Exclusive: Nursing’s past is the key to its future, suggests minister

Former district nurse Ms Milton oversaw the introduction of England’s first nurse degree apprenticeship in 2017, in the wake of the controversial move to scrap the student bursary.

“We have been losing a huge pool of potential talent that we can now take advantage of”

Anne Milton

Ms Milton told Nursing Times this move was “in effect” a reintroduction of the work-based model used to train nurses like herself before major education reforms in the 1990s.

When Ms Milton trained in 1974, student nurses were employed by hospitals and completed a three-year programme similar to an apprenticeship. But a national initiative called Project 2000 saw responsibility for nurse education transferred from hospitals to universities.

This paved the way for nursing to be established as a graduate-only profession in 2013, in what was hailed as recognition of the highly technical and increasingly complex role of the registered nurse.

However, Ms Milton told Nursing Times that she believed these changes had made the career unattainable for many people who would make “brilliant nurses”.

In addition, she said some nurses including her “regretted” the move to university-based nurse education, because they thought gaining skills on the job was a “really good way to train”.

“Apprenticeships just mean we can take into the profession people who wouldn’t otherwise have the opportunity”

Anne Milton

She believed her ultimate “success” as skills and apprenticeships minister would be judged by having reinstituted an alternative method of training as a registered nurse.

“If the only way to become a registered general nurse is through a full-time degree, you are going to lose a huge pool of talent, and we have been losing a huge pool of potential talent that we can now take advantage of.”

She added: “There’s a shortage of nurses, so apprenticeships are a way of filling those gaps in the nursing profession.”

They were key to widening access into nursing, said Ms Milton, who trained as a nurse at St Bartholomew’s Hospital in London, before obtaining a diploma in district nursing from London South Bank University.

Alongside the nurse degree apprenticeship, the past two years have also seen the introduction of the apprenticeship programmes for nursing associates and advanced practitioners.

As a result, the apprenticeship route can now take people gradually from a level two healthcare assistant – equivalent to GCSE level – right up to a level seven advanced nurse – equivalent to a master’s degree – without having to step out of work.

Ms Milton said this meant people who did not have the prior qualifications or financial means to go to university could still become a nurse. “What’s critical about the nurse apprenticeship route is that you can go from level two right up to level seven,” said Ms Milton. “You can start at the bottom, if you haven’t got very many qualifications, and you can work your way up.

“I remember the debates raging about whether to become a registered nurse you should have to have a degree and it still carries on, and I suppose the key is there is more than one way of getting a degree now.”

“If the only way to become a registered nurse is through a degree, you will lose a huge pool of talent”

Anne Milton

Asked if those without the school grades to go to university may be better suited to an HCA role, Ms Milton said employers, including the NHS, were increasingly starting to recognise that a person’s GCSEs and A Levels “do not necessary indicate your capabilities at 25”.

“People develop academic skills at various times in their lives and… I have met so many young people who didn’t do well school, maybe didn’t do well at college, maybe dropped out of their A Levels, who go on to be fantastic employees, get the qualifications, just at a few years later,” she said. “It’s a shame to shut the door on people who have got enthusiasm and passion and skills and behaviours we want to see.”

She added: “The apprenticeships just mean that we can take into the profession people who, for a lot reasons, wouldn’t otherwise have the opportunity but would make brilliant, caring, effective nurses.”

Ms Milton said the nursing associate apprenticeship was going “really well”, with 1,420 apprentices starting in 2017-18 and 1,850 in the first half of 2018-19. As well as being a profession in its own right, the nursing associate role was also introduced to act as a stepping stone for HCAs to become a registered nurse.

Conservative Party

Anne Milton

Anne Milton

“If you feel the jump into a degree nurse apprenticeship is too big a jump to make, you can train to be a nursing associate, which is at level five, as a first step into going on doing a degree,” noted Ms Milton.

In another nod to the past, she said the nursing associate role “was not dissimilar” to the state enrolled nurses that were in post when she was training.

“We got rid of those and so I’ve got to the stage where I have reinvented something that what was similar when I first trained,” she told Nursing Times.

Conversely, nurse degree apprenticeships have not been as successful as those for nursing associates. The government set itself a target of recruiting 1,000 registered nurse apprentices every year following the introduction.

However, just 300 started in 2017-18. Questioned on the low take-up, Ms Milton said: “One always sets oneself targets and targets should always be stretching, which means you don’t always meet them.”

In the first half of 2018-19, numbers improved with 530 people starting a nurse degree apprenticeship. A scathing report from MPs in the education select committee in December last year warned that there were too many obstacles in the way of making nurse degree apprenticeships work.

They said there was “little incentive” for trusts to invest in building nursing apprenticeships and highlighted the need for greater flexibility around the use of the apprenticeship levy.

Introduced by the government in 2015, the levy requires employers that meet certain criteria to pay into a pot of cash that is then used to fund the training of apprentices.

One of the reasons for the government bringing in nurse apprenticeships was to help the NHS get more out of the £200m per year that it contributes to the levy.

However, the committee argued that blanket rules around what the levy could be spent on were acting as a barrier, calling for nurse degree apprenticeships to be made a special case in recognition of Nursing and Midwifery Council requirements.

Under the NMC standards, nurse apprentices must spend 50% of their time on the apprenticeship in off-the-job training – way higher than the 20% minimum expectation for other apprentices.

In addition, the NMC stipulates that registered nurse apprentices must have supernumerary status and, therefore, employers must backfill posts with other staff.

The fact the levy can only be used on the training and assessment of apprentices means out of the £137,392 a year it costs to train a nurse apprentice, only £27,000 is covered by the levy and the rest has be fronted by employers.

“Apprenticeships can’t be a bolt on – this is how you plan your workforce for the next 10 years”

Anne Milton

Insisting that concessions were not on the cards, Ms Milton said nurse apprentices were “not unique” and that other professions had similar requirements. She said making amendments to the levy would limit the number of apprentices who could be trained.

“Any flexibility we make for nursing would be replicated across the board. You are then putting a huge strain on the apprenticeship budget,” she said. Instead, trusts needed to adapt their workforce planning to embed apprentice training costs into their budgets, said Ms Milton.

“Once you’ve embedded apprenticeships into your workforce planning, then it starts to make financial sense if you look at the bank and agency staff that you are currently having to employ,” she said. “Apprenticeships can’t be a bolt on – this is how you plan your workforce for the next 10 years.”

Ms Milton said investing in apprenticeships could also help trusts to improve their nurse retention rates, because people who completed these programmes tended to be more settled, unlike university students who she described as a “very mobile workforce”.

“This is a way of growing your own workforce that frequently live locally,” she said.

The announcement that nurse degree apprenticeships were going to be established came after the government abolished NHS bursaries in England. However, Ms Milton said the two events were not “strictly speaking connected” and pointed to the introduction of the apprenticeship levy as the main “lever”.

The axing of the bursary saw applications to study nursing drop by a third. Asked whether she had been in favour or against the removal of bursary as a former nurse, Ms Milton said: “I can’t say one way or another”.

But the minister said she believed apprenticeships could have a “big impact” in tackling the current nurse staffing crisis in the NHS, which is short of around 40,000 nurses in England.

While recognising that the scheme was “a long way off settled state” in regard to nursing, Ms Milton was optimistic about future growth, stating that the “message about apprenticeships is now starting to get through”.

“This is a way of growing your own workforce that frequently live locally”

Anne Milton

Ms Milton also encouraged those on the frontline to engage in politic debates that affected them, highlighting that nurses were “in essence the deliverers of government policy”.

After 25 years in the NHS, Ms Milton made a “spur of the moment decision”, to enter politics following the 1992 general to election, because she did not feel people like her were represented – as a woman, mother and nurse.

Serving as MP for Guildford since 2005, Ms Milton held various parliamentary positions in health before being made minister of state for skills and apprenticeships in June 2017. She said she believed many of skills as a nurse were transferrable to politics and called on more nurses to consider a career in government.

“Although people say it’s very different, in fact there are quite a lot of similarities,” she said. “It’s about dealing with people, it’s about helping them with their problems, it’s about trying to find out a solution to those problems, and so it wasn’t such as difficult a transition as people might expect.”

Anne Milton: Biography

Anne Milton worked as a nurse in the NHS for 25 years, after training at St Bartholomew’s Hospital in London and obtaining a diploma in district nursing from the London South Bank University. She has also served as a Royal College of Nursing steward during the 1980s.

Ms Milton was elected as Conservative MP Guildford in May 2005, a role she still holds. Among a range of government posts, she was a health minister from May 2010 to September 2012. She was appointed as an education minister in June 2017.