NHS Bursaries

Heidi Alexander Excerpts

Wednesday 4th May 2016 Commons Chamber

[Heidi Alexander (Lewisham East) (Lab)]

I beg to move,

That this House recognises the contribution of student nurses, midwives, allied health professionals and other healthcare staff; has serious concerns about the potential impact of removing NHS bursaries on the recruitment and retention of staff; and calls on the Government to drop their plans to remove NHS bursaries and instead to consult on how they can best fund and support the future healthcare workforce.

I have been told that the Under-Secretary of State for Health, the hon. Member for Ipswich (Ben Gummer), will be opening this debate for the Government. Given that the Health Secretary is sitting next to him, may I ask the Minister why we will not be hearing from his boss today? If he would like to give a genuine reason I would be happy to take an intervention, but if not I will take it that the Health Secretary simply does not want to defend his policy to the House. [Interruption.]

[Mr Speaker]

Order. There is a certain amount of chirruping from the Treasury Bench and elsewhere on this matter, and I simply make two points. It is entirely for the Government to decide which Minister to field, but I say gently to the Secretary of State, and to the Deputy Leader of the House, that to sit on the Bench rather than to participate while these matters are debated, is one thing—particularly in the case of the Secretary of State—but to sit there fiddling ostentatiously with an electronic device defies the established convention of the House that such devices should be used without impairing parliamentary decorum. They are impairing parliamentary decorum, and in very simple terms the Secretary of State and the Deputy Leader of the House are being rank discourteous to the shadow Secretary of State and to the House. It is a point so blindingly obvious that only an extraordinarily clever and sophisticated person could fail to grasp it.

[Heidi Alexander]

Thank you, Mr Speaker. This is not the first time that the Health Secretary has chosen not to respond to debates that I have secured or questions that I have put. [Interruption.]

[Mr Speaker]

Order. I say to the Deputy Leader of the House: put the device away. If you do not want to put it away, get out of the Chamber. It is rude for the—[Interruption.] Order! I am not inviting a response from the hon. Lady. [Interruption.] Order! I am simply telling her that it is discourteous to behave like that—a point that most people would readily understand.

[Heidi Alexander]

Thank you, Mr Speaker. I will leave my comments on that matter there.

In the past few months, Ministers and I have had a number of exchanges across the Dispatch Box about the unnecessary and dangerous fight the Government are picking with junior doctors. You might think that having totally alienated one section of the NHS workforce, Ministers would think twice about doing it again, but you would be wrong. Not content with junior doctors, the Government are now targeting the next generation of nurses, midwives and other allied health professionals: podiatrists, physiotherapists, radiographers and many more. Instead of investing in healthcare students, and instead of valuing them and protecting their bursaries, which help with living costs and cover all their tuition fees, the Government are asking them to pay for the privilege of training to work in the NHS: scrap the bursary, ask tomorrow’s NHS workforce to rack up enormous debts, and claim that this is the answer to current staff shortages.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

The hon. Lady is making a spending commitment. Why then, only a few months ago, did she stand on a manifesto that opposed the Government’s £10 billion investment in the NHS?

[Heidi Alexander]

The Labour party has always made it clear that it would have given the NHS every penny it needs.

Given the approach to healthcare students I have outlined, most people would think the Government had taken leave of their senses. They would be right.

[Diana Johnson (Kingston upon Hull North) (Lab)]

My constituents in Hull are baffled by the Government’s approach. At a time when our local hospitals have to recruit nurses from Spain and other European countries, stopping bursaries that enable more people to get training seems absolutely ridiculous.

[Heidi Alexander]

I absolutely agree with my hon. Friend. Indeed, the bursary acts as an incentive to get those students into training and into the NHS.

A few weeks ago, the Government launched their consultation on the technical detail of the changes—not the principle, just the detail. In his foreword, the Under-Secretary of State for Health, the hon. Member for Ipswich, claimed that the proposals were

“good for students, good for patients and good for the NHS.”

The opposite is the case.

Before I set out why the plans are so bad, it is important to remind ourselves of why our country has a nursing shortage in the first place. Shortly after the 2010 election, the coalition Government cut the number of nurse training commissions in an attempt to make short-term savings. The cuts saw nurse training places reduced from more than 20,000 a year to just 17,000, the lowest level since the 1990s. As a result, we trained 8,000 fewer nurses in the previous Parliament than we would have done had we maintained commissions at 2010 levels. At the time, experts such as the Royal College of Nursing warned that the cuts would cause

“serious issues in undersupply for years to come.”

It was right, but it was ignored by Ministers who were too focused on the short term and no doubt too distracted by their plans to launch a massive reorganisation of the NHS.

Our health service is now suffering the consequences of those decisions. New analysis by the House of Commons Library released today shows that the number of nurses per head of population fell from 6,786 per million people in 2009 to 6,645 per million people in 2015. A Unison survey published just last week found that more than two-thirds of respondents felt that staffing levels had got worse in the past year, with a further 63% saying they felt there were inadequate numbers of staff on the wards to ensure safe, dignified and compassionate care. Because of these shortages, hospitals are forced to recruit from overseas or spend vast amounts on expensive agency staff.

[Paula Sherriff (Dewsbury) (Lab)]

In the years 2014 to 2015, the NHS spent £3.3 billion on agency staff. Does the short-sighted step of removing the bursary mean that beleaguered trusts may actually be more reliant on agency staff?

[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?

[Richard Graham (Gloucester) (Con)]

Of course we all agree that there is a significant shortage of nurses, and the hon. Lady is absolutely right to ask what should be done. Does she therefore support the Government’s concept of associate nurses, which I believe will make a huge difference in places like my constituency where we need new nurses of this kind to increase the numbers of home-trained nursing staff?

[Heidi Alexander]

I am grateful to the hon. Gentleman for his intervention. The key question we need answered with regard to nursing associates is whether the Government intend them to replace registered nurses. If that is the case, I fear the proposals would be bad for patient care.

Madam Deputy Speaker, you might think a sensible approach to trying to resolve this problem would be to sit down with the Royal College of Nursing, other trade unions, universities and healthcare providers to work out a way forward. But no, this Government seem incapable of that. Instead, in just two lines in the Chancellor’s autumn statement, they announced that they would be scrapping NHS bursaries and asking student nurses to pay tuition fees. The Minister will argue that this will allow universities to train more students, but his problem is this.

[Nic Dakin (Scunthorpe) (Lab)]

Does my hon. Friend agree that the Government should listen to the Royal College, which said that these proposals were “high risk”, potentially

“deterring prospective students from entering the nursing profession”,

and that they risked “worsening the nursing shortage”?

[Heidi Alexander]

I entirely agree with my hon. Friend. I think the Government’s problem is this: they have failed to back up their claim with any evidence and they are now faced with a breadth of opposition to this proposal, not just from Members but from the Royal College of Nursing, the Royal College of Midwives and Unison, while organisations such as MillionPlus, the association for modern universities, are also questioning the assumptions on which the Government base this policy.

[Anna Turley (Redcar) (Lab/Co-op)]

Does my hon. Friend agree with my constituent Zoe, who is training to be a nurse and is particularly concerned about mature students? She feels that about 50% of their time is spent in unpaid clinical placements in hospitals in the community, so they do not have the opportunity to do part-time work to support themselves as many others do. Will they not be disproportionately affected?

[Heidi Alexander]

I agree with my hon. Friend, and I shall make some remarks on that precise point later.

The Opposition’s purpose in calling today’s debate is that we hope the House can rally round what many would view as a straightforward and reasonable proposal— that the Government drop these plans and instead consult on how properly to fund and support the future healthcare workforce.

Let me set out why these plans are bad for students, bad for patients and bad for the NHS. The Government claim that these plans will leave healthcare students 25% better off. What they will not say is that, according to their own consultation, in order to be 25% better off, a student will have to take out a maximum maintenance and tuition fee loan for three years and would graduate with debts of between £48,000 and £59,000.

[Angela Rayner (Ashton-under-Lyne) (Lab)]

Many Members will know that I had a son born at 23 weeks’ gestation who spent six months in intensive care with a neonatal nurse, Nicola Probert, who sadly died not long after my son came out of hospital. I am frightened, as many people watching this debate will be, that people like Nicola will no longer go into the profession because of the astronomical debts that they will have to take on. Does my hon. Friend agree that this is a regressive step, and that the Government should think again about it?

[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?

--- Later in debate ---

[Heidi Alexander]

I have already given way to the hon. Gentleman, and I want to make some progress.

These changes will effectively charge students for working in the NHS. Of course, longer term times and clinical placements also make it harder for these students to get a part-time job to supplement their income in the way many other students do. It is not just the course that makes healthcare students unique; they are much more likely to be women, much more likely to be mature students, much more likely to have children and more likely to be from BME backgrounds.

Many nursing students have already completed one degree and turn to nursing in their late 20s or early 30s—indeed, the average age of a student nurse is 28. When I think of my own friends who are nurses and midwives, I find that three out of four took the decision to re-train, having done a different first degree.

The Minister probably moves in different circles from me, but I can tell him that if he wants a dose of reality, my friends would, I am sure, be more than happy to oblige. I understand that he may not have experienced the conversations that I had in my working-class family about the pluses and minuses of racking up debts to get a degree, but I can tell him that for many nurses, under his proposals, that consideration will be all too real. Does he not realise that for the one in five healthcare students with children, the fear of debt is greater than it is for carefree, privately educated history students bound for Cambridge? My concern about these proposals is that we ultimately end up with those best placed to pay becoming nurses and midwives rather than those best placed to care. That brings me on to why these proposals are bad for patients.

[Helen Whately (Faversham and Mid Kent) (Con)]

I think we are all agreed on the need for more nurses; the question is how we fund them. Will the hon. Lady tell us how much money she would take away from front-line NHS care in order to fund the expansion of nursing places that the country needs?

[Heidi Alexander]

We set out at the last election our clearly costed plans for how to recruit additional nurses, doctors and care staff to the NHS.

The NHS should have a workforce that reflects the population it serves—just as this place should, too. The mental health sector in particular relies on mature students and the additional life experience they bring to what is a very demanding environment.

A few months ago, I met Marina, a young woman who has not had an easy life, but who is now on a mission to become a mental health nurse. When Marina says that she thinks some of the people best placed to care for others are those who have experienced hardships themselves, I think she has a point; and when she says she would not have been able to start her training without the bursary, I believe her. Why is the Minister so convinced that the NHS can do without people like Marina in the future? Why does he think they should pay to train, and why will he not consider other options for increasing student numbers?

The quality of training that student nurses, midwives and other allied health professionals receive will also depend on the quality of their clinical placements. Government Ministers claim these changes could deliver up to 10,000 extra places over the course of this Parliament, so can they set out what capacity hospitals and other providers have to accommodate these extra students, and confirm whether Health Education England has sufficient funds set aside to fund these placements? Will the Minister be clear about how this 10,000 figure was arrived at? Is it the Government’s assessment of what the system needs, what Health Education England can afford to fund or simply a big-sounding number plucked out of the air at random?

An extra 10,000 compared with when? What is the baseline year on which we should judge the Minister’s policy? I have asked him that three times in written parliamentary questions, and each time I have not received an answer. Does he not understand that if his Department cannot even answer a simple question relating to one of its key claims about the policy, that does not exactly inspire confidence? There are so many questions that the Minister needs to answer that it is impossible to do all of them justice in a single speech.

[Alex Chalk (Cheltenham) (Con)]

As has been indicated, it is agreed that we need to expand the number of places. Thanks to this Government, however, an extra £10 billion has been put into GP services, acute services, cancer treatment and hospital care. Which of those services would the hon. Lady cut to fund the alternative bursary scheme that she has in mind?

[Heidi Alexander]

The hon. Gentleman does not seem to realise that that money is plugging a very big black hole in NHS finances. I am sure that when the Minister responds to my speech, he will note that many people who apply to study for nursing and other healthcare degrees are turned away, but what proportion of those unsuccessful applicants actually meet the entry criteria? How can he be sure that his new system will deliver the required numbers of different types of nurses and other healthcare professionals in the right geographical areas? What guarantees has he given to higher education institutions that the new arrangements will fully cover the costs of delivering degrees, and what assessment has he made of the amount of un-repaid student debt that will accumulate, given that, over a lifetime, some nurses will not earn enough to repay the totality of their loans plus interest?

The proposal to scrap NHS bursaries is a massive gamble at a time when the NHS needs certainty. Put simply, it will shift the costs of training nurses, midwives and other allied health professionals from the state to the individual. If we are all happy to enjoy the benefits of the NHS, why should we not all contribute to the training of those who work in it?

I was the first member of my family to go to university. My tuition fees were paid in full, and I received a full maintenance grant. What really worries me is that people like me, and people like my friends, will be put off what could be a fulfilling and important career. We should be doing all we can to inspire today’s schoolchildren to become the nurses and healthcare professionals of the future, but, sadly, the Government are making a very good job of doing the very opposite. If Ministers want to continue to import staff from overseas, they are going the right way about it. We owe a debt of gratitude to those staff, but we want home-grown staff too.

Finally, let me return to the Government’s consultation paper. One section is entitled

“Nursing, midwifery and allied health professional students deserve the same opportunities as other students”.

Labour Members say, “No, they deserve better.” Those people should be treated differently from other students, because they are the people who will look after us when we are older, care for our relatives when they are sick and staff the NHS when this shambolic Government are long gone.

The Government should drop these proposals and think again. I commend the motion to the House.

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a great pleasure to respond to the motion, not least because I think that this is potentially one of the most exciting things that we will do in the NHS in the next five years to increase opportunity and quality, and the presence of nursing staff on wards. We will be able to do that because of the reform that has helped so many other students throughout the country in the last five years.

The hon. Member for Lewisham East (Heidi Alexander) entered the House at the same time as I did. In November 2010, we sat on opposite sides of the House and contributed to a debate; many of us expressed anxiety about the outcome, not least because of the enormous pressures that we were experiencing from our constituents. Members who have been here for many years will know that that was the first occasion on which a riot taking place outside the House could be heard from the Chamber. The rioters were complaining that we were going to destroy people’s ability to go to university. We were going to make it impossible for people from disadvantaged backgrounds to go there, and we were going to set back years of progress in the closing of the inequality gap in this country.

Members on both sides of the House who spoke in that debate felt very passionately about the issue. We believed that it could be resolved by different means, but over the last five years we have been able to see the effect—and, as posited by the hon. Member for Lewisham East, the evidence—of the changes that were made. That evidence is quite clear. This year, 394,380 people were given university places in this country, 35,000 more than were given places in 2010, the year of the debate. If those 35,000 were to make up a single university, it would be the fourth largest in the country: one university, the fourth largest in one year, following the expansion of opportunity that resulted from the reforms that the House passed in 2010.

The hon. Lady made the most important point, however, when she asked how the reforms extended opportunity to the people who most needed to go to university. I regret the tone that she adopted in that portion of her speech; it was, I am afraid, beneath her. It was indeed wrong that when I was at university my fees were paid for in part by nurses paying tax on low wages. That was wrong, and we accepted that it was wrong. We also accepted that the system was not helping the people who most needed to go to university in order to escape their backgrounds.

The result that we should be looking for now is the number of people from disadvantaged backgrounds who have been helped to get into university in the last five years, and I can tell the hon. Lady that it has increased by 10,150. That is a massive increase. Had someone said back in 2010 that that would be possible, I doubt whether anyone would have given 5,000:1 odds on it, but I can also tell the hon. Lady that 10,150 is the number of people at the University of Leicester. That is the number of people whom we have brought into the university sector as a result of the changes that we have made. We have the equivalent of one more university, full of people from disadvantaged backgrounds, as a result of the reforms that we enacted in 2010.

I know that the hon. Lady’s motivations back then were entirely honest and commendable. I also know that many Conservative Members felt likewise. But we have to accept when we get things wrong, and it is in that regard, I am afraid, that the hon. Lady, rather than us, is failing to learn from history. During the 2010 debate, in an intervention on one of my hon. Friends, she said that the proposed changes would force on students a “huge debt”, and that

“the huge debt that they could now face will act as a greater disincentive to go to university than it will for students from more affluent backgrounds”.—[Official Report, 9 December 2010; Vol. 520, c. 579.]

The hon. Lady has made exactly the same point in today’s debate. She was wrong then, and I humbly suggest that she is wrong on this occasion. She should listen very carefully to the evidence that has been presented, not by me but by so many institutions, about the progress that has been made in reducing inequalities, and the reasons why we need to press ahead. In this instance, for one reason alone—and I will come on to others—we need to bring about the reforms to nursing bursaries.

[Heidi Alexander]

Does the Minister not accept, though, that healthcare students have very different characteristics from other students, and that their behaviour will not necessarily be same as that of students affected by the reforms in the last Parliament?

[Ben Gummer]

I accept that there are differences—I will come to them in a second—but implied in the hon. Lady’s point is an acceptance that she was wrong in 2010, and she should therefore be more measured in her proposals, or lack of them.

--- Later in debate ---

[Ben Gummer]

Contrary to what the hon. Member for Lewisham East said, I did consult the royal colleges. I have spoken at length with the Royal College of Nursing and with Unison. As I would expect, we differ on key parts—though not every part—of the plan, but the royal college’s initial response accepted that the premise on which we were proceeding was, in significant part, correct. In the consultation, I want to find areas we can agree on and improve the proposals we have put before the public. We were open about the consultation and offered the full 12 weeks—many people said we would not do so, but we did—precisely so that we could listen to the concerns, proposals and exciting challenges from people across the sectors, and thereby improve the proposals we have put before the NHS.

The motion suggests a series of things, but not a proposal from the Opposition to do anything different. They are not offering the NHS any new money—they offered £4.5 billion less than we did at the last election—so I can only presume that the money would have to be found from cuts elsewhere in the service. The hon. Lady will have no credibility unless she tells the House that she will pay for the 10,000 additional training places out of taxpayers’ money, rather than by finding an alternative funding mechanism. I will not offer the House a series of suggestions that might or might not be better, or merely criticise proposals, rather than offering constructive improvements.

[Heidi Alexander]

Whenever I make suggestions, they’re just ignored.

[Ben Gummer]

The hon. Lady is welcome to contribute to the consultation. She is doing so now, although sadly we heard no solutions or alternative proposals. I intend to set out not suggestions, but a clear announcement of our plans, the reasons for them, and how we will enact them over the year to come.

[Ben Gummer]

The hon. Member for Ilford North (Wes Streeting), who has concerns about the proposals, has discussed the matter with me several times and offered some useful suggestions about the detail. I have accepted his points and incorporated them into our thinking. I am very willing to listen to people from across the House when they come with helpful suggestions, and I am sure that the Minister for Skills, my hon. Friend the Member for Grantham and Stamford (Nick Boles), would be interested in the hon. Gentleman’s contribution about the apprenticeship levy. The way not to do it, however, is to come to the House with a series of criticisms but not one suggestion, nor any money to provide for the increased number of training places in the plan.

We should make these changes not only for reasons of social equity, though that is the foremost reason; not only to produce 10,000 additional training places in our university system; and not only because we have a broken planning system, which otherwise would remain broken—even people as intelligent as the hon. Member for Lewisham East cannot predict how many nurses, doctors and allied health professionals we will need in 20 or 30 years, or the skills they will need. Even were it not for all those things, it would still be important to do this, because of the changes it will make to the quality of training we can provide to nursing graduates. Across the rest of undergraduate training, universities have been released to innovate and improve their courses. Satisfaction levels have gone up and drop-out rates have fallen; consequently, people are getting a better experience.

We have not, however, been able to spread those advantages to nurses, who, I am afraid, remain trapped in a system that is prescriptive and does not take account of the skills that they and their future employers will need. By releasing universities from their straitjacket, we can make significant improvements to the quality of the training they provide.

[Heidi Alexander]

That’s just an assertion.

[Ben Gummer]

It is an assertion that is backed up by the evidence of the past five years, and which has received the recommendation of Professor Dame Jessica Corner, the chancellor of the Council of Deans of Health. I can tell the hon. Member for Lewisham East, in answer to her barracking, that Professor Dame Jessica Corner said:

“We recognise that this has been a difficult decision for the government but are pleased that the government has found a way forward. Carefully implemented, this should allow universities in partnership with the NHS to increase the number of training places and also improve day to day financial support for students while they are studying. The plan means that students will have access to more day to day maintenance support through the loans system and recognises that these disciplines are higher cost, science-based subjects.”

Likewise, Universities UK has said:

“We support increasing health professional student numbers and will work with Government and the NHS to secure the sustainable funding system”

that the Government have provided. It is particularly pleased about the impact that this will have on placement training. These are the people who are providing training in our NHS, and they support our proposals because they will release the same kind of innovation that we have seen elsewhere in the university sector.

--- Later in debate ---

[Ben Gummer]

The economic impact assessment is part of the consultation, and the hon. Gentleman should consult that. It will obviously depend on the way in which the student workforce develops over the next 20 or 30 years, but this has been fully costed within the Treasury’s assumptions, and we anticipate that people working beneath the current limits will not be paying back more than they are doing at the moment. That is in the nature of the way in which student finance repayments are calculated. These measures will not land newly qualified nurses with new payments that they might otherwise not have expected.

[Heidi Alexander]

The Minister has urged me to be careful with my words, which I was, and I recognise that he is being careful with his, too. He is talking about newly qualified nurses. Can he confirm what the average repayment would be for the average nurse?

[Ben Gummer]

We do not currently have a figure for the average nurse, as the hon. Lady puts it. I cannot project where a nurse’s career path will take them 50 years into the future, for precisely the reasons that we have been discussing. The actual repayments—[Interruption.] I will come to the hon. Member for Kingston upon Hull North (Diana Johnson) in a second. The actual repayments are clearly listed in the consultation document. They are clear about the amount that will be paid back over and above what existing students would be expected to pay.

The only way in which we will be able to square the circle that the hon. Member for Kingston upon Hull North mentioned is by reforming student finance. Rather than shouting from a sedentary position, she might like to know that, contrary to her suggestion that many people in her constituency were none the wiser about this reform, I talked about the reforms to nurses in her constituency a few months ago. I also talked to them about the introduction of apprenticeships and of nursing associate grades, all of which are part of the reforms that I am outlining, and they were very excited about the changes that we are making to the nursing profession. All of this is possible only within a budget that is being carefully controlled, and in which priorities are placed on where the money is spent.