Unanswered questions about the government’s changes to health education

The government is about to abolish bursaries for student nurses, midwives and allied health professionals in England and issue loans instead. It has also announced that number controls for these students will be lifted. With the consultation just published, what do these proposals mean for student access and workforce planning?

In June 2015, Universities UK and Council of Deans of Health issued a statement asking for “fundamental system reform” to nursing, midwifery and allied health education in England and, in particular, for the government “to consider urgently whether the current system of NHS funded grants can be moved to a system of student loans”.

Six months later, their wish was granted. The government confirmed in the Autumn Statement that from 2017/18 there will be no more bursaries for students in the non-medical health professions – they will receive a loan instead – and there will be no cap on numbers either.

Despite being a non-repayable form of support, NHS grants have long attracted criticism. A typical bursary is too small to cover a person’s living costs over a 40 week a year course (compared to a 30 week standard for other undergraduates), and many find themselves in financial hardship as a result.

According to the Department of Health, the shift to loans means students “will receive around a 25% increase in the financial support available to them for living costs”. (And it is not surprising, given the precedent was set by the scrapping of maintenance grants, that the government should opt for loans rather than pouring extra-departmental cash into the bursary scheme.)

At the same time, we will see the end of student number controls, currently administered by Health Education England and its Local Education and Training Boards. Supporters of the new ‘capless’ system believe it will provide greater flexibility in recruiting and training the staff that health providers require.

So on paper, the changes look reasonable enough. Give students more disposable income in the form of a loan, rather than a lower-value grant, and let education and health providers recruit more students according to local needs.

The reality, of course, will be a lot more complicated and here are just a few issues that require attention in the government’s consultation.

First, can we be sure that students of nursing, midwifery, and allied health won’t be put off by the prospect of loan debt? The government will point to increases in full-time undergraduate participation since the trebling of tuition fees and loans, but there are certain groups for whom debt is likely to act as more of a deterrent. Nursing and midwifery, in particular, tend to attract non-traditional entrants including mature students (60% in the case of nursing) and it is possible that the removal of grants will have a negative effect on applications. To support widening participation efforts, the government must monitor the impact of the changes and be ready to intervene.

Let’s not assume that every applicant is suitable for the job. It is easy to get carried away by stories in The Daily Mail about thousands of British students being rejected for nursing courses each year despite widespread recruitment from abroad. But we have to recognise that quantity is never by itself enough. Not all applicants will necessarily have the appropriate qualifications, attributes, motivations and values required for healthcare practice and lifting number controls won’t do anything to address that.

Who will be responsible for workforce planning? Health commissioners and providers look set to be the principal ‘planners’ under the new system. But will they be able to see the bigger picture at the same time as managing the day-to-day affairs of an NHS Trust? Research by the OECD shows that workforce planning in healthcare is a complicated business. It requires long-term approaches – including managing the geographical distribution of workers – and the collection of data. Someone has to take responsibility.

And what will happen to the least ‘attractive’ professions? There are difficulties in recruiting for different health specialisms, such mental health and learning disabilities nursing, which a more liberalised system could end up compounding.

What about the rest of the health and care workforce? Some will argue that to change funding and numbers arrangements for the non-medical health professions in isolation is a mistake. What about student doctors, dentists, and social care workers? And what about those already in the workforce? Given the complexity of future health and care challenges, there is a case for addressing these issues in a more joined up manner. As the OECD puts it, “where health reforms in many countries are designed to improve efficiency…and to reorganise service delivery away from acute care hospitals towards greater primary care and home-based care, the current “silo” approach to health workforce planning hampers the possibility to analyse health workforce requirements.”

Finally, there will be opportunities in the new system. The contractual relationships formed between health and education providers could lead to new and innovative ways of training including the development of apprenticeships. It is not all doom and gloom…