NHS Bursary

Philippa Whitford Excerpts

Monday 11th January 2016 Westminster Hall

[Paul Scully]

I am a new Back-Bench MP so I was not around then, but I know that Martin Lewis was on a Committee at some point afterwards to determine relationships, but I will take advice on that.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

May I just clarify that figure of paying £5 a month, which is £60 a year? At £60 a year, that loan would never ever come close to being repaid over 30 years—over a whole working life.

[Paul Scully]

That is on a band 5 salary. I would expect nurses to increase that. The point of the student loans system is that it is a finite time period of 30 years.

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[Paul Scully]

I will just complete my comments regarding student loans in general, but then I will come directly to the hon. Lady’s point because it is one of the issues particular to nurses that I mentioned a little while ago. Student loans in general do not go on credit files, so the only way that a loan, credit card or mortgage company will know if someone has a student loan is if they ask for it. Obviously, for bigger loans, they tend to ask. Student debt is not accounted for by mortgage lenders in terms of the total amount owed, although they will look at the affordability of the loan and at an applicant’s outgoings. When tuition fees and student loans were first introduced, the Council of Mortgage Lenders confirmed that lenders would not use that or add that total debt to the amount owed when they considered mortgages.

[Dr Whitford]

Is it not the case that the Financial Conduct Authority has announced that the size of someone’s student loan will affect their ability to get a mortgage and will be taken into account?

[Paul Scully]

Well, I think a lot of it is down to affordability. [Interruption.] No, there is a big difference. Someone might have an amount of £50,000 or something like that, for example, but it is about the repayment. Whether someone is paying £5 or £50 a month, that is the figure that lenders will look at to work out whether they can afford to repay the loan. As I said right at the beginning, that top line figure is not the crucial one. The crucial one is actually the amount that someone will pay out of their salary each and every month.

Looking at the current case and at positions that are particular to nurses, we have talked about the fact some people going into the nursing profession may already have a degree and are doing a second one. There are mature students. The average age of those applying to study is about 28 or 29. I believe I have covered my take on people’s concerns about the diversity of the workforce changing.

Under the current rules, people cannot usually access the student loans system if they have already done a degree to the same level. The view of the Council of Deans of Health is that the Government should make those courses exempt from that rule. I will be interested to hear what the Minister says about whether that is the case. If it is, in the new system, people would be able to access student loans if they wanted to—that would be an equivalent or lower qualification exemption. As repayment amounts are based on salary and not on the total loan, the amount repaid would be the same whether someone has one or two loans. Effectively, that makes it a graduate contribution, not a traditional loan. The system is slightly different from a graduate tax, which was discussed a few years ago, because it is finite—it finishes after 30 years, and a graduate tax, as we might have had under other suggestions, would have carried on going past a graduate’s retirement. As I said to the hon. Member for Hampstead and Kilburn (Tulip Siddiq), the introduction of tuition fees and loans for other degree courses has not led to a drop in applications and has not affected the diversity of applicants.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Thank you, Mr Evans, and it is an honour to take part in such an important debate.

There is no question but that England requires more nurses. The ratio is 5.8 nurses per 1,000 patients, the lowest in the UK, and yet NHS England cannot fill nursing posts. It is bringing nurses in from overseas and using agency nurses, so that number needs to be expanded. The approach taken is the idea of simply removing the cap, but the challenge is how enough placements will be found. As the hon. Member for Heywood and Middleton (Liz McInnes) said, how will that be funded when Health Education England is facing a massive cut? Furthermore, it is not simply a matter of funding the placements; they require the contribution of nurses and other staff on the wards who are already really busy. It is not something that can be dreamt up in an office in Westminster and happen by magic.

There is also the issue of whether, at the end of training, that unlimited number of nurses will all find jobs in our NHS. It is likely that they will not. We will therefore have wasted not just their money in the tuition fees they will pay for the cost of their training, but money invested by the Government in their training. That is short-sighted, because the Government will lose control of workforce planning, which is key, and with only 5.8 nurses per 1,000 patients, clearly that has not worked too well up to now.

There is an argument for re-expanding nurse places, which were at their height in 2004 when we had nearly 25,000 places and reached a low in 2012-13 of 17,500. At the moment, they have just crept above 20,000, but that does not even bring us back to the figures seen in 2001-02. We clearly need more places, but the idea that nursing students should take on the burden is ridiculous.

Hon. Members in the Chamber will know of my interest: I have been a doctor for 33 and a half years. If there had not been free tuition—and grants back in 1977—I could not possibly have become a doctor, let alone gone on to study surgery and work as a breast surgeon for all of those years. England is already losing out on students who have talent but not the opportunity to follow any degree, and medical degrees in particular. Now we are talking about nurses and allied health professionals—as Members have said, allied health professionals are included in that important group.

Some Members have asked about an impact assessment. We have not heard about one and it is clear that there been absolutely no consultation. The Royal College of Nursing reported that there was no consultation with it: I should have thought that that is where one would start.

We need to look at the bursary. As the hon. Member for Lewes (Maria Caulfield) explained, it is not exactly generous: £1,000 is guaranteed. Above that, it is means-tested and it reaches the dizzy heights of £3,091 only for people in London. That is not a lot of money. As my hon. Friend the Member for Paisley and Renfrewshire North (Gavin Newlands) mentioned, the bursary in Scotland is £6,578, which is all non-means-tested and non-repayable, because we consider it absolutely crucial to invest in the people we need to run our health service.

The biggest kick for students will be having to pay tuition fees, which are currently £9,000 a year: we do not know what they will reach in the future. That instant debt of 27 grand will certainly put people off. Even if I had been told at the age of 18 that I did not have to pay back the loan until afterwards, the idea that someone with no support in the world, as was the case at the time, would be signing on the dotted line to take on what was almost a small mortgage would be hard. People are not going to do that.

The idea that people will not be put off is naive. It will put off the 50% of nursing students who are postgraduates and mature students, and it will put off people from poor socioeconomic backgrounds. It will reduce diversity. We have talked about the need for Parliament to reflect our population, and it is crucial too that nurses and doctors reflect the population that they serve. That will change, because becoming a nurse will be an expensive business.

We need to think about why we moved from the old days of the enrolled nurse and the registered nurse: those were the nurses I used to work with. I have to say that, from the number of stripes on their hat, I knew exactly what experience they had and exactly what they could do. Many of us thought, “Why are we suddenly doing degrees?” but when we look at where our NHS is now, we see the whole point of that, because nurses are now leaders in the NHS and the vision of the future NHS workforce is of nurses leading independent teams, being out in primary care, triaging patients and diagnosing and treating on their own. The idea of the nurse as handmaiden has thankfully long been laid to rest.

The same applies to allied health professionals. About 30% of the patients who come to primary care have a musculoskeletal problem and part of the vision of improving primary care is to allow patients access to a physiotherapist—an expert on their problem—if they have a sore back, hip or knee.

Podiatrists provide care to an increasing number of diabetics. People are probably not aware that the life expectancy of someone with a severe diabetic ulcer is poor, ranking above only lung cancer and pancreatic cancer. That is a real threat to patients, so we need podiatrists who can check feet and treat ulcers at an early point. There are only 3,000 podiatrists for the whole of England, yet student numbers have been reduced from 361 to 326.

We are reducing the numbers of the very people we envisage needing in future—it is like the right hand and left hand are not talking to each other and do not know what the other is doing. As we say in Scotland, two grey cells and they are in a huff; they are not talking to each other. That needs to change. We need to look at the NHS as a whole and the people we expect to provide care in future.

As I mentioned, we have a reasonable bursary in Scotland. I would not say that our students are living the high life on £6,500 a year but, like our other students, they do not pay tuition fees. The hon. Member for Lewes cited a figure for graduates earning £100,000 more, but we must remember that that is over an entire working lifetime, so that is £2,500 a year, which is not a huge amount, and that is reduced by their debt. If students are graduating with £50,000 or £60,000 of debt from their study and living costs and so on, those extra earnings shrink to almost nothing. We will gradually reach the point at which people who might have considered being nursery nurses or primary school teachers or contributing to society in another way that is not well remunerated will not feel able to take on that debt.

We need to look at what we will need in future. We require physios and radiographers, who they will provide the wraparound care for our ageing population, out in the community, leading their teams and working on their own. I call on the Minister to follow the Scottish example and invest in people. That is the key.

Sadly, what we have seen recently—certainly in my short time in the House—is the debt created by the bankers towards the end of the previous decade became sovereign debt, which is now becoming individual debt. All the time in the main Chamber we hear how we cannot leave public debt to future generations, but we are putting it on future generations as individuals. We need to recognise that. People struggle to get a house, they struggle to get education and they struggle to get a job. We need to change that. In this instance, our return is a coherent, diverse, broad NHS staff made up of people who are committed to what they do. I call on the Minister to answer the many challenges raised today and to say how he will invest in the future workforce that will look after the people of England.

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[Ben Gummer]

The numbers do relate to full-time students. I concede that, in the case of part-time students, there have been, for a longer period than the time since 2011, problems in maintaining a rise consistent with that across the population. The Chancellor has accepted that fact, which is why he devoted specific attention and funds in the spending review to supporting part-time mature students. However, in this case we are talking about a nursing degree that is, for the vast majority, a full-time one. For the majority of nurses—I believe the figures are not quite those given by the hon. Member for Central Ayrshire, although I do not have them to hand—their degree is a normal undergraduate degree, taken before maturity. For all those people, I want the same benefits that have been provided across the rest of the university sector. The hon. Member for Sheffield Central was a Member in the previous Parliament, as was the hon. Member for Lewisham East, and they made exactly the same claims then as they do now about a reduction in opportunity, a reduction in number of applicants and a reduction in all the areas where we want universities to perform. I am afraid they have been proved wrong and the Government have been proved right, and that is why it is important that we extend those benefits to nursing.

I will address in terms the process by which we have come to this decision, about which the hon. Member for Ilford North raised some detailed questions, and our intention for the wider reform of training routes into nursing. It is important that hon. Members should see the changes that we are making to university training as part of a wider reform enabling us to increase both numbers and the quality of courses, as well as improving the student experience for nurses entering nurse registration by whatever route. The policy has been worked through in considerable detail in the Department of Health. There has been consultation with leading nursing professionals. The Department of Health is advised by a number of chief nurses. All were consulted and involved in working up policy in this area, which is entirely how it should be.

We have been very open about the fact that we want a full and detailed consultation about how the proposals should be implemented. We want that to be thorough and to involve everyone, whether they oppose or are in favour of the changes, so that we get the detail right. While I will maintain that the overall policy direction is correct for the reasons I have given, it is important to make sure we implement the detail correctly. If we do not get it right, it could have a perverse impact. If we do, this could be an important moment for the nursing profession, because we will be able to do something that previous Governments have not been able to do. Even in the wildest spending realms of the imaginations of some colleagues of the hon. Member for Lewisham East, it would not be possible to commit the resources to expand the training places that the route we have decided on will make possible.

The Opposition must answer a central point when they set out their opposition to the proposal. The fact is that we want to give more training places to people who want to become nurses. Last year, there were 57,000 applicants for 20,000 places. We want to expand the number of places so that people get the chance to become a nurse, but within the current spending envelope—even if we were to increase it more significantly than we propose to over the next five years, and certainly far more significantly than the Opposition propose—it is not possible to do that.

[Dr Whitford]

Does the Minister not accept, on the basis of invest to save, that if agency nurses are costing the NHS £2 billion, such an investment in future nursing would, in actual fact, save money in the long term?

[Ben Gummer]

I agree with the hon. Lady that one key thing we have to do is ensure we have a permanent workforce and do not depend across the service on agency and locum nurses and doctors. However, part of that is ensuring we have the workforce numbers trained to be able to fill places. In the past, we have failed to predict workforce numbers with any accuracy, which is something all Governments are guilty of.

No matter what happened to training places, the changes required across the service because of the impact of Mid Staffs on our understanding of safe staffing ratios has meant an increase in the requirement for nurses. At the moment, in the very short term, that requirement has to be plugged by agency and locum nurses, but we want to replace them with a full-time permanent staff that is sustainable. I hope the Opposition are able to bring an alternative view—I would be interested to hear it—but if we are to increase the number of training places, we have, simply put, to be able to afford to do so. The surest way of expanding places is to repeat exactly what we did for all other university degrees back in 2011, which has seen a massive expansion in training places.

The other point that the hon. Member for Lewisham East and her colleagues must address if they wish to oppose this reform is how they would afford not only the expansion in training places, but the maintenance support for nurses going through training. I completely agree with the hon. Member for Central Ayrshire and my hon. Friend the Member for Lewes (Maria Caulfield): the current bursary funding is not generous. It is certainly not sufficient for many, especially those with caring duties, to maintain themselves, but how can we find the increase while ensuring we expand places at the same time?

Through reforming bursaries, we are ensuring that we can increase the cash amount by 25%—something that, again, could not be funded out of the existing envelope, even though we are increasing NHS spending more than any other major party promised at the last election. We are therefore able to provide the support that people going through nurse training are rightly asking for.

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[Ben Gummer]

I will write to the hon. Lady with year-by-year figures, where available—pass rates change every year. The nursing training course is one of the most over-subscribed of all undergraduate courses. Compared with other undergraduate courses, whatever metric we use, it is a significantly over-subscribed course. We know that a significant number will not receive a place on a course, even though they have met the criteria.

[Dr Whitford]

If the cap is completely removed, the Government will lose any ability to plan a workforce for the future. If all 47,000 applicants are given a place, what will happen when they come out at the other end? There will not be the placements to train them, and there will certainly not be the jobs. Is this just a way of having a flood of cannon fodder nurses, so that their pay can be frozen?

[Ben Gummer]

The hon. Lady mentioned in her speech, as did the hon. Member for Ilford North, the need by some trusts to recruit from abroad and to use locum and agency nurses. I hope she will understand therefore the internal logic of our argument: even at the moment, we are not able to fill places from the domestic supply of nursing graduates. It is precisely our wish to expand that supply. Planning the workforce will, in large part, be controlled through the placements that Health Education England buys from universities on behalf of the taxpayer and the NHS.

Several hon. Members raised the issue of clinical placements, on which we are now in deep discussions with Universities UK. The hon. Member for Ilford North raised that issue, as did my hon. Friend the Member for Lewes. I urge them both to look at the example of the University of Central Lancashire, and its relationship with Central Manchester University Hospitals NHS Foundation Trust and Bolton NHS Foundation Trust. They are delivering innovative and exciting ways of providing new placements outside the scope of the existing placement scheme, even without any Government support or change in the rules.

There is an appetite for delivering additional clinical placements, and we will see how that progresses in our discussions with Universities UK. All the while, it is important to point out that the Nursing and Midwifery Council has to register nurses at the end and ensure that the degrees are satisfactory. All of this will have to abide by the NMC’s recommendation that the placements are up to scratch, so we are constrained, quite rightly, in anything we might want to do by what it decides in that regard.

[Ben Gummer]

In the course of taking interventions, I am skipping around the points that hon. Members have raised, which I want to address. The hon. Lady is right that the University of Central Lancashire has worked up a really good course, which is partly about job security at the end of it. It is exactly the kind of scheme we are looking at to improve attrition rates, which were another point that my hon. Friend the Member for Lewes raised. We have to do better to help nurses complete their courses, and again, that metric has improved across the rest of the university sector since 2012. I hope that in freeing up nurse training a little through our reforms, we will be able to provide better incentives for foundation trusts and NHS trusts to have an end-to-end training offer for student nurses—if not modelling the one that the University of Central Lancashire has brought in, then a variant on it.

There is a lot of exciting thinking out there in universities, foundation trusts and NHS trusts about how we can implement the reforms to make nurse training better, expand the number of places and solve their workforce problems. My job is to release that thinking. I cannot do it within the straitjacket of the existing system, but I can through the reforms I am able to make.

[Dr Whitford]

Is the pilot in Lancashire that has been described not an argument for better manpower and workforce planning, rather than for simply throwing things open to the winds, which is what is proposed?

[Ben Gummer]

I was merely making the point that there is a lot of exciting thinking out there, outside the workforce planning that we are doing. Through our reforms, I hope to be able to encourage more of that. I know that there is some very innovative thinking in my part of the country. People want to get on with it in the NHS and university sectors, but at the moment they cannot, because of the constraints on how nurses are trained and recruited.

I turn to the issues raised by my hon. Friend the Member for Sutton and Cheam, who introduced the debate on the petition. He asked four specific questions. One was on specialist courses, and the shadow Minister repeated that point. Some specialist courses have suffered shortages for many years. For several years, the Higher Education Funding Council for England has been dealing with the wider attribution of training funds and university tuition funds across the sector, and it will take on responsibility for making sure that very small and specialist courses are properly funded and promoted. In liberating the universities sector a little, I hope that we will be able to excite interest in some of the more specialist courses, which have been suffering for several years, and better match foundation trusts’ workforce requirements with universities’ ability to deliver.

My hon. Friend asked whether foundation trusts will be able to pay back loans as an inducement. I do not know whether that will be possible for foundation trusts specifically, but they are free to offer pay premiums to aid their recruitment—they have been able to do so for many years. I imagine that will continue.

My hon. Friend asked about the number of placements and the financing of them. That will be determined by the consultation and in discussions with Universities UK. He also asked about the arrangement for placement expenses, and I have heard his point. I know it is a unique problem that is specific to student nurses—although to some extent, it also applies to student teachers—and again, we want to look at that in detail in the consultation to ensure that we get the implementation right. That is why it is not just a matter of pure detail; it is about how the policy works as implemented.

The hon. Member for Ilford North raised a number of points in addition to the ones he raised in his Adjournment debate. I apologise for not having answered all of them previously; I had a short time and he raised a huge number, with his usual eloquence. However, I hope I can answer some of his specific points on this occasion.

The hon. Gentleman asked about the problems of recruiting into community-based settings. There is a shortage in that specialty, which has traditionally suffered from problems in recruiting. I am well aware, just as he is, of the need to improve recruitment into community settings and primary care settings if we are to get the proper integration of primary and secondary care, and more importantly, of social care and the NHS. That is one of the key challenges facing us in the years ahead. Health Education England has a scheme under way called “Transforming nursing for community and primary care”, which it launched just over a year ago, precisely to incentivise nursing applicants into that specialty. Again, I hope that universities will respond positively, as they have in the case of other courses, so that they step up to the workforce demands placed on them as a result of the reforms that we are making.

The hon. Gentleman asked what the amount of debt to be written off was. The long-term loan subsidy—he will understand the phraseology—remains at 30%. That is the figure that the Treasury has set. As a consequence of that and because of, as he put it, reliable reports from newspapers, which he imputed to be fact, he asked whether there would be an increase in student fees above inflation. I can say to him that there are no plans at all to increase student tuition fees above inflation.

The hon. Gentleman asked whether I would be willing to meet those who disagree with my point of view and that of the Government on this matter. I would, of course, and I have done already. I would be delighted to meet anyone whom he wishes to bring to me, including the demonstrators he mentioned.

The hon. Gentleman began his speech, however, by talking about a burden of debt. It is important for all of us here to remember that the loan is an attachment against earnings, which is time-limited and limited according to the ability to earn, so it is not like debt such as a mortgage. We made the same argument back in 2011 and 2012, and it is important that we use language correctly in this place. We saw an uptake in university courses after the 2012 reforms. Once prospective students understood how the financing worked, how they would pay back the tuition fees and that it was not a debt that would saddle them in the same way that a mortgage or hire purchase agreement might, as was suggested at the time, university applications increased significantly. We all have an interest in this place in making sure that the number of people going into nursing increases. It is important, therefore, that even if we disagree with the policy, we do not misrepresent it.