The free degrees

On Wednesday the government announced that, from 2017, students starting their training in nursing, midwifery and the allied health professions (AHPs) will need to take out student loans when the current state grant is withdrawn. The spending review statement says this will create 10,000 additional training places by 2020 and help reduce the now capped, but eye-wateringly large, agency spend which has fuelled the unprecedented growth in hospital deficits across the country.

Ending the national bursary could save as much as £2.72bn over three years and it should also reduce the NHS’s chronic dependence on overseas recruitment. In 2013, almost 13% of its nursing workforce was imported.

Dispatching perspiring HR managers to foreign parts with job offers need not be the new normal. Each year in England about 54,000 people make 200,000 applications for fewer than 23,000 training places, so England isn’t short of bright young people with good intent who want to be nurses. Lancashire Teaching Hospitals Foundation Trust  already guarantees jobs to nursing students who fund their own training. The scheme was hugely oversubscribed in the first cohort, with 160 applicants for 25 places. The employer demand is there and the supply is ample, so a move from a planned to more of a market economy makes good sense on the face of it.

For students, a free course is more attractive than many years of substantial debt. But the move does mean that new self-funding students will, in the short term, be 25% better off than their state-subsidised counterparts in the year above them. So while the drinks will be on them in Freshers’ Week 2017, they will, together with the necessities a loan needs to stretch to, need to be paid for when the students eventually start work. Even so, initial estimates of repayments of roughly £27 a month are arguably a reasonable price to pay for a qualification that more or less guarantees a job for life, albeit a demanding one, anywhere on the planet.

It is easy to overplay the merits of markets over planning, but for nursing, a more open approach might well have mitigated the recent pressures on nurse recruitment. England has had a chronic shortage of domestically trained nurses for many years, a problem that became acute in recent years. HEE and the Department of Health, forecasters rather than psychics, did not anticipate the surge in demand for hospital nurses that began in the lead up to Francis and gained pace in its aftermath. Beyond the unions, few people were arguing for a big hike in nursing numbers in 2010 so as financial pressures tightened training numbers were reduced accordingly. Before the public inquiry, safe staffing simply wasn’t the issue that it is today.

Those excited by the possibility of an oversupply of nursing labour – which will finally put management in the pay and conditions driving seat – should also beware.  The public, media and parliament can be intolerant of unemployment in health professionals, particularly if the quality of health care is in doubt or access to health care is difficult. With a degree that is vocational, nurses may be less inclined to look for a different career and their unions can be highly effective advocates. So an excess of nurses might create new problems – although perhaps the sort of problem the NHS would prefer.  Today the expansion of international labour markets – sunny Australia and beautiful New Zealand, for example – may provide a safety valve for the pressures that might come from an unaffordable surplus of health care workers. It is interesting to note that England today is already a net exporter of nurses.

The Royal College of Midwives and Unison have expressed strong concerns about the potential impact on recruitment of ending the bursary, and the implications for social mobility if poorer applicants are deterred by the prospect of substantial debt. While unenthusiastic, the Royal College of Nursing and the Chartered Society of Physiotherapy recognise the devil of the move will be in the detail and want to be engaged on how the changes will work in practice. The average age of a student nurse is 28, half of them have children and a significant proportion do nursing as a second degree and might be ineligible for a second loan. These risks to social mobility will need to be designed out by policymakers.

And this is not just about nursing. AHPs include everything from chiropodist/podiatrist, dietitian and music therapist to physiotherapist, diagnostic radiographer, and speech and language therapist. While demand for nurse training places is strong, we need to be clear that the same is true for the AHPs to ensure the NHS has the right mix of staff it needs.

Finally, there will need to be careful consideration by HEE and Local Education and Training Boards (LETBs) about how to ensure high quality clinical placements and good mentors for a substantial increase in trainee numbers. Health Education Wessex have estimated that training 50 more nurses requires 1000 weeks of placement each year and HEE are spending £88m this year on placements.

Overall, with proper focussed and constructive engagement between unions, universities, deaneries, LETBs, HEE, Department for Business, Innovation and Skills, the Department of Health and NHS Employers, there should be pragmatic solutions to mitigate the most obvious risks here. However, demographic monitoring of future cohorts of students will be important to ensure that the break-up of the free degrees does not result in what one online commentator dubbed a ‘wealthy, young, single, white, female’ profession.

Gavin is a Policy Associate at the Health Foundation, www.twitter.com/gavin_larner