NHS Bursaries

David Morris Excerpts

Wednesday 4th May 2016 Commons Chamber

[Heidi Alexander]

My hon. Friend is completely right to point out that the problem of staff shortages leads to more agency staff having to be used, and that creates an enormous black hole in hospital finances. My fear is that the proposals will put off the next generation of nurses.

It now appears that the Government are making some of the same mistakes all over again. A report sneaked out on the day the House rose for the Easter recess revealed that the Government had commissioned only one-tenth of the extra nurse training places that experts said were needed this year. The report, from the Migration Advisory Committee, states:

“We were told that HEE—

Health Education England—

“has acknowledged that, on the basis of workforce modelling alone, they would have liked to commission an additional 3,000 places in 2016-2017. Funding constraints meant that they had only commissioned an additional 331 places; one tenth of what was actually needed”.

[David Morris (Morecambe and Lunesdale) (Con)]

Does the hon. Lady not agree that by changing the way we run the NHS, especially in relation to bursaries and opening it up to more competition, we will get more nurses coming into the NHS, thus plugging the gap she describes?

[Heidi Alexander]

I do not agree with the hon. Gentleman, and later in my speech I shall explain why in some detail.

I would like to return to the Migration Advisory Committee report, because it does not make happy reading for Ministers. It goes on to say:

“It seems self-evident to us that the reduction in the number of commissioned training places between 2010 and 2013 across England, Scotland, Wales and Northern Ireland, was a significant contributing factor towards the current national shortage of nurses.”

Finally, there is the crucial sentence that sums up why we are experiencing across-the-board nursing shortages:

“Almost all of these issues relate to, and are caused by, a desire to save money. But this is a choice, not a fixed fact. The Government could invest more resource if it wanted to.”

Those are the words of the Migration Advisory Committee. Hospitals are short of nurses; mental health services are short of nurses—so, too, are care homes, hospices and primary care. We therefore have a big problem. No one in this House disputes that, but no one in this House should be under any illusion as to the cause. The question, when faced with this problem, is this: what is the right thing to do? How best can the Government work with experts to ensure that we are training enough staff and supporting those staff so that they stay motivated and stay working in the NHS?

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[Heidi Alexander]

I completely agree with my hon. Friend. It seems that the Government’s argument is that students will be better off because they can borrow more. The simple truth is that loan repayments will hit nurses’ take-home pay—there are no two ways about it. The current starting salary for a nurse is £21,692—just above the student loan repayment threshold which, of course, has been frozen. This means that nurses will start paying off their loans as soon as they graduate. According to Unison, based on current salary levels nurses will be faced with an average pay cut of over £900 a year to meet their debt repayments. How can that possibly be justified? Even worse, the average age of a student nurse is 28, so the current 30-year repayment period means that many nurses will be paying off loans to within years of retirement. We Labour Members say it is wrong to burden the next generation of NHS staff with a lifetime of debt and wrong to expect tomorrow’s nurses to pay the price for this Government’s mis- management of the NHS.

Does the Minister not understand that student nurses, midwives and other allied health professionals are different from other students? Can he not see that it is dangerous to assume that just because application rates remain stable after the trebling of tuition fees in the last Parliament, the same will happen with his proposals? Assuming healthcare students will respond in the same way as other students to a tuition fees hike is one hell of an assumption and one hell of a risk.

Courses for nursing, midwifery and other allied health professions are substantially different from most other arts and science degrees. Courses are more onerous—there are fewer holidays, longer days and longer term times—while students are also required to spend about half their time in clinical practice. This means 2,300 hours in the case of a student nurse, including night and weekend shifts as a normal part of their studies.

[David Morris]

Will the hon. Lady give way?

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[David Morris (Morecambe and Lunesdale) (Con)]

It is an absolute pleasure to follow the hon. Member for Manchester, Withington (Jeff Smith), and I congratulate the shadow Health Secretary on securing this debate as it highlights the current pressures that we are facing in the NHS. We start with 20,000 nurses and we lose 3,000 a year. Perhaps that is where the Migration Advisory Committee report gets its figures from when it says that we need to plug a gap of 3,000 places. The Government say that we need 10,000 new nurses a year. In stark terms, those figures show that there is a loss percentage, so perhaps we can work out how many people drop out and what it costs, and use that money in the NHS by putting it back into an apprenticeship scheme such as that proposed by the Government. It seems that the magic figure of 3,000 plays into the Government’s thinking about creating 10,000 new nurses.

The Opposition say that we lost 2,400 nurses under the previous Government, whereas the previous Government said that we have 3,000 more. Which is correct? The truth is that both are: it depends when we take the measurement. If we measure from election to election—that is, from May 2010 to May 2014—we find that the Prime Minister was correct to say that we have 3,000 new nurses. We also take into consideration health visitors and midwives, and physiotherapists to an extent. The Opposition say there was a drop of 2,400 between September 2010 and September 2014. Believe it or not, recruitment and loss are seasonal.

We have to be grown up and address these concerns. How do we do that? The answer is, quite simply, through reform. We must open up instead of having the fixed bursaries whereby we attract in the region of 20,000 nurses a year but lose 3,000 a year. I say this with all due respect to the Opposition, but under the previous Government the Opposition said that reforming education would deter people from all backgrounds—I would not say “disadvantaged” backgrounds—from going to university. I did not go to university, but my son is at university and is the first member of my family ever to go to university. That is an aspiration, and an accolade. Here we are, five years down the line, with 10,150 new places since 2010 for students going to university. We must open up that philosophy for the NHS.

What is the difference between a student nurse starting on £21,000 or thereabouts a year and a junior doctor starting on £26,000? Nurses are as valued as doctors in the NHS; I certainly feel that. Why do some have bursaries, even though we are not attracting the numbers, and why do some not have them? My own trust, which is in difficulty at the moment but has already overcome many difficulties and is out of administration—it should be praised for that—has been abroad recruiting nurses, but we could get the nurses by taking away the bursary scheme and opening it up to academia, trying to get more people in from inside the system through apprenticeships. That could plug the gap and allow us to have home-grown skills and jobs here.

Reform will plug the gap and solve the skill shortage. It will also be fair in bringing nurses into line with doctors in the profession. Mature students who want to go into the vocation of nursing and be correctly accredited through the academic route will see that as a good starting place for a career that starts at £21,000. In all honesty, the career path does not end at £21,000; it goes up the pay scale, as it does for doctors.

In conclusion, I thank all colleagues for this measured debate. This is a subject that we need to address on both sides of the House.

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[Wes Streeting]

I am grateful for that intervention. I shall come on to thank some of the people who have been in touch, but I will never forget the very first conversation I had with a student nurse in my constituency who sat with me in the Members’ area of Portcullis House and cried because under the existing system she struggled to meet the costs of training to be a nurse, even with the NHS bursary currently provided.

I want the student support system to be more generous for these students because other students like my constituent have dreamed of being a student nurse. It is not right that financial support, or the lack of it, should be a barrier to their taking on this valuable vocation, which does so much for so many.

The Government’s policy is riddled with risk. Earlier the Minister challenged my assertions on mature student numbers. It is a fact that in the wake of the introduction of the coalition’s reforms to higher education, there was a fall in part-time and mature student numbers. The Minister claimed that there were record numbers of mature applicants to higher education; I can only assume that he was referring to last year’s figures. We should not identify a trend from one year’s figures, not least because UCAS figures for the 2016 application cycle published on 4 February 2016 show an increase in 18-year-old applicants, but a fall in most other older age group categories. I am more than happy to look at the data and conduct an evidence-based debate, but let us have an evidence-based debate and not take one year’s worth of figures and claim that there is some sort of trend.

[David Morris]

The figures that the hon. Gentleman cites are welcome, but they are different from those of the shadow Health Secretary.

[Wes Streeting]

No, I do not disagree at all with the figures cited by my hon. Friend the shadow Health Secretary. This is the problem with lies, damned lies and statistics, as Disraeli once said. We need to look at all the data in the round before we identify trends. The Minister singled out one year’s worth of application data to identify a trend.

It is also entirely possible that numbers relating to nursing, midwifery and allied health subjects account for a significant proportion of applicants to higher education and mature applicants to higher education. The Minister was talking about general applications for all subjects. We should probably ask the Library to do some work so that we can get to the bottom of the claims and counterclaims. None the less, most people involved in the higher education debate acknowledge that there are still serious challenges in access to higher education for part-time and mature applicants in the light of the coalition’s reforms. That is one of the reasons why the Government ought to tread carefully in this area.

Against this backdrop, there is a shortage of nurses. In 2011 and 2012 the number of training places was cut to the lowest level since the 1990s. Unison, the trade union of which I am proud to be a member, conducted a survey which found that two thirds of nurses believe that staffing levels were worse now than they were previously, and 63% feel that the numbers are inadequate to provide a safe degree of support on wards. That reflects feedback that I have had from NHS staff in my constituency, and it is something that the Government should take very seriously.

Since I first raised the issue in an Adjournment debate in the House, I have been privileged to meet so many nurses, midwives, other professionals and students of allied health subjects. I am particularly grateful for the campaigning that Danielle Tiplady and Kat Barber have undertaken, not least in meeting the Minister. I thank Unison, the Royal College of Nursing, the Royal College of Midwives, the Royal College of Speech and Language Therapists, and the National Union of Students. I take this opportunity to pay particular tribute to the outgoing president, Megan Dunn, for the effective way in which she has represented students during her term in office.

The reforms reflect a big risk to nursing numbers. At the very least the Minister should commit this afternoon to a further full debate on the Floor of the House and a vote of both this House and the other place before such a radical change as the Government propose is made to the funding of these crucial subjects. There is considerable concern and the Minister should not downplay the issue. I hope he will at least commit to a full vote in the House before the change goes ahead.

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[Nic Dakin (Scunthorpe) (Lab)]

It is a pleasure to follow the thoughtful contribution by the hon. Member for South West Wiltshire (Dr Murrison), who draws attention to the whole issue of workforce planning, which is clearly very challenging for those who are doing it—or not doing it.

The recent inspection of North Lincolnshire and Goole Hospitals NHS Foundation Trust exposed issues of real concern about staffing levels at Scunthorpe general hospital. The challenge of attracting, securing and retaining sufficient nurses and other medical staff has been a constant theme in my conversations with the trust since 2010. In that respect, Scunthorpe hospital is no different from many others around the country. The more I have got involved, the more I have thought that locally designed solutions have a role to play. Having talked to Health Education England, it is disappointing that it cannot do more to support healthcare assistants, for instance, in growing into nurses on the local patch, because they are clearly a potential resource.

There are lots of issues about recruitment, training and retention, as the right hon. Member for Hitchin and Harpenden (Mr Lilley) said, and about how, if we lose 3,000 nurses a year, as the hon. Member for Morecambe and Lunesdale (David Morris) said, we try to keep them. That is a big issue, as well as how we recruit and retain them.

[David Morris]

Just to clarify that, we are not losing 3,000 nurses a year—we are losing 3,000 applicants to be nurses a year.

[Nic Dakin]

I thank the hon. Gentleman, but many nurses are being lost to the system as well, as his comments clearly highlighted.

In Scunthorpe, as in other areas, we are having to recruit from Spain, Portugal and elsewhere in the world. Although that is helping and supporting us, it has impacts, as we have heard, on those areas of the globe from where those nurses are being recruited.

I would like to quote the words of a young student nurse—a constituent—because in some ways they capture the comments that people from around the country are making to us. Katie-May Taylor says:

“I’m a first year student nurse and when I start placement (for 3 months), I will just about be able to cover my travel on top of my rent and food. When you see the hours we have to complete and having a fraction of the summer holidays other students get, you have to understand why the proposed cuts to the bursary and overall funding to the NHS isn’t beneficial.

I appreciate that to other students, getting a monthly bursary must seem like a luxury, however every penny I get goes towards my rent—it’s not just pocket money.

We’re seeing reports that parents are already telling their children not to go into the nursing profession and future nurses are being scared out of applying for university. This is deeply saddening; it’s such a wonderful course to be a part of and our nurses are absolutely vital in the care of society’s health and the maintenance of OUR NHS.

If the bursary is scrapped, a lot of student nurses will end up working 70 plus hours a week (placement, study time, job/s). Is a student nurse working that many hours a week safe patient care?”

Those words capture very effectively the concerns that we have.

The Government are taking a huge gamble with the future of the NHS workforce and patient safety. There is already a shortage of nurses in the NHS, and scrapping bursaries risks making the recruitment and retention of staff even harder. Student nurses are not like other students: they are required to work in clinical practice throughout their degrees, and they deserve to be treated differently. The hon. Member for South West Wiltshire was right to say that it is worth looking at how much they are an intrinsic part of the NHS, and if they are, that must be recognised within the consultation so that they are given credit and remunerated effectively for it. My hon. Friend the Member for Ilford North (Wes Streeting) rightly emphasised the unique position of student nurses.

The longer courses and clinical placements make it harder for NHS students to get part-time jobs to supplement their income. NHS students are much more likely to be women, more likely to come from black and minority ethnic backgrounds, and more likely to be mature students. Many nursing students have already completed one degree and turned to nursing in their late 20s or early 30s. The average age of a student nurse is 28. Many student nurses have family or caring commitments. MillionPlus has pointed out that the changes to the higher education funding system in 2012 have been much less favourably received by mature students and part-time students. Those two groups make up a much greater proportion of the nursing, midwifery and allied health student body, so it is worth looking at that part of the evidence as well.

Analysis by London Economics estimates that the switch to loans will have a significant negative impact of minus 5% on participation, at least initially, especially if one bears in mind the composition of the student health cohort. The Government’s insistence that undergraduate and postgraduate loans will be repaid at the same time will require a repayment rate of 15% above the earnings threshold for those students accessing both undergraduate and postgraduate loans. That will be in addition to any tax, national insurance and pension contributions that will be due.

The savings to the taxpayer are questionable. The Minister was not clear about that when I pressed him on it during his opening remarks. The Department of Health estimate that taxpayers will be better off as a result of the switch is very much a short-term calculation. In fact, it is much less likely that these students will repay their loans as graduates in the 30-year repayment period than the general higher education cohort. Essentially this is a switch in responsibility for the funding of the education of the health workforce from the state to the workforce itself, and it is primarily designed to reduce the departmental budget of the Department of Health.

We need to know more about what estimate the Government have made of the percentage of second degree student loans that will be written off after a 30-year period. We need the Department of Health to provide an estimate of by how much the taxpayer will be better off. We need those figures.

All the key stakeholders have expressed concern, including the Royal College of Midwives, the Royal College of Nursing, the College of Podiatry and the Royal College of Speech and Language Therapists. Even the NHS Pay Review Body has said that

“the removal of the incentive of the bursary could have an unsettling effect on the number and quality of applications for nursing training places in the early years.”

Those who are closest to what is going on are all concerned.

The Minister for Community and Social Care is a very good and thoughtful Minister, and I am sure that he is concerned about the issue. I hope that he will listen to and engage with all those bodies, which know what they are talking about. They are not making it up—their concerns are real and genuine. The Royal College of Nursing is calling on the Government to work with all stakeholders to create a model of student funding that encourages people to join the profession and that recognises the unique aspects of nursing degree courses.

I hope that the Government will take this opportunity to engage with the strong initiative proposed by the shadow Health Secretary and work together to come up with a solution that will allow us not only to recruit professionals, but to retain them into the future. As the son of a nurse and the father of a speech and language therapist, I hope that the Government are listening.

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[Justin Madders (Ellesmere Port and Neston) (Lab)]

This has been a high-quality and comprehensive debate. I have to say that I have a small amount of sympathy for the Minister for Community and Social Care, because, as we all know, this policy was not devised in his Department, but hastily put together on the back of a fag packet somewhere in the Treasury following the Chancellor’s £2 billion raid on the Department of Health budget. It looks very much like a case of “Cut first and ask questions later.” I say that because in just two lines of the autumn statement, with no consultation and no evidence base, the Government have committed themselves to a huge gamble with the future of the NHS workforce and with patient safety.

I pay tribute to my hon. Friend the Member for Ilford North (Wes Streeting) for leading the campaign with his early-day motion. His record in this area is unparalleled. He explained expertly why many student nurses are in a different position from that of other students, and expressed the concern that he and many other Members feel about the deterrent effect that the Government’s proposals will have on future numbers. Other Members spoke in similar vein, including my hon. Friends the Members for Manchester, Withington (Jeff Smith) and for Coventry North East (Colleen Fletcher), as well as my hon. Friend the Member for Scunthorpe (Nic Dakin), who pressed the Minister on what estimate had been made of the number of loans that would be written off. He did not receive a reply; I trust that the Minister for Community and Social Care will be able to fill in the details.

My hon. Friend the Member for Wirral West (Margaret Greenwood), who came to this place with a strong reputation as a health campaigner, spoke with great authority about the pitfalls of the proposals. My hon. Friend the Member for Cambridge (Daniel Zeichner), who also has great experience in this area, asked a very pertinent question about the capacity of the health service to take on the extra students. The Chairman of the Health Committee, the hon. Member for Totnes (Dr Wollaston), made an important contribution, and I hope that the Minister will respond directly to some of the very real concerns that she raised.

The Government are presiding over the worst A&E figures since records began, the biggest financial crisis in the history of the NHS—three quarters of trusts are now in deficit—and a crisis in morale across the workforce, with a Secretary of State too belligerent to listen. They have already alienated a generation of junior doctors, and now they risk doing the same for our future nurses and midwives, as well as many other health professionals. Why are they looking to unsettle a huge section of our NHS workforce at a time when good will is more important than ever?

We have several concerns about this policy, many of which hon. Members have aired today and to which the Government are yet to give any credible answer. First, let us look at the actual problem the proposals are trying to address—not the black hole created by the Chancellor but the shortage of nurses in the NHS. Be in no doubt, the Government are entirely responsible for that shortage, because they decided to reduce the number of nurse training places. Had they maintained the level set by the last Labour Government, 8,000 more nurses would have been trained in the last Parliament alone. When we hear, therefore, about spiralling agency costs and staffing shortages, let us remember the cause—not the nurses, the trusts or the patients, but the Government’s chronic mishandling of the NHS.

The proposal, with all its risk and uncertainty, will, in the Government’s most optimistic scenario, deliver 10,000 more nurses, midwives and other health professionals. When they say the proposal could deliver up to 10,000 more staff, they really are looking at the glass half full. The figure comes with so many caveats that, if it were a used car, I would not even take it for a test drive. The Government’s own equality assessment acknowledges that there could be an adverse impact on parents and carers and that childcare costs could have a significant influence on participation. It is worth picking up a few quotes from their impact analysis and evidence document, to get a flavour of just how flaky the proposal is. It says that the

“precise impact is difficult to estimate with certainty”,

that

“Behavioural change is uncertain”,

that

“there may be some uncertainty over applications in the very short term”

and—my favourite—that there

“is no robust set of information to make this assessment.”

In other words, the Government are saying they have done an assessment but have absolutely no idea what the impact of the policy will be. If that does not amount to a huge gamble, I do not know what does.

If the Government will not take heed of their own assessments, they might listen to the Royal College of Nursing, which has said that

“there is a risk of people being put off from applying to nursing degrees, because of concerns over debt.”

It, like many Members, is particularly concerned about the impact on mature students. As we have heard, the average age of a student nurse is 28. The RCN has said:

“There is a worrying lack of assessment of the potential for the changes to act as a disincentive for some students, such as mature students or those from lower income backgrounds.”

Research by the trade union Unison shows that nine out of 10 student nurses surveyed said they would not have gone into training had the new proposals been in place. That is not a trivial number. If the numbers put off turned out to be even half that, the implications for the NHS would be catastrophic. So where is the evidence to reassure us that it will not happen? There is not any. The Minister prays in aid the experience across the general higher education sector, but he knows that he is not comparing like with like. The evidence from the mature student experience does not support his case. In fact, the Higher Education Statistics Agency says that between 2011 and 2015 the number of mature students fell by 17%.

Let us be clear about what the policy really means for nurses. Owing to the Government’s reprehensible decision to freeze the student loan repayment threshold at £21,000 from 2017, all future nurses are facing a real-terms pay cut. According to Unison, based on current salaries, the average nurse, midwife or allied health professional will lose over £900 a year to meet their debt repayments. Staff retention is a huge issue across the NHS, including in nursing, and as the hon. Member for Morecambe and Lunesdale (David Morris) rightly pointed out, the Government’s record is poor. Saddling nurses with extra debt will only make the matter worse.

[David Morris]

I did not say that the Government’s record was poor; I pointed out that we needed reform, which is what we are here to discuss. I am disappointed in the hon. Gentleman’s approach, because we have had a very constructive debate today.

[Justin Madders]

I thank the hon. Gentleman for his intervention. If he is stating the facts, then I interpret them as being a poor record for the Government; that is more about the facts than about the way in which he presented them.

Let us be clear: we are talking about a debt that nurses are never likely to pay off. They will graduate with debts of between £50,000 and £60,000. Many of the mature students who take nursing as a second degree will find themselves with more than £100,000 of debt. Let me repeat that figure so that it sinks in: our country is looking down the barrel of a policy that will saddle nurses with a six-figure debt. They are not bankers or lawyers; the people who keep the NHS going will be earning just a fraction of what they earn. We already have the highest level of student debt in the English-speaking world, which is not a record we should be proud of, and these proposals will only make matters worse.

It would be an error to put nurses into the same category as other students, but I think that the Government are making that error. Student nurses’ courses take up much more of the year, meaning that they have much less opportunity than other students to work while they study. They are also required to spend 50% of the time working with patients in clinical practice, including on evening and weekend shifts. That requires a real commitment of at least 2,300 hours over the length of their course, during which they do difficult jobs at unsocial times. Now the Government are asking them to pay for the privilege of doing that. This policy is like some kind of perverse extension of workfare. Last year, there were 10,000 unfilled nurse places in London alone. Is getting people to work for free really the answer to that?

The Government really need to raise their game to improve retention among nurses. The situation has been getting steadily worse over the past few years, and nearly 9% of nurses left last year. Some might have gone to work elsewhere in the NHS, but many have left the profession altogether. Surely sorting that out would provide a more effective solution to our problems than taking a punt on an untested plan. There appears to have been no dialogue with providers, who seem unaware of the oncoming rush. Each student nurse has to be clinically assessed by a registered nurse who has done their mentoring and assessing course, but no assessment appears to have been made of the capacity for trusts to take on those extra responsibilities.

It is clear that this policy, with all its flaws, was announced with no consultation, no engagement with the sector and no evidence basis. With such a high degree of uncertainty, surely it would have been sensible to consult on the principle before embarking on the policy. But not this Government; they know best, even though they do not seem to know their own record in this area. When I asked the Minister a simple written question on how many nurses had qualified in the last five years, I received the following response:

“The Department does not hold information on the number of nurses who qualified in the last five years”.

What an absolute shambles!

Anyone would think that with such a gap in the available evidence, the Government would have gone out of their way to undertake a full consultation and to seek out evidence before announcing the policy, but no. The Royal College of Midwives, the Royal College of Nursing, the Royal College of Podiatry and the Royal College of Speech and Language Therapists are all respected institutions with years of experience and a wealth of knowledge in this area, but not one of them was asked to make a formal input into this policy before it was announced, contrary to what the Minister has said today. When he was asked, in a Westminster Hall debate on 11 January, who he had consulted, he said:

“There has been consultation with leading nursing professionals.”—[Official Report, 11 January 2016; Vol. 604, c. 237WH.]

He said nothing about the royal colleges. I hope that we shall be able to clear this up. I ask him to tell us exactly who he did consult, and to place in the Library a copy of the advice that he received following the consultation.

Let us not pretend, now that the consultation has been published, that it is a meaningful consultation on the principle or the detail of the proposals. It simply asks a few technical questions on how to implement the changes. You can have any colour you want as long as it is black. It is frankly an insult to the public, to patients and to the profession. The Government should withdraw this proposal and instead commit to a full consultation on how to improve the support available to student nurses, how to increase the number of nurses in the NHS and how to improve retention. I urge all Members who genuinely care about the future of our health service, who have concerns about the potential deterrent effect of these proposals, and who are not prepared to gamble recklessly with our nurses, to join us in the Lobby today and send a clear message to the Government that it is time to think again. I commend the motion to the House.