Nurses and Midwives: Fees

Grahame Morris Excerpts

Monday 23rd March 2015 Westminster Hall

[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.

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[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.

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[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.

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

It is a pleasure to serve under your chairmanship, Mr Havard; regrettably, it may well be for the last time in this Parliament.

I congratulate my hon. Friend the Member for Blaydon (Mr Anderson) on securing this debate and the Backbench Business Committee on allocating the time. It is on an important issue, and the reason I wish to participate in it is because I serve on the Health Committee and we have looked at this issue on a number of occasions as part of our annual accountability hearings. Indeed, we produced a report, which my hon. Friend referred to; it was the fifth report of Session 2013-14, and the reference is HC 699. It is an excellent piece of work. The Committee went into some detail, covering many issues mentioned by my hon. Friend the Member for Blaydon and making recommendations about how best to proceed.

I do not want to repeat the arguments, but it might be useful to put into context the report and the concerns that have been raised. Constituents of mine who are nurses and midwives have written to me individually, quite apart from the petition. I think many hon. Members throughout the country have had similar representations.

There is an issue about fairness in respect of this considerable increase in fees, and about how the increases have come about. There is also an issue about whether those who are required, by the nature of their employment, to be registered should be placed into financial hardship, as has happened in some cases, particularly with women returners who are working limited, part-time hours. We all agree with registration, to maintain public confidence and trust in the nursing profession. However, there is an issue about whether some allowance should be made for them, in terms of a reduction in their fees.

As my hon. Friend indicated, the nursing and midwifery professions are among the oldest established and longest regulated professions in the United Kingdom, with regulation taking many forms over the last century. The current regulator, the Nursing and Midwifery Council, which has given evidence to the Health Committee, has been in operation since 2002. As we have heard, it is the statutory regulator for more than 670,000 nurses and midwives. The £67 million figure relating to its income is an old one, because it now receives more than £70 million.

In 2011, the Health Committee began holding annual accountability hearings in relation to the Nursing and Midwifery Council. Prior to that, our concentration was essentially on the regulation of the medical profession, with the General Medical Council. We have since widened the scope of the annual accountability hearings. In its report on the first annual accountability hearing with the Nursing and Midwifery Council, the Committee expressed concerns

“about the affordability of the registration fee”.

This has not just popped up: we have identified it as a trend since 2011. In that report, the Committee urged the Nursing and Midwifery Council

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

However, there have been fee rises since then. When I was first elected, the fees were £76 and they increased to £100 in February 2013. The further rise to £120 a year—that would probably account for the increase in revenue—would mean a 52% fee increase, at a time when nurses and midwives are experiencing severe and unsustainable pay restraint. These problems are further compounded by the decision of the Government and the Secretary of State for Health to veto the 1% NHS pay rise, denying a pay increase to 70% of nursing staff and ignoring the view of the independent pay review body. I want to place on record that the incredible work and effort of our nurses and midwives is of great value, and I want to say how much that is appreciated throughout the country.

[Ms Ritchie]

My hon. Friend is making a compelling case for the career position of nurses and midwives. Does he agree that the Nursing and Midwifery Council, as well as the Government, should be encouraging people into the profession, rather than providing disincentives, discouraging them from joining it and from training for such vital roles that will benefit all within the wider community?

[Grahame M. Morris]

I agree wholeheartedly. All across the country—certainly in my area—efforts are made, and have been made consistently, to recruit good quality staff. Often recruitment is done overseas, with adverts being placed in newspapers in countries that train good quality nurses and midwives, but have a surplus. It often strikes me as bizarre that although we have a reservoir of women returners, we not making it as easy as possible for them to return. Doing that would be in the interests of the service and of the country. It would be a false economy to continue doing what we are doing.

[Sir Alan Meale]

I am here today because my sister is a midwife and has been a nurse all her adult life. This is not just about times of restraint and restrictions on pay; there has also been a thorough re-grading of the whole nursing and midwifery system throughout the UK, which has already re-graded many nurses to lower grades than previously. They are experiencing a double whammy, and this is the third time they have been hit with a fee rise. We should not approve it.

[Grahame M. Morris]

I am grateful for my hon. Friend’s intervention. That is another excellent point, well made. Pressures are being placed on the NMC, including increases in its costs, that are placing a greater strain and burden on nurses and midwives. The Government have to recognise that. I know that my hon. Friend the Member for Blaydon has reservations about whether the Government supporting the NMC with one-off grants would impact on its impartiality. I do not think that should necessarily follow. We should recognise the considerable pressures being placed on it financially, not least those arising out of public concerns and the recommendations of the Francis report. We want the public to be confident that the profession is properly regulated and that the fitness-to-practise procedures are operating properly and effectively. However, I agree with my hon. Friend. There was a ministerial statement last Thursday regarding untoward practices highlighted in a report, including bullying of staff and so on, in a hospital in east London—I think it was the Barts Health Trust. If fitness-to-practise referrals are being used by employers in that way, it is reprehensible and is adding to the strains and pressures on the NMC.

The latest fee increases are being imposed on nurses and midwives who were extensively consulted about them. My hon. Friend mentioned the overwhelming numbers: 96%—many of us would be over the moon to have that as a vote of confidence in the general election—voted against those recommendations. However, it seems that the consultation served little purpose, other than to antagonise nurses and midwives, because the Nursing and Midwifery Council has, apparently, taken little or no regard of the views of NHS staff and has pressed ahead with the fee increase.

The Nursing and Midwifery Council has also failed to provide any assurances that the latest increase will not be followed up by further increases in coming years. As my hon. Friend the Member for Mansfield (Sir Alan Meale) mentioned earlier, if we are to encourage people to come back into the profession, they have to know that the regulator has a reasonable, cost-effective process in place. The Nursing and Midwifery Council stated in evidence to the Health Committee last year that it had introduced an

“annual formal review of the fee level”,

so it is not necessarily an ongoing commitment. However, we have to ask: why has there been such a huge increase, of more than 50%, in a relatively short period?

Clearly the Nursing and Midwifery Council must meet its statutory obligations. We would expect that as Members of Parliament—and the public would certainly expect that—for maintaining professional standards. Certainly more needs to be done to remove the constraints it faces through the fitness-to-practise process—a number of hon. Members have highlighted that—which is too costly. Seventy-seven per cent of the Nursing and Midwifery Council’s income of more than £70 million is being spent investigating less than 1% of the nurses and midwives on the register. That is an incredible sum of money, and I find it difficult to comprehend how that can be an efficient use of resources.

The Nursing and Midwifery Council is making progress—I recognise that, and certainly the Committee recognised it, although it said it thought the progress was “fragile”. The NMC recognises past failures—not least in IT systems—and is seeking to overcome some of them, but it is clear that further improvement is required. An assessment by the Professional Standards Authority for Health and Social Care—the organisation that oversees all the professional regulators—has found that the Nursing and Midwifery Council is failing to meet seven of the 24 standards of good regulation. By any measure, I would suggest that there is still a long way to go in bringing it up to standard. Of those seven failures, two relate to fitness to practise.

While it is important that improvements continue to be made, it is wrong to expect nurses and midwives to bear the burden of the costs by themselves, particularly when we have seen the value of their pay fall in real terms over the life of this Parliament. The Government cannot sit idly by and allow continual increases in fees without taking action or giving some guidance. We hear Ministers time and again praising the hard work and dedication of nurses, and I hope the Minister will do that at the conclusion of the debate. Nurses do an amazing job in the most difficult circumstances, but when it comes to pay, pensions or professional fees, the kind words of Ministers seem to be rarely followed up by practical action that would help NHS staff.

In conclusion, I hope the Minister will say what steps he is taking to support the Nursing and Midwifery Council to ensure that it can continue to drive through the improvements we all want to see without having to increase the fees and the cost of employment for nurses and midwives. I also hope that he will address the points made by my hon. and right hon. Friends on the need to speedily bring forward the law commissioners’ sensible and well thought out proposals on the NMC. I would be interested if he could explain why they have not been brought forward before now.

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[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]

--- Later in debate ---

[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.