Nursing degree apprenticeships: in poor health? Contents

Introduction

Background

1.The Government announced the creation of nursing degree apprenticeships in November 2016, with the aspiration that the first apprentices would begin their training in September 2017. The Government said that it envisaged 1,000 people each year starting a nursing degree apprenticeship, part of its ambition to expand the number of apprenticeships in the NHS from 20,000 to 100,000 by 2020. As the largest employer in England, the NHS’s apprenticeship levy contributions are considerable, totalling approximately £200 million per year. Health Education England (HEE) has calculated that the NHS will need to employ 27,500 apprentices annually to use the entirety of its levy.1

2.The announcement that degree apprenticeships were going to be established for nursing followed a move from a bursary-based system for undergraduate nursing to a loan system in 2017. The latest Universities and Colleges Admissions Service (UCAS) figures show that the number of applications for nursing degrees has dropped by a third since the bursary was removed. There is already evidence that this has been a significant deterrent to mature students in particular. Successful applications from people under the age of 21 rose in the first year after the bursary was removed (for 18 year-olds, an increase of 11%, for 19 year-olds, an increase of 2.3% and for 20 year-olds an increase of 6.1%). However successful applications from 21–25 year-olds dropped by 13% in the same period and successful applications from people aged 26 or over fell by 6%.2

3.The drop in applications from mature students is particularly concerning given that mature students are more likely to remain in the profession.3 Also concerning is the impact on specialty nursing courses, including mental health and learning disability nursing. Last year, Sheffield Hallam University recruited just 70% of its target intake, and London South Bank University made the decision not to run its learning disability nursing programme due to a shortage of applicants.4

4.In January 2018 the Health Committee published its report on the nursing workforce.5 The inquiry sought to assess the impact of new routes into nursing, and explored student funding reforms, the apprenticeship levy, Nurse First and nursing associates. The Committee welcomed the introduction of nursing associates; concluded that the Government needs to closely monitor the impact of the removal of nursing bursaries; and noted that stakeholders had raised concerns about financial difficulties for providers in implementing apprenticeships standards for graduate nursing.6

5.Despite the Government’s ambitions for increasing the number of nursing degree apprenticeships, initial provision was small—it is understood that there were no more than 30 starters across two universities, Anglia Ruskin and the Open University.7 Neither of these universities was among the four which had been allocated funding by the Higher Education Funding Council for England (HEFCE) to develop nursing degree apprenticeships in advance of their launch. Since April 2017 the Nursing and Midwifery Council (NMC) has approved 19 nursing degree apprenticeships, and currently approves 61 providers to deliver nursing degrees in England.8

Our inquiry

6.As the Committee with responsibility for scrutinising apprenticeship policy and as advocates for degree apprenticeships, we considered it important to examine why so few nursing degree apprenticeships had been created. We also sought to explore what action could be taken to ensure that anyone who wants to train as a nurse via a degree apprenticeship route is able to access a degree apprenticeship. We wanted to know whether degree apprenticeships as a successful and sustainable route into nursing can be a reality, or whether it will always be simply a mirage—an unrealistic hope that won’t be achieved.

7.We held an initial oral evidence session with the Council of Deans of Health, NHS Employers, the Royal College of Nursing (RCN) and the Open University, which established the first nursing degree apprenticeships in the country. We also received written evidence from the first three of these witnesses, along with the Nursing and Midwifery Council (NMC). Our second oral evidence session with the Chief Executive of Health Education England, Professor Ian Cumming, the Minister of State for Health, Stephen Barclay MP, and the Minister of State for Apprenticeships and Skills, Rt Hon Anne Milton MP, was held on 17 July 2018. We are grateful to all those who provided evidence to this inquiry.

A special case?

8.The evidence we have heard is clear that, as it stands, there are difficulties with the delivery of nursing apprenticeships. Witnesses told us that when apprenticeship policy was being developed, it was assumed that all apprenticeships were the same, and that insufficient attention had been given to adapting apprenticeships to meet the needs of the NHS.9 Concerns have been raised about the financial viability of apprenticeships for providers, the challenge for employers in the NHS at a local level of setting up a large number of new, high-quality apprenticeship programmes, and the need for more placements and learning support in the workplace.10 An additional complication is the greater off-the-job requirement for nursing apprentices; NMC requirements mean that nursing degree apprentices must undertake off-the-job training for 50% of their hours.

9.The rate of progress in the development of nursing degree apprenticeships has been slow. The Government expects over 400 nursing associates to progress to nursing degree apprenticeships from 2019, with this figure expected to grow, yet it has provided no evidence of policy changes it plans to make to achieve this.11 Given the small number of nursing degree apprenticeships to date, and the serious affordability concerns raised by universities and NHS Employers, more action is required to achieve the Government’s ambitious target.

10.The NHS is an organisation unlike any other provider of apprenticeships. It is the biggest contributor to the apprenticeship levy and faces the added complexity of external requirements set by the nursing regulator (the Nursing and Midwifery Council), including the larger “off the job” requirement (NMC requirements mean that nursing degree apprentices must undertake off-the-job training for 50% of their hours) and the supernumerary status of nursing degree apprentices. Dr Katerina Kolyva, Executive Director, Council of Deans of Health, told us about the complexity of the environment in which apprenticeships, the universities and the employers are operating and the maze of bureaucracy that must be navigated:

We are sitting between higher education regulation and healthcare regulation. [ … ] The Department for Education has full accountability working with the Department of Health, but the Institute of Apprenticeships is in charge of equality and approvals. The Education and Skills Funding Agency deals with operational management of the funding. The Office for Students, Ofsted and the NMC are the regulators of higher education in healthcare, depending on which level of apprenticeship we are talking about. We have from nursing associate up to advanced clinical practice. When we get to policy, we have the University Vocational Awards Council, individual trailblazer groups of employers and universities working together, Health Education England and Skills for Health. I could go on.12

11.The Government’s public sector apprentice target states that apprentices must make up 2.3% of the headcount of most public sector bodies with 250 or more employees. Our predecessor Committee conducted a joint inquiry with the previous Business, Energy and Industrial Strategy Committee on apprenticeships. The evidence it heard on the public sector target was “largely negative”:

NHS Employers identified a lack of higher and degree level standards, business need caused by outsourcing of services and staff to provide support and mentoring as “key barriers”. [ … ] We are especially concerned that much of the increase in numbers could come from the rebadging of existing programmes.13

12.Setting an ambitious target for apprenticeships across the public sector is vital to promoting their uptake as part of a wholesale shift in our economy. But that target must be realistic, and any barriers should be torn down. There are too many obstacles in the way of nursing degree apprenticeships, making it extremely difficult for the NHS to play its part in achieving the public sector target.

13.The Government should maintain an ongoing conversation with the NHS to ensure that it is supported to develop a sufficient number of quality nursing apprenticeships.

14.We recognise that nursing degree apprenticeships alone will not solve the nursing workforce crisis or improve access to nursing for those from disadvantaged backgrounds. However, no-one should be prevented from undertaking a nursing degree apprenticeship due to a lack of availability or take-up within the system. We welcome the Government’s cross-departmental work in establishing nursing degree apprenticeships and we look forward to it developing with a focus on expanding the programme to ensure that every future nurse has a choice about their route into the profession.

15.There is currently little incentive for the NHS to spend precious time and resource building nursing apprenticeships. It is imperative that nursing apprenticeships work for the NHS as well as for providers and nursing students.

Supernumerary status

16.The Nursing and Midwifery Council (NMC) regulates nurses and midwives in England, Wales, Scotland and Northern Ireland, and sets standards of education, training, conduct and performance. Nursing apprenticeship programmes need the NMC’s approval so that graduates are eligible to register with it after completion of their programme.

17.The NMC requires students to be additional to the staffing levels deemed necessary for safe care in any setting, because they are still working towards meeting the NMC’s standards. This is referred to as having “supernumerary status”. The NMC says that supernumerary status is

A safeguard against patients receiving unsupervised care from people who are working towards meeting our standards, and the demands of service preventing students from having the opportunity to rehearse, reflect, and apply their developing knowledge and skills.

The NMC further explains the rationale for supernumerary status for students:

Students can contribute to safe care but this shouldn’t be reliant on them, because they will gain confidence and competence at different rates. Patients also have the right to refuse to be treated by a student.14

18.In practice, this means that apprentices cannot be considered part of the workforce and cannot be included in any staffing figures or calculations. Employers will need to backfill these individuals, at a rate estimated by NHS Employers to be between £7.88 and £10.15 per hour.15 NHS Employers told us in written evidence that “this additional cost is a significant financial burden for NHS organisations wishing to offer the Nursing Degree Apprenticeship, and is proving to be a disincentive for establishing Nursing Degree Apprenticeship programmes”.16

19.We acknowledge the reasoning behind supernumerary status for students and apprentices. This was reflected in the written evidence we received from the RCN:

The introduction of the supernumerary status was designed to give student nurses the opportunity to experience nursing practice, but no responsibility for patients, so that they can realise their own needs and also understand their professional responsibilities. Any compromise to supernumerary status of nursing students would compromise patient safety as well as undermine nursing students’ learning and ability to practise safely on registration.17

20.The NMC told us in written evidence, however, that it was open to alternatives to supernumerary status, provided patient safety was protected:

We’re consulting on whether nursing associate students should be supernumerary, or whether there are other approaches that would keep patients safe and give students the opportunity to learn. We’re working closely with employers and others to explore the options.18

21.The NMC’s consultation is focused on nursing associate students, but any recognition that patients can be kept safe and students can learn effectively even when they are considered part of the workforce could have an additional benefit for nursing degree apprenticeships. We received written evidence reporting the views of current nursing apprentices which reiterated the importance of monitoring the use of supernumerary staff and how they are deployed.19

22.We look forward to the outcome of the NMC’s consultation on whether nursing associate students should remain supernumerary and whether there are alternative approaches. We urge the NMC to apply any safe and effective flexibility to supernumerary status to nursing degree apprentices in addition to nursing associates.

Apprenticeship levy

23.We are encouraged that there is support for the creation of nursing degree apprenticeships from all stakeholders in the nursing profession, with the barriers to their creation stemming largely from issues with current policy in this area.20 Danny Mortimer, Chief Executive of NHS Employers, told us that inflexibility in the apprenticeship levy is a key frustration for employers:

I think the particular frustration for my members is that we see our colleagues in the university sector moving as quickly as they can on the regulatory piece with the NMC; we see support from trade unions in widening participation and support from within the profession more broadly; but we also see an inflexibility in the apprenticeship levy as a matter of policy, which means that it is a very expensive way of training a nurse. It means that we cannot properly fund the time that we need to release on nursing apprenticeships.21

He also explained the issue of a lack of recognition around the differences between nursing degree apprenticeships and other degree apprenticeships:

The current policy and the Department for Education do not recognise or accept the difference between a nursing degree apprenticeship and other degree apprenticeships. They will not allow the flexibility in the release of time for the students to train properly and meet the standards set by the NMC.22

24.The levy was designed to cover the cost of an apprentice undertaking off-the-job training for 20% of their contracted hours, yet NMC requirements mean that nursing degree apprentices must undertake off-the-job training for 50% of their hours.23 This is in part because the NMC requires all nursing students to undertake 2,300 hours of theory learning and 2,300 hours of practice-based learning, and in part because it requires students to be supernumerary.

25.NHS Employers informed us that this situation creates financial challenges for employers, as they are required both to pay apprentice salaries and to backfill salaries for the 50% of the time apprentices are off-the-job. The majority of current nursing apprentices were part of the existing workforce, but once they start an apprenticeship programme, they take on supernumerary status. From that point, whenever the apprentice is undertaking practice hours, they cannot be counted towards the staffing levels required for safe care and must be backfilled. Other professions do not have the same requirement for certain staffing levels. Danny Mortimer told us:

It generates an additional £35,000 or £40,000 of cost per student every year for four years and people are struggling. While they absolutely agree with the intent in widening participation, that £40,000 per student is not something that comes easily to hand. We disclosed last week that the provider section in the NHS was £900 million overspent last year, so that £140,000 or £150,000 per student over four years is not readily available other than through the levy.24

NHS Employers provided a breakdown of costs for training a Nurse Degree Apprentice. It estimated that a conservative calculation would be £34,358 per year, per apprentice.

Figure 1: Estimated cost breakdown for a nursing degree apprenticeship25

26.NHS Employers set out in written evidence its key requests for levy flexibility. It requested that employers be permitted to use their levy to:

27.Rt Hon Anne Milton MP, Minister of State for Apprenticeships and Skills, told us, however, that the Government would not allow the levy to be used for any purpose other than training or assessment fees. The Minister told us that there are many apprenticeships which have a case for exceptional treatment, including other apprenticeships with a requirement for apprentices to be in off-the-job training for over 20% of their time.27

28.Danny Mortimer reflected on the Government’s position:

When we set out on the policy as a country we assumed all apprenticeships were the same and they are not. The real opportunity in apprenticeships, and at all levels of apprenticeships in the health service, is that they are different and we can adapt them into very different types of jobs, but for some jobs, we rightly need to make sure that people can spend more time off the job in training.28

29.The apprenticeship levy was designed to cover the costs of an apprentice undertaking training for 20% of their time in work. Although we acknowledge the Government’s view that many professions are exceptions to this model, the requirement for nursing students to be supernumerary is highly unusual and for nursing degree apprenticeships to be successful, it must be reflected in the Government’s levy policy.

30.Without flexibility in the levy, we can see little incentive for the NHS to spend time and resource developing nursing degree apprenticeships. Its vast levy contribution can easily be used on other apprenticeships—including administration and financial apprenticeships, for example—and it can continue to recruit nurses who have trained via the traditional undergraduate route, without incurring the substantial costs sustained through recruiting nursing degree apprentices.

31.The highest standards of nursing training must be maintained and therefore a reduction in the number of hours of off-the-job training is not an option. If the Government wants nursing degree apprenticeships to be a viable entry route into nursing for significant numbers of students (and we consider that it should), then it must accept the uniqueness of the NHS’s position and be prepared to make necessary policy adjustments to ensure that the NHS is able to provide these apprenticeships in a way which is feasible and does not disadvantage either itself as an employer or students.

32.We recommend that the Government should reconsider its position in not providing much needed flexibility in the apprenticeship levy for the NHS.

Funding for providers

33.Nursing degree apprenticeships are currently placed at the highest apprenticeship funding band, with universities able to charge employers up to £27,000 to deliver a four-year nursing degree apprenticeship. This is the maximum amount that the Institute for Apprenticeships (IfA) determines any provider can charge. It is less than the £37,750 that universities receive in tuition fees for an equivalent full-time nursing degree, and on a par with the £27,777 it cost universities on average to deliver a nursing degree to one student, according to research conducted for HEFCE by KPMG. The funding has to cover the costs of end point assessment as well as the education associated with the degree. Any reduction in the funding band would mean that universities would be receiving less money from employers than they were spending on delivery.

34.New funding bands were introduced in August. Before their introduction the Council of Deans of Health raised universities’ concerns that they would receive less money for nursing degree apprenticeships, rendering them unaffordable to deliver.29 However, both nursing degree apprenticeships and nursing associates remained in the same funding bands.

35.We were told that universities can have additional costs for students who have been out of education for some time, which includes many nursing degree apprentices, or for students with additional needs.30 Data collected by the charity National Numeracy suggests that, in one Trust, close to 90% of band 1–4 staff lack the numeracy skills to develop their careers.31

36.We recommend the funding band for nursing degree apprenticeships remains at a minimum of £27,000 and the IfA should consider increasing it. Any future reduction of the funding band must be assessed to ensure that providers can continue to deliver apprenticeships. These assessments should be published.

Continuing professional development

37.The Royal College of Nursing told us that one of the challenges faced by employers creating nursing degree apprenticeships is a lack of nurses able to supervise or mentor them. This has arisen partly due to the shortage of nurses nationally; despite an increase of 13,100 nurses on wards since 2010,32 according to Health Education England, there are currently 36,000 nursing vacancies in the NHS in England, equating to a vacancy rate of 11%.33

38.We were encouraged that the Minister of State for Health told us that he understood the importance of continuing professional development (CPD) for nurses, and how challenging it currently is for nurses to access and undertake CPD.34 We welcome the Minister’s commitment to consider the Health Committee’s recommendations on CPD from its inquiry into the nursing workforce.

39.We were also pleased to hear Professor Ian Cumming, the Chief Executive of Health Education England, express his intention to divert as much of Health Education England’s funding as possible towards CPD and to explore the role that apprenticeships could play in facilitating CPD for nurses:

There are, of course, some perfectly legitimate uses of the apprentice levy, which some people may consider to be CPD. For example, some people would say taking a registered nurse through to an advanced clinical practitioner through a level 7 apprentice programme is ongoing education and training of a member of staff, which it is, but that is a perfectly legitimate use of the apprentice levy because we are developing and enhancing an individual skill through that mix of academic learning and practical hands-on learning.35

40.We recommend that the Government should prioritise investment in CPD for nurses and that it release a strategy and timeline for how it intends to do so. We also recommend that more postgraduate (Level 7) apprenticeships should be created for nurses to enable them to further their careers and develop specialisms. The Government should provide funding for trailblazer groups to develop these apprenticeships.

41.We recommend that employers should be able to use the apprenticeship levy to develop the necessary infrastructure for nursing degree apprenticeships, including training nurses in supervision and protecting time for them to undertake such training.


3 Health Committee, The nursing workforce, The Shelford Group (NWO0114), para 30

4 Health Committee, The nursing workforce, Sheffield Hallam University (NWO0117); Q50

5 Health Committee, Second Report of Session 2017–19, The nursing workforce, January 2018

6 Health Committee, Second Report of Session 2017–19, The nursing workforce, January 2018

7 Health Committee, Second Report of Session 2017–19, The nursing workforce, January 2018, para 53

8 Nursing and Midwifery Council (NWF0004)

9 Q17

10 NHS Employers (NWF0002)

13 Sub-Committee on Education, Skills and the Economy, Second Report of Session 2016–17, Apprenticeships, para 34

14 Nursing and Midwifery Council (NWF0004)

15 NHS Employers (NWF0002)

16 Ibid

17 Royal College of Nursing (NWF0003)

18 Nursing and Midwifery Council (NWF0004)

19 University of Huddersfield Students’ Union (NWF0005)

21 Q6

22 Q6

24 Q7

25 NHS Employers (NWF0002)

26 Ibid

29 Council of Deans of Health (NWF0001), para 2

30 Council of Deans of Health (NWF0001), para 9

31 National Numeracy, The cost of poor numeracy in the NHS and a scalable solution [accessed 7 November 2018]

32 HC Deb, 9 May 2018, Col 836–856

33 Health Committee, Second Report of Session 2017–19, The nursing workforce, January 2018, p6




Published: 6 December 2018