Nurses and Midwives: Fees

Debate between George Freeman and Grahame Morris

Monday 23rd March 2015 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (George Freeman)]

It is a great pleasure to serve under your chairmanship, Mr Havard, for what will be the last time in this Parliament.

I thank the hon. Member for Blaydon (Mr Anderson) for the opportunity to speak in this debate and for raising issues that many nurses and midwives want to have addressed. I congratulate them on securing the debate through the e-petition mechanism. I pay tribute to all nurses and midwives, who do such great work in our health service, alongside all the others who keep the system going on our behalf 24/7. I also thank the Backbench Business Committee for selecting the debate, in the light of the petition on the Government’s e-petition website asking the Government

“to review the Nursing and Midwifery Council…with regard to the fees…and the processes through which those fees are decided.”

As Members from across the House have pointed out, many nurses and midwives are concerned about the way in which the Nursing and Midwifery Council has proposed to handle the costs of registration and of fitness-to-practise inquiries. Hon. Members have done a great service in raising the issue and allowing both me and the shadow Minister to respond.

The hon. Member for Blaydon will be aware that the NMC is an independent statutory body and is therefore responsible for determining the level of its annual registration fee. Under statute, it is responsible to Parliament rather than to Ministers. However, as the Minister responsible for professional regulation, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), in whose place I am standing today, takes a keen interest in the performance of the professional regulators, not least because he is an NHS clinical professional himself. He has regular contact with regulators, including the NMC, on this and a whole range of other issues.

It may be helpful to set the scene by providing some background about the professional regulatory bodies and how they are structured. They are independent statutory bodies whose statutory purpose is to protect, promote and maintain the health and safety of the public by setting robust standards for their health care professionals across the United Kingdom. For the NMC, the health care professionals concerned are nurses and midwives.

Professional regulatory bodies are held to account by the Professional Standards Authority for Health and Social Care, or PSA—an arm’s length body currently funded by the Government. Hon. Members will be aware that, following the 2010 review of arm’s length bodies, the Government have taken the decision to make the PSA self-funding and independent from Government, part of a broader change to the way in which health care and clinical professionals are regulated, given the growing sophistication and expertise of the various disciplines. The powers to facilitate that change were brought into effect by the Health and Social Care Act 2012. At its heart, the change reflects the long-standing principle that the system of professional regulation in health care is funded by the professionals themselves.

[Grahame M. Morris]

I cannot argue with the Minister’s quoted definition of the terms of reference of the professional regulators, and we would all agree that that is completely appropriate; there is no disagreement on party lines about that. However, does he accept that, as a result of recent events—most notably the specific recommendations of the Francis report—we are placing additional burdens and responsibilities on the regulators? Is it not beholden on the Government to recognise that and give due consideration as to where those burdens should fall?

[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.

[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.

[Grahame M. Morris]

The Minister is setting out an explanation of transparency and accountability that I do not disagree with, but if we follow the line of his logic, he is saying that the NMC is responsible not to Ministers but to Parliament in the round. My assumption—perhaps he will correct me if I am labouring under a misapprehension—was that the Health Committee performed the role of holding the NMC to account. Given that the Committee takes the trouble to hold interviews and evidence sessions, and to make specific recommendations, is it not beholden on the Minister and Government to act on those recommendations, not least in relation to the Law Commission?

[George Freeman]

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

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

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

[Mr Philip Hollobone in the Chair]

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[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.

[Grahame M. Morris]

Could I press the Minister? He suggested that things are tight. We have just had the Budget statement from the Chancellor. We had a list of give-aways in Tory marginals—£2.5 million for the RAF museum in Hendon, moneys for projects in Blackpool and a new theatre in Pendle—but would that money not have been better spent helping to subsidise the registration fees of nurses working part time and of women returners, who earn considerably less than the average figure the Minister cited?

[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.

--- Later in debate ---

[George Freeman]

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

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

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

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

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

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

[Grahame M. Morris]

The NMC sometimes takes two years to complete some fitness-to-practise cases. The Select Committee recommended that it should aim to complete them all within nine months, which is not an unreasonable request. That is an incredible amount of time and resource to spend on those cases.

[George Freeman]

The hon. Gentleman makes a really good point; I was trying to make a similar point myself. We have encouraged the NMC and made it easier to speed up its processes. Anecdotally, I know from speaking to nurses and midwives that there is a lot of frustration about the slow pace of basic procedures, such as getting registration and coming back to the profession.

My hon. Friend the Member for Congleton (Fiona Bruce) cogently and clearly told the story of one of her constituents, a nurse, and spoke about the bureaucratic and clumsy registration processes. There is a common message for the NMC: it has a £70 million budget, so it ought to be able to run a less inefficient, quicker organisation and direct resources away from bureaucracy and towards dealing with fitness to practise, in which there is likely to be a growing public interest. It is good that the public want to drive up standards and be clear about patient safety across the professions.

On the issue of revalidation, we believe that nurses and midwives have some of the most important jobs in the NHS. They care for patients every day, so it is crucial to ensure that they are up to speed with the standards that the public and patients expect. We support the NMC in its drive to introduce revalidation, which will improve safety and the quality of care. It will reassure patients that nurses remain fit to carry out their vital work.

The challenges of the serious debt and structural deficit inheritance that we as a society are confronting mean that everyone in our public services has to deliver more for less within the current financial constraints and to ensure that standards continue to improve. Across our public services—indeed, across our general economy—there are extraordinary levels of productivity gain day in, day out. The general economy runs at 2% to 3% productivity growth every year with its eyes shut. The challenge is to create in the public sector the right climate and leadership conditions so that our great public servants can deliver similar productivity.

That said, we recognise the importance of the level of the NMC registration fee to all its registrants, which is why the Government have assisted the NMC to introduce rules that will allow registrants to pay their registration fee in instalments. Those rules came into effect on 9 March, and they enable the front-line nurses and midwives who have to pay the £3 extra fee to schedule payment of the total £120 annual fee across the whole year.

To maintain the NMC’s independence from the Government, its registration fee must cover the full costs of its regulatory activity. I am sure that nobody in any corner of the House believes that we should downscale or curtail the quality of that regulatory work merely on the basis of members’ unwillingness to pay. The principle is that health care professionals should fund the regulation of their profession to maintain the confidence of the public and patients. However, it is for the NMC to decide how to meet its statutory functions and protect patients and the public, which is our paramount consideration. The NMC recognises that it needs to do more to maintain the confidence of registrants, patients and the public in its performance, and to continue to improve its operation, effectiveness and efficiency.

I am grateful for the chance to correct the record and clarify that the Government are prioritising the lowest-paid workers in the NHS; we applaud and support their commitment. I want to take this opportunity to reaffirm the Government’s gratitude, thanks and support for their work. Despite the difficult funding constraints, in this Parliament we have consistently supported the lowest-paid workers in the NHS, rather than the best-paid, and we have reflected that in the latest pay settlement.

At the heart of this measure are some important points that need to be reiterated. There is a long-standing convention that health care professionals pay their own professional registration fees. The reform will increase the registration fee paid by nurses and midwives, whose average salary is £31,000, by £3, against their annual registration fee of £120. The Government have given the NMC a £20 million grant to help to offset those costs. The NMC has made it clear that it is able to pay for a substantial element of the increases through its ongoing efficiency programmes. The principal driver of cost is the growing public interest in fitness to practise and the cost of handling such cases. We are helping the NMC, not least by helping it to deal with those cases much more quickly, as the hon. Member for Easington highlighted.

We should not hold back the public’s interest in fitness to practise. It is part of a new culture of transparency and accountability across the system, post the Francis report, and the Secretary of State and many others want to encourage it in the modern NHS. The NMC is an independent statutory body that is accountable to Parliament, not Ministers.

I welcome the chance to inform the debate, particularly for NMC workers and for the many nurses and midwives who have taken the time to sign the Government’s e-petition form and, through the Backbench Business Committee and Members in the Chamber, to bring this issue to the Floor of the House. We as Ministers are very aware of the needs of the lowest-paid NHS workers, who do an extraordinary job for us. That is why, in the latest pay deal, we reflected that, with a 5.6% increase for the lowest earners and a 1% pay rise, which equates to £300 in the pockets of the nurses and midwives we are talking about.

The measures in the Budget and the Chancellor’s wider tax reforms, such as raising the tax threshold for the lowest-paid workers, will take more than 4 million of the lowest-paid workers out of tax altogether. The lowest-paid nurses and midwives are now £900 a year better off as a result of the increase of the personal allowance to £11,000. That is a substantial sum, compared with the £3 fee increment. The hon. Members for Denton and Reddish (Andrew Gwynne) and for Blaydon are eloquent and persuasive men, but even they cannot suggest that a £3 fee on health care professionals earning £31,000 represents a crisis in the NHS. They rightly said that it is important that the NMC quickly develops its efficiency and upgrades its internal mechanisms, and they made a number of interesting points about how that can be done to maximise fairness for the lowest-paid workers. I want to take the opportunity to repeat that the Government are absolutely on the side of those workers.