Nursing and Midwifery (Amendment) Order 2018

Lord Willis of Knaresborough Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for his excellent explanation of this order, which provides the Nursing and Midwifery Council with the necessary legal powers to regulate the nursing associate profession. On these Benches, we will be supporting the order, and I thank the Nursing and Midwifery Council and the RCN for their excellent briefs.

We are ready to accept that the creation of nursing associates is a welcome addition to building capacity. Some of us who are long in the tooth—there may be one or two in the House today—will remember SRNs and SENs and wonder whether we have gone full circle to move forward. However, I accept that there is some urgency to get this on the statute book because, initially, 2,000 nursing associates were training at 35 Health Education England test sites, with a further 5,000 starts planned for this year. The first nursing associates will qualify to apply for registration with the NMC from January 2019, so I accept the urgency to implement this order.

The Minister says that the nursing associate role is a defined care role to act as a bridge between unregulated healthcare assistants and the registered nursing workforce. Now that that role has been created, we agree with the Royal College of Nursing that,

“there must be absolute clarity that the nursing associate … is not a separate profession, but a new role within the nursing family that works under the delegation of the Registered Nurse”.

It went on to ask for “urgent guidance” to be published on “the precise relationship between” nurse associates and registered nurses,

“in terms of delegation and accountability”.

I hope that the Minister has taken that on board.

It is important to recognise that this new role is not the answer to the huge workforce challenges faced by the NHS and the social care system. Last week when the Government announced their funding proposals for the NHS, and the creation of a 10-year plan, many noble Lords said—we agreed—that it would be meaningless if this does not cover healthcare workers and social care workers together, given their importance in the future of our healthcare and social care system. Given that Health Education England has had its budget slashed, that we have a huge decrease in healthcare workers from the European Union, and the soon-to-be-removed—I hope—ridiculous visa system for non-EU health workers, the fact is that more nurses are leaving the profession than joining it, and there is a demographic challenge in that one in three nurses is due to retire in the next decade. In that context there is a well-founded anxiety that nursing associates could be used as a substitute for registered nurses.

Also in that context, has this new role been thought through, or is it a quick response to nursing shortages, with unfilled nursing posts which, as we know, are at a record high? Linked to that, how do we ensure that this new role does not impact negatively on the social care workforce? The head of Health Education England has highlighted that problem.

The role of a nursing associate was created before this SI was even introduced. Has there been enough time to consider the standards and levels of training for nursing associates to be registered with the NMC? I have to say that I am comforted by two things. One is the comprehensive brief from the NMC which suggests that it is on top of this, and indeed the notes accompanying the amendment order itself. I want to raise two things with the Minister, which are on page 5 of the accompanying notes and concern the cost-benefit impact analysis and the regulation of the nursing associates. Two risks are identified:

“First, there is a financial risk that the agreed initial set up costs escalate beyond those currently agreed with NMC. Second, the unquantified costs mentioned above relating to setting up and/or amending existing nursing associate courses as well as the accreditation of education providers”.


Those risks need to be mitigated before this moves forward in an orderly fashion. Finally, I think that there is provision in the order to take account of European Economic Area nursing associates, but I understand that this is not a uniform description or role that fits the narrative across the board. Will the Minister also comment on that?

[Lord Willis of Knaresborough (LD)]

My Lords, I rise from the second Bench—I am not quite trusted to be on the front yet—

[A noble Lord]

Oh!

[Lord Willis of Knaresborough]

Thank you for your commiseration. I support the Nursing and Midwifery (Amendment) Order 2018. I do so with a very personal endorsement and declare my interest as an honorary fellow of the RCN; as a consultant to HEE and the NMC, with which I have been working on these regulations; and as the author of the Shape of Caring report, which is the origin of the nursing associate proposal. I recognise the work of two people in particular. The noble Baroness, Lady Thornton, kindly and quite rightly mentioned the NMC and the work that Jackie Smith has done to bring this through the process. The NMC was presented with two big issues: the new standards for nurses and those for nursing associates, which it took on at the request of the Government. She has led both those processes admirably. Although she is leaving her post next month, this House, and the profession, owe her a great deal of gratitude for what she has done.

I also want to mention and put on record Samantha Donohue, a registered nurse currently studying for a PhD. Her job has been to deal with all the pilot sites, the 8,000 applicants and the 2,023 colleagues who have started training. This has been a Herculean job; at every stage there has been some objection to overcome. I hope that, when he responds to this debate, the Minister will recognise that at times we have in our midst people who do fantastic jobs and do not require to be told how to do them by people elsewhere: they just get on and do it.

The noble Baroness, Lady Thornton, suggested that this matter has been rushed through. I understand that the regulation has followed the start of the pilots but, as independent chair of the Shape of Caring review, it took me over two years’ work to produce the 34 recommendations that led to this process and the recognition that nursing standards needed to change. Quite often, we look at the healthcare workforce in silos, instead of looking at it as a complete, interdependent ecosystem. There are also silos within silos in every section of the healthcare workforce—medics, consultants, physios, care workers or registered nurses—each of which fights for its space. When I was doing this work, particularly when I visited the United States and looked at the Magnet hospital set-up, I was drawn to the fact that nurses are right at the centre of and pivotal to a 21st-century healthcare system. Unless you put them at the centre, the rest of it will not work as smoothly as it should.

I totally support the move of the workforce to graduate status, but we have not fully realised the potential of a graduate nurse workforce. This role frees the registered nurses for the leadership in care that they have been prevented from doing because they are bogged down—I do not mean that in a disrespectful way—by the host of other tasks they have to do. The idea of being able to lead this care while safely delegating is at the heart of the report’s recommendations. Both Robert Francis, in the Mid Staffs report, and the noble Baroness, Lady Cavendish, who produced the superb report on care workers, recognised that unless those two groups of workers—the noble Baroness, Lady Thornton, mentioned them, too—are properly trained and get a recognition within the training organisation, you cannot safely delegate to people when you cannot rely on their having the skills to carry out those tasks. The nursing associate fills that gap. It liberates the registered nurse and at the same time makes sure that there is safe regulation. The establishment of the nursing associate is not, as the Minister rightly says, a substitute for a registered nurse; nor is it an investment in their long-term career. It is a point of registration—that is all. This is not the time for this debate, but unless we make provision for ongoing professional development of the whole of the nursing and care workforce, we will not get the benefit from either the nursing associate or the new role of the registered nurse.

I shall ask the Minister a number of brief questions. The first is about the apprenticeship route. I support that route, as I think most Members of the House do, and the apprenticeship levy is an obvious route for employers to take when expanding the nursing associate workforce. There will be a temptation, however, which the apprenticeship route encourages, to tailor the experience of individuals to the needs of the organisation, rather than to recognise that huge strands are working through this role which need to be applied elsewhere. We must not fall into the trap of having people who can work in only one organisation. They need to be able to develop skills that are transferable to wherever they are expected to work. Will the Minister therefore confirm that apprenticeships, in common with other routes into nursing, must be NMC-approved programmes and must be delivered by NMC-approved providers? Will he also confirm that the requirement in the pre-regulation apprenticeship standard that programmes are delivered by NMC-approved AEIs that deliver nurse education will continue? Will he also confirm that any change to those processes will be reported to Parliament for debate?

My second question is on overseas applications. How we deal with that will be a real challenge as we move forward past Brexit. Will the Minister confirm that such applicants will not be eligible for the nursing association register unless they have comparable qualifications from a higher education establishment and have passed a competence test set out by the NMC? I hope the House will appreciate that I am trying to guard against a second class of nurses. We want people whose standards are set and we want to maintain them, wherever they come from. That is important.

Thirdly, on Scotland, Wales and Northern Ireland, I was disappointed—like I think many people in the House—that they are not part of this process. The NMC regulates across the United Kingdom, not just in England, and it is a sad state of affairs that we now have this separation between England and the other three countries. If the countries decide to introduce a similar post, will they be able to instruct the NMC separately to regulate it, or can they introduce a post with identical requirements—let us call it a nursing assistant—without regulation? It would be wrong if we found ourselves within the United Kingdom having different regulatory or non-regulatory systems around the same post in different jurisdictions.

There has been much concern about the new nursing associate role being a role in its own right or an adjunct to a registered nurse. The issue is clarified in paragraph 7.20 of the Explanatory Notes, but I think it will remain an issue. Therefore, will the Minister confirm that nursing associates will not simply be the handmaidens of registered nurses? That cannot be the case. This is part of the nursing profession, full stop. It is part of that family, with a distinct role, primarily to underpin the work of the registered nurse but also to carry out functions in its own right wherever needed. A classic example is nursing homes. At the moment, a host of relatively poorly qualified people are working in nursing homes, often under the direction of just one registered nurse. At night, that provision is often only at the end of the phone. We really must not have that. We must simply say that we want people we can rely on, who will have the confidence of patients and their families.

With those comments in mind, I say to the Minister that in 10 years’ time there will be some 70,000 nursing associates registered and working in the system. What a present it is that, on the 70th anniversary of the NHS, we are establishing a new workforce to supplement and support the existing workforce to deliver an even better NHS.

--- Later in debate ---

The same argument applies to apprenticeships. Who is going to pay the fees? Is it the local employing body? If that is the case, there will be a lot of encouragement for local trusts not to have NAs, because they will have to pay for them. Why are the figures related to that?

[Lord Willis of Knaresborough]

Perhaps I might help. Some of the thinking behind the funding model, in particular for apprenticeships, relates to the levy. It will not apply to very small trusts, but most large trusts have a 0.5% employment levy, and to apply that through the apprenticeship route seems very logical. Whether it will work is a different matter, but that is the logic.

[Lord Clark of Windermere]

I am very grateful for that—and I understand that many trusts contribute to the levy. Perhaps the Minister could give us an indication of what the breakdown will be between the conventional course and the apprenticeship course for nurse associates. That would be helpful, because one has to bear in mind that the cost to a registered nurse undergraduate is £9,000 a year. That is what they have to pay—which means that they will pay £27,000 to get their qualification.

We need to continue at a high level. As the Minister said, we have increased the number of nurses in training; I found that very encouraging. He is absolutely correct. But why should somebody who wants to become a registered nurse spend £27,000 over three years when they could do a conventional NA qualification for two years at no cost, then do another year to become a fully qualified registered nurse? It just does not make sense. The Government have to look at the funding of nurse support training as a whole. I hope that they do so.

I felt that it was right and proper to raise these difficulties as they have not been raised elsewhere because, as I said, many of the consultees have other interests in putting forward their points of view.