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Nursing and Midwifery (Amendment) Order 2018

Volume 792: debated on Monday 25 June 2018

Motion to Approve

Moved by

My Lords, today we are debating legislation that puts in place provisions to regulate the nursing associate role in England.

Health Education England’s Shape of Caring review made a series of recommendations to strengthen the capacity and skills of the nursing and caring workforce. The report identified strong support from employers, managers and staff in the health and social care sectors for a new nursing support role that would act as a bridge between the unregulated care assistant workforce and the registered nursing workforce. Health Education England undertook a public consultation on introducing the nursing associate role in England. The majority of respondents, a large proportion of whom were registered nurses, supported the new role, and there was strong support for it to be regulated.

Nursing associates will have their own defined role, augmenting and supporting the work of nurses in carrying out critical functions. They will deliver hands-on care, enabling registered nurses to spend more time using their specialist skills to focus on clinical duties and take more of a lead in decisions on patient care. We do not expect nursing associates to be primary assessors of care, but they will monitor the condition and health needs of those in their care and be able to recognise when it is necessary to refer to others for reassessment.

Although this new role will open a new career pathway into the nursing profession, I reassure all noble Lords that nursing associates are not substitute nurses. We want more not fewer nurses, which is why in October 2017 the Government announced a 25% increase in funded training posts for nurses to ensure that the NHS meets current and future nursing workforce needs.

It is vital that the right safeguards are in place. The Government’s view is that the most appropriate way to achieve this is through statutory regulation. This will support employers to use the role to its full potential and help ensure patient protection.

First, the effects of the proposed amendments to the Nursing and Midwifery Order 2001 are to give statutory responsibility to the Nursing and Midwifery Council to regulate the nursing associate profession in England. Secondly, they are to extend the NMC’s current powers and duties contained in the order to nursing associates, in particular the key functions of: registration of nursing associates in England; setting standards of proficiency, education and training and continuing professional development and conduct for nursing associates in England; approving nursing associate programmes in England; operating fitness-to-practise procedures in respect of nursing associates; and recognising Scottish, Northern Irish, Welsh, European Economic Area and international qualifications for the purpose of registration to the nursing associate part of the register.

Thirdly, this order amends the offence provisions in the Nursing and Midwifery Order. These amendments provide that a person commits an offence when falsely claiming to be on the nursing associate part of the register, falsely claiming to hold a nursing associate qualification or using the title “nursing associate” when not entitled to. The offences have been drafted to reflect that nursing associates will be regulated in England only.

Fourthly, the order makes provisions that allow admission to the register for those who have completed or commenced their training by 26 July 2019 through the pilot courses being run by Health Education England or an apprenticeship route. Fifthly, it excludes nursing associates from being given temporary prescribing rights in a time of national emergency, such as a pandemic flu outbreak. Sixthly, the order also removes the screener provisions from the Nursing and Midwifery Order 2001, as these are now redundant. Seventhly, it makes consequential amendments to the Nursing and Midwifery Council’s rules and to other legislation.

Finally, the order closes sub-part 2 of the nurses’ part of the register by amending the Order in Council which determines the parts of the NMC’s register and the titles which may be used by persons included in the register.

These are important changes to the governing legislation of the Nursing and Midwifery Council which introduce the nursing associate role into regulation. Employers have told us that they need a more flexible workforce to keep pace with developments in treatments and interventions. This role will enrich the skill mix available to employers within multidisciplinary teams and support the increase of nurse numbers by providing a clear pathway into the nursing profession.

Once the order comes into force, it is proposed that the Nursing and Midwifery Council will open the new nursing associate register in January 2019. I beg to move.

I thank the Minister for his excellent explanation of this order, which provides the Nursing and Midwifery Council with the necessary legal powers to regulate the nursing associate profession. On these Benches, we will be supporting the order, and I thank the Nursing and Midwifery Council and the RCN for their excellent briefs.

We are ready to accept that the creation of nursing associates is a welcome addition to building capacity. Some of us who are long in the tooth—there may be one or two in the House today—will remember SRNs and SENs and wonder whether we have gone full circle to move forward. However, I accept that there is some urgency to get this on the statute book because, initially, 2,000 nursing associates were training at 35 Health Education England test sites, with a further 5,000 starts planned for this year. The first nursing associates will qualify to apply for registration with the NMC from January 2019, so I accept the urgency to implement this order.

The Minister says that the nursing associate role is a defined care role to act as a bridge between unregulated healthcare assistants and the registered nursing workforce. Now that that role has been created, we agree with the Royal College of Nursing that,

“there must be absolute clarity that the nursing associate … is not a separate profession, but a new role within the nursing family that works under the delegation of the Registered Nurse”.

It went on to ask for “urgent guidance” to be published on “the precise relationship between” nurse associates and registered nurses,

“in terms of delegation and accountability”.

I hope that the Minister has taken that on board.

It is important to recognise that this new role is not the answer to the huge workforce challenges faced by the NHS and the social care system. Last week when the Government announced their funding proposals for the NHS, and the creation of a 10-year plan, many noble Lords said—we agreed—that it would be meaningless if this does not cover healthcare workers and social care workers together, given their importance in the future of our healthcare and social care system. Given that Health Education England has had its budget slashed, that we have a huge decrease in healthcare workers from the European Union, and the soon-to-be-removed—I hope—ridiculous visa system for non-EU health workers, the fact is that more nurses are leaving the profession than joining it, and there is a demographic challenge in that one in three nurses is due to retire in the next decade. In that context there is a well-founded anxiety that nursing associates could be used as a substitute for registered nurses.

Also in that context, has this new role been thought through, or is it a quick response to nursing shortages, with unfilled nursing posts which, as we know, are at a record high? Linked to that, how do we ensure that this new role does not impact negatively on the social care workforce? The head of Health Education England has highlighted that problem.

The role of a nursing associate was created before this SI was even introduced. Has there been enough time to consider the standards and levels of training for nursing associates to be registered with the NMC? I have to say that I am comforted by two things. One is the comprehensive brief from the NMC which suggests that it is on top of this, and indeed the notes accompanying the amendment order itself. I want to raise two things with the Minister, which are on page 5 of the accompanying notes and concern the cost-benefit impact analysis and the regulation of the nursing associates. Two risks are identified:

“First, there is a financial risk that the agreed initial set up costs escalate beyond those currently agreed with NMC. Second, the unquantified costs mentioned above relating to setting up and/or amending existing nursing associate courses as well as the accreditation of education providers”.

Those risks need to be mitigated before this moves forward in an orderly fashion. Finally, I think that there is provision in the order to take account of European Economic Area nursing associates, but I understand that this is not a uniform description or role that fits the narrative across the board. Will the Minister also comment on that?

Thank you for your commiseration. I support the Nursing and Midwifery (Amendment) Order 2018. I do so with a very personal endorsement and declare my interest as an honorary fellow of the RCN; as a consultant to HEE and the NMC, with which I have been working on these regulations; and as the author of the Shape of Caring report, which is the origin of the nursing associate proposal. I recognise the work of two people in particular. The noble Baroness, Lady Thornton, kindly and quite rightly mentioned the NMC and the work that Jackie Smith has done to bring this through the process. The NMC was presented with two big issues: the new standards for nurses and those for nursing associates, which it took on at the request of the Government. She has led both those processes admirably. Although she is leaving her post next month, this House, and the profession, owe her a great deal of gratitude for what she has done.

I also want to mention and put on record Samantha Donohue, a registered nurse currently studying for a PhD. Her job has been to deal with all the pilot sites, the 8,000 applicants and the 2,023 colleagues who have started training. This has been a Herculean job; at every stage there has been some objection to overcome. I hope that, when he responds to this debate, the Minister will recognise that at times we have in our midst people who do fantastic jobs and do not require to be told how to do them by people elsewhere: they just get on and do it.

The noble Baroness, Lady Thornton, suggested that this matter has been rushed through. I understand that the regulation has followed the start of the pilots but, as independent chair of the Shape of Caring review, it took me over two years’ work to produce the 34 recommendations that led to this process and the recognition that nursing standards needed to change. Quite often, we look at the healthcare workforce in silos, instead of looking at it as a complete, interdependent ecosystem. There are also silos within silos in every section of the healthcare workforce—medics, consultants, physios, care workers or registered nurses—each of which fights for its space. When I was doing this work, particularly when I visited the United States and looked at the Magnet hospital set-up, I was drawn to the fact that nurses are right at the centre of and pivotal to a 21st-century healthcare system. Unless you put them at the centre, the rest of it will not work as smoothly as it should.

I totally support the move of the workforce to graduate status, but we have not fully realised the potential of a graduate nurse workforce. This role frees the registered nurses for the leadership in care that they have been prevented from doing because they are bogged down—I do not mean that in a disrespectful way—by the host of other tasks they have to do. The idea of being able to lead this care while safely delegating is at the heart of the report’s recommendations. Both Robert Francis, in the Mid Staffs report, and the noble Baroness, Lady Cavendish, who produced the superb report on care workers, recognised that unless those two groups of workers—the noble Baroness, Lady Thornton, mentioned them, too—are properly trained and get a recognition within the training organisation, you cannot safely delegate to people when you cannot rely on their having the skills to carry out those tasks. The nursing associate fills that gap. It liberates the registered nurse and at the same time makes sure that there is safe regulation. The establishment of the nursing associate is not, as the Minister rightly says, a substitute for a registered nurse; nor is it an investment in their long-term career. It is a point of registration—that is all. This is not the time for this debate, but unless we make provision for ongoing professional development of the whole of the nursing and care workforce, we will not get the benefit from either the nursing associate or the new role of the registered nurse.

I shall ask the Minister a number of brief questions. The first is about the apprenticeship route. I support that route, as I think most Members of the House do, and the apprenticeship levy is an obvious route for employers to take when expanding the nursing associate workforce. There will be a temptation, however, which the apprenticeship route encourages, to tailor the experience of individuals to the needs of the organisation, rather than to recognise that huge strands are working through this role which need to be applied elsewhere. We must not fall into the trap of having people who can work in only one organisation. They need to be able to develop skills that are transferable to wherever they are expected to work. Will the Minister therefore confirm that apprenticeships, in common with other routes into nursing, must be NMC-approved programmes and must be delivered by NMC-approved providers? Will he also confirm that the requirement in the pre-regulation apprenticeship standard that programmes are delivered by NMC-approved AEIs that deliver nurse education will continue? Will he also confirm that any change to those processes will be reported to Parliament for debate?

My second question is on overseas applications. How we deal with that will be a real challenge as we move forward past Brexit. Will the Minister confirm that such applicants will not be eligible for the nursing association register unless they have comparable qualifications from a higher education establishment and have passed a competence test set out by the NMC? I hope the House will appreciate that I am trying to guard against a second class of nurses. We want people whose standards are set and we want to maintain them, wherever they come from. That is important.

Thirdly, on Scotland, Wales and Northern Ireland, I was disappointed—like I think many people in the House—that they are not part of this process. The NMC regulates across the United Kingdom, not just in England, and it is a sad state of affairs that we now have this separation between England and the other three countries. If the countries decide to introduce a similar post, will they be able to instruct the NMC separately to regulate it, or can they introduce a post with identical requirements—let us call it a nursing assistant—without regulation? It would be wrong if we found ourselves within the United Kingdom having different regulatory or non-regulatory systems around the same post in different jurisdictions.

There has been much concern about the new nursing associate role being a role in its own right or an adjunct to a registered nurse. The issue is clarified in paragraph 7.20 of the Explanatory Notes, but I think it will remain an issue. Therefore, will the Minister confirm that nursing associates will not simply be the handmaidens of registered nurses? That cannot be the case. This is part of the nursing profession, full stop. It is part of that family, with a distinct role, primarily to underpin the work of the registered nurse but also to carry out functions in its own right wherever needed. A classic example is nursing homes. At the moment, a host of relatively poorly qualified people are working in nursing homes, often under the direction of just one registered nurse. At night, that provision is often only at the end of the phone. We really must not have that. We must simply say that we want people we can rely on, who will have the confidence of patients and their families.

With those comments in mind, I say to the Minister that in 10 years’ time there will be some 70,000 nursing associates registered and working in the system. What a present it is that, on the 70th anniversary of the NHS, we are establishing a new workforce to supplement and support the existing workforce to deliver an even better NHS.

My Lords, I support the Minister and the Motion to approve the Nursing and Midwifery (Amendment) Order 2018. I acknowledge the challenges that the noble Baroness, Lady Thornton, has raised, in particular those that the Royal College of Nursing is concerned about, but believe that they are capable of resolution. I believe that the registered nurses who stand today will ensure that substitution does not happen for the roles that they really must undertake themselves.

I qualified as a nurse in 1976, when we still had enrolled nurses. For some time, I led a team that included enrolled nurses, but I was very clear, both as a district nursing sister and as a ward sister, that I was accountable for the elements that I delegated. That did not mean that enrolled nurses were not able to undertake routine care by themselves unsupervised, but rather that they were very aware of how to get help when they needed it. I believe that, if we get the nursing associate role right, a similar structure will occur.

I applaud the fact that nursing associates will have a clear ladder—probably through the apprenticeship route, as the noble Lord has just raised—to enable those who want to and who are capable to get university-level associated registration as a nurse. I do, however, regret that we have not called this new role a “healthcare associate”, because I believe that some of the work they will do will be undertaken in social care as well as in routine nursing care. We may need to reflect on that in years to come.

I also want to make it clear that this route should enable people to come relatively young into an adjunct profession that is associated, without them necessarily having A-levels on entry. That is important, because we know that a lot of young people would like to go into nursing or associated healthcare roles but are not able at that point to enter a three-year degree course. This is why I am so supportive of the structure.

The order makes provision for the new role of nursing associate to be subject to professional regulation by the Nursing and Midwifery Council. As has been explained, the first cohort should qualify in January 2019 and it is important for this legislation to be approved in sufficient time for the Nursing and Midwifery Council to open the register and put in place safe and effective standards and requirements for new staff entering the workforce. By regulating the role, the Nursing and Midwifery Council will contribute to the protection of the public by ensuring that nursing associates have high standards of education, will be required to keep their skills and knowledge up to date, and will be held accountable to a code of conduct.

As others have said, this new role has been rapidly developed as the result of successful work between employers and educational providers, with leadership from the CNO for England, Professor Jane Cummings, and the lead nurse at Health Education England, Professor Lisa Bayliss-Pratt, both of whom should be commended for their tenacity and work to achieve this end despite reluctance in some areas of the profession.

To reiterate an issue recently raised by the noble Lord, Lord Willis, many overseas applicants will want their qualifications recognised in relation to the nursing associate qualification, particularly licensed vocational nurses from a variety of Commonwealth countries. I urge the Government to ensure that proper funding is made available to map similar qualifications across the world so that we can make sure that we protect our own public if we allow overseas registrants to apply for this kind of qualification. It may be that they will need some kind of top-up, depending on the final standards that are agreed for nursing associates here.

I am aware that there have been challenges at the NMC recently but I echo the point of the noble Lord, Lord Willis, and acknowledge the commitment of the Chief Executive and Registrar, Jackie Smith, which has ensured that nursing associates will be registered at the NMC in order not only to protect the public but to achieve a proper career route for nursing associates if they wish to proceed to study for registration as a nurse in the future. In the longer term, I hope the nursing associate route may provide a successful apprenticeship approach for some members of the public to become registered nurses, without necessarily having to enter graduate-level study at a time that is not suitable for all.

My Lords, I too welcome the order; I am struck by the knowledge of the noble Lord, Lord Willis, obviously, and of the noble Baroness, Lady Watkins, from her own practical experience. It is right and proper that we have this debate because a number of questions ought to be raised. To be fair to the Government, they have not been able to answer all the questions beforehand because, as we all know, this order is somewhat rushed. I understand the reason why and I concur with it.

As the Minister mentioned, the order was laid on 17 May; that is absolutely right, but it was first laid on 11 May and had to be withdrawn because it was inaccurate. That is an example of how the legislation has been rushed. It is therefore important that we, as a legislature, challenge the Executive on a number of issues. As has been indicated—the Minister understands this—the Government have consulted widely to try to get the feeling that, if the report by the noble Lord, Lord Willis, was implemented, it would be done in a sensible and correct manner. However, there has been a problem in that a number of the consultees have a vested interest. For example, the local commissioning trusts have an interest about who is going to pay for this. Will the funding come from the centre or from them? I shall come back to that point in a moment. Obviously the providers—the universities—have an interest because they need the income from running these courses. But of course I now see, and this is slightly worrying, that it is not only higher education institutions which are involved—further education institutions are too. The noble Lord, Lord Willis, possibly referred to this point when he said that he was “slightly concerned”—I emphasise the word “slightly”—that there could be some downgrading of the teaching input.

However, one group has not really been represented in these consultations: the nurses themselves. People will refer immediately to the Royal College of Nursing and its equivalent for midwives. But the trouble is that that organisation, in terms of this area, also has a vested interest. It is a registration body for nurses, yet at the same time it is a member organisation and there can be a conflict of views which I have come across quite often. I have no problem with the RCN registering nurses because it is both right and sensible, but we must recognise that there is a potential difficulty. I have talked to a number of nurses who are concerned about nursing associates. However, they can be reassured by this order. As the noble Baroness, Lady Watkins, and the noble Lord, Lord Willis, have both said, nurses are professionals. Indeed, the noble Lord, Lord Willis, made a very wise point. The pivotal role of caring in hospitals ought to rest with registered nurses. That is where we ought to begin because they are professional people.

Even so, nurses are concerned that their views have not always been represented in this consultation. I am therefore pleased to note that paragraph 7.20 of the draft Explanatory Memorandum makes that clear. I shall repeat that because it is important that it is on the record and nurses can see what the position is. The Government say, quite rightly:

“Nursing Associates are identified as a separate profession with different qualifications and education and training to nurses and midwives”.

Nursing associates are not nurses. They are not fully qualified and registered so in that sense they do not represent a challenge to nurses. That point must be rung out aloud because we need to ensure that a profession which is under pressure and suffering from low morale is reassured.

Paragraph 7.9 provides even more reassurance when it makes it clear that nursing associates will not be capable of,

“providing, supplying and administering medicines”.

That too needs to be shouted out. Moreover, I assume—perhaps the Minister can confirm this—that this includes giving injections. I should think it does because it refers to “administering medicines”, but we need clarification. The point is reinforced where the draft memorandum talks about situations of national emergency, when nurses and midwives can be empowered to prescribe. A flu pandemic is cited as an example. That is very sensible because we need the hands and brains of these people to do the job. Nurses help doctors, but it is made quite clear that the education and training of nursing associates is not of the same high standard as that of registered nurses. They will not be allowed to prescribe medicines in a national emergency situation or even a hospital emergency situation. I have spoken at some length, more than I would normally, but this House perhaps needs to help the Government to reassure qualified nurses that their status is not under threat.

I will deal with one or two other points. Paragraphs 7.14 to 7.16 talk about the two-year pilot courses. We understand why they were brought in, and I hope that we have learned a lot from them. Perhaps I might press the Minister on the number of people pursuing nursing associate courses at the moment. The Health Education England plan is for 5,000 nursing associates in training this year. I recollect a debate not long ago in this House in which the number of nurse associates in training was given not as 5,000 but 30—not 30,000 but 30. The Minister said, “I’m pretty sure those figures are wrong—they are too low—but the figure is disappointing”. I wonder whether he has up-to-date figures for the number of students expected to be on NA courses this year, because the projection is important in planning ahead for the workforce.

The other issue that concerns me is apprenticeships. Having done an apprenticeship, I would say that there are two ways of looking at it. Many people think that apprenticeships are a very good way of getting a trained workforce—and, if the courses are right, they certainly can be. But they are not always the answer. In this case, narrowing it down to nursing associates, we are thinking of two routes: there is the apprenticeship route and there is what you might call the normal route. As I understand it, at this stage it will be a two-year course, mainly but not exclusively for ex-healthcare workers, and the course will be in-work coupled with classroom training at a university or college of further education. Will the Minister give us a bit more information on the two training routes?

I will raise another point. There is a lot of detail in the order about set-up costs, but what about the ongoing costs of nursing associates? For example, taking the more conventional two-year route to get the status of registered nurse associate, who will pay for those two years? They will have to be paid for: the universities will need the money. There is talk of charging £7,000 a year for each student, which is £2,000 less than qualified registered nurses will have to pay. Who is going to pay that? Will the Government give a commitment that they will pay the fees?

The same argument applies to apprenticeships. Who is going to pay the fees? Is it the local employing body? If that is the case, there will be a lot of encouragement for local trusts not to have NAs, because they will have to pay for them. Why are the figures related to that?

Perhaps I might help. Some of the thinking behind the funding model, in particular for apprenticeships, relates to the levy. It will not apply to very small trusts, but most large trusts have a 0.5% employment levy, and to apply that through the apprenticeship route seems very logical. Whether it will work is a different matter, but that is the logic.

I am very grateful for that—and I understand that many trusts contribute to the levy. Perhaps the Minister could give us an indication of what the breakdown will be between the conventional course and the apprenticeship course for nurse associates. That would be helpful, because one has to bear in mind that the cost to a registered nurse undergraduate is £9,000 a year. That is what they have to pay—which means that they will pay £27,000 to get their qualification.

We need to continue at a high level. As the Minister said, we have increased the number of nurses in training; I found that very encouraging. He is absolutely correct. But why should somebody who wants to become a registered nurse spend £27,000 over three years when they could do a conventional NA qualification for two years at no cost, then do another year to become a fully qualified registered nurse? It just does not make sense. The Government have to look at the funding of nurse support training as a whole. I hope that they do so.

I felt that it was right and proper to raise these difficulties as they have not been raised elsewhere because, as I said, many of the consultees have other interests in putting forward their points of view.

My Lords, the noble Baroness, Lady Thornton, and the noble Lord, Lord Willis, asked about the impact of this new profession on the wider healthcare workforce. I wonder whether it is helpful to ask the Minister at this point a little about possible impact, if any, on health visitors. There is real concern about the decline of health visitors; they had a resurgence in recent years but are in serious decline now. I do not wish to detain the House for too long if this seems a bit beyond the main business.

I am a patron of the charity Best Beginnings, which provides mental health and perinatal support for parents. I spoke with the chief executive last week. We recognise that health visitors are very important, as healthcare professionals working in the vital perinatal period to ensure the best attachment between parent and child. I recently spoke with the president of the Institute of Health Visiting, Dr Cheryll Adams. Again, she expressed concern about the decline of the number of health visitors. As we establish a new healthcare profession, do we not need also to think about this other, declining profession under the healthcare umbrella?

I imagine that there is no plan to replace health visitors with these new healthcare professionals, but sometimes there is a misunderstanding that health visitors are just there to weigh the baby, when anyone could do that. In fact, when family-nurse partnerships were introduced to support vulnerable parents, the outcome was significantly better when higher qualified practitioners worked with the families. This job is challenging, because people are often working with vulnerable families in poor housing and poor conditions. It is a demoralising profession, unless one has a good professional foundation.

I emphasis the importance of the vital early years. As Graham Allen and Mr Field MP have established, the first 2,000 days in a child’s life are the most important. We need to ensure that the best professionals are available to them. Two or three years ago, health visitor funding went from the Department of Health to local authorities. We all know that local authorities have very little money to spend, so it is not surprising that there has been a significant decline in the number of health visitors. Does the Minister recognise concerns about that decline? Will he assure the House that he is keeping in mind the health visiting profession and what can be done to sustain it and ensure its continued health?

I have a final question. This particular new brand of healthcare professional gives rise to the problem of professionals from the developing world being pulled in to fill the niche. I am sure that the Minister can assure us that we will not poach healthcare professionals from Nigeria, Ghana and elsewhere, but the possible risk of that certainly comes to my mind. I welcome the order and I look forward to the Minister’s response.

My Lords, my contribution will be very short, as noble Lords have already said everything. We, too, welcome the role of the nursing associate. I commend the work of my noble friend Lord Willis of Knaresborough in making this happen and say to him that he can have the Front Bench if he is happy to take all that goes with it.

The noble Earl, Lord Listowel, made the point about impact. I just make one extra point. In remote locations—I live in Cornwall, but this could account for anywhere far-flung where there are hospitals and health establishments—there will be uptake from healthcare assistants who feel that they cannot leave home to train as a nurse because the distance is too great and they have family responsibilities or other commitments, but they could manage the two-year course. That would be really positive. Nursing associates would then improve in those establishments the quality, but also the skill mix, of nursing teams in areas where it is also particularly difficult to appoint.

I understand the timing of this SI. The noble Lord, Lord Clark of Windermere, said that perhaps there was still stuff to look at. It is really important that it gets on to the statute book, because we will have real live trainee nursing associates who need to register next year. Sadly, we cannot take any more time to do this, but from these Benches we really welcome the role of the nursing associate and the help it will give the NHS.

My Lords, I sincerely thank every noble Lord who has spoken in the debate and engaged with these regulations so thoroughly. It has been a really important discussion about not just the new role of nursing associate but its impact on the overall health and care workforce. I am very grateful to all corners of the House for the broad welcome, albeit with questions and conditions, for the creation of this role.

I want to deal up front with the urgency of these regulations. I agree that there has been an element of rush, and I think we are all agreed on the requirement for it. But like all overnight successes, this has been a long time brewing, as the noble Lord, Lord Willis, pointed out. A lot of work has been done, and I salute, along with all noble Lords, the many people at the RCN, the NMC and others who have contributed to this, and the many people behind the scenes. It is quite right to acknowledge them. No doubt there is more work to come.

The primary debate, or part of it, revolved around the distinction between the nurse role and the nursing associate role. It is very important to be clear, as I hope I was in my speaking note, that these are distinct professions. They may all be part of the same family—there is a certain amount of semantics involved here—but they are distinct professions, which will be regulated distinctly, albeit in a joined-up way through the same regulator, which is quite right. The NMC is currently consulting on standards of proficiency. The department, with all the necessary arm’s-length bodies and others, will develop guidance for that separate profession. While nursing associates can inevitably support nurses, doctors and others, they will not just be the handmaidens to others, in the evocative phrase of the noble Lord, Lord Clark. They will be professionals in their own right.

It is also worth pointing out that, in the consultation going on at the moment on standards and proficiency, the NMC is also looking at the code of conduct and amendments to it. That consultation ends on 2 July so, again, I warmly encourage all noble Lords to contribute to that, because some of the ideas set out today could have an important role in getting that right.

The noble Baroness, Lady Thornton, asked about the financial risks involved in setting up the courses—making sure that they are properly constituted and so on. My department has a memorandum of understanding in place with the NMC to keep the costs of the set-up within agreed cost parameters. The costs of accrediting nursing associate courses are met from the annual registration fees paid by the NMC’s registrants. Therefore, the financial modelling has been investigated and we understand what we need to stick to.

I, along with the rest of the House, congratulate the noble Lord, Lord Willis, on his role in helping to bring the nursing associate position into being. He made a very good point about it being a role that will help us to get the most out of our highly skilled registered nursing profession. The introduction of skilled teaching assistants into the education profession involved work that could be done by teachers. However, as teaching became not just a graduate profession but, in many cases, a master’s graduate profession, the introduction of that role helped to unlock the skills of the teaching workforce and provided a balance with clearly delineated boundaries—although arguably education could do with more delineation—and that is what we are aiming for by going through this route.

The noble Lord asked about the apprenticeship route. The apprenticeship courses under consideration for nursing associates are level 5 and they will be about creating transferable skills. The pilot schemes are not NMC-approved but, once nursing associate training is on a full statutory footing, the schemes will have to be NMC-approved. The order ensures that the only way for nursing associates trained in England to join the register is by holding an NMC-approved nursing associate qualification. I can also tell the noble Lord that the NMC will need to approve higher education institutes or education providers wishing to deliver nursing associate training once it is the regulator, so I hope that provides reassurance.

Several noble Lords asked about overseas applications. Again, it is important to distinguish between overseas citizens already resident in this country and those currently resident abroad. The noble Earl, Lord Listowel, made an important point about not wanting a system that relies on taking skilled individuals, in particular, out of developing countries, although we have to acknowledge that we currently allow for that in some cases. Clearly, it is important to have comparable qualifications and to pass a language test. Our future relationship with the European Union and mutual recognition of professional qualifications and so on will determine what that looks like for that particular group. However, we are clear that, once the NMC opens its register, overseas applicants who can demonstrate that they meet the standards will be able to join it. It is of course about maintaining those high standards throughout.

Noble Lords were right to comment on the absence of the devolved Administrations in taking forward this route. That of course is their right and prerogative. This route has been designed to meet the specific needs of the English health and care workforce. We have had very positive discussions and relationships with the devolved Administrations in developing this role. They intend to see how it develops and is implemented before making a decision about whether to implement it in their own countries. I can confirm that it would require a further order if they wanted to extend the regulation of the role into Scotland, Wales or Northern Ireland. I would be amazed if they wanted to introduce this kind of role on a formal basis without any kind of regulations, and I am certain that that is something we would not want to see happen and would strongly argue against.

The noble Baroness, Lady Watkins, who speaks with great experience in the area of nursing, quite rightly pointed out that this is a good route for people without qualifications to enter the nursing family, to coin a phrase. I am sure she will have seen the NMC briefing, which has a rather wonderful quotation from a nursing associate trainee at the Cheshire and Wirral NHS trust about what it has enabled her to do. She clearly has that aspiration in the long run and that is fantastic. However, equally, it is right that, when she takes those qualifications, she will gain a qualification and be a professional in her own right.

The noble Lord, Lord Clark, was right to put the Government under scrutiny, as he always does, and to ask several incisive questions. He made a point about potential conflicts, but that is in the nature of the beast. It is worth saying that the consultation responses included 203 from individuals working in the NHS or in healthcare delivery. The responses were not separately coded for nurses, although perhaps in retrospect they should have been. This was to make sure that we were talking not just to the institutions, because they can have a vested interest. Having all these professions under a single regulatory framework but as separate professions is the right way to balance those issues.

On the number of nursing associates in training, about 2,000 are on the pilot scheme. The intention is for that to rise to 5,000 in training and then 7,500 the year after. That is just for nursing associates; we are not talking about nursing. On who pays the training cost, this is absolutely intended to be an apprentice route—a level 5 foundation course. The apprenticeship levy therefore comes into play as a source of funding.

The noble Earl, Lord Listowel, talked about health visitors. I do not believe that there is any specific impact on health visitors. I absolutely agree about their importance in the early years of a child’s life, and indeed for their parents. I do not think there is any direct impact, but I will double-check and write to him.

The noble Baroness, Lady Jolly, made a very interesting point about this being particularly attractive in areas where it is hard to recruit. In one way it solves one problem, but it serves only to highlight another: if these are not substitutes, which they are not, that does not mean that we have necessarily solved the nursing shortage in rural areas. It is important that we keep those issues distinct.

May I press the Minister a little further on the training costs? Is he saying that all students on the nursing associate courses will be apprentices and that no student on the nursing associate course will pay towards the cost of that course?

I thank the noble Lord for that question. My understanding is that the nursing associate is a two-year apprenticeship that provides a level 5 qualification. Therefore, there is currently a consultation about the nature of the role—the balance between work and training and so on—but obviously if it counts as an apprenticeship any organisation providing it can draw down on the apprenticeship levy fund to pay for those training costs. Whether it is in theory possible to train through an alternative route that would involve the paying of fees is something I will need to investigate and write to the noble Lord about. Of course, I will put that letter in the Library. The funding is there and the NHS is paying it. It is not necessarily drawing it down at the moment; this is an opportunity for us, with a course that is tailor-made for apprenticeships, to take advantage of that money to fund the courses.

I hope I have been able to answer noble Lords’ questions. This is an exciting moment in the development of the workforce. It provides an extra gear to the workforce to provide for the ever more complex care needs of our population. This is a good step forward. We are moving quickly and I look forward to working with noble Lords in the coming months to make sure we can put this course and its regulation on a statutory footing, attract many thousands of people into it and welcome a new profession into the health and care family. On that basis I commend the order to the House.

Motion agreed.