§ Order for Second Reading read.
§ 2.9 pm
§ Mr. Dudley Fishburn (Kensington)
I beg to move, That the Bill be now read a Second time. This is an unusual occasion——
§ Sir Richard Body (Holland with Boston)
On a point of order, Mr. Deputy Speaker. I wonder whether the Question on Queen's consent, in respect of my Bill, may be put again now that a Privy Councillor is here. I am gratified to see that my right hon. Friend the Minister of State, Privy Council Office is in his place.
§ Mr. Fishburn
It is unusual for a 10-minute rule Bill to reach its Second Reading. Ten-minute rule Bills usually serve the purpose of presenting a particular aspect of policy that needs the spotlight of attention, but today's Second Reading gives the Bill a glimmer of the light of seriousness.
The Bill will enable nurses—29,000 community nurses, in the first instance—to write prescriptions for a limited number of products so that patients who are ill at home are able to receive them without having to go to their general practitioner's surgery to get his signature. The Bill does not cover advanced drugs or complicated matters that require diagnosis; it would permit nurses to write prescriptons for such items as bandages, wound treatments, bedpads for those who are incontinent at home and for pain killers—the type of regular medical products for cases in which a community nurse will know exactly what is required and will be as well informed about the patient's needs as would any GP. For that reason, the Bill has been welcomed not merely by the Royal College of Nursing, but by the British Medical Association. Indeed, it has the support of almost everyone in the national health service because it is realised that the Bill will strip back one layer of the onion skin of bureaucracy. It will allow patients and nurses to work out in straightforward cases what medicaments and medical products are required and to get them to the patient as quickly as possible.
Getting this far has already been a long process. The Bill is not an idea that I pulled out of a hat. There have been no fewer than three reports in Britain on the subject—the Cumberledge report, a Select Committee report and the Department of Health's own report, the Crown report. All three reports advocated nurses writing prescriptions for a limited number of products. That practice is already in place in other countries, most notably in Canada and the United States. The Department of Health agrees that the practice should be allowed in this country within the next few years. My only disagreement with the Government is how soon we can put these sensible reforms in place. This afternoon, we have an opportunity to jump the gun and to let the Bill go ahead as quickly as possible. The medical profession is ready for it, and 29,000 community nurses are ready—they have trained for the project and they know the list of medical products against which they could write a prescription. It is time for us to press ahead.
I understand that my hon. Friend the Minister for Health will have sensible reasons for saying that we should progress more slowly and perhaps have another cost 594 benefit analysis. There is considerable pressure from the nurses and from doctors and general practitioners for the proposal to go ahead. It will cost nothing. It will greatly diminish suffering by allowing nurses to provide the right medicine with the minimum amount of delay. It will be a step forward. I know that my hon. Friend the Minister is sympathetic towards it. I hope that the proposal will be accepted as quickly as possible.
§ The Minister for Health (Mrs. Virginia Bottomley)
I congratulate my hon. Friend the Member for Kensington (Mr. Fishburn) on his skill and determination in pressing his case for nurse prescribing. He has done very well to introduce his ten-minute Bill and to secure today's debate. I hope to convince him strongly of our sympathy for his cause and to offer him clear hope for the future.
The Government are fully committed to the idea of nurse prescribing. In one of my first speaking engagements as Minister for Health I said that, barring insurmountable obstacles, nurse prescribing would become a reality in the 1990s. Supporting the general idea of nurse prescribing does not mean that we can leap over some of the details that must be worked out. I hope to explain that we are making extremely good headway on overcoming the issues and concerns that have been identified.
As my hon. Friend the Member for Kensington knows, the Cumberledge report on community nursing recommended thatthe DHSS should agree a limited list of simple agents which may be prescribed by nurses as part of the nursing care programme and issue guidelines to enable nurses to control drug dosage in well defined circumstances.We accepted the recommendation in principle and established the advisory group on nurse prescribing, chaired by Dr. June Crown, to advisehow arrangements for the supply of drugs, dressings, appliances and chemical reagents to patients as part of their nursing care in the community might be improved by enabling such items to be prescribed by a nurse, taking into account where necessary current practice and likely developments in other areas of nursing practice.We are grateful to the advisory group on nurse prescribing for its excellent work. It made many recommendations, the central one being that nurses in the community with a district nurse or health visitor qualification should be allowed to prescribe items necessary for the care of conditions for which they take professional responsibility. In addition, nurses with a district nurse or health visitor qualification and certain specialist nurses in the community should be able to supply patients with items within a group protocol and to adjust the time and dosage of medicines.
The report was published and issued for comment in December 1989. In total, 330 responses were received from the four United Kingdom countries. They included replies from health authorities, family health service authorities, medical, pharmacist and nursing organisations, from individual nurses, trade unions and pharmaceutical companies. In general, commentators were in favour of implementing the recommendations in the report.
However, the report had identified various issues requiring additional work before final decisions could be taken and a schedme implemented. There are four main issues and my hon. Friend the Member for Kensington, who has worked closely with me and with the nursing organisations, is aware of many of them. First, there 595 needed to be an authoritative cost-benefit analysis. Secondly, the consequences for education and training needed to be identified and schemes established. Thirdly, the precise type of drugs that nurses can prescribe needed to be settled and, finally, detailed administrative arrangements needed to be worked out.
Those are obviously important aspects that are vital to establishing a viable and successful scheme and they need detailed attention. We are taking them all forward at the same time, but the work cannot be completed overnight to allow immediate legislation.
Perhaps the most important area requiring further work is the assessment of the cost and benefits of the report's recommendations. We all realise that nurse prescribing will bring benefits to patients and staff, but, as the report recognised, a more thorough study of those benefits and a full assessment of costs are needed before the final decisions about implementation may be made. Therefore, we have commissioned the management consultants Touche Ross to carry out a full cost-benefit analysis.
The consultants are collecting data from a representative sample of health authorities and family health service authorities, through interviews and questionnaires, to discover how nurse prescribing would affect community nurses, GPs, hospitals, pharmacists and patients. In their assessment, they have been asked to include the resource effects of potential changes in the volume and type of drugs, bandages and dressings prescribed, and in the number of pharmacists dispensing fees; any additional training required; necessary administrative arrangements; and any changes in the time worked by nurses and GPs.
The consultants' report is due at the end of August. We would hope to take decisions about implementation soon after. I hope that my hon. Friend the Member for Kensington will agree that that is a swift timetable for action. However, there are details and complexities which need to be considered and tackled properly for fear that otherwise they will emerge at a later date and will cause difficulty when a Bill goes through this place.
As I have said, much work is also being carried out on the other issues identified in the advisory group's report. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting is working on the education and training implications. We have asked it to let us have its initial views about the training programme by the end of June. Once the training requirements have been established, it will, of course, be necessary to devise training materials and to train the trainers before appropriately qualified nurses could start their top-up training.
My hon. Friend the Member for Kensington will also be aware of our great commitment to nurses' education. Recently, I was able to announce a further 14 Project 2000 courses and £71 million is being spent on Project 2000 this year. We are well aware that training and the development of professionalism in our nurses are fundamental to the health service's ability to provide high-quality patient care. Two issues will have to be tackled: initially, the training of the 28,000 community nurses, district nurses and health visitors who, it is thought, are the most appropriate groups to undertake nurse prescribing; and, secondly, the way in which that training can be incorporated in the mainstream 596 of training for nurses who plan to join those groups. No training can take place until we have finalised the details of the formulary.
This month, officials will be meeting members of the joint formulary committee of the British National Formulary to ask them to set up a nurse practitioners formulary sub-committee, along the lines of the dental practitioners sub-committee, to advise us about the appropriate contents of the nurse formulary. My hon. Friend the Member for Kensington identified, in general terms, the items that it was expected that nurses should be able to prescribe. However, he will be the first to recognise that, when it comes to deciding exactly where the demarcation line should go, there are a number of complex issues to be resolved. We expect that the sub-committee will need about a year to complete its work. If, as is likely, the nurse practitioners formulary contains prescription-only medicines, we will need it to liaise with the Medicines Commission about appropriate procedures.
My hon. Friend the Member for Kensington will understand that it is important to have discussions with pharmacists, general practitioners, nurses and with a great range of experts to ensure that they all properly understand how the arrangements should be carried out.
There is also the question of the link with general practitioners and, for example, the way in which the prescribing scheme works. We have made good headway in recent years on thoughtful prescribing. There is a strong initiative to ensure that patients receive the drugs that they need and I have no doubt that there is a place for nurse prescribing within that framework. However, we need to be sure that we have the details right as we move forward to legislation. We are also carrying out work to establish the administrative arrangements for the introduction of nurse prescribing. Officials have already had detailed discussions with the Prescription Pricing Authority about pricing mechanisms and arrangements for providing information about nurse prescribers' prescribing. In due course other practical details will have to be sorted out, such as the design of the prescription pad.
My hon. Friend will be aware that in our determination to provide a high-quality health service to patients, we need to make sure that all our professional groups work to the maximum of their ability. Indeed, 95 per cent. of health care takes place in the community. Now that we have implemented the main part of the NHS side of the National Health Service and Community Care Act 1990, we are swiftly moving towards implementation of the community care aspects. The link between the health service and social service departments in implementing care in the community is essential. The role played by community nurses, health visitors and district nurses and the full contribution that they can make is a matter to which we have given careful consideration.
Recently we produced a report under the chairmanship of Sheila Roy, a regional nursing officer, on nursing in the community. It described the various models of provision of community nursing, whether attached to GP practices, working essentially on a patch system or under the different models which are becoming commonplace in various parts of the country. All are agreed that the role, status and standing of nurses, in whom the public and the Government have great confidence, must be addressed comprehensively and thoroughly.
We have reorganised nurse management in the Department. Nurses are the largest group in the NHS.
597 They provide the hands-on, direct patient care. They understand the patient and especially the patient within the community.
I hope that I have made clear to my hon. Friend the Member for Kensington today that we see a clear role for nurses and an opportunity for them to develop and evolve their skills. I cannot give detailed support to my hon. Friend's Bill, but I assure him unequivocally that I have carefully noted his points. I value the contribution that he made by introducing the Bill. We shall work with determination and all possible urgency to give effect to the aims for which he has so effectively worked and the measure for which he argued in the House today.
§ Mr. James Arbuthnot (Wanstead and Woodford)
I join my hon. Friend the Minister in warmly congratulating my hon. Friend the Member for Kensington (Mr. Fishburn) on the measure that he has introduced today. As a former deputy mayor of the royal borough of Kensington and Chelsea, I have kept in close touch with my hon. Friend's borough, and still live in it. I am well aware of the amount of work that he puts in on behalf of his constituents. I am also aware that he is tireless in bringing to the House interesting, imaginative and fresh proposals which could help not only his constituents but the entire country.
It is a truism to say that, whenever our constituents go into hospital they agree that a body of people has been absolutely fantastic in the level of care, sympathy and expertise given to the patients. Those people are the nurses.
I recently spent a weekend at Whipps Cross hospital, which serves my constituency. I arrived at 9 am on Saturday and left at 5 pm on Monday, having spent the time in between closely shadowing a junior hospital doctor and discovering the amount of time that junior doctors have to put in. I also discovered that the amount of work which nurses put in is beyond compare. I hold in high esteem the body of nurses who serve Whipps Cross hospital, as I know my constituents do.
It was encouraging and heartening that my hon. Friend the Minister gave such a positive reaction to the principles behind the Bill. The timetable that she set out in her speech was swift and encouraging. It is true that we need to get the Bill absolutely right to avoid the risk of spoiling the good measures which it introduces by bringing them in too hastily. The Bill is of considerable excellence.
I have one reservation. If nurses are allowed to prescribe drugs, even minor drugs, which would in no way endanger or cause an adverse reaction in the patient unless the patient was taking some other form of drug and that combination——
§ It being half-past Two o'clock, the debate stood adjourned.