Education (Student Fees, Awards and Support)(Amendment) Regulations 2017 - Motion to Regret

– in the House of Lords at 3:29 pm on 27th April 2017.

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ord Clark of Windermere:

Moved by Lord Clark of Windermere

That this House regrets that the Education (Student Fees, Awards and Support) (Amendment) Regulations 2017, which pave the way for students of nursing, midwifery and allied health professionals to receive loans rather than bursaries, have already been seen to discourage degree applications by a quarter, at the same time as Brexit has already reduced European Union migrant nursing and midwifery registrations by over 90 per cent; and that these factors risk turning an increasing problem in the National Health Service into a chronic one that potentially puts at risk safe levels of staffing (SI 2017/114).

Relevant document: 26th Report from the Secondary Legislation Scrutiny Committee

Photo of Lord Clark of Windermere Lord Clark of Windermere Labour

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.

Photo of Lord Forsyth of Drumlean Lord Forsyth of Drumlean Conservative

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?

Photo of Lord Clark of Windermere Lord Clark of Windermere Labour

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.

I believe that the Government’s approach is a high-risk one; when you have such a large shortage, there must be other ways to deal with it. Why can we not for a number of years lift the cap on universities and say, “Look, train as many as you possibly can.”? If the Government are not prepared to drop the scheme, why do they not say to nursing students who go on to spend a number of years working in the NHS, low paid as it is, that they will write off their tuition fees? That would be one way around it; it is belt and braces, I accept, but I do not believe we can risk what the Government are proposing. It is high-risk indeed, and that is why it should be debated, as it is now. It is interesting and important that we have a full debate on this issue.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Crossbench 3:45 pm, 27th April 2017

My Lords, I declare my interests as outlined in the register and I believe that this afternoon I am the only registered nurse in the House. Nursing is the largest profession in the UK, with some 500,000 people on the professional register. It is vital that the international shortage of nurses and allied health professionals is recognised and that more investment is given to meet the demands for healthcare in the future. I agree with the noble Lord, Lord Clark of Windermere, about the need to spend more on health and social care—but not necessarily with his solutions.

There is a need for at least three pathways to becoming a registered nurse. As a profession, we have supported the introduction of an associate nurse route, which should enable people to be paid while learning and working and to proceed ultimately, if they wish, to train for the register through a sophisticated apprenticeship-style route. We have the pilots in progress at the moment. The second important development in the NHS’s recent five-year plan is support in principle for a graduate entry route similar to Teach First, to be known as Nurse First. This is likely to be piloted in mental health and learning disability branches this autumn and would provide an alternative route into nursing.

The third route, which the majority of students follow, is a three-year university programme with clinical placements within both the NHS and other health care providers. The emphasis on hospital placements is not nearly as important at the moment as the need to ensure that students have experience in community settings and care homes—many of which are in the independent sector—because that is where a lot of people are cared for now, as well as at home. I therefore do not believe that we should reinstate the bursary, as we know that a lot of people applied to go to university because the bursary was there and we had a very high drop-out rate in year 1—I was a dean when that was happening, so I speak from experience. There were also some who completed the course but never had any intention of going into clinical nursing. They wanted to go into HR or to become an air stewardess—neither of which I think is a bad thing—but used the bursary structure to get their degree as an entry into those programmes rather than with the intention to spend a lifetime caring.

It would be preferable to invest in the three methods of education leading to registration and to seriously consider giving a bursary for the third year of training when—I agree with the noble Lord, Lord Clark—most students give a huge amount to the NHS and are often pretty indistinguishable in their final six months from a registered nurse. I also fully support consideration of the concept of forgivable student loans following a period of employment in the NHS on qualifying, rather like those granted to some nurses and medics sponsored by the forces during their education provision.

The other thing I want to draw the House’s attention to is that there are 500,000 nurses in the four countries that make up the United Kingdom and that we have invested very little in return-to-nursing programmes and in encouraging them back to work. That action might be the fastest route to getting more registered nurses back into practice.

Finally, I support the concept that the noble Lord has just addressed. Public sector salaries have been significantly tightened in the last few years and there is a definite case that initial starting salaries in the NHS for nurses and allied health professionals should be increased to recognise that they will be expected to repay their student loans from 2020. As a woman, I get very fed up with hearing both in this House and the other House that very few nurses will have to pay back much of their loan because they do not earn very much. That is not the right approach.

I urge any future Government to invest further in health and social care in order to recruit and retain healthcare professionals. Currently, the ratio of women to men in nursing is nine to one and has remained unchanged for many years. We spend significant time and money on recruiting female engineers; perhaps we should do similarly to encourage more men into nursing and the allied health professions—but I accept that this will be possible only if there is fair remuneration for nurses’ work and funding for continued professional development, as currently happens in medicine. I believe that what I have outlined would be a more strategic approach to the challenges that we face than the straightforward reintroduction of bursaries in the first two years of university programmes leading to registration.

Photo of Lord Forsyth of Drumlean Lord Forsyth of Drumlean Conservative

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.

Photo of Lord Willetts Lord Willetts Conservative

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.

Photo of Baroness Walmsley Baroness Walmsley Liberal Democrat Lords Spokesperson (Health) 4:00 pm, 27th April 2017

My Lords, this is a terrible time for the Government to undertake a highly risky revision of the funding of student nurses. We are already short of nurses, as the noble Lord, Lord Clark, told us, and of course midwives, and the imminent Brexit has already made that worse with, as we have heard, a 90% drop in the number of applications from EEA nurses. In addition, we are losing nurses due to overwork and poor morale.

The Government’s so-called consultation focused only on implementation rather than looking carefully at alternative ways of funding nurse training to ensure both fairness and a stable increased supply of nurses. The excellent speech by the noble Baroness, Lady Watkins of Tavistock, clearly demonstrates that there are many different ways of doing that, and I am not convinced that the Government have taken all those proposals into account. They ought to stop in their tracks and look at all those alternatives before going ahead with this regulation. We are still waiting for information about how or whether the practice placements will be funded, wherever that is—in the NHS or in the care services. As we have heard, nurses have to do 2,300 hours in a clinical placement. This requires considerable resource input from the hospitals or care placements, and most hospitals are already in deficit. Without proper resources there is no way that the system can accommodate 10,000 extra student nurses, even if, as we all hope, the Government are right and universities do offer that many additional places.

I understand where the noble Lord, Lord Willetts, is coming from. Clearly, the tuition fees and loans system has not put off students on most university courses. However, nurses are different from other students, so it is not a given that they would respond like students on other courses to the need to take out loans and pay fees. They are more predominantly from lower socioeconomic groups and have a higher proportion of mature students with family commitments. They spend nearly half their course time in supernumerary placements in hospitals and have a higher number of contact hours and weeks than other students. That makes it more difficult for them to get a part-time job to fund their living expenses, as other students can do. Indeed, because they are not highly paid, it has been calculated that the vast majority of them—I apologise to the noble Baroness, Lady Watkins—will not have paid off their student loans over 30 years, so they will be written off. It makes me sad to have to say that but it is a fact. Some even have other student loans from other courses that they have previously undertaken. So this strategy of the Government will not necessarily save much money in total but will simply shift the debt off the books, which I suppose was the objective of the exercise.

The Government have been very hasty. Instead of arbitrarily removing the bursaries we need a thoroughgoing investigation into the factors affecting nurse recruitment and retention, because the latter is a very important factor. It is no use filling up the bucket if there is a great big hole in the bottom—and in this case there is. Retention of student nurses to the end of their course is poor, and retention of nurses and midwives beyond the first two years after qualification is also poor. Therefore, not for the first time I ask the Minister whether he will ensure that attrition data is collected in a consistent way so that we can identify those settings that are good at keeping their students, nurses and midwives and those that are not. We can then learn from the best practice and spread it.

The impact of the Government’s plans on admissions, student numbers and quality and on the stability of the qualified workforce is yet unclear, and the Government have not said how they intend to monitor the impact on the workforce. Without a solid evidence base this policy should not go ahead. I therefore support the regret Motion in the name of the noble Lord, Lord Clark, and call on the Government to think again.

Photo of Lord Watson of Invergowrie Lord Watson of Invergowrie Shadow Spokesperson (Education)

My Lords, when, in February, I was granted a topical Question on this subject—which, incidentally, I very much appreciate my noble friend Lord Clark raising—the Minister, the noble Lord, Lord O’Shaughnessy, chose to characterise my opposition to the Government’s damaging proposal as a sign that I did not support the policy of student loans. He was being disingenuous because, when student loans were first introduced by a Labour Government in 1988, those studying for nursing, midwifery and allied health professions were specifically excluded.

As tuition fees rose and student loans followed, successive Governments—Labour, coalition and, until now, Conservative—maintained that exclusion. We do not need to ask why. My noble friend Lord Clark and other speakers in this debate have made it quite clear that students building a career in those professions are quite unlike the wider student population. Perhaps the most revealing statistic on that—I will not repeat the others—is that 41% in those categories are over the age of 25, compared with 18% of the total student population. That sets them apart. As the noble Baroness, Lady Walmsley, has just said, they are unable to support themselves as other students can do, and often need to do, during their studies because of the hours required of students in nursing, midwifery and allied health professions.

However, none of that was taken into account by the Government—a Government anxious to make only “savings”. Worse, despite having those facts set out before them, they have declined to alter the course on which they are so dogmatically set. As my noble friend Lord Clark said, the nursing workforce already has severe shortages—up to 25,000 and rising—and already we know that fewer nurses from the EU are coming to work here and that by 2020 nearly half the workforce will be eligible for retirement.

So what do the Government do? They end the established practice of providing nursing students with bursaries and tell them to take out loans that will leave them with debts of at least £50,000 by the time they qualify. I heard what the noble Lord, Lord Willetts, said about loans—it is an argument that he repeated during the passage of the Higher Education and Research Bill. None the less, it is a fact that for those seeking to study for nursing, midwifery and allied health professions on the basis that they would have a bursary, it is quite a shock to find that that is not the case. Those going through school and going to university for what one might term more mainstream courses have known all along that that would be the situation. This is a sudden shock brought about by the Government, and it will have a detrimental effect on those wanting to study.

We like to think that, whenever we need the NHS, it is there for us and our families, but we are naturally anxious when we or our loved ones need to spend time in hospital, and we require an adequate number of nurses for that treatment. The Government are failing the NHS. A further example was provided just today when, in response to my noble friend Lord Hunt, counsel’s opinion was that the Government are acting illegally by not compelling NHS England to treat the required 92% of patients within 18 weeks. My noble friend Lord Hunt has submitted a Motion—for those noble Lords who are interested, it appears on page 4 of House of Lords Business—and I think that that highlights the fact that the Government are cavalier in the way they are allowing patients to be treated.

As we heard in February, the applications for nursing courses starting in September last year were down by some 23%, and the latest data available for March show that that decline is continuing. Although the ratio of applicants to training places is still 2:1, the fall in the number of applications could compromise the quality of candidates applying, as well as geographical provision, which of course is important in the long term. Moreover, it could deter prospective students once they understand fully the implications of the student loan system.

Janet Davies, the general secretary of the Royal College of Nursing, said:

“The nursing workforce is in crisis and if fewer nurses graduate in 2020 it will exacerbate what is already an unsustainable situation. … The outlook is bleak”.

Those are her words. She is the general secretary of the Royal College of Nursing—she should know. The National Health Service Pay Review Body in its 29th report said that,

“The removal of bursaries for student nurses could also have a disruptive impact on supply or the quality of supply”,

and that,

“the removal of the incentive of the bursary could have an unsettling effect on the number and quality of applications for nursing training places”.

They, too, should know. Why are the Government certain that, as always, they have a monopoly on wisdom? Why do they think they know better than the professionals in the NHS?

We should also ask why the Government are doing it. They have given two reasons. The first is the claim that it will add an extra 10,000 nurses up to 2020. But as I have said, far from encouraging additional training places by that time, cutting NHS bursaries will discourage many from becoming a nurse, midwife or allied health professional because of the fear of debt. The House of Commons Public Accounts Committee said in its report entitled Managing the Supply of NHS Clinical Staff in England that,

“the changes could have a negative impact on both the overall number of applicants and on certain groups, such as mature students or those with children”.

If the student numbers are not there, higher education institutions will be worse off because of the decline and the need to finance access bursaries under the Office for Fair Access guidance.

The Government’s proposal also stated that it will ensure sustainable funding for universities, but as yet there has been no indication of an increase in funding that the Government provide for clinical placements. Yet a study by London Economics, a leading policy and economics consultancy used by the Department for Education, found that higher education institutions would be worse off by around £50 million per cohort. Approximately half of that decline will be as a result of the decline in student numbers to which I referred. As a result, there is a real danger that some universities may decide to stop running some health-related courses altogether if they are deemed to be unsustainable. That is related to another government objective—to widen access to nursing training. I want to make clear that we are not opposed to that, but not at the expense of the traditional route through university.

The Government have also said that scrapping NHS bursaries will save the Treasury money. But there will in fact be no cost savings to the Exchequer because most nurses will not earn enough to repay the entire loan and the decline in numbers entering nursing will increase agency nursing staffing costs to cover shortfalls. London Economics also estimated that, with those increased agency costs to cover staffing shortfalls, there will be more than an additional £100 million cost by trusts per cohort wiping out any potential cost savings.

These proposals should not be proceeded with, at least until the Government have published the results of the second stage of their consultation on these measures—a point made and expanded on by the noble Baroness, Lady Walmsley. That consultation has been delayed and of course we will not see it now until the other side of the election, if we see it at all. That is entirely unsatisfactory. It is confirmation of what is no more than a leap into the dark. That is no way to treat the career development of some of our most valuable public servants. These changes are high risk at a time when the NHS is ill-equipped to manage such risk. We support the Motion in the name of my noble friend Lord Clark because it is a risk that should not be taken.

I end by responding to the rather dismissive jibe by the noble Lord, Lord Forsyth. Yes, we are keen to get on with campaigning for the leader of the Opposition. That is what we will do to encourage the people of the UK to an elect a Government that will properly fund the NHS and properly value its dedicated staff. Bring it on.

Photo of Lord O'Shaughnessy Lord O'Shaughnessy The Parliamentary Under-Secretary of State for Health, Lord in Waiting (HM Household) (Whip)

My Lords, I thank all noble Lords who have contributed to this debate and congratulate the noble Lord, Lord Clark of Windermere, on his prescience in scheduling this debate several weeks ago. He clearly has admirers in the Leader of the Opposition’s office if they have taken his proposal and put it in their manifesto. I leave it to others to judge whether having a policy adopted by Jeremy Corbyn is a good thing or not.

Oh!

Photo of Lord O'Shaughnessy Lord O'Shaughnessy The Parliamentary Under-Secretary of State for Health, Lord in Waiting (HM Household) (Whip)

While the noble Lord may have been prescient and influential, I fear that on this issue he, the Labour Party and the Liberal Democrat party are wrong. They are wrong because the system that we are introducing for student nurses matches that experienced by other undergraduate students—a system that has been the primary driver of the big expansion of higher education and improved participation among disadvantaged young people—and wrong because of the fears of the impact of Brexit that he has evoked. I thought that the Labour Party was in favour of leaving the European Union, although having heard the tortured exposition of Labour’s policy earlier this week that is anyone’s guess. But I reassure the House that this Government not only understand the difficult choices that need to be made to ensure that our NHS has the resources and personnel that it needs to thrive, but, if we are fortunate enough to be re-elected, intend to make a success of Brexit and, as immigration is reduced, to bring more of our domestic workers into the NHS to meet the challenges ahead.

I join other noble Lords in paying tribute to the amazing work that more than 2.5 million people working NHS and care systems do every day, often in challenging conditions. They represent values to which we all aspire—service, hard work, compassion—and are an inspiration to us all. There can be no person in this country who does not have cause to give them thanks for their expertise and commitment.

The Government are taking action on several fronts to support that workforce so that it can deliver excellent patient care through flexible working, good leadership, expanded routes into practice and new career structures. As part of these changes, from August 2017 new full-time students studying pre-registration nursing, midwifery or one of the allied health subjects will have access to the standard student support system for tuition fee loans and maintenance loans.

These reforms will enable more money to go into front-line services—around £1 billion a year to be reinvested in the NHS. Additionally, they will help to secure the future supply of nurses and other health professionals in several ways, such as by removing the cap, identified by my noble friend Lord Willetts as being a feature of the current system, so that more applicants can gain a place. Universities will be able to deliver up to 10,000 additional training places. The changes also enable a typical provision of a 25% increase in living-cost support for healthcare students and puts universities in a stronger financial and competitive position so they can invest sustainably for the long term. The noble Baroness, Lady Watkins, in her excellent and of course expert and well-informed speech, also pointed out that it removes a perverse incentive of the current system where it is the sole degree that is subsidised in that way. That brings with it a number of benefits, including addressing the issue identified by the noble Baroness, Lady Walmsley, of the retention on courses of people who are fully committed to taking part in a nursing career.

Successive Governments’ reforms to student finance have put a system in place that is designed to make higher education accessible to all, as my noble friend Lord Willetts pointed out in his excellent intervention. This has allowed more people than ever to benefit from a university education and has spread more fairly the burden of costs between society at large via the taxpayer and the individuals who benefit financially from the degree course. As a consequence, disadvantaged people are now 43% more likely to go to university than in 2009, and for the last application cycle the entry rate for 18 year-olds from disadvantaged backgrounds is at a record high: 19.5% in 2016, compared with 13.6% in the last year of the Labour Government in 2009. That is what we mean by a country that works for everyone. It is precisely because of these positive effects that moves towards a loan-based system have been supported by political parties across the House. They were introduced by a Labour Government, extended by a Conservative and Liberal Democrat Government and taken on by this Conservative Government.

Turning to the applications for nursing and midwifery courses, the latest data published by UCAS on 6 April show around a 22% fall in the number of applicants to nursing and midwifery courses in England compared with the same point in the 2016 application cycle. However, as my noble friend Lord Willetts pointed out, in previous cases when fees have been introduced application numbers have gone down but rebounded in future years. The same UCAS data also show that since January there have been more than 3,000 additional applicants for nursing and midwifery places, taking the current total to more than 40,000 applicants for around 23,000 places in England. The chair of the Council of Deans of Health, Dame Jessica Corner, has commented on the situation, saying:

“It is to be expected that there would be fewer applications in the first year following the changes to the funding system, but we would expect this to pick up in future years”.

The Chief Nursing Officer, Jane Cummings, said:

“Despite the drop, the level of applications received suggest that at a national level, we are still on track to meet this target in England although we need to monitor this very carefully. We are also introducing a number of opportunities to support future applicants including additional routes to become a graduate nurse”.

Based on all of the information available, Health Education England is confident that it will still fill the required number of training places for the NHS in England.

On the issues raised around Brexit, future arrangements for student support after the UK leaves the EU will need to be considered as part of wider discussions about the UK’s relationship with the EU. However, the Government have confirmed that EU students starting their courses in 2017-18 or before will continue to be eligible for student loans and home fee status for the duration of their course.

On numbers of non-UK nurses, it is correct that the Nursing and Midwifery Council has seen a reduction in the number of registration applications from nurses in the European Union. At the moment, it is unclear whether the drop is attributable to the introduction of more robust language testing by the NMC, rather than as a result of the decision for the UK to leave the EU. The drop in the number of applications is balanced by a reduction in outflows from the profession, meaning that, while monthly fluctuations continue, the number of EU-born nurses is broadly the same. Indeed, slightly more nurses from the EU are working in NHS trusts and CCGs than in June 2016, the time of the referendum.

Photo of Lord Watson of Invergowrie Lord Watson of Invergowrie Shadow Spokesperson (Education)

Will not the figure that the Minister has just cited be significantly skewed by the immigration skills charge, where, for every overseas person coming in on a type 2 visa, the NHS will have to pay £1,000? Will that not have an effect on nursing figures?

Photo of Lord O'Shaughnessy Lord O'Shaughnessy The Parliamentary Under-Secretary of State for Health, Lord in Waiting (HM Household) (Whip)

I am not going to speculate on the impact of that. What I can tell the noble Lord is that, despite the scare stories that numbers will have been affected, there have been more EU-based nurses in the past year. That is the point that I wish to get across.

The real issue at stake is whether the number of staff in the NHS is increasing to meet the growing demands on it, and here the Government have a strong record. Over the past year, the NHS has seen record numbers of staff working in it. The most recent monthly workforce statistics show that, since May 2010, there are now over 33,000 more professionally qualified full-time equivalent staff in NHS trusts and clinical commissioning groups, including over 4,000 more nurses.

Health Education England’s Return to Practice campaign has resulted in 2,000 nurses ready to enter employment and more than 900 nurses back on the front line since 2014. There has been a 15% increase in the number of nurse training places since 2013, plus the introduction of up to 1,000 new nursing apprenticeships and the creation of nursing associate roles—the kind of non-graduate nursing roles that my noble friend Lord Forsyth pointed out as being such a crucial part of the mix. These all form part of our plan to provide an additional 40,000 domestically trained nurses for the NHS. These new and additional routes into the nursing profession will allow thousands of people from all backgrounds to pursue careers in the health and care sectors and, critically, allow NHS employers to grow their own workforce.

I will end as I began. I believe that this regret Motion is misguided. The extension of the loan-based system to nursing and midwifery training is a natural development of reforms that have received cross-party support, successfully expanded higher education, dramatically improved the participation of disadvantaged groups and provided a fairer distribution of the costs of funding higher education.

Despite the pessimism of some, the decision by the British people to leave the European Union, which this party respects, has not had a material impact on the workforce. Furthermore, and paid for in part by the resources freed up by our changes to student finance, this Government have put in place a series of programmes that have successfully increased the number of staff in the NHS and provided more training places than ever, allowing us better to grow our own workforce among UK residents.

The true source of regret is that the Opposition have used this opportunity to run scare stories about both the impact of sensible funding changes we have made and the impact of leaving the European Union on the NHS workforce. I urge all Members of this House to vote against the Motion.

Photo of Lord Clark of Windermere Lord Clark of Windermere Labour

My Lords, I have listened very carefully to the Minister. I wanted to be persuaded; I am not persuaded. I believe that the Government are taking a big risk. They have gambled before. It may not be known, but in 2011, 2012 and 2013, they reduced the number of nurses in training because they thought we had sufficient. As a result, several thousand nurses were short-trained in those three years, because the Government got the figures wrong. I believe that they have got figures wrong again. It is a big risk that we do not need to take. It is unfair on the nurse’s career, but, most of all, it is unfair to potential patients in the National Health Service. I want to test the opinion of the House.

Ayes 121, Noes 159.

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Motion disagreed.

Photo of Lord Taylor of Holbeach Lord Taylor of Holbeach Captain of the Honourable Corps of Gentlemen-at-Arms (HM Household) (Chief Whip, House of Lords), Deputy Chairman of Committees 4:35 pm, 27th April 2017

My Lords, I think it best if we adjourn during pleasure until 5.15 pm, to enable the Chamber to be adjusted for the ceremony that now follows.

Sitting suspended.