Education (Student Fees, Awards and Support)(Amendment) Regulations 2017

Lord Forsyth of Drumlean Excerpts

Thursday 27th April 2017 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords, it is particularly appropriate that the final debate of the Parliament in this House is on a matter of such concern to the British people: our National Health Service. If there is one group of people who always top the approval ratings among the British people, it is nurses. I will not say where we politicians are.

It is widely accepted that the National Health Service provides real value for money. In fact, we get health on the cheap in this country. We spend less on health than any other member bar one of the G7 nations, and I am not sure that that can continue for much longer. I think we will have to spend more on health, with our ageing population and the growth of what is technologically possible.

In a sense, we have been helped in this debate by the report of a Select Committee of this House on The Long-term Sustainability of the NHS and Adult Social Care. It draws to our attention how we have failed over the years to have long-term planning for organising staff. We must remember that approximately 150,000 people work for the health service. It is a fascinating organisation. It is a labour-intensive organisation—which applies in one way to nursing—married to and working alongside cutting-edge technology and science. It works, and we must continue to ensure that it works. The key is the staff at every level.

Anyone who follows the press or talks to doctors, nurses or the other health professionals knows that our National Health Service is in deep trouble and is functioning safely only due to the work level of the staff and their intense dedication to the service in which they work. That cannot continue indefinitely. Repeatedly, the royal colleges of nursing, midwifery and all the other medical disciplines tell us that we are getting towards breaking point. The strain is intense; the morale is low.

Let us take just nursing. Currently, we are about 24,000 nurses short—I think there is no disagreement with that. That affects not only our National Health Service but another big issue at the moment, the after-care service. A number of care providers, nursing providers and Care England have contacted me to say that they have had to close beds because they cannot get nurses to staff them. We tend to neglect that, and I mention it only in passing today because I want to concentrate on the health service.

I gather that the Government have had a report available to them in March which is not yet public which suggested, on a worst figure scenario—I emphasise that—that by the early 2020s we would be not 24,000 but 42,000 nurses short. Morale is not helped by the fact that nurses were not well paid to start with. They are highly qualified. All nurses are now graduates. They have to do professional work. Increasingly, they are doing work traditionally done by doctors. They are able and skilled do it, and we benefit greatly from that. The 1% annual pay increase which they have had to accept since 2010 is having a massive effect on morale, especially when people are having to work so hard.

We get by only because we import nurses from overseas. We have traditionally done that—I am not just blaming the Government in this case—but the problem is now acute. Of those nurses from overseas, 20,000 originate from European Union countries. Despite effort and pleading by me and others, we cannot get the Government to commit to those 20,000 people who work so hard in our National Health Service being allowed to stay in Britain. That will be easy to do: we need only to tweak the residency rules. That could be done without causing any problem, yet it would be of great benefit in retaining those nurses. I believe that we should offer them permanent residency in this country, as they have dedicated so much effort to providing healthcare for our population but, at the end of the day, we must train more home-grown nurses. The supply is there, because for every person who is accepted on to a nursing course at university, twice as many people apply. There is the quality and quantity of individuals who want to train nurses. The reason why they are not is because the Government have insisted on a cap on the numbers. Universities are not allowed to accept more nurses than has been agreed with the Government. By imposing this cap, we are exacerbating the problem.

I challenge the Minister that we are only really talking about saving money. That is what is dominating the Government’s approach to the training of nurses.

To recap a little, the bursary system that has been developed meant that nurses who went into training did not pay fees. The quid pro quo was that most of them went on to work in the care services or the National Health Service. That system worked well and was fully subscribed. Under the proposals we are debating today, those individuals will have to pay £9,000 per year in fees for three years which, with their living costs, will mean that nurses enter their profession not well paid and with £50,000 minimum hanging on their shoulders. I doubt that that is a sensible approach.

We must accept that nursing students’ courses at universities are very different from most courses. It is not just lectures and library work. At least half the time of nurses in training is spent on the job, on clinical training. In most hospitals, most patients could not determine who is a student nurse and who is a qualified nurse, because student nurses are doing the work of trained nurses, except in a few technical, specialist areas.

[Lord Forsyth of Drumlean (Con)]

I am most grateful to the noble Lord. On his point about the number of nurses who previously got bursaries and about financial controls on the bursaries, what proportion of those applying were unable to get bursaries and, therefore, unable to get training places?

[Lord Clark of Windermere]

As I understand the question, anyone accepted on to the course got a bursary—so they all got the bursary. I am pretty sure that I am right on that. But the point I was making about the course being different was not only that it is more intensive and about working on the job—the course is also longer. The average course length at universities for nursing, midwives and allied health professionals is 39 weeks a year, much longer than the average student course. So it is a different course; they have no opportunity, or little opportunity, to do any extra-curricular work, because of the nature of the job. Yet while they are working on wards, they work as a team.

In essence, the Government are insisting—for, I think, the first time in decades—that nurses pay for working in the health service. They are paying £9,000 a year to work as unpaid nurses. That is absolutely scandalous. Even before the new system came in, going back 50 years, you were accepted on a nursing course and went to the hospitals where you were trained. There was a mixture of blocks in the hospital and working on wards; that is how it traditionally went, but the nurses did not have to pay to perform those tasks. It is outrageous that this Government are insisting that nurses should pay for their own training.

The Government’s justification for this change is to increase the number of nurses being trained, which we all welcome—we all want the number of nurses to be increased. It would help in so many ways. Virtually every hospital now survives by using agency nurses, paying far more by the hour than the NHS staff nurses get paid. We could save billions of pounds if we had sufficient nurses to staff our NHS and aftercare services. So what I am arguing for makes financial sense. The Government say that they are prepared, if nurses pay for their own education—and this is perhaps the point that the noble Lord was making—to lift the cap, so the universities could train as many students as they want. I hope that works; I want the system the Government are proposing to work. But then we come to the problem that it is easy enough for the universities to expand their lectures and provide library facilities; the difficulty comes when the National Health Service has to provide mentors, tutors and practical oversight of students when they work on wards and in clinical situations. There is no provision, as far as I can see, by the Government to provide extra money to hospital trusts to perform that critical part, which is at least half the cost of nurse training.

I want the proposal to work but it is highly risky. We are dependent on nurses from the European Union—and the latest figures are that there was a 90% fall in the registration of nurses from European Union countries since last December, which is an ominous sign. Then we have the figures from the Government, which show that the number of applicants to health courses was down by 23%. I accept the Government’s point that those were applicants, not people who had actually been accepted on to a course. What worries me is that, if it follows through, and if the Government do not get students prepared to enrol at universities, we will find that we make no inroads at all into the shortage of 24,000 nurses.

--- Later in debate ---

[Lord Forsyth of Drumlean]

My Lords, I rise briefly as I realise that Members opposite are anxious to get away to campaign for their leader in the forthcoming general election. Thirty years ago, as a junior Minister responsible for health in the Scottish Office, I was asked to support something called Project 2000 and the move that all nurses should be graduates. As a junior Minister, I thought it was a rather silly idea. I could see that there might be a case for having some health professionals with degrees, but getting rid of the old state registered nurse system seemed to me a huge mistake.

However, the chief nurse was a particularly formidable person and my Secretary of State did not agree with me. Over the last 30 years, some people have argued that we needed people who would do not the less important—these are some of the most important tasks—but the more menial tasks, such as emptying bedpans, spending time with patients and providing the general care that was so much a part of the health service, and that you did not have to have a university degree to achieve that. I very much hope that the Government will think about that again. The noble Baroness, Lady Watkins, has almost got there—I do not mean that in a rude sense—in terms of offering a path forward which might address this problem, but I do not believe that everyone needs to be a graduate.

The reason that I interrupted the noble Lord to ask him how many of the people who applied to become nurses ended up doing a degree and becoming a nurse was because I knew the answer to my own question, which is that it is a small proportion. The noble Lord’s speech contained a number of very important points with which I agreed. We will have to train more nurses as a result of leaving the European Union. That is clearly important. We will have to train more nurses because of the demands upon the health service. However, it seems to me that what the Government are proposing in these regulations, which is to remove the cap and to provide the funding through a loans scheme, will provide for that and address the problem.

Whether the Government are prepared to consider the admirable suggestion of the noble Baroness, Lady Watkins, that there may be a case at a stage in a nurse’s career when they have served the health service for a longer period for forgiving the loans is another question. The Economic Affairs Committee has looked at the representations we have received on student loans and I would not be surprised if that did not represent a better deal for the taxpayer than continuing with the repayment where people are not receiving substantial salaries. So, while I think that the noble Lord has identified some real issues, I very much hope that noble Lords will not vote for this Motion, which would set us backwards and not provide the opportunity for more nurses to be trained and brought into our health service. I also hope that the Government will consider whether it is absolutely necessary for people to have university degrees in order to perform nursing duties in our health service.

[Lord Willetts (Con)]

My Lords, in the absence of a voice from the Opposition Benches I will briefly intervene in the debate. I declare an interest as a visiting professor at King’s College London, which has a major role in medical education through Guy’s and St Thomas’.

The noble Lord, Lord Clark, is of course right about the importance of nurses and about the lack of a suitable supply of nurses in the old regime. We heard a very constructive intervention from the noble Baroness, Lady Watkins. I say to the noble Lord, Lord Clark, that nurses should not be worried about a model of fees and loans with graduate repayment. We went through all these concerns when we shifted mainstream higher education into fees and loans. In the first year, there was a decline in applications—but that stopped as soon as the students understood that they were not paying up front, and that it was a repayment scheme where they would pay back only if they started to earn more than £21,000 a year, and through PAYE. In other words, the so-called debt was nothing like a bank overdraft or a credit card debt; it was repayment through the income tax system if they were earning enough. That tackled their concerns, and since then we have seen an increase in the number of students applying to university.

My second point very much follows on from the excellent intervention of my noble friend Lord Forsyth. The reason we are short of nurses is that successive Governments have rationed the number of nurses. They have done that because nursing places have been financed out of public expenditure and the way to control public spending was to control the number of nurses. Back in 2004-05, we funded 25,000 nurse places a year. That has been in steady decline under successive Governments for a decade and is now down to around 17,000.

If we look at the evidence of what has happened in the past decade, there is no prospect under any Government of having more nurse places under the old system. A crucial part of these reforms is to remove the cap on places so that we will have more nurse places under the new system. The new system delivers more cash to cover nurses’ living costs during their nursing education. It delivers more money per nurse through the fees and loans system for universities providing nurse education and it removes the cap, thus providing the NHS with more trained nurses in total. That is a constructive reform of the NHS. It is progress on tackling the long-standing problems in nursing to which the noble Lord, Lord Clark, drew attention—and it is why I fear that this Motion is misconceived.