Nurses, Midwives and Health Visitors Bill [Lords]

HC Deb 13 January 1992 vol 201 cc696-722

Order for Second Reading, read.

5.6 pm

The Minister for Health (Mrs. Virginia Bottomley)

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

The Bill, which was introduced in this House on 10 December, constitutes an important landmark in the history of the nursing, midwifery and health visiting professions. Its main purpose, in brief, is to change the constitution and functions of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting and the four national boards for nursing, midwifery and health visiting.

The five statutory bodies were set up under the Nurses, Midwives and Health Visitors Act 1979. Prior to that, there had been a number of bodies in all four countries regulating either whole professions or specific aspects of training. The new statutory framework aimed to bring those bodies together, to establish common standards of education and training and professional conduct throughout the United Kingdom and to establish a single United Kingdom register for nurses, midwives and health visitors. It sought fully to establish the principle of professional self-regulation for the three professions. Those are important principles, which are reflected, and indeed further developed, in the current Bill.

Under the 1979 Act, the UKCC was established as the single United Kingdom corporate body, responsible for establishing and improving standards of training; maintaining a register of qualified practitioners; and determining whether a practitioner should be removed from the register.

The national boards were set up as autonomous corporate bodies in the four countries, with responsibility for making provision for nurse, midwifery and health visiting education and training in line with UKCC requirements, for arranging examinations, for collaborating with the UKCC in the promotion of improved training method, and for carrying out initial investigations in cases of alleged misconduct.

In 1987, a review of the central council and the national boards was commissioned by the four United Kingdom Health Departments as part of the regular Treasury programme of reviews of non-departmental public bodies. It was carried out between December 1988 and March 1989 by Peat Marwick McLintock. The review team produced a radical set of recommendations, and its report was issued for consultation in August 1989. On 4 February 1991, the Secretary of State announced the Government's decisions on the Peat Marwick McLintock recommendations, and indicated our intention to introduce legislation as soon as possible to implement those decisions.

The purpose of the legislation would be to change the constitution of the central council from a body the majority of whose members are nominated by the national boards, to a body the majority of whose members are elected by the professions to whom they are responsible. It would change the constitution of the four national boards for nursing, midwifery and health visiting from elected to appointed bodies. It would remove the role of the national boards in managing and financing the provision of nursing, midwifery and health visiting education and training, in line with the principles of the NHS reforms. That function would be devolved to health authorities, with the exception of Northern Ireland, where the existing arrangements would continue to apply. It would centralise all professional conduct investigations at the council, avoiding duplication of effort and rationalising this important function. Unnecessary delays in this sensitive aspect of the council's work are distressing for all those involved and are certainly uncalled for.

Mrs. Maria Fyfe (Glasgow, Maryhill)

What are the Government's plans for section 32 of the General Whitley Council appeals procedures? Some months ago, the Government expressed an intention to do away with the scheme, but there is no mention of that in the Bill.

Mrs. Bottomley

Section 32 has nothing to do with the Bill. We want to find a way of tackling the question of section 32, which is cumbersome and causes much delay and unnecessary ill will. We should like to make progress in talks with the staff side and the unions, but the hon. Lady will appreciate that section 32 has nothing to do with this important Bill, which deals with the regulation of nurses, midwives and health visitors.

Much thought and discussion has gone into the Bill. In principle, it is not controversial but is a highly sensitive matter for the profession, which is the backbone of the health service.

Mr. William O'Brien (Normanton)

Will the changes that the Minister is referring to have any impact on Project 2000? Nurses are being denied the opportunity to take part in that project because of regional differences, particularly in my constituency. Will the Bill allow those nurses to take part in Project 2000?

Mrs. Bottomley

If the hon. Gentleman will bear with me, rather than answer interventions in an ad hoc manner I shall make an announcement about Project 2000 later. The project has been a major success of the Government. We shall announce additional funding, which will mean that, since its establishment, we will have spent more than £205 million on this important new form of nurse training.

Immediately after my right hon. and learned Friend's announcement about the plans that we intended to carry forward on the basis of the Peat Marwick report, we established a legislation advisory group and gave it the remit of considering in detail what changes will be required to the Nurses, Midwives and Health Visitors Act to give effect to the Government's decisions on the recommendations. The group comprised representatives of the four United Kingdom health departments, the UKCC and the national boards.

I want to pay tribute to the work of the group. It met five times between March and September last year, and I was pleased to meet its representatives earlier in the autumn to discuss the outstanding issues that have emerged from its work. I think that it is fair to say that there is virtual unanimity on the legislative proposals that are enshrined in the Bill. I want to pay tribute to the constructive and valuable contribution that the statutory bodies and professional organisations representing nurses, midwives and health visitors have made to the development of our proposals. Without their co-operation, we would not have been able to move as fast as we have.

Before outlining the provisions of the Bill in more detail, I must underline, for the benefit of the House, a point that ministerial colleagues and I have made in other settings. The fact that there will no longer be a centrally top-sliced budget for nursing and midwifery education and training, distributed by the national boards, does not detract from the Government's commitment to ensure that adequate provision is made for education and training.

We have made it clear that we expect the regional health authorities in England to establish protected budgets for pre and post registration training for nurses, midwives and health visitors and that we are developing mechanisms to ensure that those budgets are monitored at the centre. This year, we are spending about £770 million on pre and post-registration nurse education and training. Next year—1992–93—the figure will rise to £870 million. That is a practical demonstration of the Government's commitment to invest in the major work force of the national health service.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

I am sure, therefore, that the Minister will make it clear that, if regional authorities do not comply with the suggestion that they should provide adequate education, the Government will not only take sanctions but will write into the Bill the ability to take sanctions.

Mrs. Bottomley

I do not think the hon. Lady will be surprised to hear that I am not prepared to write that into the Bill. We shall take steps to ensure that the substantial resources that are invested in nurse education and training, pre-registration and post-registration, continue and develop. Indeed, not so long ago I was able to visit the nurse training college in the hon. Lady's constituency and was most impressed by its work.

We are dependent on the skills, contribution and commitment of those who work in the health service to provide high-quality patient care. Our commitment to patient care relies on the long-term supply of well qualified staff. As a tangible example of our commitment to training and investing in nurse education, I can announce extra resources for Project 2000, to which the hon. Member for Normanton (Mr. O'Brien) referred.

I announced today that we shall make a further £98 million available in 1992–93 for the further implementation of Project 2000. That is a large increase on last year's £71 million and shows our commitment to the initiative. That £71 million was almost double the amount of money that was available the previous year. The major part of the money will be needed for the ongoing cost of the 49 schemes that already provide Project 2000 training. Sixty-two per cent. of nursing schools have Project 2000 courses, and we intend, with those resources, to ensure a further development of colleges where Project 2000 courses are available.

We shall make an announcement in April when we have consulted further. Since 1988, we have invested £207 million in Project 2000, which is a practical and clear commitment to ensuring that we have the nurses that we need for today and tomorrow.

Mr. O'Brien

I appreciate the opportunity to make a further point on this matter, because it is important to a constituent of mine who has applied for a Project 2000 course but has been denied it. Will the anomalies in the Project 2000 scheme be removed by the changes that the Minister is referring to? That is important to practising nurses.

Mrs. Bottomley

The hon. Gentleman may wish to write to me with the details of the college to which he is referring.

Since 1988, 62 per cent. of nursing schools in England—more than 29,000 nursing places—have been able to change to Project 2000 courses. I regard that as rapid progress and a considerable achievement, and I am pleased to inform the House and the hon. Member for Normanton that we have made available further resources to continue that process of change. I hope that the college to which he is referring will be one of those that joins the new Project 2000 courses.

I shall now go through the Bill in detail. Clause 1 increases the maximum membership of the central council from 45 to 60 and specifies that two thirds of the membership shall be elected, rather than nominated by the national boards as at present, under an approved electoral scheme. The remaining members are to be appointed by the Secretary of State, bearing in mind the need to secure that the members of the council shall include representatives of the three professions of nursing, midwifery and health visiting, and representatives from all parts of the United Kingdom.

The increase in the maximum membership takes into account the increased work load which will be placed on members by the future role and responsibilities of the council, in particular the centralising of all professional conduct investigations at the council. The fact that the majority of members will in future be elected by the professions to which the council is answerable reinforces the principle that the nursing, midwifery and health visiting professions should be fully self-regulating. It means that these professions have come of age in terms of self-regulation.

Clause 2 requires the council to submit proposals with respect to the overall numbers of the council, and an electoral scheme, to the Secretary of State for approval within six months of the Bill being enacted. That reflects the principle that as many detailed matters as possible with regard to the constitution and procedures of the council should be for the professions themselves to determine, acting through the council.

Clause 3 amends the Secretary of State's powers to constitute new standing committees. In future, such committees may be constituted only at the request of the council. The clause places on the council the responsibility of determining the need for a new standing committee and, at the same time, draws specific attention to the requirement placed on the council, in determining whether to make such a request, to have regard to the interests of all groups in the professions which it regulates.

Clause 4 provides for the non-executive members of a national board to be appointed by the Secretary of State rather than elected, as at present. In future, the national boards will be smaller executive bodies with a more limited role and function, directly accountable to the Secretary of State. The clause also provides for certain officers appointed by the boards to be ex officio members of the boards.

Clause 5 amends the functions of the national boards by specifying that they shall approve institutions which provide courses of training for nurses, midwives and health visitors rather than providing or arranging for others to provide courses at the institutions that they have approved. That latter function will in future, as I have already explained, be discharged by health authorities, except in Northern Ireland where clause 5(3) ensures that the role of the national board can continue as at present. The clause also removes from the boards their disciplinary investigation functions, so that professional conduct matters will in future be the sole responsibility of the council. That step is well understood and is important in streamlining the disciplinary functions.

Clause 6 abolishes standing committees of the national boards, joint committees of the council and the boards, and the board's local training committees. Standing committees and local training committees will no longer be appropriate for the smaller executive bodies the boards will become, and the clear differentiation between the roles of the council and the boards will render joint committees redundant.

Clauses 7, 8 and 9 relate to the professional conduct and fitness to practise and will add welcome elements of flexibility to the council's existing powers. Clause 7 gives the council a power to suspend the names of nurses, midwives or health visitors from the professional register held by the council. That is an important step, and is in addition to the present power to remove them from the register. It is intended that the power will be used where a nurse, midwife or health visitor is deemed by the health committee of the council to be unfit, for medical reasons, to practise. The professions have welcomed that power.

Clause 8 allows the committees of the council which deal with proceedings for removal and suspension from the register, to have a minority of members who are not members of the council. That will obviously assist the council greatly in dealing with the additional committee work consequent on the centralisation of all professional conduct investigations at the council. There will be a work load, and to discharge it effectively sufficient numbers will be needed to undertake these great responsibilities.

Clause 9 was introduced following useful discussion in another place. It puts it beyond any possible doubt that rules in relation to proceedings which might lead to removal from the register can make provisions about the giving by the appropriate committees of cautions as to future conduct. There was some debate about whether the powers already existed or whether they should be written into the legislation. In view of the great uncertainty on the matter, we decided it was fair to write them into the legislation. It is another important midway step to improve the mechanisms at their disposal.

It is envisaged that the rules will provide for such cautions to be given in cases where professional misconduct has been established, but is not deemed sufficiently serious to warrant complete removal from the register.

Clauses 10 to 12 are concerned with midwifery practice. Clause 10 removes the requirement for the council to consult the national boards before acting on any report from the council's midwifery committee on proposals regarding midwifery practice rules—an amendment which stems from the fact that the national boards themselves will no longer have statutory standing midwifery committees.

Since the council will in future be solely responsible for midwifery practice rules and their enforcement through the professional conduct mechanism, clause 11 requires local supervising authorities for midwives to inform the council rather than the boards of any notice given to them in compliance with the rules on midwifery practice. Clause 12 empowers the council to make rules prescribing the standards to be observed by the boards in relation to advice and guidance to health authorities and health boards regarding the local supervision of midwifery practice.

Since the beginning of the century, special arrangements have been made for midwives, and the midwifery committee of the council will continue to play that important part.

Clause 13 provides a reserve power for the Secretary of State—as is usual in such circumstances—to make grants to the council and the national boards towards any expenses incurred in connection with bringing into force the provisions of the Bill, while removing from the council the obligation to reimburse the boards in respect of expenditure on their part.

Clause 14 makes it clear that the council is not required to consult the national boards on any proposed rules which do not appear to the council to be relevant to the boards' functions. That recognises the fact that the council, as the elected body responsible for making the rules, is the proper body to determine what is relevant to those functions. The remaining clauses deal with transitional provisions, amendments and repeals.

Mrs. Marjorie Mowlam (Redcar)

Will the Minister clarify whether, in the detail that she has just given us, the regional health authorities will be responsible for funding the policy? If so, regional health authorities will have to decide their priorities, so it is well possible that education and training could come lower down the list of priorities of some regional health authorities because of financial considerations.

Mrs. Bottomley

I addressed that point at the beginning of the debate before the hon. Lady had time to join us. I made it clear that the money available for the education and training of nurses, midwives and health visitors would be top-sliced and held by the regions. We are carrying forward arrangements to make sure that there is a transparency of the resources so ring-fenced and that there are effective mechanisms for monitoring how the money is spent. I was able to tell the House that the money spent this year on pre and post-registration and training for nurses, midwives and health visitors amounts to £770 million. Next year that sum will be £870 million. These are large sums.

The health service has always been a good trainer of our staff. We want to ensure that we retain those trained staff. That is why our work in carrying forward the proposals under Project 2000 are so important. I am pleased to report that what is so elegantly called our "wastage rate" in the health service has never been lower. We are holding on to more nurses, health visitors and midwives than ever before.

As my hon. Friend Baroness Cumberlege said in another place, whereas the average time spent by a nurse in the service used to be about seven years, it has now risen to about 14 years. That is a significant improvement in the way in which we are an effective employer. Of course, it calls into question the importance of post-registration training—an area in which good progress is being made.

This is a short Bill, but a very significant one for the future of the nursing, midwifery and health visiting professions. It provides another demonstration of our total commitment to the future of the professions, and the key role we expect to see them continue to play in providing health care to the people of the United Kingdom. I believe that it ranks in importance with the other two major developments affecting the professions which have taken place under the Government: the establishment of the pay review body in 1983 and our decision in 1988 to implement and fund Project 2000. Not that those are the only examples of Government action to safeguard, strengthen and develop the nursing, midwifery and health visiting professions.

It is essential that those professional groups who make up the backbone of our health service are properly remunerated and trained and have effective and self-regulating organisations to ensure their well-being. It is against that background—because of the value we attach to the nursing, midwifery and health visiting professions—that we have taken such speedy action to implement our decisions on the Peat Marwick McLintock recommendations and have given priority to this Bill in our legislative programme this Session. The professions themselves have welcomed the Bill, and I am convinced it will benefit not only the professions but, even more importantly, the patients and clients whom they serve with such skill and dedication. I commend it to the House accordingly.

5.31 pm

Mrs. Sylvia Heal (Mid-Staffordshire)

In principle, the Labour party welcomes this important Bill, which has the broad support of the professional organisations and the health unions whose members are affected by it.

The Bill will update and modernise the Nurses, Midwives and Health Visitors Act 1979 by remedying some of the defects that have become apparent since then, following the Peat, Marwick, McLintock review of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting and the four national boards. However, there are some matters on which we will seek clarification or assurance.

The Bill is largely uncontentious and we wish to facilitate its swift passage on to the statute book. It seeks to streamline the bodies of representation and accreditation of the nursing professions by removing duplication of roles and removing confusing remits. It will strengthen the representation of the professions and improve the accountability of the UKCC to them.

We welcome the move to make two thirds of the UKCC elected from the professions, as we believe that that will give nurses, midwives and health visitors increased control over their professions. We agree that the centralising of elected representatives away from the national boards to the UKCC will improve the accountability of the UKCC.

We are concerned that the procedure for election to the UKCC, which will be approved by the Secretary of State, should ensure fair representation of all groups, especially minorities, and achieve a regional balance as well. We understand that the UKCC is anxious to achieve that, but we seek an assurance from the Minister that that will happen. We also want to ensure that provision is made for the representation of enrolled nurses on the UKCC. Although an enrolled nurse can represent any group, it is important to ensure that enrolled nurses are represented as an interest themselves.

We are also concerned that the members of the UKCC appointed by the Secretary of State will include representatives of nursing, midwifery and health visiting from the four national areas. It is equally important that appointments to the national boards include a registered nurse and a practising health visitor and midwife. Baroness Hooper conceded in another place that, in practice, that will happen. Therefore, we see no reason why that commitment cannot be included in the Bill. Furthermore, we want to ensure that those whose appointments are made by the Secretary of State have the appropriate qualifications and experience to fulfil their functions. We also want the interests of minorities, and consultation with them, to be given equal weight with the interests of the larger professions.

With the change of function and responsibility between the national boards and the UKCC, it is obvious that the joint committee and the national board standing committee of health visitors and district nurses are, de facto, abolished. However, will the Minister assure the House that the new standing committees to be established by the UKCC will include committees for the minority professions so that their significant contributions to nursing are heard and they are consulted on the issues that concern them?

Minority or specialist groups are naturally anxious about their status. They do not want it diminished by the Bill. We want to stress that the term "minority" is in no way a reference to the importance of the work carried out by health visitors and nurses in the community, such as district nurses, community psychiatric nurses, school nurses, residential care nurses, occupational health nurses, practice nurses, nurse practitioners as well as those nurses who are working in terminal care. Those people may be a minority in number but they are not in stature.

The Labour party attaches immense importance to the role of primary care and to the nursing profession, which is at the forefront of health in the community. The Labour party is fully committed to health promotion and prevention care. The next Labour Government will have a vigorous public health strategy in which those groups of health workers will play a vital role.

Community nursing is the face of the NHS in homes and workplaces nationwide. Nurses in that sector have to cope with the effects on their patients of poor housing conditions and a deteriorating social fabric. They are the face of the NHS and they play the crucial role of promoting better health through advice on life style, a healthy diet, exercise, alcohol, smoking and drug addiction. The work of midwives in helping mothers and young children and the work of the district nurse in clinical medicine are crucial.

Community nurses are witnesses to the everyday health of the population. Their testimony on it represents crucial, first-hand experience of which those planning for the hospital-based sector must take significant account. Through health promotion and the prevention of conditions that lead to ill-health, those nurses seek to lift some of the burden from their colleagues in the acute sector. The nurses in that sector are the constant face of the NHS with patients in its care. They observe and participate in every moment of a patient's time in hospital. They have to cope with the constantly changing needs of patients, doctors and management.

Nurses are the linchpin of the NHS. There are 500,000 nurses in Britain today on whom we depend for our good health at home, in hospital and at work. I am extremely aware of the important and valuable role that nurses play in my constituency and I want to pay tribute to them.

The financing of the UKCC comes from individual nurses themselves who pay a fee of £30 tri-annually to maintain their names on the register. In the past, questions have been raised about the publication of financial reports and the accountability of the UKCC for its use of funds to those who supply them. We recognise that the fact that the Bill introduces a two-thirds elected representative element to the UKCC means that that accountability has been improved. The UKCC itself has tightened up the process of disclosing its financial status. However, it would be prudent and sensible to place the UKCC under the regular inspection of the Audit Commission as an assurance to the professions of the UKCC's commitment to sound and open financial management. That would prevent such problems arising again.

The issue that is of most concern to the Labour party is the future of nursing education. At a time when it is important to attract more women and men to the nursing professions it is vital that education facilities exist to offer excellent training and a career structure through pre and post-registration specialities as well as courses for those wishing to return to the profession.

Furthermore, it is crucial that those already in the profession—whether students, auxiliaries, enrolled, registered or specialist nurses—have the opportunity to seek the nursing career that they desire through adequate educational facilities, which must also take account of developments such as nurse prescribing and nurse practitioners. Although short-term courses such as intensive care training, bereavement and other counselling, improvement of inter-personal skills, control and restraint—to name but a few—do not lead to specific qualifications, they are still significant aspects of a nurse's training and advancement and give nurses an opportunity to refresh their skills.

The UKCC has now made it mandatory for all nurses to attend a five-day refresher course every three years to maintain their registration. It requires employers to meet the costs and plan the time for courses. Under the Bill, responsibility for the administration of funding for nurses' education will be transferred from the national boards of Wales, Scotland and England to health authorities and health boards.

Opposition Members and the professional and trade union organisations fear that post-registration training and education may suffer. Because regional health authorities will be concerned to prioritise resources, especially in the market-driven planning now prevalent in the national health service, they are more likely to be influenced by financial consideration than the clinical needs of a nursing staff trained in all specialties. They need to ensure that staff stay within the national health service and do not become disillusioned by a lack of educational opportunity and thus career advancement.

Regional health authorities will now be responsible for planning nursing education and will be primarily concerned with their regional responsibilities. They may be unable to assess or contribute adequately to national nursing education needs or desires. Furthermore, they may be reluctant to invest in expensive post-registration education funding. There will be no guarantee that their investments will see fruition in the regions because staff may move elsewhere to take advantage of opportunities created by improved training and qualification.

We welcome the Government's express commitment to ring-fence the funds that the regional health authorities will administer but we remain concerned about how long that will last. Education is often the first to be squeezed at a time of cuts. The pressures of the health market which the Government have created mean that balanced books and a worried look over the shoulder at the competition are the immediate concerns of NHS managers and accountants. Longer-term planning, which is vital for education, will not receive the priority that is attached to praying that each financial quarter will be survived without having to close wards and hospitals, cancel operations, incur building repair expenses or experience increased waiting lists.

Many post-registration courses such as psychiatric nursing and health visiting do not last a matter of weeks but require years of dedication and training. We are worried that regional health authorities may not have the necessary outlook required to ensure adequate long-term and national provision and that that will be reflected in the allocation of funding.

The pressures of long-term planning will affect not just post-registration courses. Enrolled or second-level nurses are especially vulnerable when attempting to convert to first-level registration. The implementation of the UKCC's Project 2000 educational reforms includes plans to promote opportunities in nursing by conversion to first-level registration. The implementation of that policy will now be the responsibility of the regional health authorities. Although I welcome the Minister's comments about increased funding, there are currently 96,000 enrolled nurses, of whom at least 35,000 seek conversion, with only 2,430 places available.

When the additional money is spent on training nurses, it is important that every effort be made to retain their services over a much longer period, which may involve making the terms and conditions more flexible for women returning to work. We estimate that, given the current rate under Project 2000, it will take 14 years before all nurses have that opportunity for advancement. The regional health authorities must be aware of and able to respond through their educational strategies to the problem of the national perspective.

The Government's assurances on ring fencing are welcome but, unfortunately, inadequate. The commitment to ring fence for as long as necessary, as Baroness Hooper said in another place, will allow the Secretary of State arbitrarily to decide that, if he wishes to allocate the funds to some other project, he could deem the necessity to have ceased. Ring fencing needs to be enshrined in the legislation to prevent the funds from being diverted by regional health authorities or the Government. If the Minister believes that education in nursing is a vital investment in the profession and the nation, she will ensure that those funds remain for education only and will strengthen the Government's commitment to ring fencing.

The situation of nurses in opted-out trusts is of particular concern, as trusts are not obliged to provide for the education and advancement of their staff. It will be up to trusts to decide whether to pay for training and permit time off for it. If the Government's plans continue to force many more units to opt out of health authority control, training and standards are likely to suffer. Trusts take a much narrower view on long-term needs than regional health authorities, and nursing education is not even an obligation.

Mrs. Bottomley

What evidence does the hon. Lady have for that suggestion? All the evidence from the trusts is clear: their commitment to patient care and to their staff is at the forefront. For example, Guy's is seeking to tackle the problem of junior doctors' hours. It is a wild and mischievous allegation, for which the hon. Lady has not a shadow of evidence.

Mrs. Heal

Can the Minister give us that evidence? The opted-out units are no longer under the direct authority of the regional health authorities but report directly to the Secretary of State. The regional health authorities will now be responsible for education.

Mrs. Dunwoody

Will my hon. Friend explain to the Minister that, in the trust in my area, newly trained nurses were told that there were no jobs for them? In addition, the existing nurses, who were given undertakings when the trust was set up that their posts would be protected, are now being told that all their jobs are up for re-examination and that anyone seeking extra education will soon be told that someone else is waiting to take her position——

Mrs. Bottomley

rose——

Mrs. Dunwoody

The Minister cannot intervene on me.

Mrs. Heal

My hon. Friend's comments echo the concerns that already exist. Ministers regularly say that the opted-out units are independent, so the Minister cannot then argue that they are part and parcel of the structure. The health service is being fragmented.

Mrs. Bottomley

The hon. Lady has failed to understand that the ring-fenced money held by the regions is for the trusts or directly managed units. Therefore, if such a cynical interpretation of the motivation of those committed professionals who are carrying forward the first wave of trusts were to apply, it would be irrelevant because the resources are ring fenced by the region and the trusts would be at no disadvantage. That cynical interpretation of the commitment of all those dedicated professionals who are carrying forward the first wave of trusts is so bitterly resented by the health service, which is why the Labour party has lost all credibility with the health professionals.

Mrs. Heal

Despite what the Minister has said, we are not embarrassed by our policy on health-far from it. We are saying that, under the legislation for the trusts, there is no obligation for them to train, despite what the hon. Lady has said.

Mr. O'Brien

May I substantiate my hon. Friend's point? I referred to the example of St. James's college in Leeds, which is a trust-funded college. It now discriminates against trained nurses taking the Project 2000 scheme. My hon. Friend has evidence. A person who is prepared to be named—I shall give the information if called to do so—has told me about the discrimination on training in a trust hospital in Leeds. The evidence is there and my hon. Friend is right to bring the matter to the attention of the House.

Mrs. Heal

I thank my hon. Friend for that helpful intervention.

Mr. Keith Mans (Wyre)

Where is the evidence?

Mrs. Heal

My hon. Friend the Member for Normanton (Mr. O'Brien) has already said that the information is there.

We are concerned about nurse education, which is why we believe that it will be crippling for the NHS and for the nation's health if, in years to come, we have poorly trained nurses who leave the profession because they are denied the opportunity of advancement and the capacity adequately to treat patients. Training does not make cash as extra-contractual referrals do, but it is an investment in Britain's health. The problem is that the Government will let opted-out units opt out of training and education. That will not happen under a Labour Government because units will not opt out.

We welcome the Bill and support it in principle. The desire to modernise the UKCC and the national boards, and to condition them for the 1990s is uncontentious and is supported by the Opposition, by the professional organisations and by the health unions. The Bill is a commitment to nursing arid to the esteem in which the professions are held throughout the country. We are concerned about some issues and we may wish to raise them again later in the Bill's progress to safeguard the position of all nurses throughout the 1990s.

5.51 pm

Mr. Roger Sims (Chislehurst)

I warmly welcome my hon. Friend the Minister's announcement about Project 2000 and its funding. I vividly recall speaking at a meeting of nurses when Project 2000 was first announced. Although nurses were delighted by the Government's saying that they intended to implement the proposals, there was understandably some doubt about whether resources would be made available for that. The Government have lived up to their word all the way along, and this afternoon my hon. Friend has said that the Government are backing Project 2000 with increasing amounts.

I venture to speak on the Bill, first, because I have a general interest in health and, secondly, because I am a lay member of the General Medical Council, a self-regulating professional body which has much in common with the United Kingdom Central Council as it will be and as it has been.

It may be something of a cliché to say that some features of our country are the envy of the world, and it may not always be true. However, it is undoubtedly true in respect of both hospital and community nursing. It is commonplace to hear anyone who has been looked after by nurses expressing the highest praise for their diligence and sympathetic care, whether in hospital or in the home. I personally endorse that sentiment, having spent time—happily only a day—during the recess in hospital as a patient.

Our nurses are very much in demand in the United States, in Commonwealth countries and in the middle east, and they do wonderful work in parts of the third world. The reason is simple. They have a high standard of education and of professional performance, which is what the Bill is all about.

The Bill simplifies and improves the systems of nursing education and of disciplinary procedures for the purpose of imposing and maintaining the highest possible professional standards. I wish to comment on two matters. First, the UKCC will continue to deal with professional misconduct, unlike the General Medical Council whose brief is to deal with serious professional misconduct. The definition of those two terms is a matter for discussion, to be decided by the respective councils and, if necessary, the courts.

Hitherto, the only power that the UKCC had in such cases was erasure from the register. As the Minister has explained, the Bill adds the possibility of suspension and, since the discussion in another place, the sanction of a caution. That is entirely admirable, because there are bound to be cases in which suspension and a caution will be more appropriate than complete erasure.

There is another dimension. As one of the two lay screeners on the General Medical Council, I see letters of complaint about doctors on which the council is unable to act. The reply to the complainants explaining why the council is unable to act has to be approved not only by a medical member of the council, but by one of the two lay screeners. I see a number of complaints that do not come near serious professional misconduct. Under the present powers, the GMC is unable to deal with them, yet the complaint, sometimes about one incident and sometimes about a series of incidents, may demonstrate that the doctor's behaviour is below the standard that patients are entitled to expect. At present, the GMC cannot deal with such a case. The GMC is addressing the problem under its performance review and my hon. Friend the Minister will be aware that various proposals are under discussion and are likely to appear before the House in due course.

I cannot see that the Bill addresses a similar issue with regard to nurses, I am not talking about a specific offence of commission or omission, but about a nurse whose performance is simply not up to scratch. If that is the case, neither erasure nor suspension would serve any purpose, and a caution would help only if it were accompanied by more positive measures. What is needed is a mechanism for reviewing the nurse's performance, and for proposing and supervising some means of improvement.

One other clear difference between doctors and nurses is the fact that a doctor, once qualified and registered, is free to practise at any time regardless of whether he or she has been in regular practice and has kept up to date with medical developments. An example well known to the House is the right hon. Member for Plymouth, Devonport (Dr. Owen) who, as I understand it, could put up his plate as a general practitioner tomorrow morning despite the fact that he may not have seen a patient and certainly has not practised for 20 or 25 years. I hasten to add that he has made it clear that he has no intention of doing so. As an officer of the Hong Kong group, I might be tempted to consider other ways in which the right hon. Gentleman's talents might be directed—although you, Mr. Deputy Speaker, might feel that that was a little outside the scope of the Bill.

It is, rather worrying that what I have described could happen. Let us suppose that a nurse who is trained, qualified and practising leaves the profession to raise a family and returns to it after an interval of some years. As I understand it, in the nursing profession there is a clear requirement that, on re-registering, a nurse must satisfy the UKCC every three years that she has kept her skills and knowledge up to date. That appears to me to be admirable, and it is an example from which the GMC could perhaps learn.

Mrs. Dunwoody

I have great sympathy with the hon. Gentleman's point and if, in future, he seeks to amend the Bill to suggest some form of retraining, I shall be happy to support his amendment. Having said that, there is a mild barrier in the case of doctors. In practice, if not in law, anyone seeking to go back into general practice who had not undertaken the necessary training period would find it virtually impossible to get another job. I agree absolutely that, in theory, anyone could return to general practice, but in practice he or she might find very real barriers.

Mr. Sims

The hon. Lady is quite right, and I remind her that I used the words "in theory", although I think that there would be nothing to prevent a doctor from starting up in private practice. Clearly, it would be difficult to get a job within the health service, but we know that there are plenty of doctors in private practice.

I should like also to comment on the lack of lay involvement proposed for the UKCC. The UKCC is to be composed of 60 members in all, 45 of whom will be elected and 15 of whom will be appointed by the Secretary of State. But clause 1 gives the Secretary of State pretty clear guidance on the sort of appointments that he should make, and it looks likely that all 60 will be members of the nursing profession of one sort or another. That compares with a GMC of 100-plus members, of whom a dozen are lay members.

I fully understand the anxiety that all branches of the profession should be represented on the council and that there should be the right sort of geographical spread. My own involvement makes it difficult for me to be entirely objective about this, but I suggest that there should be some form of non-professional representation on the UKCC. One reason for that is that I think that lay involvement is right in principle. After all, nurses do not operate in a vacuum: they deal with patients all the time. Every one of us has been, or is likely to be, a patient. It is surely right that patients, as users of nurses' services, should at least have a voice on the council.

Secondly, I suggest that lay people have something to contribute to the UKCC's deliberations and work and, although I say it myself, I think that the professional members of the GMC would endorse the view that lay members have a useful contribution to make.

Thirdly, it would be good public relations for the council not to be seen as an entirely closed body. I am sorry to keep referring to the GMC, Mr. Deputy Speaker, but it is a comparable body of which I have some knowledge. There is a tendency for people to refer to the GMC as the doctors looking after their own, but having worked for the GMC, my own impression is that doctors quite often wish to be harder on their own than lay members might be. Be that as it may, the implied criticism is at least modified by the fact that people know that a lay element exists within the GMC. Whether we like it or not, public image is important nowadays, and I wonder whether it would not be in the interests of the UKCC to consider the benefit of lay involvement, especially where matters of professional misconduct are being dealt with.

I apologise for detaining the House with those thoughts. I hasten to add that my comments have been in a constructive spirit. The Bill seems to me to be entirely admirable. I hope that it will command the full support of the House and will receive Royal Assent before other events intervene.

6.4 pm

Mr. Tom Pendry (Stalybridge and Hyde)

First, I congratulate my hon. Friend the Member for Mid-Staffordshire (Mrs. Heal) on her debut; indeed, I thought it rather churlish of the Minister not to recognise that her opposite number was speaking from the Opposition Front Bench for the first time. I look forward to my hon. Friend making her debut as a Minister, and I am sure that that occasion will come in the not too distant future. When I was campaigning for my hon. Friend, I told the electors of Mid-Staffordshire that they would be sending a star to the House; my hon. Friend has certainly lived up to that already.

If ever evidence was needed that we are in a general election year, the Bill before us provides it. Why else would the Government at last be listening to the views of professionals and trade union representatives who work in the national health service, who for years have been giving the Government the benefit of their experience and knowledge of working in the health service, day in and day out, only to find their advice falling on deaf ears?

Like my hon. Friend the Member for Halifax (Mrs. Mahon), I am sponsored by the National Union of Public Employees. We are well aware of the problems faced by those who have given their lives to working in the health service. My hon. Friend and I have raised their concerns in this place on many occasions. It is regrettable that it has taken the Government until now—as they approach the day of reckoning at the ballot box—to show some belated willingness to take those people's knowledge on board.

For all that, the Bill is welcome and it is to be hoped that the Government's apparent Saul-like conversion to the concept of listening to our NHS professionals will extend beyond the immediate measures proposed in the Bill. Certainly, I know that my constituents—workers, users and passionate supporters of the health service—are looking to the Government to match their own commitment to the NHS.

One important reason why it is to be hoped that the Government's attitude, as demonstrated today, will remain is that the nurses' pay awards are soon to be announced. My colleagues in the NUPE group of Members and I hope that, this year, the Government will listen to staff representatives as well as their own pay review body. I am well aware that our nursing staff are anxious that, rather than the pay award being staged, leaving the health authorities to make up shortfalls of up to £44 million, it should be implemented in full on the due date and fully funded.

The enormous value of the jobs that our nursing staff do should be recognised not only through the words that Ministers utter in this House but through actions to back those words. If the Minister wants to give concrete evidence of the Government's commitment to the national health service, she will announce today, in reply to the debate, that the Government will indeed fully fund that award and not seek to stage it. My hon. Friends and I look forward to hearing her make that announcement.

The general thrust of the measures in the Bill has commanded widespread support, as evidenced in the co-operation extended by my noble Friends in the other place to get the measures on to the statute book as quickly as possible. The Minister will be aware, however—from the contributions made in the other place by my noble friend Lord Carter among others—that there are still reservations on some issues that many of those working in the national health service would wish to have raised and taken on board by her and her boss, the Secretary of State.

My hon. Friend the Member for Mid-Staffordshire mentioned some of those reservations. I should like to back her up on a couple of issues so that we may be sure that, together, we have caught the Minister's ear and that the hon. Lady can pass on our concerns to her boss.

For example, the health service unions have expressed concern about the proposed changes to the constitution of the UKCC, to increase the council's maximum membership from 45 to 60, with the specification that two thirds be elected by the professions and the remainder appointed by the Secretary of State. Under that move, although the council would increase its membership, the opportunity to be a representative elected by the profession will be radically reduced. The Minister must recognise that.

Currently, 102 members are elected to serve the national boards rather than the council. It is entirely proper that there should be direct elections to the UKCC, but the Minister knows that the proposed number of elected representatives on the council would deplete representation by more than half. The Minister will also know that the health service unions think that this balance needs to be changed. She should give a commitment to take their views on board.

The Minister should assure midwives and health visitors that their voice will continue to be heard. I am told by some of them that if that does not happen they will feel isolated, unsupported and unable to influence policy. I am sure that the Minister will wish to allay those fears when she replies to the debate. That matter is especially important in view of the transfer of responsibilities for financing nursing, midwifery and health visitor education and training to the regional health authorities. That will mean that the RHAs will be responsible for determining the allocation of funds based on their own priorities and the regional interpretation of education and training needs.

The unions feel that this will create a gulf between policy developed by the UKCC and the implementation of that policy by the regions. The Minister has given some reassurance, which I accept, that she will do everything in her power to see that education and training in the NHS are extended and promoted. However, that does not go far enough, and I hope that, during the passage of the Bill, we shall have a more positive statement from the Minister.

In the context of Project 2000, my hon. Friends were right to impress upon the Minister the problems that are emerging in nursing education and causing a great deal of concern. My hon. Friend the Member for Normanton (Mr. O'Brien) was right about that. I have been informed by the nursing unions that enrolled nurses are afraid to come forward for the training schemes intended by the reforms, because there is no guarantee of a job to which they could return. My hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) also made that point. Many have lost motivation and have become demoralised by the fierce and unrealistic competition for the tiny number of places available. The Minister must surely agree that that is scandalous and should tell us the action that she intends to take. She has gone some way by speaking about extra funding, but nurses want more positive assurances.

The Minister must answer the questions that have been asked in the debate. Although in the main the Bill is not contentious, we shall attempt to improve it. The Government are at least listening to what is happening in some parts of the health service, but they have a long way to go to ensure that the people who staff our NHS feel that they have the commitment that they need from the Government.

6.13 pm

Mr. Charles Kennedy (Ross, Cromarty and Skye)

I shall be exceedingly brief, because other hon. Members want to speak in this short debate. We must be making history because, since 1979, I cannot recall a Department of Health Bill having all-party support. That is an astonishing development, but, of course, we are on the eve of a general election. As the hon. Member for Stalybridge and Hyde (Mr. Pendry) said, it suggests that, as the Government are about to face reality, they are trying to do something in the health service that might command broader support.

I should like to underscore points that have already been made and to stress some anxiety about the Bill. One of the worries is about the proposal to transfer responsibility for education and so on down to local level, with consequent pressure on budgets. Such strain could lead to erosion of the importance of education and related matters. In her response, the Minister should dwell on that, because I am sure that she remembers only too well the passage of the National Health Service and Community Care Bill, the consequences of which may yet help to consign the Government to oblivion in the election.

The Minister will remember the lengthy arguments about community care, as will the hon. Member for Ynys Mon (Mr. Jones), about the ring fencing of community care. The hon. Member may well speak about that in the debate. The Minister and other members of the Government trotted out arguments about why it was not acceptable to have such ring fencing. The most remarkable argument of all from this centralising Government was that it would undermine local democracy. If it was not acceptable to ring-fence community care at that time, how can the Government stand equivalent arguments on their head and rightly accept ring fencing in the context of nurse education?

Perhaps the Minister could say more about the issue mentioned by the hon. Member for Mid-Staffordshire (Mrs. Heal) and discussed in another place—the stipulation that the function of the board in relation to midwifery is included in the legislation. However, a guarantee of the involvement of professional midwives in terms of direct representation is not mentioned in the Bill. Would it not be sensible to redress that? Judging by the Minister's opening speech or by pledges given by her colleague in another place, I do not think that the Government intend to exclude midwives in this way, and it would be sensible to include a provision in the Bill. The Bill commands all-party support, and I do not anticipate a Division.

6.16 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

I shall be brief. As a vice-president of the Health Visitors Association, I shall deal especially with the worries of members of that association and those of midwives. A good midwife is worth 10 doctors, a theory that I proved somewhat practically many years ago. Their special skills should not only be retained but fully understood, and I am sorry to say that I see no clear evidence in the Bill that those people will be fully consulted and their needs taken into account. It is pointless to produce glossy patients charters stating that people will have freedom of choice and consultation about the facilities they receive when they do not have access to midwives who are able to transmit their worries upwards and downwards within the profession.

It should be realised that midwives and health visitors are not only constantly learning new techniques and developing their skills, but that they frequently have to change their responses to meet developments in medicine and social care. That puts tremendous stress on the profession and requires a flexible, skilled and trained response from the practitioners in midwifery and health visiting. I hope that such matters will be addressed by the Bill.

I would be happier about the Bill if it were not so clear that the trusts will face great difficulties not only in the immediate future but in the continuing future in relation to nurses who seek further training courses, almost of any kind. In the first wave of trusts, the word "nursing" seems to have almost disappeared from the job descriptions. There are hardly any senior nursing posts listed in the trusts. That bodes ill for proper representation at every level of the professional structure.

The Minister is so reasonable and balanced that, whenever she appears, I know instinctively that the Government must be trying to put over something shady. They would not need such an apparently reasonable member of the House of Commons if their doings were above board. Therefore, the Bill must be looked at carefully. Although we may say, in a slightly dismissive way, that it is a straightforward, non-contentious Bill, it concerns the level of health care, not only for mothers for many generations to come, but for sick people at many levels of the health service, both within and without the hospital service.

In the past seven months, I have unfortunately had a rather close association with the health service as a patient, as the grandmother of a patient and as the daughter of a patient, and with a large number of London teaching hospitals. It is about time that the House of Commons realised that there is no point in bringing forward structures in which we talk about a high level of nursing care if, when it comes to the point, there is nobody on the wards capable of carrying out that level of nursing.

We should be concerned that a nurse can appear at the beginning of a shift, say, "My name is Susan, and I am looking after you," and then never be seen again because, like many others who are brought in in large numbers, she is an agency nurse, knows no one on the ward and is unable to have any relationship with the patients.

Like several of my hon. Friends, although I have a word of commendation for the Bill, I feel that we should be asking for more undertakings. It is nonsense to say that the money for education will be ring-fenced. In my area, the regional health authority is the most placid political lapdog of all the RHAs. It does exactly what its masters want, showing a level of dogma that, were it representing the Labour party, would warrant six-inch banner headlines in The Sun. Therefore, an undertaking that the RHAs will ring-fence money for training is not worth the paper that it is written on. Apart from that, I am sure that this is an excellent Bill.

6.22 pm

Mr. Ieuan Wyn Jones (Ynys Môn)

It is pleasant to turn to a considered and measured debate on a Bill that commands general support, after the hype that we heard in the statement by the Secretary of State for Wales about local government finance. It is nice to have an atmosphere in which we can debate constructively the future of some of our great professions, particularly nursing.

I had better declare a family interest, in that my mother was a qualified nurse and for many years was a district nurse in north Wales, and my wife is also a qualified nurse and midwife and has recently returned to the profession after a career break. I know something about the practical problems of nurses and how devoted they are to their professions and patients. I remember in particular during some pretty wicked winter months the problems that my mother and some of her district nurse colleagues had in reaching their patients through snow and drifts.

It is right that we should look, from time to time, at the way in which nurses are educated and trained, and at how they conduct themselves. Therefore, this small Bill is to be welcomed, in as far as it goes. However, one or two points need to be underlined. One, as hon. Members on both sides have said, is that we must recognise the challenges that face nurses, and particularly health visitors, in the current climate in the NHS.

A number of health visitors are worried about the direction in which their branch of the profession is moving, in the light of the new responsibilities that general practitioner practices are taking on, which mean that their clinics are taking over work that health visitors used to do.

If those changes mean that health visitors are taking on more responsibility for such things as health promotion, they are welcome. There is an extensive need for health promotion, especially given the recent report published in the county of Gwynedd, which showed a great increase in the number of girls who take up smoking at the ages of 12, 13 and 14. The work done by health visitors in health promotion, especially in this sector, is valuable. If that work can be extended, we should welcome such a move.

The new powers on disciplining of nurses who transgress are to be welcomed. To have just one power, that of erasure, is to take a sledgehammer to crack a nut. Many cases could be dealt with either by a caution or suspension. The disciplinary bodies would have more flexibility in dealing with problems if they did not have to go to the full extent of erasure. The morale of nurses would be improved if they knew that, for minor transgressions, they would not face the ultimate penalty.

A number of us have rightly underlined the need to look closely at the Government's proposals for the devolution of training responsibilities to regional health authorities and health authorities in Wales. We understand that the Government have accepted ring fencing, but when I looked closely at the arguments advanced in another place, I noticed that we were not told how long ring fencing would apply.

I hope that the Minister will tell us whether it is to be for one year only or for a number of years. This is important for one basic reason—if regional health authorities and district health authorities are to have proper provision for training, it must be planned over a number of years. An assurance on that would be helpful.

I make a final plea. In some cases—this is not necessarily personal experience—I have seen that nurses find it difficult to go back into the profession that they left many years ago to raise a family. Often, they re-enter the health service at grades lower than those to which they should be entitled. It would be useful if the Government were to say that nurses, after a career break, should be welcomed back into the profession, given proper training and guaranteed a proper job at a proper rate of pay and proper grading.

I welcome the Bill, and hope that it will have a speedy passage through the House.

6.27 pm

Mrs. Maria Fyfe (Glasgow, Maryhill)

I congratulate my hon. Friend the Member for Mid-Staffordshire (Mrs. Heal), whose contribution I enjoyed. I thoroughly agreed with the points that she made, and in particular with that about full representation of the various regions—a point not made by the Minister. I want to take that up, because it is a question not only of the regions within England, but of the nations within the United Kingdom. Although this is a United Kingdom Bill, it does not explain how it will be ensured that there will be proper representation among the appointments that the Secretary of State makes, to lake account of nurses, midwives and health visitors living and working in Scotland. There may be an answer, but we have not yet had it from the Minister.

If health boards in Scotland are answerable to the Scottish Office, I want the Minister to answer this question about funding for training and education for health boards in Scotland. Is it proposed that there will be a difference, and if so, what will it be?

In the discussions that I have had, midwives and health visitors in Scotland have told me of their concern about the changes in the practices that they are expected to undertake. The role of health visitors is being changed substantially in ways they are unhappy about. For a long time, midwives have been concerned about their role being undervalued and diminished by the high-tech treatment given by hospitals. It is essential that training and education give people occupying these positions the respect that they deserve and maintain the status of the profession, rather than diminishing it. The women who occupy most of the jobs in the profession feel that the latter is a more likely result.

When I intervened earlier, the Minister confirmed that there was nothing in the Bill about the section 32 arrangements of the Whitley council. If the Government do not introduce changes to the appeal procedures in the Bill, it is surely important to know when they are planning to do so. It is only weeks before we shall have a general election. I suspect that they hope to introduce changes at a later stage by means of a manoeuvre. If that is not their hope, I want an assurance from the Minister to that effect this evening.

It is pointless to complete a rigorous, expensive and highly specialised form of training if the health visitor or midwife finds that there is no job at the end of it. That has happened recently in Scotland's central belt. Health visitors were told, "I am sorry, but there is no work for you." Surely hon. Members on both sides can agree that the training of health visitors and midwives can be planned so that time is not wasted. In most instances, these people cannot apply for jobs in places throughout the United Kingdom. It must be recognised that they have family responsibilities in their own area.

6.31 pm

Mr. William O'Brien (Normanton)

I was content with the Minister's reply when I intervened earlier, especially with the parts relating to the principle and practice applied to those applying to be enrolled for the Project 2000 scheme. The Minister said that, if I would provide details of the constituent to whom I referred, she would take the matter up, and I shall do so.

I have been provoked to contribute to the debate by the position adopted by trust hospitals. The hon. Member for Wyre (Mr. Mans) asked for evidence, and I will supply it.

St. James's hospital in Leeds is a trust hospital with a nursing college attached to it. One of my constituents—Linda Bichard, who lives in Outwood—wrote to the Prime Minister on 7 January setting out details of her concerns. It is surprising that a letter received by the Prime Minister's office has not yet been passed to the Minister for Health. My constituent telephoned the director of nursing services at St. James's to inquire about enrolment for Project 2000. She is a qualified nurse with 14 years experience, a background which qualified her for a place within the scheme.

Mrs. Virginia Bottomley

If the hon. Gentleman's constituent is a qualified nurse, how could she be applying for a Project 2000 course? The course would prepare her to become a qualified nurse.

Mr. O'Brien

The young lady wishes to further her career within the nursing profession. She wishes to take advantage of the opportunities offered by Project 2000. If a person is dedicated to nursing and there are further qualifications that he or she can obtain, no restrictions should be placed on the person who wishes to obtain them.

As I have said, my constituent telephoned the director of nursing services at St. James's hospital in Leeds. She was told that her qualifications made her eligible for a position on the Project 2000 course. She was further advised that the decision of the nursing college to refuse to take her and others like her was an executive one. In the Cambridge area, however, a person with the same qualifications could be allowed to enrol. Therefore, there is discrimination. My constituents are losing out because trust hospitals are denying people such as Linda Bichard an opportunity which is being given to people in other areas by the national health service.

When my constituent wrote to the Prime Minister she set out her qualifications and explained that she was engaged in part-time studies to obtain further qualifications so that she would be qualified to participate in the Project 2000 course. She explained that she was astonished when she was told by the director of nursing services at Leeds that, although she was qualified to embark on the course, her application was being refused. As I have said, she was told that it was an executive decision.

As Linda Bichard wrote, although many people drop out of the course, there are many others who are dedicated to the NHS and to the nursing profession, but are being told that there is no opportunity for them to further their aims within the nursing profession. Like my constituent, I find that astonishing. People wish to gain further qualifications and to help the nursing profession, but because of dogma—in this instance, and executive decision—they are being denied the opportunity to do so.

My constituent was told that she should contact the clearing house in Bristol to ascertain where the decision was taken and where enrolled nurses would be accepted for a Project 2000 course. On 7 January she wrote also to the officer in charge of the clearing house in Bristol. She explained her position and set out her qualifications. She told the officer that she had applied for Project 2000 training at Leeds college of nursing and that the local policy decision was not to accept enrolled nurses as candidates, regardless of their academic qualifications. She told the people in Bristol that she had discussed the matter with several organisations and that they had advised her to contact the clearing office to obtain a ruling. She wrote: I understand that this is not a nationally agreed decision and hope that you could furnish me with information on which colleges are accepting E/N applicants and perhaps how many are at present on Project 2000 courses. Surely the Minister should investigate the case that I have outlined. The right hon. Lady intervened to tell the House that, if my constituent is qualified, she does not need to apply for the course, and that view has been supported by other Conservative Members, but that is not the position in the regions. My concerns are increased because Ministers and Conservative Members do not know what is happening throughout the country. We are being told about the results of Project 2000 which emanate from the Government's policy when Ministers are not aware of what is taking place in the regions.

As I have said, the Prime Minister has been notified of the position in which Linda Bichard finds herself. There is evidence that there are anomalies when applications are made for Project 2000 courses. Among the applicants are people who are dedicated to the nursing profession, people who are qualified and are taking on further part-time studies in their own time to gain more qualifications so that they can be accepted within Project 2000, but who in certain areas are being denied that opportunity.

If constituents of Conservative Members are being accepted on the course while my constituents are being denied similar access, I want to know why. I ask the Minister to deal with that matter when she replies. I am very concerned about it, and I hope that she will be able to give me some satisfaction.

6.40 pm

Mr. Frank Haynes (Ashfield)

I was very pleased with the speech of my hon. Friend the Member for Mid-Staffordshire (Mrs. Heal). This is the first occasion on which she has spoken from the Front Bench in an important debate. It may be a short debate, but it is certainly important.

Having listened to the Minister, I have become aware of something else. I want her to listen closely. It seems that, because we are coming up to a general election, the Government have thought again about the word "democracy". Clause I refers to elections to the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. The Minister may smile, but I remind her that the Department of Health—especially when the right hon. and learned Member for Rushcliffe (Mr. Clarke) was Secretary of State—has ignored the professional organisations and the trade unions within the health service.

The former Secretary of State appointed people to the various health authorities, but he was not interested in any representation from the community. The Minister looks surprised. She should go to the regions and discover for herself what is happening there. Indeed, my hon. Friend the Member for Normanton (Mr. O'Brien) recommended that she should do just that. Certainly, in my region I have protested loudly about the fact that representatives from the community have been denied places on district and regional health authorities. Instead, the Government have appointed bosses from industry. We need local representation—councillors, for example. They were elected to such positions until the Government got their hands around the throats of the bodies and destroyed democracy. Now the Government are attempting to introduce a little democracy into appointments to the UKCC.

My hon. Friend the Member for Mid-Staffordshire got under the Minister's skin when she talked about the fiddling in opted-out trusts. It was a sore point for the Minister when my hon. Friend questioned whether the trusts would spend money on nurses' training.

I attended a meeting of my local community health council last week. The House was not sitting, so I had the time to go and listen to some of the comments from those who represent the community on that council. Who was there to give a report? It was none other than the community physician, who talked about his annual report and the issue of community services.

The Government seem to be going down the wrong road in the provision of training for nurses, midwives and others who work in the community. I was a little concerned to discover that the report showed that the Government were not providing the necessary support for community services. They are ducking their responsibilities and giving them to local authorities, which have to provide that support.

I do not think that the Bill will work in the way the Minister suggests. I want the general election to take place very soon, because when the Labour party is in government it will implement this properly, although I shall not be coming back after the next election, as hon. Members know.

There are some good provisions in the Bill and we shall not vote against it today. The Minister is looking at her watch, but she will have enough time to say what she wants to say in response to the debate. I wish to make it clear that I do not accept that what the Minister said would happen will, in fact, happen. I do not accept that the opted-out trusts will spend money on nurses' training.

I have said my piece and shown how I feel about the matter. I hope that the Minister will respond in the right way and provide some guarantees or assurances, but I wonder whether she will do so. I think that she has been put up for the job this afternoon by that wally—hon. Members know who I mean—the Secretary of State for Health. Nevertheless, I hope that what she has said will come to fruition.

6.46 pm

Mrs. Heal

With the leave of the House, Madam Deputy Speaker. I have enjoyed participating in the debate on what was thought to be an uncontroversial and uncontentious Bill. My hon. Friends have managed to inject some controversy into the debate. I am sure that, when members of the nursing, health visiting and midwifery professions read the report of the debate, they will note that the majority of contributions have come from the Labour Benches and that, with the exception of the Minister, there was only one contribution from the Conservative Benches. That is not an insignificant fact.

6.47 pm

Mrs. Virginia Bottomley

With the leave of the House, Madam Deputy Speaker. Like other hon. Members, I congratulate the hon. Member for Mid-Staffordshire (Mrs. Heal) on her inaugural Front-Bench speech. We have become used to her contributions during Question Time, but this is the first time that she has led for the Opposition in a major debate.

This has been an important debate, and I am pleased that it has been marked by a spirit of consensus. The matter is important for the nursing, health visitor and midwifery professions. I felt a tinge of sadness when I realised that this might be one of the last debates in which I participated when the hon. Member for Ashfield (Mr. Haynes) spoke. I felt a sense of nostalgia when he spoke.

I wish urgently to deal with a number of matters. First, on the point raised by the hon. Member for Normanton (Mr. O'Brien), I visited St. James's hospital shortly before Christmas and I was impressed by the progress that has been made by the trust. Its new day unit for children is a remarkable initiative and is of a standard that any hospital in the world would find hard to beat. There have also been many other initiatives, such as the new £15 million redevelopment of renal medicine, general surgery and intensive care facilities, which began in August.

There is some confusion about the case to which the hon. Gentleman referred, and I shall certainly study it. It may be that his constituent is an enrolled nurse wanting to take a conversion course, in which case Project 2000 would not be suitable. These are complex matters, but I give the hon. Gentleman the assurance that I shall personally consider that case.

I am concerned by the comments about the match between enrolled nurses wishing to take further courses and the availability of such courses. There were about six conversion courses for enrolled nurses in 1985; now, there are 225. It is a condition of Project 2000 places that arrangements should be made for enrolled nurses. However, I recognise points made by Opposition Members about the position of enrolled nurses.

The hon. Member for Mid-Staffordshire referred to the role of enrolled nurses on the UKCC and we shall certainly consider that further. She referred to the various minority groups, each of which has a valuable part to play in nursing care. Once we look beyond nurses, midwives and health visitors, we take in community psychiatric nurses, practice nurses, mental handicap nurses and so on. We can all recognise, therefore, how easy it would be for the Bill to become enormously bureaucratic and prescriptive, so tying the UKCC's hands. As was made clear in another place by my noble Friend the Under-Secretary of State, we certainly intend that the major interests will be properly represented on the board—possibly as officers in some cases. That matter is one for further discussion, and I look forward to the debates in Standing Committee when the intentions of this important Bill can be made clear.

Much has been said about the important role of the midwifery profession, whose special position dates back to the beginning of the century. The Nurses, Midwives and Health Visitors Act 1979 made provision for the midwifery committee, and that will continue with the UKCC. I assure the House that there have been no difficulties between the midwifery committee and the UKCC. It is important that they should have a proper and balanced relationship, and we do not intend to alter the pattern that was established by the 1979 Act, in respect of the terms under which reference would be made to the midwifery committee. It will no longer be the case that reference will be made to the boards, because the midwives' role has changed. However, there should be proper recognition- of their role, and I entirely endorse the powerful words of the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) on the value of midwives. Few women Members of Parliament would not reinforce those words.

The hon. Member for Crewe and Nantwich made a somewhat tendentious point when she suggested that London teaching hospitals were entirely staffed by agency nurses.

Mrs. Dunwoody

I did not use the word "entirely".

Mrs. Bottomley

Then the hon. Lady said that they were largely staffed by agency nurses.

That point was raised in several ways by hon. Members, but there is no doubt that our ability to retain the nurses whom we train has improved markedly. One difficulty relates to those who go on courses and want to be sure that there are jobs for them when they return. The retention rate has risen faster than we expected, and in some cases there has been a mismatch between training and manpower needs. That must be more effectively addressed, but I assure the hon. Member for Crewe and Nantwich that the number of agency nurses fell from 7,400 to 7,000 in the year 1990.

We also have a record low wastage rate. The length of time that nurses are remaining in the health service is double what it used to be. The points made about the importance of continuing training are extremely important. The UKCC prepared a report on post-registration education and practice and, although it is not yet a requirement that there should be five days training every three years, already many regions are implementing just such a programme. I have been involved in training seminars for health visitors and community nurses in my constituency, and such activities are spreading ever more widely throughout the service.

I strongly endorse the comments made by many hon. Members about the importance of community nurses. It is too easy to think of nurses in an "Emergency Ward 10" or "Casualty" context, but we are all aware that the work done by community nurses—in terms of their particular professional skills, autonomy and individual judgment—is extremely important.

Health promotion and disease prevention—to which the hon. Members for Mid-Staffordshire and for Ynys Mon (Mr. Jones) and others made reference—are addressed in our "Health of the Nation" strategy. I am charged with responsibility for the wider implementation steering group, whose members include—apart from those representing the wider interests of the general public—nursing representatives. They are Beverley Bryans from the Royal College of Midwives, Sally Gooch, from the Royal College of Nursing, and Alison Norman, chairman of the Health Visitors Association.

That steering group is able, powerfully and effectively, to widen the debate from the concern about beds, ambulances and the infrastructure of health care to a broader health strategy. When we look back on this period of the Government's work, we will see not only the reforms and practical improvements—such as NHS trusts and fundholding practices—but the important introduction of the health strategy that prevention is better than a cure. That is the way to ensure that this country continues to combat illness and disease.

The hon. Member for Stalybridge and Hyde (Mr. Pendry) was a little impetuous in referring to the review body. In my non-controversial remarks, I did not intend to draw attention to the 48 per cent. increase in nurses' salaries under this Government, compared with a 3 per cent. fall when Labour was last in power. That will serve as a salutary reminder to all nurses, midwives and health visitors, as they come to reflect on matters in the forthcoming weeks. I make that point only to move swiftly from it.

Mrs. Fyfe

If the Minister is so concerned about fair pay for nurses, why does she support the proposal to do away with the procedure for appealing against unfair gradings?

Mrs. Bottomley

The section 32 question and the issue of appeals are enormously complex, subject to much discussion and difficult to resolve. No one pretends that the present arrangements are satisfactory. The sooner that we bring an end to the appeals, the better it will be for the profession and the health service.

My hon. Friend the Member for Chislehurst (Mr. Sims) made, as ever, a distinguished and thoughtful contribution. He referred to the General Medical Council, and I thought that many nurses, midwives and health visitors might have a certain ambivalence about the way in which the GMC conducts its affairs. Arguably, our proposals will in some ways steal a march on some of the UKCC's mechanisms.

Nevertheless, most right hon. and hon. Members are aware of my hon. Friend's commitment to the nursing profession. Any who are not will be aware of it when he is able to make further progress with his private Member's Bill, to which we look forward with interest and enthusiasm.

My hon. Friend the Member for Chislehurst made an important point about lay representation. When it comes to the establishment of the UKCC, we certainly expect lay representation to play an important part.

This has been a useful, constructive and positive debate. The Bill has an enormously important part to play in reorganising the disciplinary framework, education and training of nurses, midwives and health visitors. I look forward to the opportunity to give it further consideration in Committee. Much work has been done in clarifying the Bill, and I have no hesitation in commending it to the House with great enthusiasm.

Question put and agreed to.

Bill read a Second time and committed to a Standing Committee pursuant to Standing Order No. 61 (Committal of Bills).