This isn’t a story about Mary Seacole or Florence Nightingale, but it’s a useful place to start. When it comes to an emblem of duty, it’s hard to top Nightingale with lamp in hand, or Seacole adorned with her medallions. They both represent the restorative power of courage and sacrifice, and rightly stand amongst the great and the good.
Their routes to heroism, however, were very different: Nightingale benefitted from governmental and private patronage, whereas Seacole operated on what you could gently refer to as a “self-funded model”. With access to ongoing financial support, Nightingale was able to substantially grow the nursing profession upon her return from Crimea. Seacole, indebted from the outset, returned to a daily struggle to make ends meet.
That being said, Nightingale didn’t charge for her services whereas Seacole largely did. So, questions like “was it fair that Seacole faced financial hardship given her good work?” and “was it fair that Nightingale, who was already wealthy, received state support?” become somewhat harder to answer. Are nurses like soldiers, called to the common good and worthy of the same access to state-sponsored training and living support? Or are they a bit more like the grocers and clothiers at the edge of the battlefield – aligned and essential, but ultimately in a for-profit and free-to-come-and-go sort of way?
To say on one hand you have a Nightingale model and on the other hand you have a Seacole model oversimplifies the situation, but let’s call the sponsored route of entry ‘Nightingale’ and the self-funded route ‘Seacole’. As of 2017, most nurses in England will pass through a Seacole-style of entry. They will assume debt for their training, but then have the flexibility of working in private settings upon graduation if they wish, although only about 10% do full-time. The debt may impact on their standard of living after graduation, particularly in a high-cost city like London, but gives them a better standard of living during study, as they can borrow more money than they would receive under the old bursary model.
Was this policy change fair? Some argue that it’s inappropriate to ask students to assume debt given the beneficial and essential role nurses – as well as other ‘soldiers’ of the NHS – hold. Some point out that many health students will have placements as part of their study requirements and are now effectively self-funding to work for the NHS. But some will argue that health is often a well-paid and secure career path, and other public servants pay for their education. Others will add that a self-funded model, if supported properly, should broaden access, as the old ‘Nightingale’ model had caps on entry.
It’s not that the ‘Nightingale’ sponsored model has completely disappeared, but much like Nightingale herself, it’s selective. Apprenticeships are a funded entry route, although they are usually available to those already employed in care roles, potentially introducing access inequalities. They are also expensive and complex to deliver, raising the question of whether this route in publicly-funded settings is fair to the public purse. On the other hand, they give people already committed to the NHS a route into higher education and career advancement, an entitlement that is available to soldiers and other public servants.
It’s worth reflecting on the shift away from the Nightingale model: when in place, bursaries cost the government at least £800 million a year. To reintroduce them would add to the £200 million already being ring-fenced by the NHS for the apprenticeship levy (and not including the £14 million top-up for health subjects funded by the Office for Students). Unlike enlistment, neither the apprentice model or bursary model can guarantee that someone will work for the NHS – or even as a health professional – upon graduation. So, is it really fair to spend over £1 billion a year on educating a health workforce without having the assurance that it will actually fill NHS vacancies in either the short or long term?
But take that away, and how fair is it to expect higher education providers to grow, or even sustain, their programmes in the face of market uncertainty? Following the withdrawal of the bursaries, applications for most health courses have fallen significantly, and deans can come under pressure from university leaders to cut programmes with low uptakes. There is consensus that severe workforce shortages are unfair to health staff and the public alike, but questions persist on how to attract and support health students in a Seacole world. The recent Closing the Gap report by the King’s Fund, Nuffield Trust and The Health Foundation posits some potential middle-ground solutions including maintenance grants, but the estimated price tag of £900 million by 2023/24 may be viewed as unfair given cuts to other services.
The questions that arise from Seacole and Nightingale’s example highlight the complexity around fairness, and the cost of living in London, the diversity of its population and chronic workforce shortages only amplify issues pertaining to access, reward and the public good. So, when it comes to entry into health professions, what’s the answer to getting the balance right between public spending and student success, as well as the sustainability of health education and the workforce? When it comes to funding, what’s fair?
On 19 June, we will be joined by representatives from the Nuffield Trust, the Council of Deans of Health, London’s medical and health higher education institutions, the NHS, the Office for Students and the Royal College of Nursing to carry this conversation forward. Our panel discussion “Educating London’s Future Health Workforce: When it comes to funding, what’s fair?” is organized by the London Healthcare Education Group, our network deans of health and social care across the capital and will look at the issue through a London lens. This panel discussion is open to all and forms part of London HE Week. For further details and to register, visit https://www.londonhigher.ac.uk/events/london-he-week/.
Author’s note: The views expressed in this article are not necessarily representative of London Higher, its members and those participating in the panel. They are provided strictly for illustrative purposes only.