midwives and the Royal College of Nursing, the Government offered a £20 million grant to the NMC. The Secretary of State for Health agreed to the grant because he was also appalled by the regulator’s poor financial management—and he would know about poor financial management, given the state into which he has got the health service in general. The result of that grant was that the registration fee was kept down to £100 a year, although we should remember that it had gone up to £76 only a few years earlier, so there was a big increase at a time when people were not receiving pay rises.

[Grahame M. Morris]

Is there not an argument for placing a moral obligation on the Government to make a contribution in the wake of the Francis report, which identified failings in a number of organisations, including the Nursing and Midwifery Council? Surely the Government have an obligation to help to meet the costs in order to put things right.

[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.

[Ms Ritchie]

My hon. Friend is making a good point. By and large, the NMC’s members are women and some of them are in part-time employment. Does he agree that the disproportionate payment to the Professional Standards Authority for Health and Social Care will have an adverse impact on equality and could infringe equality regulations?

--- 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.

[Grahame M. Morris]

I wonder if we can get clarification on that last point; perhaps the Minister can provide it. Given the dearth of legislation, especially in the last Session, why was not parliamentary time found for something on which there could have been cross-party consensus, such as a draft Bill based on the Law Commission’s report?

[Mr Anderson]

My hon. Friend makes a very good point, and I am very interested to hear whether the Minister will respond to it when he sums up and say exactly why we have not been discussing this issue during the past two or three years, when we have been going home at ludicrous times, such as 5.20 pm on a Monday, week after week during the past few months.

We count on nurses and midwives every day. Our families count on them; the people of this country count on them. I have heard loud and clear from my constituents that the fee increases are unaffordable and my fear is that people will start to vote with their feet.

The NMC is subject to parliamentary scrutiny by ourselves and the Health Committee, but we have little opportunity to comment on fee rises such as this one. We need to get the NMC to work together with the employers, the trade unions and the representative bodies, to review what it is doing and to provide a better service for all concerned.

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[Mark Durkan (Foyle) (SDLP)]

As other Members have said, it is a pleasure to serve under your chairmanship, Mr Havard. I commend the hon. Member for Blaydon (Mr Anderson) on securing this debate. I suppose he is a gamekeeper turned poacher on the Backbench Business Committee. He ensured that the e-petition, which gathered a significant number of signatures, would be debated before the close of this Parliament.

It is a pleasure to follow not only the opening speech from the hon. Gentleman, but also the insights from the hon. Member for Easington (Grahame M. Morris). His teasing out of where some of these issues could go are reinforced by his experience as a member of the Health Committee. It was also a pleasure to hear from the hon. Member for Congleton (Fiona Bruce), who talked about a particular constituency case that has given strong, more than anecdotal evidence that corroborates some of the issues raised by other Members on how the NMC is having to work, because of the position it is in. It is important that we consider issues relating not only to how the NMC works and whether its cost burdens should be alleviated in different ways or apportioned, but to the Professional Standards Authority, the funding source and scheme of which seems to be fundamental to the inequities we are discussing.

Many people wonder what Parliament’s role is in all this. They think Parliament is meant to oversee the health service and strong public service ethics, but it appears to wring its hands when these changes come along but everyone seems powerless to do anything. I tabled a prayer of annulment against the order that has brought about the increase in fees—early-day motion 697 if any Members want to scrabble in and sign it before Dissolution. However, it is only a prayer of annulment. As the hon. Member for Easington said, many people have written to MPs in all parts of the UK, but they are left bemused by the responses they receive. At least now we are having this debate, courtesy of the hon. Member for Blaydon. I look forward to hearing the Minister respond to it.

The point has been made that those who have to register with the NMC have faced pay restraint for a number of years. They are locked into pay freezes, and many are coping with the perverse and inequitable outcomes of the “Agenda for Change”. That has been the case for many professionals in my constituency in Northern Ireland, who have not only questioned where they are in relation to particular bands and how their responsibilities have been correlated with others, but found themselves at odds with what has been decided in neighbouring health trusts.

If people are already facing so many frustrations relating to their pay and conditions, they are particularly aggrieved when they are hit with what is essentially a vocational tax. They are being told that because their vocation is so important and sensitive and is subject to a registration process that is open to fitness-to-practise procedures, they have to pay more for the privilege of continuing to work. They are not being paid any more—they are actually being paid less—but they are having to pay more to register to turn up to work. Surely that is unfair and inequitable.

The fees have gone up from £76 to £100, and now to £120. That is just shy of a 60% increase in a small number of years, and people are rightly aggrieved. If that has been the form over a couple of years, they will ask whether it will be sustained—will it project into the future? There is a proper question for us to ask in Parliament and for Ministers to answer. It is not enough simply to say, “Well, this is the process we have. The NMC has to make the decisions and there is nothing we can do about it.” A couple of years ago, because of the pressure of the number of fitness-to-practise cases, the Government saw fit to use a £20 million subvention to help to relieve the situation, so why could not a further subvention be used? That would at least provide cover while other changes were introduced.

There are questions about the PSA’s funding being sourced on a per-registrant basis, which seems to line up the NMC for a particularly undue hit in terms of its source funding to the PSA. I will not go through it all again, but hon. Members asked about the cost burden that will arise and the procedural length of fitness-to-practise cases. Other hon. Members asked whether there might now be impressionistic evidence that health service management is using fitness-to-practise cases as a crude management tool. Perhaps they allow management to abscond from some of its more subtle and intelligent responsibilities by transferring crude enforcement to someone else. The cost in such cases is clearly giving rise to what seems to be a completely disproportionate working burden on the NMC.

[Mr Anderson]

I related to what a trade union representative told me about taking people through a fitness-to-practise hearing that lasted 10 days and cost £30,000. Employers may well be trying to prevent exactly that sort of thing from happening and tying up their HR staff—all the witnesses and people they have to suspend. Instead of taking responsibility, employers are parking such issues with the NMC, which has hugely increased its work load and the related costs.

[Mark Durkan]

I thank the hon. Gentleman for making that point and for giving colour to the concerns we feel when we look at the number of cases, the cost burden, the wider impact on the NMC and the costs faced by those who have to register with the NMC. We must remember that the NMC does not only work to service its members’ professional standing. It is there to safeguard not only professional standards but public assurance and the wider public interest.

There is a case for asking whether anything can be done to alleviate and re-profile the NMC’s costs and whether those costs can be better shared so that they do not fall only on nurses and midwives but are spread more widely among all of us who rely on the work and good standing of the regulators of such services.

A number of hon. Members mentioned the proposals in the offing that might allow some of these issues to be addressed. It is not a case of some of us just screaming against a fee increase and saying, “Something should be done about it”—there have been opportunities. Reference has been made to the Law Commission’s draft Bill on the regulation of the health and social care professions. It is disappointing that that has not been taken forward in this Parliament, but it should be soon, because it would provide a context for addressing some of the structural and operational questions about the NMC, as well as other issues of fairness and standards.

When the hon. Member for Easington referred to some of the issues arising from the Francis report, the hon. Member for Blaydon got sensitive about that, but we should recognise that as something else that is affecting nurses’ and midwives’ morale. As well as facing pay restraint and bigger fees, they are facing the wider issue of morale relating to their professional reputation, what with some of the headlines that have come out of the Francis report. No doubt the Minister will pay great tribute to the work of nurses and midwives, but we must listen to their concerns and worries. That is why so many people—not just nurses and midwives—signed the e-petition. They want to hear Parliament speak on this issue, which is why this debate is so welcome. I look forward to hearing the Minister’s response.

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[George Freeman]

The hon. Gentleman makes an interesting point. As the challenges for the NMC’s members and for it as a professional body change, adapt and evolve in the new landscape of greater transparency and accountability in the public interest, one issue for the NMC as a professional body is how it deals with that internally. Members across the House have raised a number of concerns about that, and I will touch on some of those later.

The intention is that in future the PSA will be funded by a fee raised on the nine professional regulators that it, in turn, serves. It is important to note that the fee is raised on the professional regulators—the regulatory bodies—not on registrants. The formula for calculating what contribution each of the nine regulatory bodies should pay was subject to consultation. It has been based on the number of registrants, simply because it was judged that that would most fairly equate the fee to the amount of service that the PSA provides to each regulator.

The NMC has nearly 50% of the total number of registrants so its contribution to the fee equates to nearly 50% of the overall costs of the PSA. However, it is important to remember that the fee per registrant is likely to be in the region of £3, which represents only 2.5% of the NMC’s overall registrant fee of £120 a year.

[Mr Anderson]

I am trying to understand what the Minister is saying. Is it that the regulators have to pay a fee but the registrants will not, and if they do, it will be £3? Where else are the organisations going to get the money from?

[George Freeman]

My point is that it is important to understand that the reforms mean that the PSA is funded by the nine regulatory bodies. How the bodies seek to cover that cost is up to them. In this case, the NMC has decided to apply it equally across all its members.[Official Report, 25 March 2015, Vol. 594, c. 3MC.] A number of hon. Members have raised a number of issues connected to that; the point about part-time nurses and midwives was an interesting one. There are issues with how the NMC chooses to allocate the cost internally. However, I repeat the key point that the fee increase is likely to be in the region of £3 per registrant. That represents 2.5% of the NMC’s overall registrant fee, which covers a whole range of other services.

It may be helpful to the House if I set out some details about the services that the NMC provides. It is the independent regulator for nurses and midwives in the UK. Its primary purpose is to protect patients and the public through effective and proportionate regulation of nurses and midwives. It is accountable to Parliament—not Ministers—through the Privy Council for the way in which it carries out its responsibilities. It sets and promotes standards of education and practice, maintains a register of those who meet those standards and takes action when the fitness to practise of a nurse or midwife is called into question. It also has a role in promoting public confidence in nurses and midwives and in regulation.

Members from all parties would agree that we welcome the growing sophistication of the role of nurses and midwives and the extra responsibilities reflected in salaries and professional standards. That is part of the evolution of the professionalisation of standards that we all welcome.

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[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.

[Mr Anderson]

I am interested in the average figure the Minister cites. Obviously, if he could give us his figures now, I would be happy to look at them, but could he also put them in the Library? The average he gave seems very high, when we are talking about the lowest point on the scale being £14,500. The average is more than double that—the scale must be heavily loaded at the top, which is not my experience from working in the public sector.

[George Freeman]

I will happily make those data available to the hon. Gentleman and put them in the Library. They are from the NHS staff earnings survey’s provisional statistics by staff group in England.

It is worth noting that UK taxpayers can claim tax relief via Her Majesty’s Revenue and Customs on professional subscriptions or fees that they must pay to carry out a job. That includes the registration fee paid to the NMC. Nurses and midwives on a salary of £30,000, confronted with a fee increase of £3, can therefore claim tax relief on it. A basic rate taxpayer would be eligible for £24 tax relief on the £120 fee.

[George Freeman]

I note with relish and interest what I assume is official Opposition policy—that they do not support the Chancellor’s announcement about funding for the RAF museum. The point that I am trying to make is that he already set out in the autumn statement a serious pay commitment to the lowest-paid staff in the NHS, which I was summarising.

I am glad that the hon. Member for Easington (Grahame M. Morris) has raised the issue of the Budget. The reporting on it has made it clear that for a pre-election Budget it was, far from making give-aways, surprisingly light on them, and was very much “steady as she goes”, continuing to pare down the deficit with fair tax reform. The truth is that we have cut income tax for 27 million people, and particularly for the lowest-paid nurses and midwives. The impact of that is nearly £900 a year from changes to the personal allowance. That is not fashionable stuff that captures the top line in red-top newspapers, but nurses and midwives do not exist in isolation. They have the NHS pay deal but also the important tax allowance changes introduced by the Chancellor. The Government are taking pressure off the lowest-paid workers in the NHS and elsewhere. Viewed in the round, those changes give us a record that we can be proud of, albeit within a difficult set of funding requirements.

[Mr Anderson]

Will the Minister give way on that point?

[George Freeman]

I really need to make progress.

[Mr Anderson]

We have got an hour and a half.

[George Freeman]

I happily give way.

[Mr Anderson]

The Minister made a point about tax, and that is welcome, but does he deny the fact that overall, people, including those we are talking about, are worse off under the present Government as a result of VAT rises and other rises across the economy? People are worse off than when they came to power.

[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.

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[Mr Anderson]

Thank you, Mr Hollobone; nothing would give me greater pleasure than to take the pith with you any time you like.

I thank my hon. Friends for speaking in the way they have. My hon. Friend the Member for Easington (Grahame M. Morris) is hugely respected across the House, particularly for his work on the Health Committee. I assure him and the hon. Member for Foyle (Mark Durkan) that when I said that I was not sure about accepting Government money to support the NMC, that was not to say, “Don’t do it.” I am not in a position to say it should not be done; it is down to the professionals to work out what their view is.

The intervention from the hon. Member for Congleton (Fiona Bruce) was absolutely brilliant. She spoke about the real world. The big issue is not so much about people paying the registration fees; it is about what they are getting for their money, and the hon. Lady showed exactly what they are getting. Her constituent was breaking the law by working without being on the register, in genuine ignorance. She could have been brought up on disciplinary or, potentially, legal charges. That is real the worry: what are people getting for their money?

It is always a great privilege for me to work with the hon. Member for Foyle, as I have done over almost 20 years. Some of the greatest work I did before I came into the House was with health service workers in the north of Ireland, who really were at the cutting edge at some of the worst times in this country’s history. It is brilliant to work with him, and he more than anybody else pressurised the Backbench Business Committee to get this debate held today.

My hon. Friend the Member for Denton and Reddish (Andrew Gwynne), as always, robustly defended our NHS and our party’s plans going forward. I thank the Minister for his words, but warm words do not put bread on the table. The health service workers who I represent, who I spoke to on the picket lines before Christmas, told me that they were organising shoebox collections for their members in their workplace at the same time as the chief executive of their trust was getting a 17% pay rise and the foundation trust members were getting an 88% increase in their allowances. That is the real world out there; that is the world where we are “all in this together.”

The Minister said that the regulatory bodies would have to pay the PSA, but ultimately it would surely be the registrants who cough up. It is like the brewery saying to the landlord of a pub, “You’re going to have to pay me more for your beer,” and then where does the landlord get the money from? Obviously he puts the price on a pot or a pint. Talk about having a “pith up” in a brewery—well, this is clearly one of those things. It is quite clear that the cost will fall on the people on the front line.

I am not sure whether I lost track of the Minister, but I do not believe he answered the question he was asked a number of times about why the Government did not introduce a Bill. He mentioned that something happened in December, and perhaps that is related—I am quite happy for him to come back and put us right—but I am not sure whether what happened in December gave the same rights to the NMC to do what it would have done if the Bill on the regulation of health and social care professionals had gone through. I asked him to reflect on that, as did my hon. Friend the Member for Denton and Reddish, but I do not believe that happened.

I do not want to repeat what the Minister said in his speech, but it did not address the issues. He said that £3 on people’s registration fees is not a crisis—he said that to me and my hon. Friend the Member for Denton and Reddish. We did not say that, but I will tell him who did: the 114,000 people who signed the petition; the people out there who are struggling to get by in the health service; the people we all owe a duty to. We should be putting this right. We are not necessarily calling for the fees to be stopped, but for the system to be reviewed to make sure that it is working properly. Let us sort out the fitness-to-practise issues. Seventy-seven per cent of the time is spent on that, but the problem is that they are all after-the-event interventions. If the job was done beforehand, that would not only save money, but stop incidents that have an impact on the professionals concerned and the people they look after.

Question put and agreed to.