Lords debate on a motion to regret the Education (Student Support) (Amendment) (No. 2) Regulations 2018 - May 21

Lord Hunt of Kings Heath 

That this House regrets that the Education (Student Support) (Amendment) (No. 2) Regulations 2018 extend the normal student maintenance regime to more categories of nursing students as a replacement for the NHS Bursary Scheme; and calls on Her Majesty’s Government to postpone the introduction of the Regulations until the current review of post-18 education and funding has been completed (SI 2018/443).

Relevant documents: 21st and 25th Reports from the Secondary Legislation Scrutiny Committee

Lord Hunt of Kings Heath (Lab) 

My Lords, the huge pressure which the NHS is under is taking a massive toll on our nursing, midwifery and other health professionals. It has been estimated that the NHS in England has approximately 40,000 nursing vacancies, with a vacancy rate of over 10%. A similar rate applies to midwives, although the RCM estimates it to be higher, to reflect the number of babies being born. The other health professions covered by this regulation are similarly affected. More nurses and midwives are leaving the profession before retirement; one in three nurses is due to retire in the next 10 years. For various reasons, including Brexit, work pressures and the age profile of the nursing profession, the number of nurses and midwives on the NMC register at the end of March 2018 was less than that in March 2017 and significantly less than at the peak in March 2016.

The House of Commons Health and Social Care Committee inquiry found that the nursing workforce in England must be,

“expanded at scale and pace”,

and that,

“future projections of demand for nurses should be based on demographics and other demand factors, rather than on affordability”.

Given this, one would have thought that the Government would do all they could to support and encourage entry to these professions. Instead, they are doing the opposite, reflected in these regulations, by ploughing ahead with their plan to scrap bursaries for yet more students, despite knowing full well the disastrous consequences that will follow.

Two years ago, the Government scrapped the undergraduate bursary. The results were predictable. In 2016, before the abolition, there were more than 47,000 nursing applicants in England. In 2018, the figure fell to about 31,000—a fall of over 15,000. It is clear that this is the reason why we have seen the sharpest ever decline in nursing applications. I have no doubt that the Minister will say that the number of applications is less important than the number of acceptances. I disagree: I want nursing to be seen as a profession where there is hot competition for places because it is such an attractive profession to be in.

No doubt the Government will say that they have committed to create more training places for nurses. They certainly promised an extra 5,000 nursing places and said that nursing bursaries had to be scrapped to make that possible. What has been delivered is a mere 700 fewer students training to be nurses. It is worrying, too, that there has been such a huge drop-off in mature students applying—the extraordinary figure of 42%. The very people we need to apply, who have often brought up a family, are now being denied an opportunity to make a career in nursing or face the consequences of being forced into huge debt.

We know that postgraduate students in particular are more vulnerable to the introduction of fee loans: 64% of postgraduate healthcare students are aged over 25 compared to only 18% of students generally. Women are largely attracted to the healthcare postgraduate route and represent 80% of the course places. There is a higher percentage of ethnic minority students on postgraduate healthcare courses compared to the general population, and the Department for Education equality analysis clearly states that these groups are known to be more debt averse. So introducing loans is likely to undermine recruitment of this cohort and represents yet another missed opportunity to grow the nursing workforce at a time of severe shortage.

The Government claimed in the other place that raising the cap will unlock additional places, but it was the Government themselves who set the cap through their funding of Health Education England. They also say that they can fill some of the gap with nursing apprenticeships. They have promised 1,000 of them, yet only a handful have started the course. This shortfall is not the only problem with overreliance on apprenticeships. A nursing apprentice will take four years to become a registered nurse. Even if there were a miraculous surge in apprenticeships starting this summer, we would not see any qualified nurses on our wards until 2022. Contrast that with an undergraduate nursing course, which can take three years, or postgrad courses referred to in the regulations, which can take two years, which makes them the quickest way to tackle the shortfall in numbers.

Another solution the Government have come up with is nursing associates. But there is clear evidence that using support workers or trainees as replacements for qualified nurses has potentially disastrous consequences for care. I hope that the Minister will confirm that that is not the Government’s intention. The nursing associate is a support role and must not be used as a substitute for registered nurses. Research is clear that diluting and substituting the registered nursing workforce with nursing support workers has ill consequences for many patients.

In pushing ahead with this regulation, Ministers ignore their department’s impact assessment. The DfE’s assessment of the changes to the bursary said that it would disproportionately affect women and ethnic minority students, yet Ministers have pressed ahead. Then the department found that the change could make women, older students and students with lower incomes less likely to participate. Again, Ministers pressed ahead.

This is not just a matter of fairness or even just about the benefit of having a diverse working population. In fact, older nursing graduates, to take the nursing profession in particular, are more likely to stay longer in the NHS and are more likely to choose areas such as mental health or learning disability nursing, which are facing such severe staff shortages. Nearly two-thirds of postgraduate nursing students are over 25, more than a quarter are from minority ethnic groups and 80% are women, so the impact of today’s regulations will surely be even worse than the previous cuts.

I welcome the golden hellos to postgrad students in specific hard-to-recruit disciplines, but the Government need to do much more to financially support postgraduate students.

Even if the Government are determined to make the change, there are good reasons not to make it now. This policy would move postgraduate nursing students over to the main student finance system, which means dealing with the Student Loans Company. There is every reason to believe that that company may not be ready. In recent weeks, the Government have been dealing with an error made by the company that has led to 793 nurses being hit with unexpected demands to repay accidental overpayments they were unaware of. I do not know whether the Minister has seen the recent NAO report on the company, but that also gives great pause for thought about whether it is able to accept this new responsibility. It strikes me that, before embarking on these regulations, we have the flagship review of higher education. The Government could have allowed that review to take account of this matter, rather than going ahead with the change today.

My final point is about student finances in general, and the impact on the Government. How many postgraduate students affected by this policy will repay any or all of their additional loan? How is this financially sustainable? Or is it just another example of what the Treasury Select Committee called a “fiscal illusion”—in this case, a student financial system that allows the Government to pretend that they have made a saving when all they are doing is passing the bill to the next generation?

It is little wonder that the devolved nations have retained the NHS bursary system. We in England should do the same. I beg to move.

Baroness Walmsley (LD) 

My Lords, like the noble Lord, Lord Hunt of Kings Heath, we, too, oppose the introduction of these regulations—and for very similar reasons. It always makes sense to make policy based on evidence and on the advice of experts. This is what the Government have failed to do in relation to the funding of student nurses. The removal of the bursaries for undergraduate nurses has already considerably reduced the number of applicants, and the number of those taking up a place was 705 lower last year than the year before. Given the 40,000 nurse vacancies that the noble Lord mentioned, this is a serious matter for patient safety, as pointed out by the Care Quality Commission. I accept that these are only one year’s figures, but I believe that, before upsetting the apple cart even further, the Government should postpone removing bursaries from postgraduate nurse trainees and other important groups until we have clear evidence of the effect on the number of undergraduate student nurses.

If we want to increase the number of registered nurses quickly, which we need to do, it makes more sense to support the two-year postgraduate route, not put it at risk by removing those bursaries, too—because this is the quickest way to get more nurses. Most suppliers of the two-year courses indicate that capacity could be increased by 50% given the right financial support, yet the Government are planning to deter applicants by removing the bursary. This does not make sense. Instead, the Government are focusing on the two four-year routes into nursing, yet the apprenticeship route is not providing the expected 1,000 extra nurses per year. The most recent data tells us that there are only 30 apprentice nurses—hardly a success. Will the Government look into the barriers that are preventing NHS employers taking on apprentices? It could be the 60% cut in funding for further professional development, which has affected the number of those who would like to become training assessors and mentors for student nurses and apprentices.

Nursing associates have a role both as assistants to registered nurses and as users of an alternative four-year route into nursing—but, again, it takes a long time and these associates, as the noble Lord, Lord Hunt, said, should not while training ever be seen as substitutes for fully qualified nurses. So why are the Government planning to deter applicants for the rapid postgraduate route, where 64% are over 25, where they are predominantly women and where they are more diverse than the general student population? In a career such as nursing it would be advantageous to attract people with a little more life experience than the average 18 year-old.

Also, we know that older women and ethnic minority students are more debt-averse, as well as already having a student debt of up to £50,000 from their first degree. Therefore, it is vital to look at how this fast route into nursing could be supported. The RCN tells us that, if the fees were paid and a modest bursary towards living costs provided, the total would be less than the average annual premium paid by trusts over a single year for a full-time agency nurse. This is short-termism of the worst kind.

While the Government carry out their review of post-18 education, they might benefit from looking at the measures introduced in Wales by Kirsty Williams AM, the Liberal Democrat Minister in the Welsh Government responsible for medical education. Her conversations with students revealed that the main concern and deterrent was not fees but living costs. Therefore, she has introduced the equivalent of the minimum wage for students during their course. This method of student funding should be carefully considered by the Government while carrying out their review, particularly for nursing students, who have more contact time than other students because of their clinical placement and therefore less time to get a part-time job to support themselves. Will the Government please consider this sensible idea?

The House of Commons Select Committee on Health and Social Care stated that the nursing workforce should be expanded at scale and pace to avoid dangerous levels of vacancies. It should be based on need and demand rather than affordability. It is up to the Government to say how the money will be raised, but from these Benches we recommend some sort of hypothecated taxation or a reformed national insurance scheme which is truly progressive and demonstrates intergenerational fairness. The Liberal Democrats are also in favour of restoring the bursaries for undergraduate student nurses and we are against these new regulations, which would remove the bursary from postgraduate nursing students and other important health professional courses.

Baroness Watkins of Tavistock (CB) 

My Lords, I draw the House’s attention to my interests as listed in the register and I congratulate the noble Lord, Lord Hunt, on securing this debate.

I should like to put my contribution in context. At lunchtime I came back from Geneva, where I had been at the World Health Organization working with the International Council of Nurses, representatives from the Nursing Now campaign and the Chief Nursing Officer of the WHO in looking at the future of the profession. One of the big discussions was on the need to increase the number of nurses worldwide and to ensure that we have health security across the globe. A major topic of discussion was, not surprisingly, the re-emergence of Ebola in the Congo. At least one Health Minister asked me how, as a country, we could really justify a recent advertisement from, I believe, the Home Office, encouraging nurses with a two-year graduate qualification to come to this country.

The noble Lord, Lord Hunt, has outlined the key concerns over extending the normal student maintenance regime to nursing students undertaking programmes at postgraduate level. As others have said, these programmes take two years, including theory and practice, and enable successful students to register as nurses with the NMC. I do not need to remind noble Lords that this is an intensive programme with significant periods of work in a practical setting.

The aim of introducing new systems of funding was to increase the number of nursing students, yet on undergraduate programmes this was not achieved in the 2017 intake, where a fall took place, particularly in applications for mental health and learning disability nursing courses. Why should there not be a similar fall in the number of students entering the postgraduate programmes this year if the change takes place? In effect, this would result in an even more significant drop in the number of nurses qualifying in 2020, in that the undergraduate numbers due to qualify in 2020 will be much lower than originally planned. If we could boost the postgraduate intake numbers for 2018, this could provide additional nurses ready for registration in 2020—just as they will be so desperately needed according to the NHS Five Year Forward View.

Therefore, does it not make sense to delay the implementation of the regulations while a systematic review of post-18 education funding is undertaken and retain the current system of funding for the group due to commence in 2018? This would provide us with an opportunity to run a campaign to increase the numbers for this year in the way that campaigns have been conducted to attract people to social work and teaching programmes in areas where there are similar staffing challenges.

We know that sufficient levels of registered nurses are critical for the health and social care system to ensure patient and client safety. The sombre reading of both the Francis report and the learning disabilities mortality review remind us that not only do we need to retain our current staff but that we must train new nurses to further enhance the quality of our provision.

Graduates who enter postgraduate nursing programmes add value to our workforce, bringing a range of life skills. In particular, many mature entrants come into mental health nursing through the post-graduate route, and yet we know we are not meeting the numbers required to meet mental health services workforce demands.

I recognise that the Government have offered a new pay deal for nurses that may improve retention and recruitment and plan to offer golden hellos in some hard-to-recruit areas for nurses entering the profession, both of which I have expressed my support for and hope will be effective. However, until the new degree apprenticeship routes into nursing at both undergraduate and postgraduate level are properly designed and funded through the apprenticeship levy, I urge the Government to think again and to wait to introduce the reform we are discussing today.

NHS Providers reminds us that plans to boost the NHS workforce will take years to deliver, but to change this decision for at least one year would result in a larger cadre of nurses qualifying in only two years. I urge this because society expects us as policymakers to ensure safe healthcare in the NHS. This, I argue, cannot be achieved without a sufficient supply of newly qualified nurses and allied healthcare professionals.

Lord Clark of Windermere (Lab) 

My Lords, I find the Government’s approach to NHS staff very perplexing indeed. They continually pay tribute to them, and I think they do understand the commitment of the workforce, yet repeatedly they take action that makes the life of nurses and other staff even more difficult than it is at the moment. At the same time, they make it more difficult for those nurses to guarantee the safety of patients in our NHS.

I congratulate my noble friend on drawing this SI to the attention of the House and allowing us an opportunity to debate this critical issue. In making my case today, I accept the points made by the noble Baronesses from the Liberals and the Cross Benches—they were absolutely right in the points that they made. But let us remind ourselves of the serious situation we are in. The points I am going to make now are agreed right across the National Health Service; points which every royal college and every responsible organisation in the health service agree with.

The first point has been raised already: we are 40,000 nurses short, and the Government have a real responsibility for that. The number of nurses and midwives leaving the profession is greater than the number of those entering the profession—that is a recipe for disaster. We have critically relied not only on nurses from the far ends of the globe but especially on nurses from the European Union. Since the Brexit vote, they are deserting the National Health Service, and who can blame them?

Let me go right back to 2010, when this Government assumed office. That is when they started making massive errors, from which they have not recovered. Neither, critically, has the National Health Service. In an Answer to me, the noble Viscount, Lord Younger, pointed out that, when they assumed office, there were more than 97,000 entrants to nursing courses. The coalition Government’s first response was cut, cut, cut, and by 2012 the figure had dropped from over 97,000 to 75,000, a drop of 22,000 nurses entering the profession in one year alone. The figure improves marginally but does not get much better for many years. When I say the Government are 40,000 nurses short, it is because of their mistake in 2012 in cutting the numbers of young people and older students entering the nursing profession. We have never recovered from that.

I accept the point that the Government want to widen the area of recruitment—I will come back to that—but, having made the mistake in 2012, only two years ago they scored another own goal by abolishing the bursary scheme and introducing a charge of over £9.000 a year for people training for the nursing profession. Last year that led to a drop of 705 students. I admit that is not the same as the 22,000 drop the Government were responsible for in 2012 but we cannot afford any drop whatever. Now, having created a serious recruitment policy, they are introducing even more costs into the system by this SI we are discussing today. It is affecting older graduate entrants, those who do postgraduate courses and usually graduate after about 18 months or two years, which is the quickest way to get qualified nurses, as we have already heard.

However, the Government do not seem to have learned anything. The point from the Liberal Front Bench was well made when the noble Baroness pointed out that the cost of training a postgraduate student was £33,500—a lot of money—but we should not forget the cost of the agency nurses needed to fill that vacancy. That £33,500 cost is less than the average annual premium paid by trusts for a full-time equivalent nurse filling a post that is vacant because of shortages. It is a false economy and yet the Government do not seem able to see the picture in the round, which is the position we should be looking at.

There are other ways in which the Government could ease the nursing situation. Instead of bringing forward SIs such as those we are discussing at the moment, if they have got a bursary scheme, as they have, why do they not write off the cost of repaying the student loan for nurses who have spent a number of years in the National Health Service? One of the Minister’s predecessors said that the Government were looking at a similar proposal for doctors but I never saw whether it materialised. However, that would be one way of equalising the situation.

Many nurses from European Union countries and other National Health Service workers have got permanent residence status to live in Britain. After five or six years, they were entitled to apply for permanent residency, and they got it. To me, and to most nurses, permanent residency means just that: you have residence in this country which is permanent, but the Government will not admit that. They say that the permanency may not be honoured after Brexit. That is a terrible thing to say. A British Government are breaking their word to people who work in the health service and give so much. Why not say that those people who have permanent residency can remain in this country permanently? That would do a lot to retain the confidence of EU nurses.

I shall finish with a word about financing nursing apprenticeships. As we have heard, the Government’s target of 1,000 apprentices in nursing has not only fallen short, it has fallen ridiculously short. The Minister may have more up-to-date information than either I or the Royal College of Nursing have, but its figures show that there are not 1,000 apprentice nurses, there are 30. Of course, one of the difficulties lies in the whole concept. An apprenticeship requires a mix of work on the ward and work in the classroom at university, but that is exactly what undergraduate nurses do at the moment. Over the three-year period, 50% of their time is spent working—I emphasise that word—on the wards. Why should they pay more than £9,000 when apprentices may get that for nothing—or is it nothing? The universities which provide the classroom opportunities for these apprenticeships tell me that they have no alternative but to charge for them. I do not think that the apprenticeship levy will cover it because they are talking in terms of £7,000 a year for apprentices to do the university courses for their apprenticeship. I wonder who is going to pay that £7,000. Is it to be the student, or is it the trusts which are already hard pressed, or is it the Government? Most of us would agree that it ought to be the Government. It is their baby, their scheme and how they see the gap being filled—their salvation to ease the nursing shortage. It is the Government’s responsibility.

We are debating a statutory instrument, which shows how ill thought through and chaotic the Government’s policies are when it comes to nurse training in this country.

Baroness Garden of Frognal (LD) 

My Lords, I rise to speak briefly in support of the noble Lord, Lord Hunt, and my noble friend Lady Walmsley, who set the scene very comprehensively for us. I note that these regulations came into force on 7 May, so presumably any impact we can have on them is going to be retrospective at best.

I share the concerns about adults coming back into the nursing workforce. They will be more risk averse but by and large they are invaluable members of the nursing community, so putting them off seems extremely foolish. I also share the concerns of the noble Lord, Lord Clark, about the apprenticeship route, which obviously has got off to a very slow start. I think that the health fraternity is finding it complex working out how the apprenticeships are going to fit in. In due course degree apprenticeships may be able to take up some of the slack, but it will be a long time before that happens and certainly it will not be quick enough to solve the nursing shortfall that we are experiencing at the moment.

Equally, as the noble Lord, Lord Clark, also said, we must take into account the fact that EU nurses are leaving in droves at the moment because they find this country unwelcoming, as indeed are EU workers in a number of other sectors as well. That situation is not going to get better. I will therefore add my voice to those asking for a delay in implementing these damaging proposals until there has been time for a full impact assessment, or at least until the review of post-18 education and training has reported. The NHS is too important to be left to chance like this, and with a crisis in the nursing workforce, this is not the time to embark on measures that will do nothing but worsen the position. I urge the Minister to think again.

Lord Puttnam (Lab) 

My Lords, I will probably not be quite as brief as the noble Baroness, Lady Garden, but I support the Motion of my noble friend Lord Hunt. In doing so, I hope to help the Minister with some experiences from the past, which I think are very germane.

My noble friend Lord Hunt and I entered this House on exactly the same day: 5 November 1997. He came as someone with great authority and experience in the National Health Service; I came from a terribly different world, with the specific job of working for the right honourable David Blunkett—now the noble Lord, Lord Blunkett, then the Secretary of State for Education. We had a crisis in teaching and with teachers. I commend to the House the front page of the Times Educational Supplement from 6 April. It states:

“Missing: 47,000 secondary teachers. In a system already struggling to fill the gaps, some are thinking the unthinkable: is it time for teaching without teachers?”

I would add this: is it time for nursing without nurses?

The situation is very serious because any possibility that the Minister and his department have of resolving the problem depends entirely on the pipeline supplied by the teaching profession. That has a time factor attached to it, which is very important. It took the Blair Government—I worked constantly at the department for education—six years to get back to equilibrium after the teaching crisis. We were short of around 47,000 teachers—ironically, almost exactly the same number that we are short of today.

Here is the problem: a demographic bulge will hit us in 2024. At that point, we will be short of something close to 50,000 secondary teachers. It is totally predictable; we can see it coming. It happens to be coming at a time when the number of graduates entering the profession are, necessarily, quite light because of an inverted demographic. I am sure that the noble Lord, Lord Willis of Knaresborough, will understand and attest to the figures I am giving. We had an enormous problem. This Government have an enormous problem, and the less they solve their educational pipeline problem, by ensuring that there are enough teachers in the system, the worse the nursing problem will get.

I commend the past to the Minister. We learned a powerful lesson between 1997 and 2003. Unless the Minister wants to revisit a similar lesson in the National Health Service, he must address this issue now.

Lord Willis of Knaresborough (LD) 

My Lords, I thank the noble Lord, Lord Puttnam, for reminding us of those days, which were both terrifying—I say that as an ex-educationalist—and exciting. Meeting the challenge, based on an evidence base, enables you to move forward. I declare an interest, having worked for the past few years for Health Education England since its formation as a non-departmental body, following the 2012 Act.

What I find terribly sad about this SI is the lack of evidence behind the move. I do not know, and I suspect very few people in this House know, whether the move to an all-graduate profession—treating nursing graduates the same as teaching graduates or graduates going into law or other professions—should be done on a loan system. There is an argument for that, but in reality, we have absolutely no evidence to demonstrate that it will be effective, particularly at undergraduate level. Like many Members of the House, I look forward to the student funding review, because at least we will get that evidence base, which will be put before both Houses.

I find what I think is behind this deeply disappointing. Your Lordships spent many months debating the Health and Social Care Act 2012. There were a lot of fierce arguments. One of the reasons why the then coalition Government put forward the proposals was to take many of the decisions, particularly about staffing and education, out of the political arena and give them to an NDPB, to allow them to plan ahead. Health Education England was created for that very purpose. This is doing the exact opposite. It is pointless having an organisation which is there to plan a workforce and then taking away the means by which it can generate that workforce, be it at undergraduate or postgraduate level. It saddens me that after some of the excellent things that have been introduced—I declare an interest as having been involved with the nursing associate proposal—the belief is still peddled that this is somehow substitution. It should not be, it is not and it must not be a substitution. The noble Lord, Lord Hunt, is absolutely right to make that point: we do not want to move back to a lower quality simply to produce more people.

Will the Minister give us an idea of the quality, particularly at undergraduate level? I am sure that he will say that while we might not have as many applicants, we still have as many actual posts and that the quality of people applying for those posts is going up. I can find no evidence at all in the HESA survey that that is actually happening. If it is, I will celebrate it, and I am sure the Minister will tell us. The issue I want to raise—it is why I have spoken in this debate—concerns one of the great areas of weakness at the moment, and that is our ability to recruit and retain mental health nurses. This is a massive issue, and not simply for traditional reasons but because the demographics and the epidemiology show that ever more of us who, like your Lordships, have an average age of 70-plus are likely to have a mental health problem as part of their comorbidities as they get older. Few of us can deny that.

I am working at the moment at how we can provide the mental health workforce in 10 or 15 years’ time. I look around at where there is a stream of potential workers who could come in, and frankly it is at postgraduate level, using psychology graduates. I can tell the House that over the last three years, 49,466 psychology graduates have come out of our universities, yet we have a dire shortage of postgraduate mental health nurses. Instead of proposing, as my work does, that we really target these people to try to fill this gap in relatively quick time, this SI is saying that that is no longer possible, that these people with debts already from their university days—their undergraduate days—will now face having to fund work in a specialist area. Will the Government look seriously not just at narrow shortages but at wholesale shortages, which we certainly have in mental health nursing? Can we find a better way of attracting and retaining these people?

I finish with three brief questions. We are going to get, through the NHS and indeed through private sector organisations, 0.5% of their payroll being spent on the apprenticeship levy. I ask the Minister whether trusts and private sector organisations, particularly those in adult social care, will be able to use part of that levy to create in-house bursaries to support the development of staff. As yet we have not talked about the role of other sectors in bringing these people through. Will that be possible?

Secondly, if the Minister says, “Ah, no, BEIS says that you can use this money only if it is for apprenticeships”, are we able to rebadge postgraduate work in nursing, in the different fields, through the levy to provide the bursary—and, of course, fee remission—as a result of that route? There is a big pool of money coming in here, which could be used much more effectively.

Thirdly and finally, I ask the Minister, in trying to solve this conundrum, to make an assurance to this House that it is quality that we want and quality we must give to the people of the UK—particularly the people of England, to which this SI applies—rather than quick fixes in other ways, which I am sure will come down the track if we do not resolve this matter now.

The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con) 

My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate, and express my gratitude to all noble Lords for speaking. I always welcome the high profile that issues relating to NHS staffing receive in this House and I am always pleased to debate our approach with noble Lords, who I know are motivated by a desire to protect and promote our world-class NHS, and bring both wisdom and expertise.

I will start by explaining the overall rationale behind the reforms that the Government are making. The decision to remove bursaries for nursing, midwifery and allied health profession students and to provide them with access to the student loan system was taken by the Department of Health—as was—in the 2015 spending review. One reason for that was that this group of students had access to less money through the NHS bursary system than students in the student loan system. By moving to the loan system, these students now typically receive a 25% increase in the financial resources available to them for living costs during their time at university.

Lord Willis of Knaresborough 

Before the Minister goes one second further, will he confirm that the bursary money was free money? They did not have to pay that back. Now they have to pay back the whole loan.

Lord O’Shaughnessy 

If the noble Lord will let me finish, I will get to that point. Like other graduates, student nurses will be required to repay these government-funded loans only once they are in employment and earning. It is important to state that the student loan repayment terms are progressive. From April 2018, individuals will make their contribution to the system only when they are earning more than £25,000. Monthly repayments are linked to income, not to interest rates or the amount borrowed, and the outstanding debt is written off after 30 years.

I am not the Education Minister in this House, although I seem to be covering this topic not only tonight but in other forums, but it is important to underline that the reason this system was introduced into this country by a Labour Government, reaffirmed by a coalition Government and continued by a Conservative Government, is that it means that the best-earning graduates, instead of having their fees entirely paid by taxpayers, including people who have never gone to university, make a contribution to the costs incurred, whereas those who are lower-earning through their lives, including those who will perhaps never earn more than £25,000, will make no contribution. That is a more progressive system of funding than one in which everybody gets it for free, no matter how much money they make in their life.

As I said, these reforms give student nurses access to more financial support, albeit they have to pay that back if they can afford to do so later in life. It also provides a level playing field with other students. But perhaps most importantly of all, these actions released about £1 billion of funding to be reinvested in the NHS front line. As a consequence, Health Education England plans to increase the number of fully funded nurse training places by 25% from September 2018. It is important to stress that Health Education England has made that decision as an independent body to meet the need for more nurses that we all agree is there.

As the noble Lord, Lord Hunt, pointed out, this equates to around 5,000 more places each year—a major and welcome boost to our much-admired nursing workforce. My background is largely in education and I assure the noble Lord, Lord Puttnam, that we understand the urgency of this task and the parallels with education that he mentioned.

Baroness Watkins of Tavistock 

Is that for the clinical placement funding?

Lord O'Shaughnessy 

That is quite right. That is fully funded clinical placements—just for the sake of clarity. I thank the noble Baroness.

There is understandable concern among noble Lords, which has been expressed previously in this House, about the new system of financial support, but I want to be clear that we are giving the group of postgraduate students that we are discussing access to undergraduate maintenance and tuition fee loans, just as we do with postgraduate teachers. This represents a more generous package of support than the postgraduate master’s loan. We are also making available additional funding for childcare, travel to clinical placements and exceptional hardship funding to ensure that the students are fully supported and are able to complete their studies.

Furthermore, as many noble Lords have mentioned and as the noble Lord, Lord Hunt, and the noble Baroness, Lady Watkins, welcomed, in the debate on the regulations in the other place on 9 May, my honourable friend the Minister of State for Health set out a range of additional support that we are investigating for postgraduate nursing students. This includes specific incentives such as “golden hellos” for postgraduates who go to work in mental health—where the noble Lord, Lord Willis, was quite right that we need to attract more nursing and where there has been a shortfall—the area of learning disability and community nursing. The Government have announced £10 million to support such incentives and we are considering how this should be best delivered.

Many noble Lords have expressed concern about the drop in number of undergraduate applications to nursing courses. We acknowledge that early indications from the latest UCAS data, published in April, show that the number of students applying to study nursing has decreased from this point in the cycle last year. However, that cycle is not yet over, so we need to apply some caution.

It is also worth noting, as noble Lords have pointed out, that there is a distinction between the decline in number of applications and that in the number of students starting their courses. That was exemplified last year, which showed a 23% drop in the number of applications compared to a 3% decline in the number of acceptances. That is regrettable, but it was still the second-highest number of acceptances on record. Several noble Lords have expressed their desire for further information on how this develops. I can confirm that my department has committed to publish an update in autumn 2018 following the close of the 2017-18 application cycle.

As the noble Baroness, Lady Watkins, pointed out, there is a global challenge to recruit more nurses. We are working hard to make nursing as attractive a profession as possible. As a result of constructive dialogue over recent months, NHS Employers and the relevant trade unions began a consultation exercise on a three-year pay deal for NHS staff employed under the Agenda for Change contract. Under the plan, the starting salary of a nurse will rise to £24,907 by 2021, not only rewarding current staff for the incredible work they do but sending a clear signal to the country about how much nurses are valued.

We are boosting the attractiveness of the profession in a number of other ways, too. Nearly 4,500 nurses have started the return to practice programme and 3,000 have completed it. Across the country, NHS trusts are developing arrangements for flexible working and there is a concerted effort to tackle workplace bullying through an NHS-wide call to action. Our homes for staff programme is supporting NHS trusts to dispose of surplus land to help up to 3,000 nurses and other staff access affordable housing. I hope that gives the noble Lord, Lord Clark, some concrete examples to back up the warm words we use about supporting the nursing profession.

Several noble Lords have touched on new routes into nursing, which the Government are prioritising. The most significant innovation in this area was the announcement of a new nursing associate role in November 2016. Health Education England has already trained 2,000 nursing associates in a pilot programme and is planning to train up to 5,000 in 2018, with up to 7,500 nursing associates trained through the apprenticeship route in 2019. As well as creating a much-needed new role in its own right—I emphasise “in its own right”, as it is an augmentation to the nursing and other professions—nursing associate training offers an alternative route to becoming a registered nurse. We expect this “earn and learn” approach to be more attractive to older students, a concern which many noble Lords have raised.

To support this career path, Health Education England is developing a shortened nurse degree apprenticeship to facilitate transition from nurse associate to registered nurse, which will also automatically recognise the prior learning and experience gained in the nursing associate role. For the first time, apprentices will be able to work their way up from entry-level health work through to advanced clinical practice in nursing.

Several noble Lords expressed their concern about the apprenticeship route and the figure of only 30 nurses. The official data has been delayed and we believe that the figure is more like 250. We will be able to confirm that. It is a better start but, clearly, not yet the target that we want to reach. However, we believe that this stepped approach through the nursing associate role, giving the opportunities for a pause after two years and then to go on for two years, ought to be more attractive to employers than the current four-year commitment. This development of the nursing associate route therefore provides for a better use of the apprenticeship route.

I want to address a couple of what are perhaps misconceptions. The figure of 40,000 vacancies is used often in this House. I might be pedantic and disagree with that number—the quantum is just about right—but it is important to say that these are not empty places. They are being filled by agency and bank staff. Part of the reason for that is that people want flexibility and more pay, two of the things that we are trying to address so that we can provide more permanent contracts for those people who currently work flexibly.

The noble Lord, Lord Clark, and the noble Baroness, Lady Garden, talked about EU staff. I hope your Lordships will agree that I miss no opportunity to say from this Dispatch Box how much we value those staff and that they have just as much right to apply for settled status as anyone else in this country, provided they fit the criteria. However, it is worth pointing out that there are more EEA staff in the NHS than there were in June 2016. The one category where the figure is lower is in nursing and midwifery but the reason for that was the introduction of a more stringent language test. We are dealing with that issue, which I hope will mean that we continue to see an increase in EEA staff working in our NHS.

The noble Lord, Lord Willis, asked specific questions about the apprenticeship levy. I will need to write to him on that issue having consulted my colleagues in the Department for Education.

Turning quickly to the second point of the Motion, several noble Lords, including the noble Lord, Lord Hunt, the noble Baronesses, Lady Walmsley, Lady Watkins and Lady Garden, and others said that we should postpone the introduction of the reforms until the post-18 education and funding review has been completed. As noble Lords know, the Prime Minister launched the review earlier this year to ensure that we have a better system of higher education support that works for everyone. Many aspects of the current system work well and, as was set out in the terms of reference for the review, there are important principles that the Government believe should remain in future. One of those is that sharing the cost between taxpayers and graduates is the right approach, as I rehearsed earlier in my speech.

I take the point made by the noble Baroness, Lady Walmsley, about looking at the Welsh example. I have looked at it myself and I am sure it is something that the review would want to consider. However, it is important that we do not prejudice the work of the expert panel established to support the review or prejudge its outcomes. The fact of the review should not delay these healthcare education reforms, not least because they predate the launch of the review by some distance and already apply to the vast majority of nursing students. We believe it would do more harm than good to further delay these reforms, although it is worth underlining that any relevant reforms stemming from the review will apply equally to this group of student nurses.

In conclusion, I recognise the well-motivated concerns expressed by noble Lords during this debate. However, I hope I have been able to demonstrate that the student finance reforms that this Government have introduced have allowed both the removal of the artificial cap on nurse training places and the largest expansion of student nursing places in a single year ever seen. These two facts are not coincidental; they are inextricably linked. The latter is possible only because of the former and they form part of a wider set of workforce reforms designed to expand, train and reward our nursing profession better so that we can continue to deliver the high standards of NHS care that patients demand. On that basis, I hope the noble Lord, Lord Hunt, will feel able to withdraw his Motion.

Lord Hunt of Kings Heath 

My Lords, I am grateful to all noble Lords who have spoken in this debate, particularly the noble Baroness, Lady Watkins, who returned early from the WHO to take part in it.

I am left, though, with huge concerns and a real puzzlement as to the Government’s approach. As the noble Lord, Lord Willis, said, faced with this huge crisis in nursing in particular but also among the other professions covered by the regulation, the Government, without any evidence base, seem to be setting out a plan to discourage older women and people from black and minority ethnic groups from entering nursing, midwifery and other professions. In the breakdown of postgraduate healthcare students, the statistics show clearly that 64% are over the age of 25, women are largely attracted to this route and there is a higher percentage of minority ethnic students. We also know from the Department for Education’s own analysis that those groups are known to be more debt-averse. So the consequence is bound to be a negative impact on the very group of people we probably most need to come into the nursing profession.

Lord O'Shaughnessy 

I do not want to get into an argument about funny money and magic money trees, but it is worth pointing out that the proposal to treble student fees came from the Browne review, which was instigated by a Labour Government, and indeed the 2010 Labour manifesto committed a future Labour Government to implementing the findings of that review.

Baroness Walmsley 

I would add that the Browne recommendations had no cap at all.

Lord Hunt of Kings Heath 

My Lords, I would pray in aid my noble friend Lord Adonis, who sadly is not here tonight, and take the Minister back to the original intent of the loans that we introduced.

The Minister does not seem to have responded at all to the issue that, essentially, we are transferring this debt to future generations. At some point, the fact that so little of the loans is being paid back will have to be confronted. The Minister justifies increasing the number of places now on the basis that at some time in the future some Government are going to be faced with a massive problem. So not only are we discouraging some of the most important people that we want from coming into the profession, but we are also engaging in the most extraordinary financial trickery to justify current expenditure.

The Minister mentioned apprenticeships and associates. Of course we should welcome apprenticeships, and I welcome the associate profession, which is a good thing. However, the problem is that we know what the health service gets up to. We know that directors of nurses do not have as much influence on boards as they need, and that NHS trusts up and down the country will substitute associates for qualified general nurses whenever they can. Given the debacle of the whole apprenticeship approach, in putting all our eggs into that basket we are very much risking the future of this profession.

My noble friend Lord Puttnam talked about the problem that it takes a long time to recover from a situation of drastic shortage, and my noble friend Lord Clark talked about some of the implications. When you see a car crash about to happen, you usually attempt to stop it. I see this policy as putting the foot on the accelerator, leading to an inevitable crisis.

However, this was debated in the other place. I see no purpose in prolonging the debate. I hope that, under the auspices of the review of student finance, the Government will start to think again. I beg leave to withdraw the Motion.