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Nurse Training

Volume 646: debated on Wednesday 5 September 2018

Motion made, and Question proposed, That this House do now adjourn.—(Iain Stewart.)

It is a great privilege to be drawn for one of these end-of-day Adjournment debates, as they give Back Benchers such as me the opportunity to debate a subject dear to their heart. Tonight’s topic is fairly dry, but it is very important. I hope the House and those watching will forgive me if I plough into a lot of detail, because the detail is important on this issue. I welcome the Minister, for whom I have a high regard, to his place. Another advantage of these debates is that the poor Minister has to sit there and listen to me, and there is nothing he can do—he cannot escape. So I hope my words will fall on receptive ears.

This debate follows a recent public meeting on Portland hospital in my constituency; the beds at the island’s much-loved community hospital have been closed, but more on that shortly. We have heard it before, and it needs to be said again: we are facing a desperate shortage of nurses. Health Education England believes there are 36,000 nursing vacancies in England, whereas the Open University says it is 38,000 and the Royal College of Nursing gives a figure of 40,000. That last figure equates to an 11% vacancy rate, with learning disability and mental health nursing the most affected, followed by community nursing. These gaps may be filled by bank or agency staff on a temporary basis, but Health Education England estimates that 1% remain permanently unfilled. The knock-on effect places nurses under “relentless pressures”, according to a report this January by the Select Committee on Health. It added that

“nurses felt their professional registrations were at risk because they were struggling to cope with demand.”

Meanwhile, any increase in nurse numbers is swallowed up by the demand for more of them. For example, although the number of new nursing positions created between 2012 and 2015 rose by 8.1%, the number of those who actually joined the profession increased by only 3.2%. What is the consequence? Well, obviously, costs rise. Temporary nursing staff are expensive, with NHS trusts paying an average of 61% more for every extra hour they worked compared with that paid for a newly qualified, full-time, registered nurse. A Freedom of Information Act request by the Open University in January revealed that, if the hours worked by temporary staff were instead covered by regular nurses, the NHS could save as much as £560 million a year. The independent health think-tank, the King’s Fund, revealed that on average NHS trusts were spending nearly 7% of their salary budgets on agency staff, with the figure rising to more than 25% in some cases. Dorset HealthCare, which covers my constituency, forecasts an overall spend of £4 million this year on agency staff alone. That is down from a staggering £12 million three years ago but still represents a significant share of the healthcare budget.

As I mentioned at the start, 18 beds were closed at Portland Community Hospital last month due to a lack of nursing staff.

I thank the hon. Gentleman for giving way: I sought his permission to intervene beforehand. He is outlining the shortage of nurses in his constituency, but there are nurse shortages in many other parts of the United Kingdom, including in Northern Ireland, which has a shortfall of some 1,800 in nurse numbers. Does he agree that the training of nurses must be a priority for trusts and the Department of Health and Social Care? Part of the way to attract new nurses is to show how we value our current nurses through decent pay and working conditions. It is important to ensure that nurses are regarded highly for the work that they do—and paid accordingly.

I do not disagree with anything that the hon. Gentleman has just said, and I will come on to his points a little later in my speech. Of course all nursing staff should be appreciated and paid properly. One of the issues, as I shall describe in a minute, is the work environment, which is one of the factors leading to fewer nurses—or insufficient numbers—entering the profession.

Before the intervention, I was talking about my community hospital in Portland, where almost half of all nursing positions were unfilled this summer. Agency staff, costing as much as £58 per hour—and £135 per hour on bank holidays—were still hard to find. The trust’s chief executive, Ron Shields, for whom I have enormous respect, decided he could no longer safely keep the beds open. So, despite the understandable protestations from islanders who wish to keep their frail and elderly relatives close by, the beds were migrated to a hospital in Weymouth, where the nursing staff available can be consolidated. I suspect that that situation is not uncommon across the rest of the country.

The crux of the matter is the recruitment and retention of nurses. Recruitment depends mainly on training new nurses for the future. The numbers required are traditionally set by Health Education England, which then commissions the nursing places from further education and training establishments, including colleges, universities and the Open University. Standards are set and approved by the Nursing & Midwifery Council, ensuring uniformity across providers. Those establishments, in turn, invite applications, for registered nurses, nursing associates, nursing apprenticeships and Nurse First.

The first role requires a degree, the second a prior healthcare qualification, the third is a joint initiative between individual health trusts and further education establishments and the fourth is a new initiative for high-flying graduates and follows the lines of Teach First. The three-year degree option remains the main route into nursing. While many, including me, dispute the need for a degree, the Nursing & Midwifery Council says that that is to misunderstand modern nursing. Registered nurses are now an “officer class”, according to Geraldine Walters, the NMC’s director of educational standards, with much of the work for degree-level nursing now highly technical and demanding. In some cases, registered nurse prescribers replace doctors and indeed even run their own primary care clinics in London.

So far the nursing associates programme has been a success. In December 2017, 2,000 nursing associates were in training. This year, it is hoped that figure will be 5,000, rising to 7,500 in 2019. The Nursing & Midwifery Council is clear that more recruitment and widened access into nursing training are essential, as is the diversity of training provision.  The Open University, for example, provides for those who, for a variety of reasons, would not gain access to the profession via the traditional, campus-based route.

Since 2002, the Open University has offered a four-year registered nurse degree apprenticeship in addition to the straightforward apprenticeship. This is aimed specifically at existing healthcare support workers who welcome the chance to earn while they learn. So far, it has trained more than 1,000 applicants as registered nurses, with 940 more currently on the programme in England. One huge benefit to the scheme is that participating trusts seem better able to retain the nurses they have trained. Compare this with the 24% drop-out rate for student nurses on the degree course. As the NHS is the nation’s biggest contributor to the 5% apprenticeship levy, it would be odd for it not to participate.

The loss of the bursary scheme has been keenly felt, with the Royal College of Nursing saying that it is a serious own goal. It was a support package including tuition fees, a non-means-tested maintenance grant, a means-tested bursary itself, and other elements designed to help students with placement, travel and childcare costs. It was overwhelmingly popular, attracting more applicants than there were places. It was replaced by the student loan scheme, requiring students to borrow money to pay for their training.

The problem is that nursing is a vocational training and does not cater for school leavers unsuited to the profession. Significantly, following the removal of the bursary, the number of applications for nursing through UCAS has fallen by a third since March 2016. Although the Department of Health and Social Care says that there are 52,000 nurses in training—more than ever before—the number of those accepted on to courses is still down by 9.3% in England. That threatens the pipeline of new nursing talent and, at the very least, should and could have been anticipated. Much-needed mature applicants, many with care experience, are also deterred by the burden of debt and loss of earnings, and Ms Walters told me that these are exactly the people the profession needs. Mature applicants also tend to choose careers in specialist areas worst hit by the staffing crisis, such as learning disability and mental health.

New figures from UCAS show that applications for nursing degrees and from mature students are down by 33% and 42% respectively since March 2016. As the latter group are the very people who would be grateful for any support given, and probably remain in the organisation until retirement, Mr Shields suggests that trusts should provide some form of financial support in the absence of bursaries. A recent survey by the Open University showed the effect of the loss of the bursary on recruitment. Only 30% of nurses asked said they would have been willing to self-fund or partially self-fund their initial nursing education. In addition, more than half of those surveyed believed that applications would continue to fall.

Attracting nurses back into the NHS after they have left is another crucial focus for recruitment. The return to practice campaign, run by the Nursing & Midwifery Council, which provides refresher training and a re-entry route back into the NHS, has already recruited almost 2,500 former nurses and is currently registering another 1,800. However, as the Health Committee report states,

“too little attention has been given to retaining the existing nursing workforce, and more nurses are now leaving their professional register than are joining it.”

The Committee cites many causes, including workload pressures, an inability to meet patient expectations, concerns about providing adequate care, poor access to continuing professional development, poor organisational culture, pay restraint and budget cuts. The impact of Brexit was another reason, although—interestingly—briefings from the Library show that overall EU staff numbers in the NHS have, in fact, fractionally risen since the referendum, with numbers of EU nurses falling by just 0.3%.

Another issue is the current pensions arrangements. Senior and experienced staff who might want to work beyond 55 are leaving because their pensions reduce in value if they stay on. Mr Shields has recently lost two senior and valued members of his team, and believes the Government must look at this urgently.

A partial solution to increase nurse numbers is to recruit from abroad, including Commonwealth countries. However, this was, until recently, severely limited by immigration rules, which were wisely relaxed in June after an intervention by the Home Secretary.

In December 2017, Health Education England published its draft health and care workforce strategy for England to 2027. “Facing the Facts, Shaping the Future” anticipates a significant shortfall in nursing numbers due to an increase in the number of posts needed. The Health Committee has emphasised that future projections of demand for nurses should be based on demographics rather than on affordability alone. A final workforce strategy is expected from Health Education England at any minute. Perhaps the Minister can enlighten us, as it was expected, as I understand it, at the end of July.

Finally, I thank all those who work in our NHS for the wonderful job they do, not least the fantastic teams in South Dorset.

I pay tribute to my hon. Friend the Member for South Dorset (Richard Drax) for his assiduous campaigning on behalf of his constituents and for securing the debate. Its importance is reflected by the fact that my hon. and learned Friend the Solicitor General and the Under-Secretary of State for Wales, my hon. Friend the Member for Eastleigh (Mims Davies), were in the Chamber to listen to the points that my hon. Friend the Member for South Dorset raised.

My hon. Friend spoke passionately about the training of nurses in England and the pivotal role of training in ensuring that we have a workforce to deliver first-class services in the NHS. With a budget in which two thirds of our spend goes, quite rightly, on our workforce, the importance of that workforce is absolutely critical. Indeed, that was reflected by my right hon. Friend the Secretary of State when he set out his three key priorities for the NHS after taking over that post. He particularly emphasised the importance of the workforce within those priorities.

I apologise, Mr Deputy Speaker, for not being here at the start of the debate. A number of constituents who have contacted me are clearly concerned about the fact that the demand for nurses is not quite being matched by recruitment at the moment, particularly in the areas of learning disability and mental health. What specifically can the Government do, in addition to what they are doing, to really focus on those two specialist areas?

The hon. Gentleman makes a valid point. I think that we all recognise that learning disability has traditionally been one of those areas in which it is harder to recruit, compared with, for example, midwifery, where the number of applicants to training places is a lot higher. I do recognise that there is an issue.

Let me give just one example of what we are doing. When we looked at the situation in postgraduate training, particularly for more mature applicants, one of the issues was the possible impact on the area of learning disability. That was why we put in place golden hellos, with a budget of up to £10 million, to provide an incentive for applicants taking the postgraduate route into nursing to go particularly into the areas of learning disability, mental health or district nursing. That is one of the measures that we put in place to address the hon. Gentleman’s very valid point, but I am not suggesting that that alone fully deals with the issues that we need to look at, and we are paying very close attention to the situation.

I now turn to some of the specifics in the very well-put speech made by my hon. Friend the Member for South Dorset. He quite rightly highlighted the cost of agency staff within the NHS, suggesting that there could be more than half a billion pounds of savings if those staff were permanent. It is fair to say that the cost of agency staff is a key issue, and he was very fair in putting on record that Dorset HealthCare has reduced its agency staff spend over the past three years from £12 million to £4 million. That has not happened by accident. This is something that the Government have been prioritising nationally, and I pay tribute to the NHS Improvement’s work in placing a cap on agency spend in 2015, which very much addresses his point. Indeed, we have seen agency costs come down nationally by £1.2 billion since 2015, which shows the progress made under this Government.

My hon. Friend also understandably put on record his concerns about local beds moving from Portland Community Hospital to Weymouth. He mentioned the chief executive, Ron Shields. As he will be aware, Ron Shields has pointed out that twice as many patients using those Portland Community Hospital beds come from Weymouth, 6 miles away in my hon. Friend’s constituency, than from Portland. Clearly there is a benefit for patients if twice as many of those using the hospital are from Weymouth and the beds move to Weymouth. On average, four beds are taken by islanders, so it is a relatively small number, but I appreciate that it is an issue for those on the island.

However, there is a wider patient benefit, particularly for those from Weymouth. There is a benefit for all patients who move to Weymouth, because they can access a wider suite of services, including the services of a consultant with specialist expertise in elderly medicine, as part of a wider range of professional support. It is also important to emphasise to my hon. Friend’s constituents that the site is not closing; services are being reconfigured to reflect changes in the way in which healthcare is delivered. Again, that is happening nationally. As patients present with more complex needs and multiple conditions, we need to look at how we address that and how we deliver care more in the community, which is what patients want and is better for them, as well as how we better embrace technology, which is a key priority of my right hon. Friend the Secretary of State.

I am listening carefully to my hon. Friend’s reply. He is absolutely right: Mr Shields instinctively would like to keep community hospitals. In rural parts of the country, and certainly in South Dorset, with an ever-increasing number of elderly people moving there, there is very much a feeling of, “Where are they all going to be?” Experience in the past has shown that the best place for an elderly person to recover is near their home in a cosy community hospital. The system works. As the beds go for the reasons I have explained—Mr Shields rightly had no choice but to do it, and it is true that the hospital will remain open—those fears will not just disappear overnight.

My hon. Friend is right that being cared for close to home is in patients’ interests. I would actually go a step further and say that most patients want to be cared for and supported at home, if possible, because they are more likely to be mobile and to get up to make a cup of tea in their familiar surroundings. If that is not possible, they want to be in a community setting, but in that community setting it is better that they have access to a wider suite of services, including a consultant specialist, so that we can avoid the 43% of patients on average who are currently being treated in probably the most expensive part of the NHS family, the acute setting, where they are, for example, at greater risk of infection, notwithstanding the fact that since 2010, under this Government, the rate of hospital infections has halved. Even so, there can be muscle deterioration, or what one clinician called “PJ paralysis”. Staying in acute hospitals is often not in the best interests of an elderly patient, so treating them at home or in a community setting with the right support to reduce their length of stay is in their interests.

The crux of my hon. Friend’s remarks was a challenge as to what the Government are doing to tackle the need to recruit more nurses as we face a growing demographic. I remind him, as he is well aware, that the Prime Minister has committed to more funding for the NHS—a £20 billion-a-year additional funding package. There is a commitment to staff in the NHS through “Agenda for Change”, and the Government are introducing an increase in pay for nurses.

We are looking at additional pathways such as the nursing associate programme, which my hon. Friend referenced. There are 5,000 places this year and 7,500 next year. The programme enables people who perhaps thought they would not have the opportunity to be a nurse and were trapped in a particular role to have a ladder of opportunity and to move from roles such as healthcare assistant into that of nursing associate, with the option of then progressing into a nurse role.

We need to look at the nursing degree apprenticeship, and we are using the apprenticeship levy that the Government have introduced through the tireless work of the Minister for Apprenticeships and Skills. Again, that provides a great opportunity for people to progress within the NHS. We should also look at the measures the Prime Minister has taken on tier 2 visas—removing the cap—and recognise that attracting talent from overseas is an important part of addressing the concerns about recruitment raised by my hon. Friend.

We are looking at measures to give giving staff greater flexibility, such as through e-rostering, and using technology to provide greater certainty. There are also measures in relation to returning to work. Since 2014, 4,800 nurses have started on the return to practice programme to bring that talent back into the NHS. The Government are taking a whole suite of measures, because we recognise that there is a need for more nurses, exactly as my hon. Friend said.

The Minister is being most kind and generous in giving way. Will the bursary return? I would have thought that the bursary was more likely to attract home-grown talent. I am not saying that nurses from abroad are a bad thing, because they are not—they all do a wonderful job—but we are always trying to train our own. If the Minister brought back the bursary, I would have thought that was more likely to attract people from this country.

The problem with the bursary scheme was that it involved a cap on the number of places, so a massive number of people who wanted to be nurses were rejected and denied the life chance of being a nurse. The removal of the cap has allowed us to increase the number by 25%—an additional 5,000 places. That is 5,000 people who will have the opportunity to train as a nurse who did not have such an opportunity under the bursary scheme. It is also means that while they are training as a nurse, they will have a higher maintenance grant through the Student Loans Company than they did previously under the bursary system. I appreciate the concerns raised about the bursary, but this Government are all for giving people the opportunity to progress, life chances and the opportunity to increase their skills. The removal of the bursary scheme has allowed us to offer more people the opportunity to become a nurse, rather than fewer, as was the case under the bursary.

I do not want to choke off the opportunity for someone who aspires to be a nurse, but we should recognise that people want to progress at different stages of their lives. That is why the right option for some is to be a nursing associate. Some people may want to stay as a nursing associate, some may want to progress to being a nurse, and some may want to do a nursing degree apprenticeship. It is important that we offer the flexibility that people increasingly want in society so that they can pursue their careers at different rates and at different times.

The Government have taken a whole range of measures. I mentioned the “Agenda for Change” pay award, under which the pay of a healthcare assistant will go up by 26%, or nearly £4,000, over the next three years. A nurse with between three and four years’ experience will receive a 25% increase, which is more than £6,000 over three years, and a band 6 paramedic with between three and four years’ experience will have a £4,000 rise over three years. Again, as my hon. Friend mentioned, that recognises the hugely valuable contribution that staff make to the NHS.

I touched on the fact that we are looking at specific areas in which we recognise that there are issues and referred to the postgraduate golden hellos as a way of targeting recruitment. I have also said that we have lifted the cap on tier 2 visas. Under the existing arrangement, 40% of tier 2 visas were actually going to the NHS, but we have none the less lifted the cap.

I pay tribute to my hon. Friend’s campaigning on behalf of South Dorset. He is always assiduous in speaking to Ministers and raising concerns on his constituents’ behalf. We are repurposing services, but we are moving beds to where there will be better support, and these are some of the changes that will deliver an NHS fit for the future. I am happy to continue discussions with him so that we ensure the NHS continues to serve his constituents with first-class care.

Question put and agreed to.

House adjourned.