HC Deb 13 April 1988 vol 131 cc289-94

The following sub-paragraph shall be substituted for subsection (2)(a) of section 55 of the Medicines Act 1968 (exemptions for doctors, dentists, veterinary surgeons and veterinary practitioners) (1) to the sale or supply of all medicinal products that are not prescription only medicines, where the product is sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph in the course of her professional practice; (ii) and to the sale or supply of prescription only medicines which, by virtue of an exemption conferred by an order made under section 58(4)(a), may be sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph, otherwise than in accordance with a prescription given by an appropriate practitioner; or".'.—[Sir David Price.] Brought up, and read the First time.

Sir David Price (Eastleigh)

I beg to move, That the clause be read a Second time.

Madam Deputy Speaker (Miss Betty Boothroyd)

With this, it will be convenient to take new clause 9—Nursing practitioners— 'In subsection (1) of section 29 of the National Health Service Act 1977 (general medical services), there shall be inserted the words "and nursing" after the word "medical" (both in "medical practitioners" and in "personal medical services"). The following subsection shall be inserted after subsection (8) of section 29 of the National Health Service Act 1977: (9) Regulations may provide— (a) for the definition, registration and remuneration of nursing practitioners; (b) for the definition of the personal nursing services to be provided and for securing that the arrangements will be such that all persons availing themselves of those services will receive adequate personal care and attention; (c) for conferring a right on any person to choose, in accordance with the prescribed procedure, the nursing practitioner to whom he is to be attended, subject to the consent of the practitioner so chosen and to any prescribed limit on the number of patients to be accepted by the practitioner; (d) for any additional arrangements the Secretary of State may deem to be necessary for the adequate provision of personal nursing services.".'.

Sir David Price

New clauses 8 and 9 stand on the Notice Paper in my name and the names of a number of hon. Members who, the House will agree, cover a very wide spectrum of opinion in the House. I hope that this will make the new clauses appeal to hon. Members—[Interruption.]

Madam Deputy Speaker

Order. I wonder whether we might have a little order in the Chamber so that I can at least hear the hon. Member who is moving this motion.

Sir David Price

As I was endeavouring to tell the House, Madam Deputy Speaker, new clause 8 pertains to the power of nurses to prescribe. New clause 9 is directed towards nursing practitioners and is relevant to new clause 8. I wish to say a few words in support of each proposition. I am conscious of the desire of the House at this hour to make fairly rapid progress, so I shall endeavour to be brief.

The matter of nurse prescribing is not new. I remind the House that at present nurses have no power to prescribe even simple drugs and appliances, including pain-killers which can be bought over a pharmacist's counter. Frequently, district nurses and other nursing staff working in the community waste a considerable amount of time obtaining for their patients items such as new dressings. They must first obtain a prescription from the doctor, who may never have seen the patient in question, then obtain the item from the pharmacist, and take it back to the patient. Delays in treatment and inconvenience to patients can thus occur. Nursing time and travelling costs are wasted.

In many instances, the community nurse is, in reality, the prescriber and the general practitioner merely authorises what she advises. Similarly, many community nurses have special expertise in the care of terminally ill patients and are quite capable of using their professional judgment on matters such as varying the timing and dosage of pain-relieving drugs prescribed by doctors.

The House will be aware that the increasing development of primary health care teams is breaking down the old division between doctors, traditionally responsible for prescribing, and nurses, traditionally responsible only for administering treatment. With the recognition that individuals from different health professions can provide effective care to patients on their own, responsibility becomes a team rather than an individual approach.

I remind the House that some groups of nurses, including occupational health nurses, midwives, and some nurses in the armed forces, already have the powers that we are seeking in the new clause. We are attempting to extend to nurses the power to prescribe. That was one of the recommendations of the Cumberlege report and of our own Social Services Select Committee report. I remind the House that paragraph 61 states: We recommend that the Government introduce legislation to permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage.

In their primary health care White Paper, "Promoting Better Health", the Government responded favourably to that general proposition, stating that they will consult the Professional Standing Advisory Committees about the professional and ethical issues of prescribing by nurses with a view to producing appropriate guidance. The new clause offers my right hon. Friend an opportunity to respond to his own White Paper and to our recommendations. I know that there is legal discussion as to whether amendments in primary legislation are necessary.

There is a view that all we seek in the new clause can be done by my right hon. Friend under existing powers, by statutory instrument. I am advised that there is doubt about that and that it needs a change in substantive legislation. We are seeking the opportunity of the Bill to get the primary legislation put on the statute book, although the details are obviously still open to negotiation, and it would have to be implemented in the form of a statutory instrument in due course.

I hope that I have said enough at this hour to make the case for new clause 8.

I turn briefly to new clause 9, which flows from it, and again relates to the changing role of nurses. I can put the case most succinctly by quoting paragraph 59 of the Select Committee report on primary health care, which stated: Nurse practitioners are a relatively new concept in the UK. Other countries such as the USA and most developing countries have had such an element in their medical services for many years. In the UK there is no precise definition at present of their role. At one extreme we have been told that health centres could be run entirely by nurse practitioners. Others see nurse practitioners as more akin to health visitors or district nurses, providing a mainly preventive and health education role. It is clear that with better education of nurses and as primary health care teams develop, the role of nurses is changing fast. It is that which has led some of my hon. Friends and myself to push the question with my right hon. Friend. He will know that in Birmingham a research project was set up in 1982 to test the hypothesis behind the concept of nurse practitioners. It was found that nurse practitioners had a valuable role in a number of areas: first, acting as an alternative consultant for the patient; secondly, screening for serious disease and abnormal physical signs and symptoms; thirdly, the management and treatment of minor and chronic ailments and injuries; fourthly, and most important, the health education of the patient; and fifthly, counselling.

As I think the House knows, the surveys which were done at the time of the Cumberlege report, and in a way for the report, supported the proposition that more of us would rather discuss our health problems with a nurse than with a doctor. I could go through the figures but the hour is late.

I hope that I have said enough to indicate that we are concerned about the development of nurse practitioners and that we feel that they have a positive role to play in the scheme of things, particularly when there is more emphasis on care in the community, on the primary care team and, above all, on good health rather than on running just a sickness service.

Ms. Harman

I support the new clauses and thank the hon. Member for Eastleigh (Sir D. Price) for proposing them. I hope that the Government will take them as a spur to action. We have had a lot a discussion about points of controversy and agreement has been reached. The arguments in favour of limited nurse prescribing and of recognising and institutionalising the role of the nurse practitioner have been well advanced.

As the hon. Member said, with the development of care in the community the work of both the nurse prescriber and the nurse practitioner will be even more necessary. We had a debate earlier about cervical cancer screening. If the nurse practitioner were to carry out smear tests, that would be a useful role.

I hope that we shall hear from the Minister that the Government intend to take action about nurse prescribing and nursing practitioners. We want to hear about specific action, hopefully with a timetable. The discussion should move to a close and we should see action on these two important issues.

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

I echo the remarks of the hon. Member for Peckham (Ms. Harman) and congratulate the hon. Member for Eastleigh (Sir D. Price) on bringing forward the two new clauses. I was surprised to hear him say that he thought that primary legislation might be necessary. That is not my under-standing from reading the detail of the Medicines Act 1986. In sections 55(2) and 58 there seem to be prima facie powers available to the Government to carry out the proposals in the new clauses. Midwives and occupational health nurses are allowed, in certain constrained circumstances, to prescribe items from the general sales list and some prescription-only medicines. No one is suggesting that there should be anything other than careful training and limitations on the powers.

All the evidence available to the experts and commentators shows that the profession is developing substantially in that direction. To move along the lines suggested in the new clause would recognise established best practice. The matter was considered in the Cumberlege report and by the Select Committee. The primary care White Paper considered it in principle, too. There should be no difficulty about the principle of limited nurse prescription and nursing practitioners.

There is some evidence that the Government are dragging their feet somewhat on the issue. As the hon. Member for Peckham said, the purpose of the debate is to request the Government to tell us what the up-to-date situation is, and, if there are delays, to explain why they should take place. In particular, after the introductory remarks of the hon. Member for Eastleigh, the Government should tell us whether primary legislation is required. Obviously, the implementation of any schemes will be postponed until parliamentary time is available.

Had the hour been earlier, we could have had a much more substantial debate on the detail and practice that are to be worked out. On that basis, my right hon. and hon. Friends and I support the principle and the need to develop the practice and to implement the new clauses.

Mr. Newton

I congratulate my hon. Friend the Member for Eastleigh (Sir D. Price) on moving the new clause, even though I hope that he will not press it too far.

Indeed, I recall one of my early indiscretions, within a day or two of being appointed to my present position. On the radio I stated that nurse prescribing sounded rather a good idea, which caused quite a fit when I got back to the Department that morning. My view that it is rather a good idea has been strengthened in the intervening period. As my hon. Friend will know—we referred to this matter in the primary health care White Paper—we saw merit in giving nurses more freedom to prescribe a limited range of items, such as dressings, ointments and medical sprays, and to exercise their professional judgment on the timing and dosage of drugs prescribed by doctors for the relief of pain. It is not a matter of foot dragging, to pick up the point that was made by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood). We have not reached the point at which we can say, "This is what nurses should be able to prescribe and this is how the arrangements will work." But I am glad to be able to report to the House some further progress, which I hope will go further fairly soon.

Following an initial approach to the professional standing advisory committees—in the White Paper, we stated that we would do that—we are in the process of setting up a joint working party to examine the professional and ethical issues of nurse prescribing. We expect the working party to begin work next month. I hope that that will give the House some encouragement.

Frankly, it is not possible to say—I pick up some other remarks of my hon. Friend and the hon. Gentleman—what, if any, legislative implications there will be, because we need to examine the work of the working party first. It is clear that we can do several things without primary legislation, but I could not put my hand on my heart and say that it is absolutely certain that all that one might want to do can be done without primary legislation.

Ms. Harman

Who is on the working party, and what will be the representation of nurses on it?

Mr. Newton

I cannot answer that question without notice, I am afraid. Should an appropriately armed carrier pigeon arrive from a certain quarter in the next moment or two, I shall see whether I can get the message off its leg. Otherwise, I shall see what information can be provided to the hon. Lady and, indeed, to other hon. Members by some other means.

I have to be just a fraction less forthcoming about the concept of nurse practitioners. [Interruption.] Before dealing with that, however, I shall return to nurse prescribing. I cannot give names, but the answer to the question asked by the hon. Member for Peckham (Ms. Harman) is that there will be three nurses from the standing nurses' and midwives' advisory committee, two pharmacists from the standing pharmaceutical advisory committee and two doctors from the standing medical advisory committee, plus a chairman. Therefore, while it would not be quite right to say that the nurses will have a majority, there will be more of them than of anyone else, and I think that that position will be regarded as reasonable.

12 midnight

I am equally sympathetic to the general principle of nurse practitioners, as the White Paper and the circular that the Government issued following the Cumberlege report suggested, but it is a more difficult subject because, as my hon. Friend the Member for Eastleigh acknowledged by implication—or perhaps even explicitly—in his remarks, the concept is not frightfully well defined. Our first problem, therefore, is to define exactly what we mean by the phrase "nurse practitioner" which we all tend to use in rather generalised terms. The Department is continuing work—again not with the aim of dragging its feet—with a view to deciding how best the work of agreeing a clearer definition can be carried forward with the professions. I shall certainly ensure that that work is undertaken as fast as it reasonably can be, but I cannot say much more this evening.

I hope that I have conveyed to the House the Government's continuing sympathy for the concepts, the further progress that we hope to make fairly rapidly in relation to nurse prescribing and the fact that we have by no means forgotten the concept of the nurse practitioner.

Sir David Price

I thank my right hon. Friend for that reply. I was encouraged by what he had to tell the House about the working party. I hope that he will be able to persuade it to put a time limit on its discussions, because there is nothing like a time limit to settle the mind. I can imagine the various bodies concerned going on indefinitely, and I hope that my right hon. Friend will get them to agree at their first meeting a time by which they will report. I shall, of course, expect my right hon. Friend to tell us the results. He will certainly have our support if any primary legislation is needed, although I very much hope that provision can be made by statutory instrument under existing legislation.

I am encouraged by what my right hon. Friend said about new clause 9, to which I also spoke. It is rather urgent to get a proper definition because the subject has a bearing on the future supply of nurses, nurses' career structure and training and, ultimately, pay for extra responsibility for nurses. The concept is therefore relevant. In considering demographic forecasts of the number of young people with the necessary qualifications coming out of our schools, we must take more very much more seriously than hitherto the optimisation of nurses' professional qualifications. The concept of the nurse practioner is primarily directed towards that.

With those few remarks, I beg to ask leave to withdraw the motion.

Motion and clause, by leave, withdrawn.

Forward to