The Chair of the Education Select Committee, Robert Halfon MP, recently stated the skills shortage in the NHS could be addressed by expanding nursing apprenticeships. He said that while the skills shortage is across a variety of sectors, apprenticeships are not growing as enough.
And he is quite correct. Degree and higher apprenticeships offer an opportunity to boost productivity and increase social justice and mobility and we absolutely need people from all walks of life to work within health and social care. This could be addressed by increasing the number of apprenticeships in the NHS (and independent sector – let’s not forget how much care the independent sector delivers on behalf of the NHS), but is it possible?
Apprenticeships
The Institute for Apprenticeships approved the nursing degree apprenticeship (NDA) for delivery in May 2017. A small number of universities initially began to approve apprenticeship routes to registration but this has subsequently increased and there are now 14 universities approved to deliver this programme. The University of Derby received approval from the Nursing and Midwifery Council to offer the NDA in October 2017, but to date, we have not started any apprentices. There are several reasons for this – it’s not all bad news, but there are some significant challenges.
In January 2017, the first nursing associate pilot commenced (the University of Derby hosted 120 trainees in this first cohort) and is now an apprenticeship (we recruited 130 in our second). The nursing associate programme is two years in length and is delivered on a day release model. All of a sudden, here is an alternative for employers to the full nursing degree. Whereas it was once clear that if you wanted to increase the number of registered staff you needed more nurses, now employers have a choice.
Although the nursing associate is not a nurse, and has a more limited scope of practice, they will be registered with the Nursing and Midwifery Council. Their training will take two years rather than the potential four for the registered nurse. Managers working to resolve the current staffing problems in the NHS (and beyond) quite rightly see the nursing associate as one of the solutions. This has potentially shifted managers’ thinking – where once the aspiration was to train nursing degree apprentices, they may now be considering the shortened programme for nursing associates.
This doesn’t mean that the nursing associate cannot go on to become a nurse – in fact this is the model we are advocating at the University of Derby. The two years spent training to be a nursing associate can then be utilised to gain access to the nursing degree programme (apprenticeship or traditional routes). For employers, this may offer several advantages. Four years is a long time in an individual’s life, and to make a four-year commitment is risky. By having a ‘break’ at the two year point, successful students can achieve a registerable qualification and then step back in to studying if their personal circumstances allow and they are keen.
For employers, it is better to have a worker with a named, registerable qualification at the end of two years, rather than one with ‘half’ a nursing degree apprenticeship (which offers neither registration nor a qualification). The nursing associate apprenticeship offers a safety net for all parties and means that employers and apprentices can make sure they are doing the right thing for the right reasons at the right time without the four year commitment from the outset.
Affordability
The bigger challenge that we are starting to hear about is affordability. Employers are concerned about paying an apprentice’s wages for four years for the duration of the apprenticeship. Recent research about the first year of the Apprenticeship Levy (Open University, 2018) suggests that 20% ‘off the job’ training requirement is a barrier to engagement with apprenticeships and that the associated costs of apprenticeships is too high and cannot be funded by the Levy. Here, we have two scenarios – a student nurse takes out a loan, attends university and has a placement hosted by the employer. Cost to employer? Time for staff to support the student and engagement with the education provider, but some additional monies from Health Education England are given to the employer to offset these.
The apprentice nurse, however, needs to have a salary for the duration of the apprenticeship, needs all the support required by student nurses but additional support from the employer is also needed to meet the needs of the apprenticeship. Cost to employer? Potentially £30k for the salary alone, and in this instance, there is no funding to offset the training and support required by the apprentice. When the additional costs of administering the apprenticeship are added in (and these seem to be significant at the moment as employers and training providers seek to develop an appropriate and compliant offer), the cost of the apprenticeship to the employer is far above that of employing a nurse straight from university.
While apprenticeships undoubtedly offer opportunity, the problems are weighing heavily on employers’ and training providers’ minds. Of course, when you add in the need to be compliant with the requirements of regulatory bodies such as the Nursing and Midwifery Council, there is an extra layer of complication – degree apprentice nurses need to be supernumerary and cannot be counted as part of the staffing numbers. This means that there is a requirement to replace ‘like for like’ – if a healthcare assistant becomes an apprentice nurse, another healthcare assistant needs to be employed in their place, so employers have not one, but two salaries to find. Even though there is one more person in the team, the need for student nurses to be supernumerary (apprentice or otherwise) means they cannot be counted in the safe staffing levels.
Unfortunately, we are seeing the tip of the iceberg. Other professional health and social care programmes are becoming apprenticeships and really could offer a solution to the workforce development issues we currently face. But without some flexibility in how the levy can be used, an already stretched financial system will not be able to stretch to this. Employers may be tempted to write off their levy as another loss and the funding will disappear from the health service. Can we and employers do more? Yes, but we need some help please.
