In the last Spending Review, the Government announced that all new nursing, midwifery and allied health professional (AHP) students would no longer have their fees paid for by Health Education England (HEE) and be eligible for a bursary to support their living costs. Instead, they would receive funding and financial support through the standard student support system.
The official rationale behind these changes is threefold. The new system would aim to boost the number of student nurses and AHPs, create a sustainable funding system for universities and increase the amount of money full-time students receive to live on. But while it's not publicly acknowledged, this policy is implicitly driven by the need to cut the amount of money invested in NHS staff training.
Money the Government saves from cutting nursing and AHP bursaries – estimated to be around £650 million a year – is not being reinvested elsewhere in the service. These proposals therefore represent a significant loss of funding to the health sector in this country.
While we recognise the urgent need to find savings, cuts to the training budget seem short-sighted. Shortfalls in staffing threaten safety and the quality of patient care, and can ultimately cost significant sums if they fuel a reliance on bank and agency staffing. The nursing shortage in England's NHS is significant and growing; and the planned withdrawal from the European Union is likely to exacerbate the situation. Some 20,000 European-trained nurses have registered to work in the UK in the last four years. There are clear signs of shortage in some allied health professions as well. There is an urgent need to address this shortfall.
But do the Government's bursary proposals actually address this challenge?
Will the proposals increase the number of students training to be a nurse or AHP?
As the Government consultation document lays out, places to study nursing at university are generally oversubscribed. In addition, recent experiments with offering courses without bursary support seem to have been successful. For example, Lancaster Teaching Hospitals is involved in an early adoption of loan-funded nursing courses with the University of Bolton. This would suggest that the numbers of nurses could grow if the constraint on numbers of university training places imposed by HEE commissioning decisions was removed.
Workforce planners in England and elsewhere have had significant difficulty accurately forecasting health care workforce numbers. The number of variables and degree of uncertainty make it very difficult for accurate estimates of future demand to be reached. HEE has had particular difficulty recently matching nursing output to service need. A reliance on estimates from hospitals has proven not to be a robust way to forecast the need for nursing staff.
Some bodies representing AHPs have expressed concern that while the policy may work well for nursing, where places are relatively oversubscribed, the situation will be very different for other subjects without such unmet demand for places. Figures from UCAS support this in some cases: the ratio of applications to acceptances is 12 per cent for nurses, and similar for the category including physiotherapists. However, it is higher, at around 18 per cent, for categories including occupational therapists and dietitians. This is roughly in line with the average ratio of applications to acceptances in other educational fields that are not limited by HEE commissioning. In other words, these fields may already be accepting as many applicants as they would if places were unlimited.
In addition, the prospect of taking on over £50,000 of debt could act as a significant disincentive. Many studies suggest that, like almost any other service, demand for academic courses is 'elastic', with higher prices putting people off. This situation could be made worse by the demographic profile of those applying to do nursing. Health care profession courses have an intake that is disproportionately female; older than 25; and with children. The new loan-based support system is less generous for childcare and for people with dependents. The Department of Health's own impact assessment shows that the original introduction of student fees had a much more significant impact on those over the age of 21 compared to younger students.
There are also unanswered questions about how the proposed more flexible approach to university funding aligns with the intention to continue funding student placements in hospitals centrally – both in distribution and volume. If courses are expanded, will the money for placements follow the students and will local hospitals have the capacity to take on the additional students? If so, we can assume that this would require significantly increased funding if student numbers do expand.
Furthermore, it might mean certain geographic regions and sectors receive far more clinical placements, and others far less. This would seem difficult to reconcile with the limits on the capacity of local health services to provide experience. The Royal College of Nursing has already expressed concerns that clinical placements, where nursing students spend 50 per cent of their time, may not be providing enough of the mentors who oversee students.
Alternatively, will placements be allocated to universities in advance, as suggested by the College of Occupational Therapists? If so, this would retain a powerful role for central planning.
Alternative proposals
In addition to challenges in recruitment, the NHS faces a significant issue with retention. These problems will not only be exacerbated by our withdrawal from the European Union, but by the forecast shortfalls in nursing in many English-speaking countries. It is highly likely that nurses trained in England may increasingly start to see working in the United States, Canada, New Zealand and Australia as an attractive career option. This argues for an approach that not only opens up training places but provides incentives for nurses and AHPs once trained to stay in the NHS.
One way of doing this may be to offer nurses and AHPs reductions or repayments of loans on condition that they work in areas of need and/or continue to work in the NHS for a defined period of time – say five years. This could either be done centrally or via the local employers (with central funding).
In addition, there needs to be central funding to support courses and training in specialist fields which may find it difficult to attract the same or higher numbers of applicants. Otherwise, there is a very real risk that not only will numbers fall, but the number of universities offering training in these areas could fall.
These reforms come at a time of significant crisis for the NHS in staff recruitment, retention and morale. There is a risk that, if improperly executed, they could do more harm than good. Adjustments and safeguards need to be put in place to ensure that the need for savings now is balanced with the need to attract and retain nurses and AHPs across England for the service's future.