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Agenda for Change: NHS Pay Restraint

Volume 620: debated on Monday 30 January 2017

I beg to move,

That this House has considered e-petition 168127 relating to pay restraint for Agenda for Change NHS staff.

It is a great pleasure to serve under your chairmanship, Mr Evans. At a time when the number of deeply concerning and time-consuming issues on the international political agenda is increasing, it is important that we and, most importantly, the Government do not lose focus on our domestic priorities and the challenges affecting our constituents’ day-to-day lives. The national health service is at the very top of that list, so I am pleased to introduce this debate. The way we treat our NHS staff is surely one of the most decisive factors in whether we have the functioning health service that we all need.

The petition is titled:

“Demand an end to the pay restraint imposed on agenda for change NHS staff.”

It has been signed by more than 104,000 people across the country, including 4,500 from my region, the north-east. It reads:

“Agenda for change staff including nursing, midwifery, healthcare assistants and associated healthcare professionals have suffered a pay restraint since 2010. Losing approximately 14% in real terms of their pay, staff are struggling nationwide and many have been pushed into poverty.

The impact of the pay restraint is harsh. Many are sadly leaving the professions they love. There is an NHS staff crisis. In London we lack 10,000 nurses. Yet two fifths of nurses living in the capital plan to leave as they are unable to pay their rent. Staff reporting using food banks and hardship funds is increasing. The pay restraint must end.”

The petition’s creator, Danielle Tiplady, a nurse and supporter of the Royal College of Nursing’s “Nursing Counts” campaign, said:

“Nursing staff deserve a pay award that reflects our knowledge, skill and dedication.”

She added that the interest in her petition

“is a huge achievement, but colleagues are struggling to pay bills and even turning away from the profession, and it’s time Parliament debated why.”

Danielle Tiplady is one of my constituents, and I am proud that she started the petition. The Royal College of Nursing’s most recent employment survey of its members found that 30% had struggled to pay gas and electricity bills, 14% had missed meals because of financial difficulties, and more than half had been compelled to work extra hours to increase their earnings. Given the demands of the type of work that nurses do, does my hon. Friend agree that our nursing profession is in a terrible place and that the Government surely must act?

I absolutely agree. It is hard to emphasise enough my support for people working across the NHS in increasingly challenging circumstances, without whom our health service would, quite frankly, cease to exist.

The way to show respect for our nurses and other NHS staff is to act now to remove the cap, as has been described, and listen to the independent pay review body.

My hon. Friend makes an important point. It is not enough for us to state our support for our NHS workers; we must show it through real action.

I agree with the points that the hon. Lady has made. Does she agree that, given the shortage of about 24,000 nurses, the fact that about one in three are due to retire in the next 10 years, and the challenge of Brexit, which might make recruitment more difficult, one potential consequence of pay restraint, along with the sense of injustice for nurses, is that we will face a real recruitment crisis? People will just vote with their feet and not work in the NHS. That presents us with a real challenge.

I very much share the right hon. Gentleman’s concerns. He anticipates some of the points that I would really like to get across.

My view of the importance of those who work in our NHS is shared not only by Opposition Members. The Department of Health stated in its response to the e-petition:

“Agenda for Change staff are vital. They work incredibly hard for patients and deserve to be fairly rewarded. We are committed to ensuring trusts can afford to employ the staff the NHS needs.

NHS staff are our greatest asset. Despite the pressures on the NHS driven by an increasingly aged and frail population, nurses, and all our hard working NHS staff continue to put patients first, keeping them safe whilst providing the high quality care patients and their families expect.”

How have we found ourselves in a situation in which hard-working, dedicated, exhausted nurses, midwives and other healthcare professionals are genuinely struggling to make ends meet?

Are we not in danger of getting into a downward spiral? Staff feel stretched, undervalued and underpaid, and many are looking to move abroad, or possibly even into other professions— I have had emails to that effect. Many are also going to agencies, and we know how much money agencies make. That costs extra, especially at a time when the retail prices index is moving inexorably up as a result of currency effects.

I hesitate to interrupt my hon. Friend, because she is making such a good case, but does she agree, as my right hon. Friend the Member for Warley (Mr Spellar) said, that agency working, which is very expensive, is really a false economy? If nurses leave full-time employment in the NHS to work for agencies, they cost the NHS two or perhaps three times more, so there are no savings whatsoever.

My right hon. Friend is absolutely right. It is also a false economy to lose professionals, given all the money that has been invested to make them a well-trained, well-performing workforce.

As hon. Members will be aware, Agenda for Change was introduced in 2004 as a system of pay, terms and conditions, and it applies to more than 1 million directly employed clinical and non-clinical NHS staff, with the exception of doctors, dentists and some very senior managers. It was designed with the intention of delivering fair, transparent pay that is better linked to career progression, skills and competencies. Agenda for Change is based on the principle of equal pay for work of equal value. According to NHS Employers, the system allows NHS organisations to

“design jobs around the needs of patients rather than around grading definitions”

and individual NHS employers are better able to define the skills and knowledge that they want the staff in those jobs to develop.

Importantly, in relation to this debate, Agenda for Change was also designed to enable employers to address more local recruitment and retention difficulties. However, as with hundreds of thousands of people who work in the public sector, all Agenda for Change staff have been affected by the previous and current Governments’ imposition of pay restraint.

My hon. Friend is making an excellent speech. Is it not perverse that the Conservative party seems to favour the introduction of all sorts of markets in the NHS apart from a labour market? The devolution of responsibility to trusts that it often heralds is completely inconsistent with a centralised, state-imposed pay freeze.

My right hon. Friend makes an important point. There was a two-year pay freeze from 2011-12 and a 1% increase in 2013-14 and 2014-15, followed by confirmation in the Budget of summer 2015 that the Government would fund an average public sector pay award of only 1% for the four years from 2016-17. As has been pointed out, the Government decided to reject the independent NHS Pay Review Body’s recommendation of a further 1% uplift to all pay scales from 2014-15, stating that there would be an annual increase of at least 1% for Agenda for Change staff in England through either contractual incremental pay or a non-consolidated payment.

I congratulate the hon. Lady on her excellent speech, which I am following closely. Is there not very thin moral justification for the Government rejecting the review of an independent pay body when each of us as MPs has our pay independently assessed and awarded? I can see no justification for saying to hard-working nurses in Kettering, “You can’t have the pay rise that an independent pay body said you should have” when I, as an MP, automatically get a pay rise awarded by our independent body.

I congratulate the hon. Lady on leading this debate, despite the other debates going on elsewhere. I rarely find myself in agreement with the hon. Member for Kettering (Mr Hollobone), but I fully agree with him. Hundreds of nurses across Northern Ireland feel desperately demoralised by the pay freeze, which has gone on for such a long time. When we got a new Prime Minister, on 13 July last year, who talked about a fresh beginning and new opportunity, they were encouraged, as many of us were, and thought that this would be an ideal opportunity for her Government to show that they mean what they say and that they care about removing pay restraint.

I thank the hon. Lady for that intervention—I think that many of us are surprised that we agree so entirely with the hon. Member for Kettering (Mr Hollobone). She raises an important point about the concern that many people up and down the country feel about some of the Prime Minister’s early actions in her time in office.

There are real concerns that the continuation of pay restraint in the NHS threatens to undermine the very benefits that Agenda for Change was supposed to bring to employers and staff. A centrally imposed cap on pay rises limits employers’ ability to respond to recruitment and retention problems while compromising the extent to which skills and competencies acquired by staff throughout their careers can be properly recognised and rewarded.

The extended nature of the pay restraint imposed first by the coalition Government and now by the Conservative Government also throws up this question: what is the point of having an independent NHS Pay Review Body, given that the Minister is clearly content to impose a figure on NHS Employers and staff each year? Indeed, the Royal College of Midwives has warned that the policy

“undermines the integrity of the system; and will cause lasting damage to the morale and motivation of staff, worsening the staffing crisis in the NHS.”

Despite the widely promised but yet to materialise extra £350 million a week for the NHS, we all know that our health service faces real and significant challenges in financial terms, both now and in the years ahead.

I add my congratulations to the hon. Lady on securing this important debate. She has somewhat moved on to the topic of Brexit. In Bedford hospital, to fill vacancies in our nursing staff we have relied on bringing in staff from the European Union. Does she not agree that the Government have a choice: they can continue with pay restraint if they wish, but if so we must retain that ability to attract people from within the European Union and secure the rights of those already here?

The hon. Gentleman raises some important points. I would never admit to having strayed into the subject of Brexit in this important debate on the NHS, but his comments are on the record and should be noted by the Minister. As NHS Employers stated in its 2017-18 submissions to the NHS Pay Review Body:

“The NHS continues to face unprecedented financial and service challenges. The majority of trusts fell into deficit during 2015-16 and the overall shortfall has now reached over £2.5 billion… The financial settlement for the NHS up to 2020 is extremely challenging, with employers set ambitious targets to deliver efficiency savings. At the same time, demand for services continues to rise. Performance indicators show the service is under great pressure as demands for care increase and other public services reduce provision.”

Does the hon. Lady agree that the physical demands of nursing, as a family member who worked as a healthcare assistant over the summer reflected to me, mean that sometimes conscientious nurses might be tempted to lift patients on their own, such are the demands of the job, and seriously strain their backs? That is something we should have regard to.

I very much agree. That is a factor right across the NHS and the social care sector, and it is an issue we see arising increasingly as staff come under increasing pressure, with the increased pressure to make efficiency savings, which ultimately compromises the health and safety of staff who find themselves in such situations.

Just last week the National Audit Office published its report into NHS ambulance services, which concluded, among other things, that:

“Increased funding for urgent and emergency activity has not matched rising demand, and future settlements are likely to be tougher”.

Crucially, in the context of this debate, it also concluded that:

“Ambulance trusts face resourcing challenges that are limiting their ability to meet rising demand. Most trusts are struggling to recruit the staff they need and then retain them. The reasons people cite for leaving are varied and include pay and reward, and the stressful nature of the job.”

That very much ties in with the concerns the hon. Gentleman raised.

I congratulate the hon. Lady on her speech; I agree with a number of the points she has made. On ambulance trusts and the point about very senior managers, we need good managers and senior managers in the NHS. However, ambulance trusts are a particular example—my trust, East of England, is an example—of where managers have sometimes received huge pay rises at the expense of frontline staff, who have received pay rises of nought or 1%. That is unacceptable. Does she agree that that further lowers the morale of frontline staff in a difficult period of pay restraint?

The hon. Gentleman makes an important point, which is why it is important that staff under Agenda for Change have the opportunity to have their voices heard today. When the Government look at how the NHS’s limited resources are distributed among the workforce, they need to approach the matter very much in the round.

I have no doubt that the Minister, when he responds to the debate, will be tempted to repeat the Prime Minister’s mantra that the Government are putting an additional £10 billion into the NHS by the end of this Parliament. However, as we all know, that figure has been comprehensively debunked by the hon. Member for Totnes (Dr Wollaston) and her fellow members of the Health Committee, and more recently by the chief executive of NHS England, Simon Stevens, when he appeared before that Committee. Indeed, Ministers confirmed only last week that NHS England will face a 0.6% real-terms fall in per capita funding in 2018.

How would an end to pay restraint for Agenda for Change staff help address the enormous difficulties the NHS faces? As the Royal College of Nursing has highlighted, chronic staff shortages have led to an “over-reliance” on “expensive agency staffing” to the extent that spending on agency nurses equates to about one tenth of the NHS’s total nursing pay bill. Indeed, the Royal College goes on to state that

“the over-reliance on agency staffing is a reflection of a nursing shortage and a direct consequence”

of the limit on pay for nurses working in the NHS.

We therefore have the nonsensical situation whereby nurses are leaving the NHS because of increasing workloads, stress and feeling undervalued following years of pay restraint, so the NHS has to turn to expensive agency nurses to fill the gaps left behind. Those concerns are mirrored by the Royal College of Midwives, which, following a freedom of information request, uncovered that NHS trusts in England spent almost £72.7 million on agency, overtime and bank midwives in 2015—enough to pay for 2,063 full-time experienced midwives or 3,318 full-time, newly qualified midwives.

The Minister might also refer to an increase in the number of nursing and other NHS staff since 2010. Again, that addresses neither the fact that there is currently a shortage of about 24,000 nurses in England and Wales, nor the shortage of nearly 3,500 midwives across the UK. Nor indeed does it address Health Education England’s worrying confirmation that last year some 8.8% of nurses left the NHS—the highest number since 2011. All that surely shows that the NHS is facing a perfect storm, not least in the light of the Minister’s ludicrous decision to axe bursaries for new nursing, midwifery and allied health students—I should perhaps say “Ministers’ decision”, rather than directing that comment at the Minister of State—the Government’s continued disgraceful failure to confirm the long-term future of 33,000 nurses from other EU countries working in the NHS, and the fact that one third of nurses are due to retire in the next 10 years. I look forward to hearing him explain how continued pay restraint for Agenda for Change staff will help resolve the staffing crisis.

The hon. Lady makes a good point about bursaries. Most nurses enter the profession in their late 20s—at about 28 or 29. We are talking about a recruitment challenge in nursing and the fact that the number of applicants for nursing courses dropped by 25% this year. Surely that demographic group needs the bursary as an enticement into nursing.

The hon. Gentleman makes another valid point. I hope that the Minister is listening, because although we are focusing specifically today on pay restraint for Agenda for Change staff, there is a much wider issue for the Government to take on board. A variety of factors is affecting recruitment and retention of NHS staff. The axing of bursaries is just one significant factor that the Government should seriously examine, and reverse.

What has the pay restraint for Agenda for Change staff meant to individual nurses, midwives, paramedics, cleaners and other healthcare professionals since 2011? Depending on the measure of inflation used, it has resulted in a drop in real-terms earnings of up to 14%. To put that in context, the trade union Unison has calculated that it is equivalent to annual pay cuts of £2,288 for a cleaner, £4,846 for a nurse, £6,134 for a midwife and £8,364 for a clinical psychologist. Indeed, ahead of the 2017-18 NHS pay review process, Unison surveyed its members working in the NHS and received the following responses, which are a matter of deep concern: nearly two thirds felt worse off than they did 12 months ago; 49% had asked for financial support from family or a friend; 13% had used a debt advice service; 11% had pawned possessions; 11% had used a payday loan company; 15% had moved to a less expensive home or remortgaged their house; and just under one fifth took on paid work in addition to their main NHS job, 64% of whom did so because their NHS salary was not enough to meet their basic living costs. More than 80% said they had considered leaving the NHS in the past year.

My hon. Friend is making a powerful speech. Does she share the concerns of the London nurses at the lunchtime lobby today, who said that punitive London housing costs are making the situation even more acute? They feel that they are being forced out of the capital, which needs nurses, and that what is happening is almost social cleansing by the back door, pricing nurses out of our city.

Yes, I share those concerns, particularly about the significant shortage of nurses in London. The issue affects places throughout the country, but I fully appreciate the acuteness of the situation in London.

The findings that I have set out are mirrored in the most recent Royal College of Nursing employment survey of its members. It found that 30% had struggled to pay gas and electricity Bills, 14% had missed meals because of financial difficulties, 53% had been compelled to work extra hours to increase earnings, and 32% were working extra night and weekend shifts to help pay bills and meet everyday living expenses. The RCN stated:

“This corresponds with our year on year increase of 30%, over the past five years, on the number of our members seeking specialist money advice from our RCN Welfare Service. This contact from our members focuses predominantly on dealing with unmanageable consumer debt.”

It is shocking and depressing stuff. It is bad enough that the Government continually expect NHS staff, many of whom are at breaking point, to do more with less and treat more patients with fewer resources in what are usually physically and psychologically demanding roles, but to expect them to do so while they face such anxiety and stress over their own financial situation is completely unacceptable.

We do not need to take Unison or the RCN’s word for what is happening. I have received emails containing powerful testimony from NHS staff in my constituency. One explained:

“I have been qualified as a children’s staff nurse for 12 years and I reached the top of my pay scale four years ago. I have not had a pay rise since. 4-5 years ago I was in a comfortable position, I could afford the basics and if I wanted extras like holidays or treats I would just do overtime or extra shifts to afford these luxuries. However, due to the fact my pay against my cost of living has reduced by 14%, I now struggle to afford the basics and am having to do extra shifts just to be able to provide food and pay my bills… I am missing out on valuable time with my family as I have to work nearly every weekend in order to be able to get a wage that can cover our costs. It is now becoming such a stretch each month that I may have to leave nursing and find a job that pays me better... Working as a children’s nurse in a busy A&E unit is amazing and worthwhile, but it is very stressful. On a daily basis we deal with and see things that are devastating and can be difficult to switch off from. Our pay should reflect this.”

Another constituent challenged the claim made in the Government’s response to the e-petition:

“Average earnings for qualified nurses were £31,214 in the 12 months to June 2016”.

She described herself as an average nurse in her 40s with a partner and a child:

“I have been qualified and working in the NHS for 11 years. I don’t earn £31,214. The top of my band (band 5) is £28,464. So, I am paid about £14.50 an hour to clean up faeces, vomit, blood and other bodily fluids. To hold the hands of patients who are dying. To comfort the relatives of patients who are dying. To maintain complicated machinery/equipment that is keeping a person alive whilst watching the newly-qualified staff nurse who doesn’t feel confident and make sure they don’t do anything dangerous.”

Another constituent painted a very concerning picture about her financial situation. She recently qualified as a nurse—a year and four months ago. She is a single parent of three children, and commented:

“After studying hard for 3 years mixing university, placements and guided learning, I gained my degree only to find myself in more dire financial circumstances than I was as a student.

I live to a tight budget, I drive a car that is 16 years old, I don’t smoke or drink, and I rarely socialise with my friends unless it’s a special occasion. This month I was paid £1,450 after tax—from that £300 is childcare; £400 is rent; leaving £750 for the month covering gas, water, phone, food, insurance etc. I also receive £35 tax credits a week which covers my daughter’s bus fare to college and her lunch money.

I am a qualified professional and yet I would class myself as being on the breadline. I know there are others in greater need than I am; however I feel like I work hard and sacrifice my family time for nothing.”

Finally, a senior sister with 30 years’ experience in an acute trauma unit explained:

“After six years of pay restraint, I now see nurses struggling day to day to make ends meet. Those who have stayed are now planning to leave the NHS early and newly qualified nurses are unable to stay without reasonable remuneration.

I feel like I grieve every day for my profession now. We have an NHS workforce currently willing to work as hard as the service asks them, but this goodwill is now eroding faster than I have ever seen in all my years’ service.

I am retiring within a couple of years. This request comes not for me, but for those who come after me and who will be caring for me and my family in the future.”

It is clear that our NHS is facing a crisis, yet the people the Government entirely rely on to make the NHS work are being badly let down. Nobody would suggest for a minute that those working in the health service do it for the money. However, we have reached a situation in which nurses, midwives and other invaluable NHS staff are struggling to pay their bills or put food on the table, or are pawning their possessions or taking out high-interest loans just to get from one month to the next.

How can we expect people to continue to provide high-quality care to us and our loved ones in what are already increasingly challenging circumstances when they are also facing this level of stress and anxiety at home? I strongly urge the Government to look at this situation again and to take on board the concerns being raised not only by organisations such as Unison, the RCN and the RCM, but by NHS frontline staff who are saying loud and clear that this pay restraint simply cannot continue.

It is a pleasure to serve under your chairmanship, Mr Evans. It is a particular pleasure to follow the excellent contribution from the hon. Member for Newcastle upon Tyne North (Catherine McKinnell). She set out the compelling case for why the pay regime for nurses, midwives and associated health service professionals across our health services is becoming increasingly exploitative.

The hon. Lady spoke of the particular experience in England; I obviously speak from the experience of Northern Ireland. Unfortunately, the Administration in Northern Ireland have chosen to void the clear recommendations from an independent pay review body, as in England, and have not taken the more constructive approach followed in Scotland to pay recommendations and to meeting the proper pay needs and aspirations of hardworking professional staff. As other hon. Members have said, those staff provide such a valuable service day in, day out. They work long hours with huge responsibilities, but with less and less of a sense of reward and with ever more inadequate remuneration.

We now have the situation in which many things have been brought forward. People were promised that Agenda for Change would ensure greater equity and transparency on pay, that they would see salary paths improving naturally—with more than just token increments—and that it would reward people’s sense of vocation. Of course, it does nothing of the sort, because people have found themselves locked into highly contested bands. Certainly in Northern Ireland, people doing the exact same work in different trusts are paid differently, which is causing huge frustration and a grave sense of grievance and injustice for many people.

The health and social care system in Northern Ireland is supposed to be operating increasingly as a single employer, with the commissioning role of Health and Social Care Board moving to the Department and the Minister. However, we have the bizarre situation in which people who are doing the same job and delivering on the same targets set by Ministers and the Executive are supposedly employed by different trusts and are paid differently—not because their working terms are different, but because the terminology on their contracts might be different here or there. The slightest difference in terminology in job descriptions is being used to keep people in lower pay bands than their counterparts in a neighbouring trust who are doing the exact same job. Of course, not being able to address those issues absolutely suffocates people with frustration.

This has happened in the context of those staff being locked into the 1% pay rise cap that has endured for a number of years. It is one thing to ask people to take a pay freeze in the name of austerity and managing public financial pressures for a year or two, but it is another to be locked into such a pay freeze while seeing other people, including on the public sector payroll, being able to escape those constraints. Again, it adds to the sense of injustice.

On the pay freeze, over the past five or six years it has worked out to roughly the equivalent of between a 6% and 8% wage cut. That is the reality that those people face. The Government say they value people in the health service, but the only way to demonstrate that is through their wage packets at the end of the day. The other issue, which will certainly affect mature students who want to be either a nurse or a midwife, is that the education maintenance grant has also been cut. So much for valuing people who work in the national health service.

I agree with all of the hon. Gentleman’s points; they touch on points made in interventions by other hon. Members. Let us be clear: the long-standing freeze is, in essence, a long-term pay cut in real terms. People are left feeling frustrated and aggrieved by that. People are leaving the profession; they feel they are being driven out—we heard references to the number of people who are switching to agency roles, but many people do not want to do that, and their sense of vocation is being exploited in a way that now probably more than borders on the cynical. A better response is needed.

I have made points particularly on Northern Ireland. On Agenda for Change, we know, as other hon. Members have mentioned, that pay in the lower bands actually falls below living wage standards. One appalling vista—which will bite this year in Northern Ireland, where these adjustments are being made—is that the money for that 1% pay rise will be used to bring people in the lower wage bands up to the living wage. In other words, if the 1% envelope is to be used to cover that, other people will lose out; there will be a trade-off between nurses and health service professionals in different grades, with that 1% being prioritised towards bringing people up to the living wage. Nobody should be asked to endure inadequacy as the price of affording a micro-concession to equality for those who are locked into the lower bands that pay below the living wage. That is going to bite in Northern Ireland this year.

It should not, because as part of the Stormont House agreement and other things, Northern Ireland has a voluntary exit scheme that was meant to reduce the cost of the public service payroll. If that overall voluntary exit scheme saves money on the public service payroll, my party made the point that, rather than those savings being used to pay for a cut in corporation tax in future years, they should be used for restorative pay measures—starting first in the national health service for those staff who have suffered as a result of freezes and who are stuck on inadequate and unfair pay bands under Agenda for Change. Their case could be met because public sector payroll savings are on the way.

Health service staff in Northern Ireland will be asked to manage yet more change. People already work long hours in heavy-demand services, but more structural changes will be made to health services following the Bengoa review and others. If people are being asked to manage all of those changes and keep those services going during those transitions, the one thing they are entitled to is some long overdue consideration of the inadequate pay they have been asked to endure.

No Members indicated that they wished to speak by standing in their place, but I can be flexible, with your permission.

Thank you, Mr Evans. I also thank the SNP spokesperson. I had not intended to speak but will grab this opportunity because it is an incredibly important debate.

First, I pay tribute to the Royal College of Nursing and the Nursing Times, which have captured the voices of nurses all over the country. We heard some of those voices in the excellent speech by my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell), and I think they speak for the vast majority of those in the nursing profession.

We meet at a time when the NHS is under unprecedented strain—certainly in recent times. Workforce morale is at the heart of the quality and sustainability of NHS services. What is often forgotten and missed when we debate this subject is that the vast majority of nurses in the NHS—nearly all, actually—work beyond their contracted hours.

I will never forget being at a meeting in Bristol with a nurse from the Bristol Royal infirmary. It was when the Government were looking at introducing regional pay, which the RCN led a campaign against. At the time, the nurse was being presented with a contract and asked whether she was prepared to vary her Agenda for Change conditions by moving from a 37-hour working week to a 39-hour one—it may have been 39 to 41 hours, but it was an increase. I asked her, “What did you do?”, and she said, “Well, I signed it straight away.” I asked why, and she said, “Because I’m currently doing a 45-hour working week, but they don’t know that.” In many ways, that illustrates the point: management do not know the value of what they get from the nursing profession.

That anecdote tells the story about the job. It is more than a job to people. As my hon. Friend the Member for Newcastle upon Tyne North said, people give all of themselves to this job, but they have limits. When they feel as though those above them do not understand the commitment and the huge contribution they make to the NHS, and when they feel taken for granted, the good will and morale start to dry up. That is when the Government are in danger of achieving a false economy. The price of holding down nurses’ pay in the way that has been done over the past six years is, in the end, nurses not feeling able to go above and beyond as they normally willingly do.

I agree with the points that my right hon. Friend is making. The RCN has told us that the pay of a significant group of nurses has fallen in real terms by 14% over the period he refers to. Does he agree that that is a pretty startling statistic?

My hon. Friend the Member for Foyle (Mark Durkan) said that this is a pay cut. We should not call it a pay freeze because it is, in fact, a pay cut. The Government have manipulated the figures in this area. Let us call it what it is: a pay cut that has now been sustained over a number of years.

People are at their limits. They cannot carry on having their pay cut every single year while they face other pressures and rising costs, such as accommodation costs, without there being a consequence. The consequences will be for their own sense of wellbeing, their own mental health or, indeed, their children’s quality of life. Nurses are now saying, in large numbers, that enough is enough.

Further to what my right hon. Friend just said, does he agree that there is a culture under this Government and the previous coalition Government of devaluing the whole of the public sector? This is one stark example of what is happening across the public sector.

That is how it begins to appear. The Government are pushing people beyond their limits. There was the attempt to introduce regional pay, and there was the attempt to cut what is called the unsocial hours payment—there has been a whole series of initiatives that try to strip away support for the profession. It begins to feel like an attack on the profession. That is certainly how junior doctors felt, and I think GPs feel the same. The nursing profession is making clear today that it feels the same too.

As I said, this is a false economy. As well as damaging the good will and the extra hours that people were willing to offer before, it has also, as my hon. Friend the Member for Foyle indicated, pushed people into the arms of private staffing agencies. That, in the end, is another false economy for the national health service. Over recent years, we have seen the bill for private staffing agencies in the NHS increase year on year, to the point where it is now in the region of several billion pounds every year. Many trusts are in the grip of the private staffing agencies. That, of course, is also a factor in the cuts to nurse training that we have seen in recent years.

The right hon. Gentleman is making some very fair points. I hope he recognises that one of the first things I did in ministerial office was to reverse what was happening on regional pay and stick to the national pay contracts. He makes an important point about temporary staffing. If we look at the approach with the junior doctors’ contract, many junior doctors will now see a huge reduction in in-house locum pay for the work they are doing; it is sometimes a reduction of £10 an hour. That will feed locum agencies and drive up the temporary staffing bill. We need to see nurses and other Agenda for Change staff paid properly, to stop them needing to do agency work. That is one of the main drivers of the agency business.

I am glad to hear the intervention of the former Minister, whom I worked well with in the previous Parliament. I want to take this opportunity to say that he did listen on regional pay. We made an argument about that issue, backed up by the RCN and others, and, to be fair, it did not go any further than the experiment in the south-west. I give credit to him for that. I also give credit to him for consistently showing a real regard for the pressures faced on the frontline.

The hon. Gentleman makes an important point that the Minister would do well to reflect on. There is a huge false economy here. It makes sense to have fairness in terms of headline pay for staff, to maintain good will, but on top of that, it makes sense to provide them with incentives to give any additional shifts or time to the in-house bank, rather than private staffing agencies. The Government have lost sight of that in recent times.

My right hon. Friend makes an interesting point. It can be a false economy to rely on agencies to staff hospitals, whether it be nurses or doctors. At the end of the day, training suffers. That makes it difficult for the NHS to recruit, so it is a false economy in a number of ways.

It is not only a false economy; it directly damages the quality of patient care. When people arrive on the ward who do not know the team or the environment and have to be told everything, it builds in confusion and delays because staff have to take them through things. It does not make sense to use private staffing agencies to the extent that they are being used in the NHS. The cost is exorbitant—that is No. 1—but it also damages morale, because it leads to staff in the permanent employ of the trust working on the ward alongside people who are being paid significantly more than them for the same shift, despite having just arrived on that ward. That does not build a sense of team on the ward; it builds a sense of resentment.

My right hon. Friend makes a powerful point about the lack of continuity with agency staff coming in. He talks about recruitment and retention. The NHS traditionally has had a large overseas workforce. Does he agree that the £35,000 salary required to settle in the UK has not helped matters? Nurses normally start at £23,000. Our NHS would crumble without overseas workers. We have also heard that in the post-Brexit climate, people from overseas feel less welcomed by this nation. Does he have any comment on that?

My hon. Friend makes two important points. The first was on the effect that Home Office immigration rules could have had on the nursing profession. I think the former Home Secretary, now the Prime Minister, made some changes in that regard.

My hon. Friend is right that there is a much bigger context here: the post-referendum climate. The Government have been absolutely wrong not to guarantee the status of EU nationals currently working in our national health service. I have an example from my constituency of a Polish community nurse, who every day gets up early to go on her local round delivering insulin to vulnerable patients who are diabetic and housebound. One morning she heard a cry of, “Go home!”, out of one of the bedroom windows opposite. What does that make that nurse feel like, and is she likely to stay when we are in this prolonged period of uncertainty in which this growing hostility is felt to be around? There is a real risk here. We cannot simultaneously refuse to give clarity to those tens of thousands of nurses from other parts of Europe who are currently working in our NHS and run down the good will of nurses who are UK nationals. In the end, something will give, and it will be patient care, if we operate policies of that kind.

Alongside that, there is the attack on nurse training. We have seen cuts to nurse training places over a number of years, so there is a shortage of nurses coming through. Many places are being and have been forced to recruit from overseas. In those circumstances, with everything else that I have described, including the downward pressure on headline pay, how can it possibly make sense to scrap the nursing bursary? Will that not just be another factor that adds to the growing sense of crisis in the profession? Every single piece of support that is there to develop the nursing profession is systematically being stripped away.

We have seen years of that approach and are beginning to see the consequences in the national health service. Labour, of course, did not get everything perfect—I am not saying that—but I can say with some pride that when I was a Minister in the Department of Health, we brought through a major programme of investment in the nursing workforce, through Agenda for Change. It was the subject of hard discussions, but in the end it was agreed between the trade unions and the Government of the day. We did have in the Department of Health a social partnership forum, which brought together NHS Employers, trade unions and the Government to iron out problems relating to the nursing workforce. We did massively increase the numbers in the nursing profession. We did ensure that they were properly rewarded and had proper access to training. My worry is that we are seeing some of that break down.

In the immediate aftermath of the financial crash, it was acceptable, it seems to me, to ask the nursing profession to make a contribution to deficit reduction, but here we are, six years on, expecting people who are out there today, working flat out to keep an NHS in crisis going, to take pay cuts for the privilege of doing so. At some point, that strategy begins just to fall apart, and the NHS falls apart with it. I say to the Minister that we are not far from that point now.

Is there not a wider economic point that if we keep pay freezes in place for so long—six years—that ends up harming the private sector economy, because if 70p in every pound of public sector money ends up in the private sector economy, some of that is wages, including nurses’ pay?

Of course, and the point is very well made, but I will also say again that it does not help deficit reduction if nurses are being pushed into the grip of private staffing agencies as a consequence of pay policies. That is another way in which the Government’s short-sighted approach has not in the end produced benefits for the economy, as the hon. Gentleman says, nor helped us meet the target of deficit reduction, because so much money is being wasted every year.

I will conclude on that point. The voices that have been mobilised in support of the lobby of Parliament today are real voices, as we heard from my hon. Friend the Member for Newcastle upon Tyne North. These people are the backbone of the national health service, the backbone of our communities and the backbone of our country. They have limits, though. Their limits are higher, but they do have limits, like everyone else. They feel taken for granted. Right now, the NHS cannot afford to lose the good will of the nursing profession. The Minister needs to listen carefully to what is being said today and he needs to make urgent representations, through the Secretary of State, to the Chancellor of the Exchequer in advance of the spring statement. A signal needs to be given to the nursing profession that the Government are listening and will take action, within the bounds of what is possible, to treat the nursing profession properly. I hope that, if nothing else, the Minister takes that message away from today.

It is an honour to serve under you, Mr Evans.

We seem to have been in this place before. We had a lot of debate about the nursing bursary, and these things are connected, because it comes down to how we are treating people and valuing them, as has been said. In Scotland, we also have a pay cap of 1%, but one difference is that that is being paid each year, whereas for three of the last six years, nurses in England have faced a freeze—an award of 0%. What they are told is, “Well, your increment gives you a rise.” The increment is how people move through the Agenda for Change structure, so if they are not getting any cost of living rise, the increment structure of Agenda for Change is being undermined.

The Scottish Government are a real living-wage employer and are recognised and registered as such, so people earning less than £22,000 get £400 to keep them above the real living wage. Starting in the next financial year, 2018-19, those in the lower bands in England will fall below the national minimum wage; they do not come anywhere close to a proper living wage. We know the Government’s living wage as “the pretendy living wage”, because people cannot actually live on it. That term should not be used because it is confusing. The result is that at band 1 or 2, a nurse or healthcare assistant in Scotland will earn £881 more than their equivalent in England. The common band for a nurse graduate is band 5, and at the top of that band, the nurse in Scotland will earn £284 more than the nurse in England.

Scotland has had no compulsory redundancies since the crash. In England, there have been 20,000. That seems bizarre when we are short of nurses. The vacancy rate in England is 9.5%; in Scotland it is 3.5%. We get what we pay for. If we treat people badly, eventually they go away, or, if they are approaching retiral, they do not go on working; they finish, because frankly they are burnt out. Nursing is a hard, heavy and stressful job. Nurses in Scotland feel stressed because of the gap caused by vacancies, the increased demand, the ageing population and the complexity of the cases they look after, so we can only imagine what it must be like in hospitals in England, with almost 10% of places not being filled and having to be covered by agency staff, which, as we have heard, is just a circular, self-defeating argument.

On the hon. Lady’s point about how difficult and wearisome the work of a nurse is—it is hard work—those nurses born in the 1950s who are affected negatively by the Government’s pension policy cannot now retire until they are 65, 66 or, indeed, 67. Has there not been a double whammy for those nurses who want, for the love of the job, for the love of the patients and for the love of service of the community, to stay in post? The Government have an opportunity to recognise that contribution. If they will not do something on pensions—I hope that they will change their mind on that—they could at least remove the pay freeze.

The whole message that is sent by nurses, particularly those who are in their late 50s and approaching 60, is that they are burnt out; they do not feel valued. When they have to work hours and hours beyond their shifts, doing what is frankly heavy labour—coming from that background, I can vouch for its being heavy physical work—they will of course leave as soon as they can manage to do so. The problem is that that exacerbates the pressure on all their colleagues, and that is what we are seeing with the huge shortage of thousands of nursing posts across England.

We have to recognise that we will face more increased demand and more complexity as our population ages. When patients in their early 70s were coming to me with breast cancer, they had multiple morbidities. By that stage, they had had a heart attack, were type 2 diabetic, had a bit of kidney failure and were severely immobile from arthritis, obesity or one of the many other conditions that people are getting. The nurses were trying to deal with all those things. Going forward, we will face more cases of dementia and Alzheimer’s, which is a particularly challenging morbidity for patients and the staff looking after them. Working in that environment, where everyone around them is having a bad day at the same time that they are having a bad day, means that people do not enjoy going to work. If there is any chance to get out, they are going to take it.

We need to attract more nurses to deal with demand. As was mentioned earlier, approximately a third of nurses are due to retire within the next 10 years, and we need to prepare for that. Some of that relates to the expansion that we had under Labour; when there is a big expansion in a profession, a whole lot will tend to retire at the same time. Unless succession planning is ongoing and established, we will reach an absolute crisis.

That brings us to the other difference: the nursing bursary. In Scotland, we still pay a nursing bursary of more than £6,500. We also have free tuition, which is equivalent to £27,000. We have additional funding for nurse trainees with additional support needs. They tend to be older—they are around their late 20s and early 30s —so they get more than £2,000 for childcare, a dependency allowance if they have either an adult or children dependent on them and a single-parent allowance.

The Scottish Government know that we have a challenge to recruit and retain nurses to grow the nursing profession, and they are putting that money in. They are not putting it in by giving high pay awards each year, but they are the only Government that actually accepted the independent review body’s recommendation of 1% on top of any steps within Agenda for Change. What is the point in doing all the work around a review body, if the Government do not bother listening to it?

I suggest that the Government need to show nurses that they are valued. They need to look at the decision to get rid of the nursing bursary, because we already know from NHS England that there has been a decrease of 20% to 25% in applications, so it is having exactly the opposite effect than the Government talked about. We know from the Nursing & Midwifery Council that registrations from the EU have dropped by 90% since last July. That means that whole source is drying up, regardless of rules, because people do not want to take the risk of moving here. We cannot shut down every possible source for having enough nurses. A lot of this is about calling on the Government to change their attitude and realise that this is a difficult job. We need to attract people into it and we need to retain people for as long as we can. Nurses are worth every penny they are not being paid.

It is a pleasure to serve under your chairmanship, Mr Evans. I congratulate my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) on the eloquent and knowledgeable way that she introduced this debate on behalf of not only the Petitions Committee but the more than 100,000 people around the country who signed this petition.

When she introduced the debate, my hon. Friend said that it is not enough for us simply to state our support for NHS staff—it has to be shown. The excellent attendance that we have had today, despite the important international business taking place in the main Chamber, has shown the huge support for our NHS staff and it is high time that the Government matched that support with action. In an intervention, the hon. Member for Kettering (Mr Hollobone) put the proposition that it is incredibly hard for the Government to justify ignoring the recommendations of an independent pay review body when we as Members of Parliament have our own pay agreed and implemented by an independent body. Can the Minister not see how repeatedly ignoring independent pay reviews strikes at the very heart of the bond of trust that exists in an employment relationship? Can he not see how it makes us look like we are uncaring and wrong? It is self-defeating and the approach needs to change.

My hon. Friend rightly highlighted the particular problems in ambulance trusts and the issues with the recruitment and retention of paramedics. She described the expenditure on agency staff as “nonsensical”. Certainly, no business would consider this a sustainable model. The personal testimonies that she gave from her constituents were compelling. None of us could fail to appreciate how difficult the situation is for some of our nurses. One said that she grieves for her profession, and that highlights just how dire the current situation is.

We also heard from the hon. Member for Foyle (Mark Durkan) about his perspective in Northern Ireland. He told us how the use of terminology appears to lead to people in different jobs being paid lower rates of pay for effectively the same job. That is certainly not how Agenda for Change should work in practice, and the pay freeze only exacerbates the sense of injustice that individuals feel. He summed up the situation perfectly when he said that the long-term pay freeze is in fact a pay cut. He said their sense of vocation “is being exploited”. He was right about that, but is it not incredibly sad that a Member of this place can say that without fear of contradiction? Just how low have we sunk?

We also heard from my right hon. Friend the Member for Leigh (Andy Burnham), who has great experience in the health service. He rightly said that nursing is “more than a job” and it is clear that he appreciates that, but he is right that when nurses feel that those above them do not appreciate what they are doing, it becomes a false economy and drives people into the arms of staffing agencies.

My hon. Friend has just mentioned people feeling a sense of fairness, particularly in the pay of those above them. Does he share my concern that in this current climate, while nurses’ pay is being cut, we are seeing large pay increases self-awarded to members of clinical commissioning groups and senior management? Does that not completely demoralise the whole local profession?

I agree entirely. We all know—it is well documented—the financial pressures that the health service is under. It defies belief or explanation that those in senior positions can still fly in the face of that. I can only sympathise profusely with how nurses must feel when they see those headlines.

Important as nurses are as the backbone of our health service, many other NHS staff are affected by the Agenda for Change pay freeze. Does my hon. Friend share my particular concern for the many staff who work in support services? Given the financial pressure that trusts are under, they have been forced to privatise parts of the service, and support services staff have moved off Agenda for Change terms and conditions altogether, which is what has happened at my local trust. The private sector tries to recruit new members of staff for less than Agenda for Change, because it is implementing the funding cuts that it faces.

My hon. Friend has encapsulated the challenge we always face when a service is privatised. Most often the only way in which the savings promised by the private company can be delivered is by changes to staff terms and conditions. I also agree that the pay freeze affects not only nurses, but the whole of the Agenda for Change workforce. Today we are focusing in particular on some of the effects on nurses, because there are clear reasons why that position is unsustainable.

To return to some of the contributions we have heard today, my right hon. Friend the Member for Leigh described clearly the impact on a ward of having agency staff, and how that creates uncertainty and is not the most efficient way of working. There is also the manifest unfairness of having someone on the same ward, who is only there for that particular shift, earning significantly more than permanent members of staff. How demoralising must that be for those involved? He was right to say in conclusion that we cannot afford to lose the good will of the nursing profession further.

In common with many hon. Members who have spoken today, I pay tribute to everyone who works in the NHS and the health and social care sector, not only to doctors and nurses, but to other allied health professionals such as porters, healthcare assistants, cleaners, receptionists, care workers, paramedics and countless others. It is important to remember that behind every story about the crisis that our NHS has faced this winter are patients waiting too long for treatment, and hard-working public servants doing everything that they can to prevent a very difficult situation from getting worse.

The NHS is the biggest employer in the country—and one of the biggest in the world—and it depends on the tireless efforts of its staff to keep going and meet the challenges of rising demand and insufficient funding. Let us be clear: we cannot indefinitely keep asking them to do more for less. I would argue, as other hon. Members have, that only the good will of NHS workers has stopped the current crisis from turning into a catastrophe. I recently heard the staff who work in our NHS described as “shock absorbers”. That seemed to be a pretty good description of how they are taking and absorbing the relentless pressure and stress of being on the frontline of an underfunded health service. They can take that for only so long before something snaps, which is why it is so important that we fully explore these issues today.

The incredible determination, professionalism and compassion that we see from staff comes against the backdrop of six years of pay restraint. Salary increases for NHS staff have either been frozen or capped at a level far below the rate of inflation. According to Unison, between 2010 and 2016 that represented a cut of more than £4.3 billion from NHS staff salaries, or a loss of between 12% and 19% in actual value since 2010. The Royal College of Nursing believes that since 2011 there has been a real-terms drop in earnings of 14% for its members. With Treasury forecasts indicating that the cost of living will go up by more than 3% every year between 2018 and 2020, it is not difficult to see how the current policy on pay restraint is unsustainable.

The policy is already beginning to have a huge personal impact on some of those affected. Registration fees have gone up by more than a third in two years, and we know well that wages have not kept pace with the cost of living. As we have heard, particularly from my hon. Friend the Member for Newcastle upon Tyne North, staff surveys from the RCN and Unison found that nearly two thirds of staff feel worse off financially than they did a year ago. Forty-nine per cent. had asked for financial support from a family or friend, 13% had used a debt advice service and 11% had used a payday loan company. About a third of nurses are struggling to pay their gas and electricity bills, 53% are working extra hours just to pay their everyday bills and 11% had pawned possessions. The Cavell Nurses’ Trust also found that 20% of nurses had skipped a meal in the last year due to money worries. Those are not abstract figures; they represent real people.

There was a lobby of Parliament today, and I am sure that some hon. Members in the Chamber went to hear at first hand from nurses how they are struggling. I met a nurse from the west midlands who works three days a week because of her caring responsibilities. She told me that she is living below the poverty line. Are we not ashamed that someone caring for our most vulnerable has to live like that? Are we really comfortable with a situation in which the people we are asking to care for our loved ones are having to pawn their possessions in order to make ends meet? In one of the richest countries in the world, can any of us accept the sight of nurses going to food banks?

Nowhere is the problem more acute than in our capital city. The Nursing Times reported that 40% of nurses who currently live in London say that the cost of housing means they will be forced to leave the capital in the next five years. Of course that challenge is not unique to the health service, but vacancy rates in the London area are among the highest in the country, with at least 10,000 nursing vacancies. How long will it be before we reach a tipping point from which there will be no recovery?

The impact is not just on nurses in their daily lives outside work, but on their working environment. NHS staff surveys paint a picture that cannot be ignored. The 2015 survey for England found that 48% of those surveyed stated that a lack of staff was impinging on their ability to do their job, and only 43% felt able to manage all the conflicting demands on their time. The warning signs are there for us all to see.

Analysis of NHS England data by the Health Service Journal found that 96% of NHS hospital trusts in England had fewer nurses covering day shifts in October than they had planned, and 85% did not have the desired numbers working at night. In 2013, the regulator Monitor, now part of NHS Improvement, warned about the potential impact of continuing pay restraint, stating in a report:

“Capping wages for longer to keep costs down would be self-defeating for the sector in the long term as it would make recruiting and retaining good quality professionals increasingly difficult.”

We had that very clear warning four years ago, but we have not heeded it.

The evidence that we have heard today and on previous occasions has proved that that prophecy was correct. The Public Accounts Committee reported that the number of nurses leaving their jobs increased from 6.8% in 2010-11 to 9.2% in 2014-15. Simon Stevens gave evidence to that Committee in 2014, stating that pay restraint would not be an “indefinitely repeatable strategy”, yet that is exactly what the Government propose to do.

Pay restraint, along with a cut to the number of nurse training places in 2010, led to a situation in which the amount of money that the NHS spent on agency staff soared by £800 million in a single year to £3.3 billion in 2014-15. Although considerable steps have been taken to bear down on the figure since then, the situation only developed because of poor and short-term decisions made by the Government, and it remains the case that we still spend far too much public money on agency staff because the NHS has been unable to recruit and retain enough of its own. If we had maintained the levels set by the last Labour Government, we would have had 8,000 more nurses trained during the last Parliament.

Recent figures have revealed that the agency staff cap has been breached almost 2.7 million times in its first nine months of operation. That is a clear example of the impact of the recruitment and retention crisis on all areas of the NHS and how the current workforce balance is completely out of kilter. The use of agency staff is meant to be a temporary measure in times of particular demand and stress for the workforce, not a permanent feature. The fact that these incidences have run into the millions in less than a year should be a huge concern to the Government and a clear warning that the stability and continuity that we all want to see in our workforce is a long way from being achieved. The Government urgently need to address the situation in which hospitals seem unable to provide safe levels of care without relying permanently on agency staff.

The dependency on agency staff has made the case for a pay increase as strong as it has ever been. That is the view not only of the Royal College of Nursing, but of those that look at the impact of skills shortages on the wider economy. In March 2016 the Migration Advisory Committee found that many nurses are moving to agency work or leaving the profession altogether. The fact that the Government have had to put nurses on the skills shortages list should have been the point at which they realised that their pay restraint policy had reached the end of the road. Instead, they have ploughed on regardless, treating the symptoms rather than the cause.

In that regard, the disastrous policy of having tuition fees for student nurses will almost certainly make the position worse, not better. The Royal College of Nursing warned at the time that the policy could act as a disincentive for students from some backgrounds—particularly mature students and those on lower incomes—and early indications are that applications to study are down by at least 20%. If that turns out to be an accurate reflection of the position, the pressure on existing staff can only increase.

At the weekend, on the doorstep, I met my constituent Dr Linda Burke, who is pro vice-chancellor for health and education at Greenwich University. She is really worried, because her university’s figures look like they are down by between 20% and 30%—UCAS will have final figures for late applications. She says that that is serious because it will directly reduce the number of nurses for the NHS. We should be thinking about our future workforce. Does my hon. Friend have anything to say about that?

I am glad to hear that my hon. Friend is out on the doorstep on a Saturday morning, but sorry that the news she was given is so concerning. It is not, however, a surprise. This is something that just about everyone interested in the matter warned the Government of and, as she says, we will find out in the next month or so what the final figures are. If they are of the order that we are hearing about, the Government will have the opportunity seriously to reconsider the policy. Today, when I attended the lobby, I heard some student nurses saying that they are finding it difficult to get staff mentors, because senior staff are exhausted. They do not blame those staff for that; they understand the intolerable pressure, because they too see it for themselves.

The change to student fees will add an extra penalty on those training from this year onwards, due to the Government’s decision to freeze the student loan repayment threshold at £21,000. That means that all future nurses will face a real-terms pay cut. According to Unison, based on current salaries, the average nurse, midwife or allied health professional will lose more than £900 per year to meeting their debt repayments. In practical terms, for a nurse on band 5, that means a salary cut approaching 5%. It is abundantly clear that that will make staff retention harder, not easier; there is a clear link between pay and retention levels.

Nobody is suggesting for a minute that anyone who goes into nursing is motivated by money, but when someone who has just finished yet another draining shift, going above and beyond the call of duty time and again, finds that they do not have enough cash in the bank to feed themselves and their family, and when each year their wages buy them less and less, they could be forgiven for thinking, “Is it all worth it?” It is morally wrong for the Government to put our nurses in that position, and it makes no sense economically either.

That is precisely the point that one of my constituents, a nurse, made when she wrote to me. She said that she graduated last year and is earning only £21,900, one of the lowest starting salaries among her graduate friends. She says that only months into her dream profession, she feels

“worn down by the strains put on the NHS. I face continued pressures every day. Most 12-hour shifts I don’t get my unpaid break, and I leave late.”

That is on top of knowing that she is not being properly rewarded for the work that she does. Is that not precisely why our nurses are feeling so demoralised?

Yes. It is sad to hear that someone who has only just started out in the profession is being ground down so much already and is feeling so unappreciated. It is a story and a message that we hear repeatedly from our constituents who work in the health service. The Government need to listen carefully to it.

The RCN’s submission to the pay review body not long ago said:

“Having faced a long period of pay restraint, it is inevitable that a large number of staff are now undertaking agency work as a way of restoring the real value of their earnings. Further restraint will only lead to even more damaging impact to the recruitment, retention and motivation of the most valuable asset the NHS has.”

Those comments were echoed by the House of Commons Health Committee in July 2016, which said that

“a long term pay squeeze has unintended consequences for recruitment and retention, which may drive higher costs.”

The independent Nuffield Trust made a similar statement after the 2015 summer Budget. It said that

“curbing public sector pay may make it even harder for the Government to realise some of its totemic pledges, such as seven-day working and reducing reliance on temporary staff.”

All those comments have come before the implications are clear for recruitment and retention of the thousands of staff who come from the EU. If they left tomorrow, it would make the current staffing gaps seem like a golden age.

I conclude with a couple more quotes. The first states that

“as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff.”

That quote is from a document that I am sure is known to us all, the NHS “Five Year Forward View”. Median weekly earnings for full-time employees in the private sector rose by 3.4% in 2016. I referred earlier to the anticipated increases in the cost of living over the next three years, which are bound to put more upward pressure on private sector wages.

The second quote is from a document entitled “The Conservative Party Manifesto 2015”, which I do not generally quote. Page 38 says:

“We will implement the NHS’s own plan to improve health care even further—the Five Year Forward View.”

As the Conservative party manifesto includes a clear commitment to delivering “Five Year Forward View”, and as it is clear that pay restraint needs to end to improve recruitment and retention rates, I must ask exactly what is preventing that from happening. I would be grateful if the Minister, when he responds, could tell us whether he considers the current policy of pay restraint to be consistent with the successful delivery of “Five Year Forward View”.

Labour agree with what has been said, be it by the cross-party Health Committee, the King’s Fund, the Nuffield Trust or the Health Foundation, about the need to end pay restraint. We agree with their crystal-clear message, and that of many hon. Members who have spoken in this debate, that further pay restraint for NHS staff would be self-defeating and unsustainable. We therefore endorse the wording of the petition.

I conclude with another quote from the Migration Advisory Committee, which said:

“The restraint on nurses’ pay instituted by the government was presented to us, and in the evidence to the pay review bodies, as an immutable fact. It is not. It is a choice”.

That is the nub of it: this is a political choice that does not need to continue. The Government have persisted with a damaging policy in pursuit of an objective that they have now abandoned, yet despite all the evidence that that policy is self-defeating and will cost more in the long run, the pay cap remains in place. It is a choice that they have made. It is the wrong choice, and it is time that they accept that they have got it wrong and change course before it is too late.

Mr Evans, I am grateful to you for calling me to wind up the debate. It is a pleasure to serve under your chairmanship. I congratulate the hon. Member for Newcastle upon Tyne North (Catherine McKinnell) on taking up the petition and giving a well-constructed speech, with which many people listening to the debate—not just Members from her party, but those outside—will feel considerable sympathy. I express similar sentiments towards the hon. Member for Ellesmere Port and Neston (Justin Madders). Although I do not agree with his prescription, I thought that he conducted himself in a thoroughly considered way, as usual. It is a pleasure to be shadowed by him, as well as by the hon. Member for Central Ayrshire (Dr Whitford), who as usual made a constructive contribution.

[Sir Roger Gale in the Chair]

First, I should say that we are all rightly proud of our national health service and the staff who work incredibly hard day and night for the benefit of patients. They undoubtedly deserve a cost of living increase, but we must recognise that the financial and quality challenge facing the NHS is unprecedented. These are not normal times. I deny the allegation that Agenda for Change staff are undervalued, as the right hon. Member for Leigh (Andy Burnham) indicated in his speech, which was knowledgeable, given his previous role as Health Secretary. Staff at all levels in the NHS do a fantastic job, and it is vital that we in Government and the leaders of the NHS recognise that staff morale is important to maintaining staff commitment to services.

In my experience of making visits across the NHS, hard-working staff put patients first every single day of the week. They do so because caring for sick and vulnerable people is as much a vocation for them as it is a job. I know that pay restraint is challenging, but when I speak to staff, they tell me that they want to know that the right number of staff will be working alongside them in the hospital or community setting. The Government have listened. Contrary to some of the contributions made by hon. Members, staff numbers have increased significantly across most grades since May 2010. We have recruited almost 11,800 more doctors. More than 13,300 more nurses are working on our wards today than in May 2010—the overall number of nurses working for the NHS is at an all-time high. There are over 2,100 more midwives, and more than 6,300 currently in training, as well as over 1,500 more health visitors and over 2,400 more paramedics.

The allegation that people are leaving the NHS in droves is simply not borne out by the facts. The most recent workforce statistics were published last week, covering the period ending October 2016, and they showed that a record number of full-time equivalents were working in our NHS.

The Minister is giving figures for the current workforce, but does he have any for the future workforce? I mentioned my constituent, Dr Linda Burke, of nursing and education studies at the University of Greenwich. She is worried that due to the cut in nursing bursaries, the number of applications is falling, possibly by as much as 30%. The RCN itself has said:

“We have consistently raised concerns to the Government… Despite 100 years of nursing knowledge and expertise, our advice fell on deaf ears.”

The RCN is effectively saying, “We told you so.” Will he remark on that?

I can say to the hon. Lady that there are 51,000 nurses in training today—I cannot tell her whether that is a record number, but it is a very significant number. There are 1,600 paramedics in training, which I believe is a record number. She and one or two other hon. Members have given anecdotes today about applications for new courses starting in the autumn, but I cannot tell her what the figures will be, because I have not yet seen any numbers published by UCAS. I think that they are due in the coming days, so we will have to see.

Honourable but not right—I accept that. The figures from NHS England itself suggest a drop in nursing applications of at least 20% to 25%.

The hon. Lady must have access to figures that my Department and I do not have. My information is that we have yet to receive any formal numbers from UCAS; there may be some early indications, but they do not represent the actual numbers. We will just have to wait for them. There is no point in speculating any further.

A number of hon. Members mentioned the potential impact of Brexit on EU staff, who currently represent a significant number of the professionals working in the NHS. Some 43,000 non-UK-born nationals work in the NHS—about 15% of the workforce—and about half of them come from the EU. It is very important that none of those staff are unnecessarily concerned about their future. The Prime Minister has sought to make it clear on several occasions that she wants to protect the status of EU nationals who are already living here and that the only circumstances in which that would not be possible would be those in which the rights of British citizens living in EU member states were not protected in return. We wish to provide as much reassurance as we can, both to NHS workers and to their employers, that they have a constructive future here in the UK.

However, it is important that we move towards a self-sustaining workforce. Frankly, that is at the heart of the reason behind the change in funding for nursing places, which is to bring nurses in line with doctors and those doing other degrees in England, so that from this autumn onwards they receive funding through student loans rather than bursaries.

The Minister is right to highlight the increases in many staff numbers across the NHS. He will also be aware that because of the increased focus on quality of care, many trusts have had to acknowledge that they did not have enough staff in the first place. If there are enough staff working in the NHS at the moment, why is the locum bill about £3 billion a year?

I will come on to agencies shortly. I am not denying that there are vacancies within the NHS, but my point is that there has been and continues to be a significant investment in increasing the number of people working in the NHS, which was not the impression that other hon. Members gave.

I have listened very carefully to the Minister, but I have to tell him that nursing staff, midwives and others in the nursing profession—certainly those in Northern Ireland who have contacted me—feel very demoralised by the attitude that the Government have held for several years. People in the nursing profession do a wonderful job and perform a great service for us all and for our families and friends when we have accidents or are ill, and the Government really must recognise their sense of demoralisation. If the Government will not change their policy on pay restraint—the Minister has already hinted that they will not—what steps will they take to address the serious problem of low morale in the nursing profession?

Obviously I cannot speak about circumstances in Northern Ireland, because we do not have responsibility for that. As I develop my remarks, I will go on to explain some of the things that we are doing to ensure that people who work in the NHS feel valued, as the hon. Lady asked, and get the kind of motivation that encourages them to get out of bed every morning and come into work day in, day out.

I will make some progress.

We recognise that the NHS faces a number of very challenging pressures: not just the ageing population, but the expectations of the public, who rightly demand quality personalised care at home or in hospital every day, not just from Monday to Friday. Those pressures will not be resolved just through pay, but by engaging with staff as they adapt and respond to new ways of working, including by introducing change that comes with scientific development and by supporting them through appropriate training and development.

We know that inflation is increasing. We continue to rely on the independent pay review bodies, which for decades have applied their expertise and objectivity in making recommendations to Government, and we have huge respect for their important work. The hon. Member for Newcastle upon Tyne North and the hon. Member for Torfaen (Nick Thomas-Symonds) referred to the NHS Pay Review Body’s 2014-15 recommendations. Last year the Government accepted its recommendations for 2016-17. We have provided our evidence to the current round—as have others, including trade unions—and we expect its recommendations in the coming weeks.

I will first answer, if I may, some of the comments made about the NHS Pay Review Body’s recommendations and how they sit alongside other elements of the NHS.

The allegation was made that there have been significant pay rises across NHS boardrooms, which are demoralising for those who have suffered pay restraint. However, I say to the hon. Members who raised that point that in 2016 the median rise across all board positions in NHS trusts was 0%. There are individual examples, when very senior managers are introduced to trusts that are going through a management change or are in difficulty, where higher pay rates may have to be introduced than for the previous incumbent, but generally speaking the opposite is happening: in many cases, those coming into new positions are coming in on slightly lower salaries.

The Minister talks about respecting the independent NHS Pay Review Body’s recommendations. Without having seen them, can he say whether the Government are likely to respect those recommendations?

The hon. Gentleman will not be surprised to hear that I cannot give him any reassurances on that. We will have to see what the recommendations are and then take a view. However, we are not very far away from that point now.

The hon. Member for Foyle (Mark Durkan) referred to the national living wage. I got the impression from him that some NHS staff members in Northern Ireland are earning only the national living wage; I can reassure him that no NHS staff in England are earning only at that level.

Looking at the graph going forward, however, those on bands 1 and 2 of Agenda for Change will fall not only below the real living wage, which they are already below, but below the national living wage, which is the minimum wage, in the coming years—2018-19 and 2019-20.

Once again, the hon. Lady is speculating about what might happen in future, and I am afraid that not only can I not comment on that, but I am not sure whether she is correct or not. There are some assumptions in what she said about what will happen to the national living wage. The Government are making some assumptions, but what the Government choose to do about the matter we will have to see. At present, the policy is certainly that nobody will be paid less than the national living wage. I can reassure her about that.

Just to clarify, like the hon. Member for Central Ayrshire (Dr Whitford), I was referring to the living wage and not to the national living wage, which is a figment of Government policy.

I was basing my assumptions and suppositions on what the Government themselves announced when they said that the pay freeze would continue in the next four years. That was announced in the comprehensive spending review, so I am not just making it up, and if pay goes on the trajectory that was announced last year, it will fall below the national living wage, which is obviously due to rise towards 2020.

I have made the Government’s current position clear and we will have to see what emerges from the NHS Pay Review Body’s recommendations, and then how those are implemented over the coming years. I think it is fruitless to speculate on what might happen in future years, based on the suppositions that the hon. Lady made—

Because I have been very clear that at the moment nobody will be paid less than the national living wage, and that is all I am going to say on that.

On the current position, can my hon. Friend clarify what the average annual increase in pay in real terms is for NHS staff who have been at the top of the Agenda for Change pay scale since 2010?

I will come to that point. If my hon. Friend will bear with me for a few minutes, I think I will be able to satisfy him on that.

No, I am afraid I am going to make some progress.

Hon. Members need to recognise that there is clearly a balance between pay and jobs in the NHS and across many public services. I note that the Opposition spokesman was full of recommendations about what not to do but had none, as far as I could calculate, about what should be done in relation to the delicate balance between pay and jobs. If pay were increased beyond the proposal from the NHS Pay Review Body, or beyond what the Government intend to pay, clearly there could be an impact on the number of jobs that can be afforded in the NHS within the financial envelope that we have.

We are very clear that we believe that the recommendations of the independent NHS Pay Review Body should be accepted. Much of what I said was about how we should recognise that, given the pressures on nurses’ pay, that will not necessarily cost the Exchequer anything in the long run.

I am not sure that that provides much clarification, but I thank the hon. Gentleman for having a go.

Employers in the NHS know that they need to deliver greater efficiencies and improved productivity to help protect frontline jobs. Making the workforce more expensive, through higher pay rises, will not help.

It is therefore disappointing that trade unions have alleged that staff have suffered a pay cut of about 14% in real terms—an allegation that has been repeated by a number of hon. Members in the debate. The truth is that the Government have ensured that no NHS employee —indeed, no employee—should be paid below the national living wage. As I have said, no NHS employee employed under the Agenda for Change pay system is paid below that.

The truth is that average earnings of NHS staff as a whole remained well above the national average salary for 2015, which was £27,500, and have increased by more than annual pay awards. For most NHS staff groups, half of employees employed in 2010 and still in employment in 2015 benefited from double-figure increases in earnings, equating to between 2.2% and 2.9% annually, depending on staff group. The average annual consumer prices index figure over the same period was 2.4%.

I specifically asked about those who are at the top of the Agenda for Change pay scale, which many Agenda for Change staff are. Can the Minister confirm what the figures are for that group, because I think that the figures he has given include those in receipt of incremental rises?

They do, and it is important for hon. Members to understand the impact of incremental pay rises. The truth is that some half a million Agenda for Change staff are eligible for incremental pay rises each year of more than 3% on average, on top of annual pay awards. I am not saying that NHS staff should have no concerns about the level of pay award they receive; what I am saying is that since the 2008 recession, NHS earnings and public sector earnings have generally compared well with those in the wider economy.

A number of hon. Members talked about regional pay and in particular the challenges of working in London. Of course, we are very sympathetic to individuals who face the pressures of working in London—in both inner and outer London—and that is why we have the increments available to recognise the extra costs of living there.

I will make a little progress, if I may.

NHS organisations spend about two thirds of their entire expenditure on pay. Ensuring that the NHS has the staff it needs relies, crucially, on controlling pay and on making every penny count for the benefit of patients.

I give way to my hon. Friend.

My hon. Friend the Minister may not have the answer to my specific question here today, but will he write to me after the debate to confirm the answer to my question about those members of staff who are at the top of the Agenda for Change pay scale? What, in real terms, has been their pay increase since 2010?

I will be happy to look at that; if my hon. Friend would write to me with his precise question, of course we will give him an answer.

I thank the Minister for giving way. I am slightly concerned by his response, in that he does not seem to be taking on board the very significant concerns that have been raised right across the board, not only by unions but, significantly, by the National Audit Office. Last week, in its report on ambulance services, the NAO said:

“Ambulance trusts face resourcing challenges that are limiting their ability to meet rising demand.”

One of the “challenges” that is specifically cited is “pay and reward”, which is hampering recruitment. It is not just the unions and NHS staff who are saying these things; it is the NAO and other bodies as well.

The hon. Lady refers to ambulance staff. In recent weeks—just before Christmas, in fact—the Department agreed a deal with trade unions whereby paramedics working in ambulances would have their banding increased from band 5 to band 6, phased in over two years so that they can demonstrate they have the increased skill competence required. That represent a significant increase in reward for paramedics; some 12,000 paramedics will receive a higher pay award, precisely to address recruitment challenges for that specific profession. So we are listening and we are doing something about this issue. I will try to give the hon. Lady other examples of where we are responding to specific pressures.

No. The hon. Lady has had a fair crack. I will make a bit more progress.

I was challenged in this debate to refer to what the Government are investing in the NHS and I obviously take some relish in responding to that challenge. We are investing an additional £21.9 billion in nominal terms, which is equivalent to £10 billion in real terms, to fund the NHS’s own plan for the future. By doing so, we believe that we are playing our part, through the measures announced over the last 12 months or so, to help the NHS achieve its five year forward view. It needs to do that not only by realising benefits from the Carter review to improve productivity, but by clamping down on rip-off staffing agencies and encouraging employers to use their own staff banks for temporary staffing needs, so that they can invest in their permanent workforce. That has been referred to by a number of right hon. and hon. Members.

Agency and bank working provide an opportunity for NHS staff to engage in more flexible working to suit their own circumstances, so I would not want to characterise all agency working as bad. What is challenging is when NHS organisations need, in some cases, to go out to external agencies beyond their immediate bank and pay significantly higher rates. That is why the Department introduced, a year ago, a number of measures to start to limit the ability of agencies to charge the NHS such high fees, and we have had some success in that. In the period for which I have figures—roughly the middle of last year—the agency costs to the NHS had been reduced by 19% over the equivalent period the year before, so we are doing something about those fees. We are apprised of the problem and are bringing down the cost to the NHS of employing agency staff.

This issue is not just about pay. NHS staff, like many people, work hard to improve our public services. They have families and commitments, and they deserve to be rewarded fairly for what they do. However, as has been said, pay alone will not necessarily persuade the skilled and compassionate people that we need to choose a career in the NHS. It would be wrong to see the NHS employment package as just about headline pay. NHS terms and conditions have been developed over many years, in partnership with trade unions, and they recognise that it is a combination of pay and non-pay benefits, which need to keep pace with a modern, changing NHS, that help to recruit, retain and motivate the workforce.

Certainly the nurses I met during the lobby here, who had come from all over England, but particularly from London, described literally struggling and facing great financial hardship. That is very difficult for them. They work so hard for the benefit of all of us, yet feel that they cannot go on in their profession because they simply cannot keep their families here in London.

I have already explained to the hon. Lady that we have a London weighting, which reflects the increased costs of living in London. I have also explained to her that average pay for nurses is significantly above the national average pay. She herself referred to average nursing pay of some £31,000—

If not her, then another hon. Member referred to it, and that is from the latest available workforce statistics.

Picking up on the hon. Lady’s point, it is important that NHS staff are confident that their employment package is competitive. We want employers to make better use of the full package in their recruitment and retention strategies. NHS Agenda for Change staff have access to an excellent pension scheme, far in excess of arrangements in the wider economy, which includes life assurance worth twice the annual salary, and spouse, partner and child benefits. They have annual leave of up to 33 days—six and a half weeks—plus the eight bank holidays, which is far better than that which is available in the private sector, and in many other elements of the public sector. They have sickness and maternity arrangements that go well beyond the statutory minimum and, as I have touched on, there are flexible working, training and development opportunities for staff at all grades. For too long, the NHS employment package has been a well-kept secret and we want leaders to make the very best use of the overall NHS employment offer to help recruit and retain the staff they need.

The Minister has outlined the pay and conditions package—or part of it. Does he believe that staff within the nursing profession are confident at the moment about their pay and conditions package, or does he feel, as I hear, that they are undervalued within the system?

I have tried to indicate in my remarks that we do not undervalue anyone who works in the NHS. The role of our nurses in particular provides the backbone of the entire health service. Understandably, people are concerned about their level of pay. With several years of pay restraint, that is no surprise—it is the case right across the economy—and that is why we will look carefully at the recommendations of the NHS Pay Review Body. I have already said that we recognise that there should be some increase in the award to take into account the cost of living.

You will be pleased to hear, Sir Roger, that I am going to conclude my remarks, by reconfirming that as a nation we are extremely proud of our NHS. The patient surveys we undertake every year tell us that our patients are proud of our NHS. Our staff tell us, in the surveys we undertake of them, that they are proud of working in our NHS. This is not just me saying this, reading it from a sheet; it is what staff tell me whenever I visit an NHS facility. They are proud of their job. They are proud of looking after their patients, and they want to continue to do so.

The Government have to take tough decisions, and in this area we have done so to protect jobs through pay restraint. Average NHS earnings for most staff groups have continued to grow. We are committed to ensuring that they have the right number of colleagues working alongside them in hospitals and in the community.

I strongly believe that the issue of recruitment and retention is not just about pay. It is about creating a culture in which learning, development and innovation are encouraged. It is about creating an environment where staff want to work, take pride in what they do, and are well motivated and feel safe; an environment where employers promote the importance of the values of the NHS and work incredibly hard to keep staff safe, and where bullying and harassment are not tolerated.

I do not think that anyone could argue with what the Minister has just said about NHS staff being proud of what they do and wanting to continue. But even while this debate has been going on, I have seen several tweets. For example, one asks:

“please tell me what the RCN”

—it says the Royal College of Nursing, but I say the Government—

“is going to do. I am seriously starting to struggle now”.

Others say that they

“know so many young people who would be great nurses but lack of bursary & low pay put them off”.

Those tweets reflect NHS staff’s real live experiences of the current pay situation under Agenda for Change and the continued pay freeze.

I thank all right hon. and hon. Members who have contributed knowledgeably and passionately to this very important debate, whether in speeches or interventions. I feel very strongly that we have won the argument today. There is a high degree of cross-party consensus on many of the issues we have outlined, and the Government are either burying their head in the sand or deliberately not facing up to significant challenges regarding pay, recruitment and retention for NHS staff. As my right hon. Friend the Member for Leigh (Andy Burnham) pointed out, by failing to address the issue we are taking advantage of those who work in the NHS and are pushing their good will to the limit. What disturbs me even more is that not only their good will is being tested; their very ability to survive in the job is being tested, too. I have received a number of testimonies and seen the evidence—the Government seem to deny the figures, even though they are there in black and white and I set them out clearly in my opening speech— about the real-terms pay cuts that NHS staff are facing. They simply cannot manage, and that is a shameful situation.

I said in my speech that it is the very people the Government rely on to deliver a high-quality NHS service in extremely challenging circumstances who are being badly let down by the Government’s current policy. How have we reached a situation where nurses, midwives and other invaluable NHS staff are struggling to pay their bills and put food on the table? They are pawning their possessions and turning to payday loans. On the softer side, they are turning to agency work to top up their pay—not to afford the luxuries in life, but the basics. It is a completely unsustainable situation, and the Government must take urgent action to lift this burden off our NHS staff so that they can do their job, which is caring for us and our loved ones without the fear of financial insecurity hanging over their every working day.

Question put and agreed to.


That this House has considered e-petition 168127 relating to pay restraint for Agenda for Change NHS staff.

Sitting adjourned.