Casualty?

The Department of Health has just launched its consultation on changes to funding of student nurses, midwifes and other allied health professions (radiographers, physiotherapists and similar) in England. This is a big deal. What’s the issue?

Currently, such students in England pay no tuition fees, and get a bursary to cover living costs. The NHS contracts with individual universities to provide a set number of training places, and universities recruit and teach these students. As part of the programme, there are clinical placements in real NHS settings.

The contract process has been brutal in some cases: the ending of a contract (and this has happened) means that universities have staff with no students, leading to reorganisations and problems in teaching out cohorts; contract management has involved monitoring students in ways different to and often very much more intensive than for other courses. So you might think that the ending of this process (elements of which, at least, are surely implied by the proposals to end bursaries and move to ‘normal’ tuition fees and student loans) would be good news for universities.

Perhaps it will be. The case for the changes, as argued by Ben Gummer, Health Secretary, is that it will enable universities to take more students, and meet student demand (Gummer claims that two out of three nursing applicants are turned down.) But of course this will only happen if universities are able to find placements for students, and that depends upon the NHS being willing to host students.

An utterly gratuitous carry on 

It’s instructive to compare this with medical education, where (in England) universities have money (SIFT, or Strategic Increment for Teaching) to pay NHS trusts to take medical students. Medical student numbers are also capped, recognising the practical limit on the number who can be accommodated by the NHS. These conditions – a fund to pay trusts the costs, and a cap on numbers) make finding placements workable for medical schools. NHS trusts have an incentive to do activity which is slightly removed from core healthcare, and there’s a practical limit on the costs of this and the logistical burden.

Could the same happen for nursing, midwifery and allied heath students? There won’t be a state-imposed cap on numbers – that’s the whole point! – so it will be down to universities and NHS trusts to manage this. And in the absence of an equivalent to SIFT funding (and I haven’t seen reference to this) NHS trusts will face a real cost in providing the educational supervision to placement students which makes the placement a learning experience, rather than the student simply being an auxiliary in a clinical setting. Will universities have to provide the staff to do this, making the educator part practitioner? Will universities need to pay NHS trusts to take placement students?

There are some big risks in here. The contacts for providing education at least guaranteed placements. Take that guarantee away, and the job of finding placements becomes harder. No doubt the new system will work well in some places, but equally likely, it seems to me, is that there’ll be market failure in other places. Leading to fewer trainee nurses, midwives and allied health professionals in some English regions. And possibly fewer clinical staff and students on wards.

It seems clear to me that the rationale for this is cost: by passing the cost onto students, it enables the NHS to deal with tighter budgets. And maybe that’s necessary. But it’ll be important to have a robust system to guard against the sort of market failure that impacts upon healthcare, and it’s hard to see how to make that happen without more resource somewhere. My guess is that universities will find this bargain less good than you might at first think.