A mixed picture is emerging of the impact of the move from bursaries to loans for student nurses in England, with placements seen as a pivotal factor, according to an investigation by Nursing Times.

Some universities have said plans to expand courses look set to be derailed by a lack of placements, while warning other parts of the country may in any case have problems attracting applicants.

Universities have reported a 20% average drop in applications to nursing, midwifery and allied health courses starting in the autumn, compared to last year. But, due to the popularity of nursing, it is still not clear whether this will lead to fewer students actually starting courses.

Unions and nurses have previously warned the prospect of taking out loans for tuition fees and day-to-day costs to cover the three-year course – which the government estimates to be at least £47,000 – would deter people from nurse training.

University leaders have predicted variations between regions and specialisms with traditionally smaller programmes, such as learning disability nursing, and areas with many competing universities, as with London, potentially seeing reductions in student numbers.

On the other hand, the national workforce planning body Health Education England has reported some universities are planning a “significant expansion” in course sizes in 2017, in particular for adult and children’s nursing. At the same time, the Nursing and Midwifery Council has said it has unusually received applications from a number of education providers to run new pre-registration courses, sparked by the funding changes.

“We need greater clarity over how clinical placements might be funded in the future” Guy Daly

The government has always maintained the funding reforms will allow an extra 10,000 training places to be created by 2020. But a group of universities that Nursing Times contacted said that, while they wanted to boost student nurse numbers in 2017 and beyond to meet workforce demand, it was still unclear how placements could be increased – which threatened to put a stop to the plans.

Professor Guy Daly, pro-vice chancellor of Coventry University, which offers adult, children’s, mental health and learning disability nursing and midwifery degrees, said: “The major obstacle to the expansion of student numbers is how we support the development and expansion of clinical placements.”

He said that, based on application rates so far, he was “confident we will continue to recruit fully to our programmes” at the level they are now, but the university was in discussion with local NHS trusts about how to support more trainees.

Bursary reform Guy Daly

However, HEE has said it has no additional money to fund an increase in placements this coming year. Professor Daly said Coventry was, therefore, looking at either the university or the employer paying for extra, or them both coming to a “non-payment” arrangement in which the university offered an “in kind” service, although he said those discussions were ongoing.

“If we could sort the clinical placements out, then the expansion would be for this coming September,” he said. But ahead of that point, he warned there was “still an awful lot of working out to do”.

“We need greater clarity over how clinical placements might be funded in the future to allow for expansion,” he said. “We also need to get clarity over the actual cost of these courses and clarification over what things might be funded that have been in the past – such as occupational health and uniforms.”

Professor Daly said the average 20% reduction in applications across the country “could be a problem” for some universities, adding: “It’ll be played out differentially both across the country and across particular programmes”.

“It’s in their interests – they need the nurses” Paula Holt

At the University of Derby, Dr Paula Holt, dean of the college of health and social care, said she had not seen the significant drop off in applications that some had expected. While there had been a slight decline, she said it was in line with a recent trend linked to the university raising its entry requirements.

She said Derby was looking at a small increase to its adult nursing intake and almost doubling its mental health nursing course in 2017-18 by enrolling a second cohort in the spring to meet demand from local employers. In future years, it was also hoping to bring in new branches of nursing, she told Nursing Times.

However, she also noted that “placement capacity will restrict the amount of extra places we can offer”. The university had been developing relationships over the past few years with primary care, private, voluntary and independent providers such as nursing homes, which would help, she said. In addition, the university had been “recruiting heavily” to mentorship courses.

Bursary reform Paula Holt

Dr Holt said some NHS trusts were hoping to be able to offer more placements within the same amount of funding from HEE. When asked how this could be achieved, she said: “It’s not going to be easy but we will have to work together… It’s going to be individual agreements with local trusts.

“It’s a mismatched policy that you allow universities to increase their numbers, but don’t fund additional placements,” she added.

She stressed that it was in the interests of trusts to make room for more students. “There are nursing shortages across the NHS and our NHS partners are working closely with us to help us to support increases in numbers coming into pre-registration education,” she said. “It’s in their interests – they need the nurses.”

Dr Holt also said it was important to “be more creative” in the way mentors were trained, adding that Derby was looking at shorter, more intensive courses, delivered on site with employers and using online elements to make training more accessible.

“I don’t know whether it’ll be a smooth transition to the new system” Bridie Kent

Meanwhile, Professor Bridie Kent, head of the school of nursing and midwifery at Plymouth University, said it was not planning on boosting its course sizes or adding new ones in 2017. She blamed “the lack of clear info from HEE around the tariff” that is used to fund placements.

“There doesn’t appear to be a willingness at the moment from providers in our area to have students without tariff,” she said. Based on application rates so far though, she said there was some “potential” to increase numbers if student were guaranteed quality placements.

“If more placements were available across acute and primary care, then we could certainly consider increasing,” she said. “At the moment it’s a bit of a ‘catch 22’. The trusts have got so many vacancies – and they’re using agency staff to deal with that – but then are at capacity with mentors.”

Professor Kent said application levels for its adult nursing course had remained steady. At the same time, there had been reductions to its children’s nursing and midwifery courses – but the university “always have far more applications than we can take”, she said, suggesting it was not a concern.

Bursary reform Bridie Kent

However, the 20% drop in applications to its mental health nursing programme so far was more of a worry, she said, because this course typically attracted more mature students who may be deterred by loans.

The change in funding had meant the university was considering taking on its first cohort of international students on top of its usual domestic trainees in 2017, she said, noting that the bursary contract with HEE had previously prevented such a move.

When asked whether she thought other parts of the country would struggle to recruit student nurses and midwives this year, she said: “I’ve got some concerns around the London hospitals where there is a lot more competition and the cost of getting to placements is so high.

“I don’t know whether it’ll be a smooth transition to the new system,” she said. “I don’t know whether we’ll see a pattern similar to when university fees went from £3,000 to £9,000 a year and applications dropped off, then picked up again.”

“We are committed to increasing the number of training places for home-grown nurses” Department of Health

All the education leaders from Coventry, Derby and Plymouth stressed it was important to ensure potential trainees understood the funding changes and were encouraged to enter the profession.

A spokesman for Universities UK, which represents vice chancellors, noted that it was possible applications may have picked up since it recorded the 20% drop in December. It would not become clear until February, he told Nursing Times.

His comments were echoed by a spokeswoman from the Universities and Colleges Admissions Service (UCAS), who noted the deadline for course applications was 15 January.

“At this point in the admissions cycle, it’s not possible to predict what the demand for nursing courses will be. Application patterns are typically weighted towards the deadline and are affected by the pattern of weekends and public holidays among other factors,” she said.

Nursing and Midwifery Council Katerina Kolyva

Dr Katerina Kolyva, executive director at the Council of Deans of Health, said: “We are continuing to work with government to ensure that we have a system of placement funding that allows universities the flexibility to grow capacity, while promoting quality of placement learning.”

A Department of Health spokesman said it was too early to predict application rates to nursing courses for 2017 but noted that, in recent years, two thirds of applicants were not offered a place.

“We are committed to increasing the number of training places for home-grown nurses, as well as making sure there are more routes into nursing including through apprenticeships,” he said.

He told Nursing Times that the DH was set to publish plans on a future model for commissioning clinical placements in “due course”.