§ Order for Second Reading read.9.36 am
§ Mr. Roger Sims (Chislehurst)
I beg to move, That the Bill he now read a Second time.
I imagine that I am not the first hon. Member to be faced with a dilemma on learning, with a mixture of pleasure and trepidation, that he has won a high place in the ballot for private Members' Bills. Should one propose a controversial measure that is likely to attract publicity but will have little chance of ultimate success; or should one introduce a modest Bill with some value, unlikely to make front-page headlines but with a reasonable prospect of reaching the statute book? It was obvious to me that, given that little of the parliamentary Session remained, I should choose the latter course, and I had little difficulty in deciding to introduce a Bill to allow a nurse prescribing.
We are all familiar with the respective roles of doctors and nurses. Doctors diagnose complaints and propose treatment, usually involving drugs. They may see the patient from time to time thereafter, but the responsibility for supervision of the patient and the administration of treatment lies with the nurse, who will see the patient far more frequently. That applies particularly when the patient is being treated at home—in the community—rather than in hospital.
Clearly, in some circumstances, when a nurse sees the need for drugs and dressings to be applied, it would be an advantage for her—or possibly him—to be able to issue a prescription without having to trouble the doctor, who will certainly have full confidence in the nurse. The case is particularly strong when the patient needs perfectly straightforward medication or dressings which can be bought over the counter but to which the patient will be entitled free of charge if he has a prescription.
It is not difficult to imagine the frustration that is experienced by a district nurse who makes a regular visit to a patient and finds that that patient needs further supplies of a medicinal product or dressings. The nurse will have to return to the surgery, interrupt the doctor to get a prescription signed, and then go back to the patient to hand over the prescription.
The concept of nurse prescribing is not new. In 1986, the then DHSS commissioned a review chaired by Mrs. Julia Cumberlege on community nursing. Its report was entitled "Neighbourhood Nursing—a Focus for Care". I apologise to the House for the length of the quotation that I am about to give, but it is very much at the core of the issue that we are discussing. Under the heading "Power to Prescribe", the report said:We found district nurses waste time in requesting prescriptions from general practitioners for such things as dressings, ointments and medical sprays—those for leg ulcers, for example. In addition, many nurses have become very skilled in managing pain relief programmes for terminally ill patients. We believe therefore that community nurses who work with terminally ill patients should be permitted to use their professional judgment on matters such as the timing and dosage of drugs prescribed for pain relief. We recommend that the DHSS should agree a limited list of items and simple 1197 agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well-defined circumstances. Detailed medical protocols should be drawn up with general practitioners which encourage community nurses within strictly agreed limits to vary the timing and dosage and use of alternative pain relief agents for patients who have been diagnosed by general practitioners as terminally ill and in pain. This may require nurses carrying on their own small supply of drugs, as midwives do now.Its views were supported by a 1987 report of the Social Services Select Committee. Based on the evidence that it received, it recommended thatthe Government introduce legislation to permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage.In the same year, the Government's primary care White Paper said that representatives of the professions would be consulted. Paragraph 7.13 said:The Government also sees merit in giving nurses more freedom to prescribe a limited range of items (such as dressings, ointments or medical sprays) and to exercise their professional judgment in relation to the timing and dosage of drugs prescribed by doctors for pain relief. To some extent this development is already taking place. The Government will consult the Professional Standing Advisory Committees about the professional and ethical issues of prescribing by nurses with a view to producing appropriate guidance.The Government then set up the advisory group on nurse prescribing under Dr. June Crown. Its terms of reference were to make recommendations on the circumstances in which nurses might prescribe, the categories of items to be covered and methods of prescribing them, the circumstances in which nurses might vary the timing and doses of drugs prescribed by doctors, the implications for nurse training and the resource implications.
The advisory's group's report was published on 20 December 1989. It comprises a detailed analysis of what might be involved in the proposal. I quote simply from some of its core recommendations, one of which was thatsuitably qualified nurses working in the community … should be able, in clearly defined circumstances, to prescribe from a limited list of items and to adjust the timing and dosage of medicines within a set protocol.It suggested thatNurses with a district nurse or health visitor qualification (including those employed as paediatric community nurses, practice nurses or private nurses …) having had the additional necessary training: should be empowered to prescribe items necessary for the care of patients with those conditions for which the nurse takes independent clinical responsibility; should be able to supply certain categories of patients with items within a group protocol and adjust the timing and dosage of medicines within a patient-specific protocol.My hon. Friend the Minister indicated general acceptance of the report's recommendations and that work and consultation on it would proceed.
Almost a year ago to the day, my hon. Friend the Member for Kensington (Mr. Fishburn) introduced his Nurse Prescribing Bill under the ten-minute rule. Shortly afterwards, the Minister announced that a cost-benefit analysis was being commissioned. That did not happen until April, when Touche Ross was asked to assess the cost and benefits of nurse prescribing. No doubt my hon. Friend's Bill was talked out because that analysis had only just been put in hand.
It seemed to me that this was an admirable measure for the Government to introduce, particularly in a short 1198 parliamentary Session. I suggested that course to my right hon. Friend the Secretary of State and was encouraged by his comments at the Royal College of Nursing congress in May and at the Conservative party conference at Blackpool in October, when he expressed his general support for the concept.
I was rather surprised, therefore, that such a measure was not included in the Queen's Speech. I know that the Royal College of Nursing and other professional bodies were disappointed by that omission. When I drew third place in the ballot for private Members' Bills, my choice of Bill seemed obvious.
Fortunately, my success coincided with the publication of the Touche Ross report—a formidable document which gives a most detailed analysis of the costs and benefits. I do not think that I would endear myself to the House if I went into them. There are obvious difficulties in making precise assessments of costs and savings when one is faced with a range of variables such as to what extent giving nurses the right to prescribe will lead to more prescriptions. It is difficult to translate savings in time and greater convenience into cash terms. Perhaps I could quote from part of the conclusions at paragraph 5.4:We conclude that the nominal value of time saved and the gross costs of nurse prescribing are relatively close before allowance is made for benefits not evaluated in this study, namely"—these seem very important benefits—faster treatment, at times, for patients, benefits from additional items prescribed and increased job satisfaction for nurses.The publication of the Touche Ross report appeared to remove the only remaining ground on which the Government might prefer to defer action. Once I had persuaded the Department of Health that I was anxious to proceed with the Bill, it offered complete co-operation. I should like to take this opportunity to offer my thanks to my hon. Friend the Minister for Health and her officials for their help in introducing the Bill, to the Royal College of Nursing for its persistent and effective campaigning, briefing and help in publicising the Bill, and to my hon. Friend the Member for Kensington for blazing the parliamentary trail. I am happy that he is a sponsor of the Bill, and I hope that he will speak later in the debate.
The Bill is brief and simply amends existing legislation. Clause 1 brings nurses, midwives and health visitors into the category of "appropriate practitioners" for prescribing purposes and gives the Minister the power to specify, by regulation, categories of nurses who may prescribe and the qualifications and training that they would need. Clause 2 makes it legal for dispensers to dispense prescriptions written by such authorised nurses. Clauses 3 and 4 merely make similar provision for Scotland and Northern Ireland.
I emphasise the fact that if the Bill becomes law there is no question of nurses in general immediately being able to prescribe. The Minister would have the power, which she does not have at present, to make regulations to turn the principle of nurse prescribing into practice. Of course, the cynic might think that that means that once the Bill has been passed nothing more needs to be done. I assure the House that that is not so.
Discussions have been taking place for some time about the formulary covering the range of drugs which nurses would be allowed to prescribe, although that is likely to be relatively small because the majority of items that nurses will want and need to prescribe are those which can be purchased over the counter, and various forms of 1199 dressings. Discussions are also in hand about the training and the qualifications needed, and work is being done to set up the appropriate training courses.
The report to which I referred suggested that people with district nurse and health visitor qualifications should be authorised to prescribe. If that happens, it will apply to about 28,000 district nurses and health visitors who are serving the community. Their ability to prescribe will clearly save time, avoid troubling doctors, save patients' and carers' time and will generally be more convenient. The measure will be especially beneficial to the elderly, to the disabled being cared for at home, to diabetics and to the terminally ill. The Bill has been welcomed on an individual and an organisational basis by nurses, by general practitioners and by patient organisations.
As I have said, it is merely an enabling measure. Once it reaches the statute book it would be up to the Secretary of State—not to me—to take further steps because lie will have the regulation-making powers. I need hardly say that I shall be keeping an eagle eye on my hon. Friend the Minister, although I suspect that by then it may be her successor, as she is destined for higher things. However, I shall be pressing the occupant of that office for action if it proves necessary to do so.
I know that nurses in particular are anxious to see the intentions of the Bill translated into action. I hope that the Minister will be able to tell us more about the preparatory work in hand and give some idea of the timetable that she envisages for the Bill's implementation, when the regulations are likely to be laid, when training will start and when the first batch of authorised nurses will be able to exercise their right to prescribe.
I understand that the likelihood is that initially only nurses with district nurse and health visitor qualifications are likely to be involved. I should mention the fact that I have received representations from practice nurses suggesting that they should also be included. If they have the qualifications to which I referred they would in any event be included in, as it were, the first batch of qualifiers, but perhaps the Minister will confirm that some thought could be given in due course to extending the authorisation to practice nurses. I want to make it clear—and perhaps the Minister will confirm this—that there is no quest ion of extending prescribing rights to hospital nurses in general. That is clearly not necessary, because doctors are invariably on site.
Of course, there will be costs involved in the implementation of the Bill and perhaps the Minister will say how she envisages that they will be met. I presume that her Department will meet the training costs, but as to the costs incurred in the prescribing operation, where nurses are attached to a fund-holding practice I imagine that those costs will be charged against the practice's budget, and I hope that that will be taken into account when the budgets are fixed. Otherwise it would seem appropriate that the costs should be met either by the health authority or—more likely—by the local family health service authority.
This is a simple Bill which will benefit many of our fellow citizens. It will ease the burden on hard-pressed general practitioners, will facilitate the work of the unsung heroines of our communities—the district nurses and health visitors—and will improve the treatment of their patients, among whom any of us might find himself numbered in the fullness of time.
1200 I mentioned the fact that the Bill started with the report of a body chaired by Mrs. Julia Cumberlege. The House will be aware that she is now Baroness Cumberlege, and I am happy that she is standing by, ready to sponsor the Bill should it find its way—as I hope that it will—to another place. Therefore, I hope that the Bill will receive the House's support and that its progress will be facilitated so that it may pass into my noble Friend's hands in another place and reach the statute book before it is overtaken by events.
§ Ms. Harriet Harman (Peckham)
I congratulate the hon. Member for Chislehurst (Mr. Sims) on choosing this subject for his private Member's Bill. He said that he had faced a dilemma about whether to choose a Bill that would make the headlines or one that would be passed. I am sure that the 7 million or so patients who will benefit from nurses being able to prescribe will be grateful that he has chosen a Bill which will certainly be passed and will certainly—once it has reached the statute book and is implemented—have practical benefits for that many patients.
The Bill will also help district nurses and health visitors. They do not want to waste their time going backwards and forwards to the general practitioner's surgery. The hon. Gentleman rightly said that it is a waste of the doctor's time for him to turn his attention to something that has already been decided by someone else and merely to rubberstamp it. Such a situation also undermines the role of district nurses and health visitors if they have to go through that procedure when they know that they should be able to take the responsibility. The Bill has the confidence of GPs and will suit patients.
The hon. Member for Chislehurst can be certain that the Bill has the Opposition's support. It is important but not controversial. Everyone agrees that it makes sense and that it is a long-overdue reform. I do not want to concentrate on procedural matters, but, as the hon. Gentleman said, it is curious that the Bill has not been introduced by the Government, especially as the Nurses, Midwives and Health Visitors Bill has just completed its Committee stage. It would have made sense for the Government to include this measure in that Bill so that it could be dealt with at the same time. Having publicly committed themselves to extending legislation to protect residents in small private residential care homes, the Government left it to a Back-Bench Member to bring in a Bill, and they have done the same thing again. Having said that this is not the procedure by which such a measure should reach the statute book, I welcome the Bill because it will result in a long-overdue reform.
I wish to raise three issues that are part of the backdrop to the Bill. The first is training, which the hon. Gentleman mentioned. The second is retaining those district nurses and health visitors who, as a result of the Bill, will be better trained, more skilled and more useful. We need to keep them within the national health service work force and to make better use of their additional skills. The third is the question of nurse prescribing in community care.
I am simply flagging those issues; I do not want to go into them in great detail. The Bill has the support of the Government and both sides of the House. It is uncontroversial. I should be sorry if the debate on the Bill 1201 were to be unnecessarily prolonged and so prevented the House from debating the Civil Rights (Disabled Persons) Bill that hon. Members are waiting to discuss.
The issue of training was partly dealt with in the Nurses, Midwives and Health Visitors Bill. The training of nurses to prescribe will be vital if the service is to be as widely available as we want it to be and if it is genuinely to benefit patients. However, there are problems with post-basic education. Training for nurse prescribing is likely to be at post-basic level. Although there is usually an incentive to safeguard funding for pre-registration education to maintain the supply of nurses coming into the NHS, the incentives for post-basic education are less secure.
The Royal College of Nursing has expressed its particular concern that trust employers might offer a poor deal to nurses who want to undertake training courses. The RCN suggests that nurses in trusts who want to undertake post-basic training are being required to transfer to fixed-term training contracts, with no guarantee of employment on completion of training. We do not want any disincentives in the system that would prevent people doing post-basic training and becoming nurse prescribers. Can the Minister assure us that training for nurse prescribing will be provided and that it will be accessible to those nurses who need it? I wish briefly to deal with two other issues, but we shall explore them further in Committee. We need to retain trained staff. Prescribing will be carried out by specially trained and experienced nurses, yet trained nurses are leaving the NHS at the rate of 80,000 a year—a quarter of all nurses. That is bad enough for nurses with the basic qualification, but it will be an absolute waste of training and experience if we do not retain within the NHS those who are qualified to be nurse prescribers.
So far, the Government have made a large number of verbal commitments to creating the terms and conditions of employment that would enable women to stay in the work force and not give up when they have families. However, at district health authority and hospital level there have not been the practical measures needed to achieve that. That is why the figures for nurses leaving the NHS remain so bad.
It all comes down to practical implementation of flexible working hours and job sharing, so that women working in the nursing profession do not have to follow male patterns of employment, where eventually they find that combining family responsibility with work is simply too difficult, and they leave. That point applies to nurses at the basic level, but it is even more important when they become a more valuable resource after their post-basic education has given them the ability to prescribe.
Community care is also an issue. Nurse prescribing should be an important component of care for those who have long-term continuing needs, but are living in the community. I want community care to be properly implemented and funded, with nurses prescribing as a part of their work in the care of people living at home.
Nurse prescribing will happen, and I hope that it does so promptly. I hope that the Minister gives the assurances about timing asked for by the hon. Member for Chislehurst. The Bill will work better if it is implemented properly, if there is access to training for all who want it, 1202 if there are flexible patterns of employment to enable nurses to stay in the work force following post-basic training and if community care—where they will be doing their work—is implemented and fully funded. I hope that the Minister will also assure us on those points.
Once again, I congratulate the hon. Member for Chislehurst on choosing this subject for his Bill. He will not hit the headlines, but he will receive the gratitude of patients and nurses. We welcome the Bill.
§ 10.5 am
§ Sir David Price (Eastleigh)
Like the hon. Member for Peckham (Ms. Harman), I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on his good fortune in winning a high place in the ballot. I am delighted that he has chosen to introduce a Bill on nurse prescribing and I am honoured to be associated with it as one of its sponsors.
As my hon. Friend said, the Bill deals primarily with the delivery of health care in the community. As presently envisaged, it has little relevance to medical practice in hospitals. However, I wish to put down a marker that, as the provisions of the Bill succeed in care in the community—for health visitors and community nurses—I hope that the possibility of its being extended to certain aspects of hospital work will be considered. Both I and my hon. Friend have received representations from the Southampton eye hospital, suggesting that there might be a case for extending the provisions of the Bill to ophthalmic casualty.
I shall not develop that point today, because it is not immediately relevant; I am simply putting down a marker that, as the Bill's provisions succeed in the community, we should not exclude an extension into other areas. As the Bill is drafted, such an extension would be possible at a subsequent stage through the Minister of the day introducing the necessary order.
My hon. Friend quoted from the Cumberlege report in support of his proposition that there should be a limited extension of prescribing from doctors to nurses. The report of my hon. and noble Friend Lady Cumberlege has clearly impressed my hon. Friend. It equally impressed those who served on the old Select Committee on Social Services. Paragraph 61 of the Select Committee report succinctly encapsulates all the arguments for the immediate move proposed by my hon. Friend. It states:The CNR team, and many witnesses believe that nurses should have freedom to prescribe a limited range of items, such as dressings, ointment and medical sprays".I pause here to point out that items such as dressings are available on prescription. Hon. Members can buy them over the counter in a chemist's shop. It continues:and that they should be able to use their professional judgment on matters such as the timing and dosage of drugs prescribed by doctors for pain relief.Pain relief is greatly important to many people. Our experience of people in that condition is that they are not in a steady state so, rightly, the prescription must be altered almost day by day according to the pain of the patient. It continues:Both suggestions have merit; to some extent they reflect developments which are already happening, for example in the care of the terminally ill where many nurses have special expertise. It is obviously wasteful nonsense for a district nurse needing a new dressing for a patient to have to return to the surgery, tell the doctor what is needed, possibly even draft the 1203 prescription for him, get the prescription dispensed by a pharmacist and then make a second visit to the patient to apply the dressing.Those last few words describe the present position. I am sure that all would agree that it is nonsense and that there must be a simpler way. My hon. Friend's Bill would provide that simpler way. Our report continued:We recommend that the Government introduce legislation to permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage.I hope that my hon. Friend the Minister will forgive me if I say that the Treasury, as always, seems to have made rather heavy weather of this matter. What are the extra costs of nurse prescribing? The truth is that nobody knows—and in so far as there will be an extra cost, that cost shows an unfulfilled need.
That is the story of the resource implications of care in the community. One factor after another shows unfulfilled needs. As we become more successful in delivering health care in the community, we discover things that we should have been doing in the past but have not done. Now that those things are identified, we do them and—surprise, surprise—it costs more. I ask the Treasury to be relaxed about that.
§ Mr. James Arbuthnot (Wanstead and Woodford)
Does my hon. Friend agree that in practice, costs may be reduced? Nurse prescribing will save the waste of time that he has described when district nurses have to go backwards and forwards to doctors, and will allow them to give their time to more beneficial activities, rather than wasting petrol on such journeys.
§ Sir David Price
My hon. Friend has made an excellent point, succinctly put, which has not yet been fully recognised by the Treasury.
The Touche Ross report had to be completed in a considerable hurry, for reasons that we understand. Let us not attach too much weight to it, because the overall response rate from the 18 district health authorities surveyed was 15 per cent. of district nurses and 23 per cent. of health visitors. That sort of return is even lower than those used by political pollsters.
All that we know is that nurse prescribing will cost a bit more in medication. The extra costs will be those for the extra prescriptions generated; we cannot say more than that. It is not possible to put a figure on the costs. However, I am delighted that the Government are giving my hon. Friend a money resolution—that is all very proper—but I beg the House not to be too concerned about what the figure is. Let us recognise that there is a figure and settle for that.
I warn the House—I am afraid that I have been an awful bore in continually pointing this out—that, as we extend the concept of health care out into the community, we shall find more and more unsatisfied demands that have not previously been recognised. I hope that in so far as we are achieving a consensus on care in the community, there is a general recognition that it will cost more and use more resources.
I shall say nothing more about the financial side. The Touche Ross report had one or two nice things to say about the advantages of nurse prescribing. Under the heading, "Other Benefits"—uncosted—it said: 1204The further benefits from Nurse Prescribing are the benefits to patients of faster access to some prescription items and the benefits they will derive from additional items prescribed for them by District Nurses and Health Visitors.That sentence encapsulates one of the obvious advantages that will accrue from the Bill.
I am sure that both sides of the House will welcome my hon. Friend's Bill. In modern jargon, it is a patient-friendly Bill, and as such, it will appeal to both sides of the House.
§ Mr. David Bellotti (Eastbourne)
I congratulate the hon. Member for Chislehurst (Mr. Sims) on deciding to promote the Bill. It is important, because, as the hon. Member said, there have been earlier opportunities for such legislation—the Government could have chosen to include a measure in their order of business, and a private Member once introduced a Bill, but unfortunately did not have enough time to secure its progress. I believe that the Bill will make headline news, because millions of people will benefit from it and they will see the advantages to them. So, although the hon. Member for Chislehurst feels that he may not achieve headlines in the newspapers, I feel that he will.
The hon. Gentleman has the opportunity of warning us all not to speak for too long, because another important measure, concerning the civil rights of disabled people, is to come before the House today. I hope that we shall be able to ensure that both these important measures make progress.
In principle, the Liberal Democrats support the Bill because it puts patients first; it brings their needs and concerns to the fore. It is so important that the person nearest to the patient should have the right to prescribe that I am sure the measure will receive all-party support.
We are told that there are 28,000 qualified district nurses and health visitors. With so many people who may eventually receive the training to prescribe, we can imagine the advantages that patients will derive from that training and delivery.
Such a measure has taken a long time to appear. I wonder why. The Government have had opportunities, but have not taken them. Nevertheless, the Bill will form an important part of the full delivery of their policy of care in the community. We shall not see real care in the community without nurses being able to prescribe drugs at the point at which they are needed.
We have an aging population and a growing number of residential care homes in the private, voluntary and statutory sectors. It is important that the health visitors and nurses who go to those homes can meet the needs that they find there. If we support care in the community we must realise that nurse prescribing is part of that and will help to make it work. That is why I was especially pleased to hear that the Government are prepared to allocate the necessary funds. If they did not, the costs would fall elsewhere—or the job would not be done.
Elderly people and chronically sick people in residential and nursing homes will not be the only ones to benefit. People in the community will benefit, too. I know from my work with homeless families that such people invariably need help late at night, in the early hours of the morning or at weekends, when it is especially difficult to find a general practitioner who will respond quickly to a call to 1205 see someone who has arrived on the doorstep—in my case that means the doorstep of the YMCAs for which I worked.
§ Mr. Michael Stern (Bristol, North-West)
I accept what the hon. Gentleman says about the homeless, but does he agree that we should not be in danger of slighting the work of many general practitioners in inner cities where there are many transient homeless people? To give those GPs credit, working with family health authorities they have developed specialisations in dealing with the needs of transient people.
§ Mr. Bellotti
I agree that some of the work of GPs is outstanding in such areas, but they are greatly overburdened and have considerable calls on their time. Those of us who have worked with homeless families have found that many hours can pass between the telephone call and the arrival of a general practitioner. In recent years that situation has grown worse. Many of our GPs now have technology in their surgeries whereby calls are transferred to other doctors in the area. One tends not to know the GP who turns up, whereas one always knows the local health visitors and community nurses. I accept the hon. Gentleman's point, but he should also consider what I have said.
Terminally ill patients would also benefit. Not long ago I had the opportunity to visit St. Wilfrids hospice in Eastbourne, where wonderful work is done. That is true of hospices in every constituency. The hospice movement is wonderful, caring for people in their last weeks, days and hours. In those circumstances prescribing can relieve an enormous amount of pain, but it needs to be done very quickly. The Bill will help enormously there, and the people in Eastbourne certainly support that aspect of it.
In rural areas, the time taken by the GP to travel or the time taken by a family friend to go to the surgery to obtain a prescription can be considerable. Through the Bill, we seek to achieve the relief of pain for patients at the earliest opportunity. The Bill will be especially appreciated in rural areas.
I warmly commend the Bill and 1 congratulate the hon. Member for Chislehurst on introducing it. It has all-party support, so I hope that hon. Members will have the opportunity of saying a few words on it and of making progress on the Civil Rights (Disabled Persons) Bill. I commend the Bill to the House.
§ Mr. Jerry Hayes (Harlow)
It is a pleasant and unusual experience to speak in a health debate in which we are united. Not even the hon. Member for Peckham (Ms. Harman) has said a word against the Bill, which is supported not only by the Government, but by the British Medical Association, the Royal College of Nursing, general practitioners, phamacists and many charities. I join in congratulating my hon. Friends the Members for Chislehurst (Mr. Sims) and for Kensington (Mr. Fishburn), who set the ball rolling, on their collective good judgment and common sense in introducing such legislation.
We should also congratulate Christine Hancock, the general secretary of the Royal College of Nursing. Even my hon. Friend the Minister must accept that Christine 1206 Hancock has always criticised the Government constructively. She, with her members, has shown much support for reforms such as the NHS trusts and GP fund holding. I also congratulate the chief nursing officer, Dame Anne Poole, who, sadly, will be retiring in a few weeks' time. All involved in health would wish to express thanks for what she has done for the Department of Health and for nursing. We shall all miss her and we send every good wish for the future to her successor.
My hon. Friend the Member for Eastleigh (Sir D. Price), who will, sadly, be leaving the House in a few weeks' time, made a masterly speech in which he summed up the position perfectly. I am not sure how one persuades the Treasury to be relaxed about anything, but the fact that the Government have tabled a money resolution is encouraging.
My hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) made an especially good point about the time that is wasted at present. From briefings that I have seen, it seems that 1.2 million hours of nursing time are lost. As the hon. Member for Eastbourne (Mr. Bellotti) said, there will be benefits for the terminally ill and for the elderly.
§ Mr. Stern
Although it is unfashionable in this debate, I will say a word on behalf of the Treasury. My hon. Friend the Member for Harlow (Mr. Hayes) will have noticed that, although the Touche Ross report accepts the principle that the Bill would help to save a great deal of time by reducing the hours that nurses, especially district nurses, spend travelling backwards and forwards, the monetary savings would be almost insignificant. Inevitably and rightly, the nurses, who are full-time employees, would use the time in other ways, to the great benefit of patients.
§ Mr. Arbuthnot
I believe that my hon. Friend the Member for Bristol, North-West (Mr. Stern) is wrong. Health authorities will be able to make choices. As we shall save nurses' time, we can either give the nurses more productive work to do or reduce the number of nurses and spend the money saved on other health care procedures or drugs. The options would be wider and I do not think that the Treasury should be quite so restrictive.
§ Mr. Hayes
I do not want to sound too much like a Liberal Democrat, especially before a general election, but I must say that I agree with my hon. Friends the Members for Wanstead and Woodford and for Bristol, North-West (Mr. Stern) at the same time. We shall utilise nurses' time and there will be savings, although there is a row over how great the savings will be.
The Government and the whole House accept the crucial role that nurses play in the health care team. It is significant that, since 1979, the three aims of Trevor Clay, the then general secretary of the Royal College of Nursing, have been achieved. First, he wanted an independent review body system for pay, and we have that. Secondly, he wanted the modernisation of the nurses' career structure, and we have that. Thirdly, he wanted a modern training system, which nurses will receive under Project 2000. The hon. member for Peckham mentioned Project 2000, and I will say a few words on it. 1207 Project 2000 gives more weight to the process of learning and less to sharing the work load in hospital wards. That has been welcomed by nurses. Trainees will have student status and 62 per cent. of colleges in England have now converted to the system. Some £109 million has been spent in the past three financial years, and another–98 million has been allocated for 1992–93.
The trouble with nurse training, as the Government and the Royal College of Nursing accept, is that the training and education programmes have a high degree of rostered service which is not conducive to the learning process. All that will be changed. The education changes should go a long way towards providing a future nursing work force who are better equipped to meet the complex demands of modern health care, and who will have more interesting and satisfying careers. For the first time, nurses will have a broadly based education which emphasises health promotion as well as the care of the sick. It will enable them to work either in hospitals or in the community without the need for extensive further training. I agree wholeheartedly with my hon. Friend the Member for Eastleigh. When the regulations are introduced, we should look again at the hospital sector. I suspect that nurses are very much like sergeants and sergeant-majors in the Army. They tend to hold the hands—I do not mean that literally—of young doctors in training and they know far more about diagnosis and about prescription than do many of the young men and women who have just entered the medical profession. Nurses should have an even more professional role in prescribing in hospitals, and 1 hope that my hon. Friend the Minister will consider that point carefully.
There will be a better alignment of the practical and theoretical components of nurse training so that the practical component, which will not diminish significantly, will reflect the theoretical stage reached. There will also be an opportunity to rationalise the confused pattern of post-basic training, thus eliminating duplication and overlap. Provided that we can encourage as many nurses as possible to come in, the end result should be more flexible and adaptable practitioners who can respond to changes in the provision of service. I hope that the whole House recognises that.
I am sure that nurses will take into account the fact that their pay has increased substantially—I know that some would say not substantially enough—by 48 per cent. in real terms since 1978–79. Since that time the number of nurses has increased by 69,000, despite the difficulties in recruitment, which are being overcome. I am sure that my hon. Friend the Minister accepts that this Government are very pro nurses. We have embraced the majority of sensible suggestions proposed by the Royal College of Nursing.
§ Mr. Hayes
I wholeheartedly disagree with my hon. Friend. Nurses' pay was not cut by 3 per cent. in real terms. In the five years to 1979, the Labour Government cut nurses' pay by 21 per cent. in real terms—even if the overall figure was 3 per cent. Nurses should be aware of that. I do not want to introduce a party political note, 1208 given the unified stance that we have achieved on the Bill, but I had hoped that the hon. Member for Peckham would say that what she said last year and the year before about indicative budgets was totally wrong. I remember all the scare stories—how the elderly, sick and vulnerable would not get their drugs from the doctors. That has not happened at all.
§ Ms. Harman
I came to the House this morning warmly to welcome the Bill introduced by the hon. Member for Chislehurst (Mr. Sims), which has all-party support. I hope that, in addition to securing the Bill's passage through the House today, we shall proceed to debate the Civil Rights (Disabled Persons) Bill—a measure which profoundly affects many of our constituents. I shall not be rising to party political provocation and I am confident that the Minister will not either, so I suggest that the hon. Member for Harlow (Mr. Hayes) addresses himself to the Bill and does not try unsuccessfully to waylay and mislead the House so that we cannot proceed to the next item of important business. Shame on him!
§ Mr. Hayes
I apologise profusely for giving in to temptations of the flesh. The hon. Lady referred to the next Bill on the list which I wholeheartedly support—as, I suspect, do the majority of hon. Members present. That will be debated at another time.
I ask the Minister to consider the question of head lice—not a pleasant topic for a Friday morning. At the moment, we are in difficulty because parents do not like to think that their children have head lice, but they do have head lice. The presence of head lice does not mean that a child is dirty: they are often to be found on very clean children. Head lice are a taboo subject in many areas.
As a result of a change in the regulations, district health authorities cannot supply schools with the prescribed shampoo. My hon. Friend the Minister will no doubt point out that one can still get the shampoo free, but parents will still have to go to the chemist and ask for it, or go to their GP. They will find that extremely embarrassing because everyone knows what the shampoo is for.
I have received a number of letters on the subject. I do not expect my hon. Friend the Minister to comment today, but would ask her to re-examine the regulations and consider carefully allowing district authorities to prescribe to schools the shampoo that is needed to eradicate head lice. There is quite a lot of feeling on the subject.
Another matter relating to drugs on which I do not expect an immediate response from my hon. Friend the Minister is generic prescribing.
§ Mr. Arbuthnot
My hon. Friend has suggested quite an extension of the idea of nurse prescribing for individual patients—nurse prescribing for entire schools. I should have thought that that would be better handled by a doctor, if by anyone.
§ Mr. Hayes
I honestly do not care who handles it as long as it is handled in such a way as to spare many of my constituents the embarrassment of asking for head lice shampoo publicly—a matter on which they feel very 1209 strongly. This may not be a subject which ought to be considered on the present Bill, but I ask my hon. Friend to think carefully about it.
I shall refer briefly to the great potential savings from generics on GP prescription. About£50 million could be saved if GPs were given the opportunity to tick a little box on their prescription forms, with the consent of the patient, to indicate that, when the drug was dispensed, its generic equivalent could be given. I understand that the matter has been carefully researched and that £50 million-plus could be saved and ploughed back into the health service.
I warmly welcome the Bill. I wholeheartedly congratulate my hon. Friend the Member for Chislehurst and ask that the Bill be put on the statute book as soon as possible—taking into account the general election. I hope that both Houses will be wholeheartedly committed to rushing it through, because it is needed.
§ Mr. Hugo Summerson (Walthamstow)
I do not intend to detain the House. I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on his excellent Bill. It is a commonsense measure. There is no reason why nurses, with all their practice and training, should not be permitted to prescribe to some limited extent. As we have heard, the measure is supported by the Royal College of Nursing, and I look forward to the time when nurses can, indeed, prescribe. It will help them; it will help patients; and it will help to take a little of the burden from doctors.
I want to make a plea for the continuing expansion of the categories of people who can prescribe and suggest that we draw pharmacists into that widening network. Increasingly, people go to the pharmacist when they have some minor problem and pharmacists are becoming the centre of attention for those who do not want to bother their doctors with petty complaints. At the moment, people have to go to the doctor's surgery to get a prescription. Then they have to take it to the pharmacist to get whatever medicine has been prescribed.
There is a bit of a problem, however, and the process can be obstructed if someone living on his own is so ill that he cannot get to his doctor. What can he do? He can ring up the doctor and say, "I am ill." The doctor may know something about his condition and may agree to let him have a prescription. If he is too ill to go to get the prescription, he has to ring friends or relatives to ask them to collect it for him from the doctor, to go to the pharmacist and to bring him the medicine.
I suggest that pharmacists have a valuable role to play. There may be a pharmacist just down the road from where the patient lives and if there were a little more co-operation, perhaps sick people who could not collect medicines themselves could have them delivered to their doorsteps.
The Bill will be of particular value in rural areas where there is rather a waste of petrol as cars rush back and forth. Nurses visiting patients have to return to the doctor's surgery for a prescription, then get the medicine and take it back to the patient. Nurses who visit patients regularly may know their needs better than the doctor does. If the nurses can say what the patient needs and prescribe that item, it will be much better for the patient.
1210 I was sorry to hear the hon. Member for Peckham (Ms. Harman) bringing in a note of complaint. She said that the Bill could have been tacked on to the Nurses, Midwives and Health Visitors Bill. I have a copy of that Bill and it is clear that there is no way that the present measure could have been tacked onto it. My hon. Friend the Member for Chislehurst has introduced a welcome measure, which has the wholehearted support of the Government and of hon. Members on both sides of the House. We look forward to its becoming law.
§ Mr. Dudley Fishburn (Kensington)
It is no coincidence that my hon. Friend the Member for Chislehurst (Mr. Sims) should have introduced the Bill. He is a wise man who has long been interested in all aspects of the medical services, and was a sponsor of the idential Bill which I introduced in the previous Session. I am pleased to be a sponsor of the present Bill and to assist in my hon. Friend's far more successful attempt. I think that I can say that I support every word of the Bill, because it is almost word-for-word the Bill that I introduced last year.
My hon. Friend the Minister for Health, who is present in the Chamber today, is the very same charming Minister who killed the Bill then. Indeed, my hon. Friend the Member for Chipping Barnet (Mr. Chapman) from the Whips Office, although less charming, is from the same Whips Office that used the mechanics necessary to ensure that the Bill did not proceed. I recall being ticked off for writing a letter toThe Times which advocated nurse prescribing and which pushed the Government in that direction. All that is now water under the bridge. I am delighted that we are all on the same side and that the Medicinal Products: Prescription by Nurses etc. Bill will make it to the statute book.
If primary legislation is to have distinction and life—and so much does not—it must be rested upon an idea or principle. This short Bill has a principle attached to it—the principle of liberalisation. That principle is the belief that the more responsibility we give to people, the more welcome it will be. Indeed, these new responsibilities are welcomed by the nurses. The more we can peel back layers of the onion skin of bureaucracy—in this case the bureaucracy of health care—the better society will be. That principle gives the Bill life.
That principle first caught the attention of Mr. Samuel Brittan, the economics writer for the Financial Times. He, perhaps more than anyone, even in this place, has pursued the concept of liberalisation over the past decade. He wrote a column in the Financial Timeslast year supporting the prescribing Bill and it was no conincidence that he entitled the column:A Modest Blow for Freedom.That, of course, is just what the Bill is. It is modest and it is certainly a blow for freedom. It will free up the system.
Sam Brittan got to the core of what is interesting about the Bill when he wrote:The main thrust of economic liberalism is to remove unnecessary restrictions and barriers; and there is no reason for health to be exempt . . . Liberalism is concerned with putting the onus of proof on those who want to restrict.
There are many cases in which there are genuine costs of deregulation to be weighed up against the benefits. Here is a rare case where there seem only benefits. I wholly agree. That is why the Bill should make progress. 1211 Although my hon. Friend the Member for Chislehurst has spelt out clearly that the Bill will allow 25,000 community nurses—those with the highest training—to write prescriptions against a limited formula agreed in advance by the British Medical Association and the Government, we should push this a little further. We must consider the ideas put forward by my hon. Friend the Member for Eastleigh (Sir D. Price). In time, some hospitals may seek to have this liberalising measure applied in their wards.
There is an interesting precedent here in that midwives can alter the amount of painkillers, without recourse to a doctor's permission, in hospital, during childbirth. They have done that for years with tremendous skill and without anyone taking any notice or believing that that was a new measure. In time, I hope that we will look to an expansion of the measure to hospital nurses so that they can write their own prescriptions.
§ Mr. Arbuthnot
With regard to expanding the measure to hospital nurses, will my hon. Friend consider a point made by my hon. Friend the Member for Chislehurst (Mr. Sims) who said that the proposal would not be necessary in hospitals because of the constant presence of doctors in hospitals? The Bill deals with an area where nurse prescribing is necesssary.
§ Mr. Fishburn
The point is that if it is not necessary, it will not happen. If it is necessary or desired, in a liberal society, it should happen. My hon. Friend the Member for Eastleigh made that point.
The hon. Member for Eastbourne (Mr. Bellotti) referred to the advantages of the Bill in a rural setting where community nurses have to travel great distances. I believe that the Bill will be equally welcomed in an urban setting like my constituency of Kensington. Picking one's way through the urban jungle can be every bit as time-consuming for a community nurse as travelling over the rustic downs of Sussex.
A community nurse in an urban setting experiences an enormous waste of time. She may finally arrive to see a bed-ridden patient in a tower block only to find that a bandage, lotion or painkiller is required, but she must return to base, to her GP's office, to get a prescription. That could easily take an hour or even the better part of an afternoon. That is extremely frustrating for the nurse and worrying for the patient.
I want to question my hon. Friend the Minister on a point which will be important as the legislation makes progress. Will practice nurses be able to prescribe? As I understand it, if a practice nurse has the qualifications of a district or community nurse, she will be able to prescribe. The thrust of this Government, through GP fund holding and the reforms of the past few years, has been to allow family health practitioners to have within their boundaries a range of health provision that brings care as close as possible to the patient.
GPs across the country have increasingly recruited practice nurses and the Government have rightly supported that. It would be a great shame if, as the Bill makes progress, it was not made clear that practice nurses could, particularly if a GP so wished, write prescriptions.
I have four children under the age of 10. When I am not in the House, I spend most of my time in the doctor's surgery. One of my children has mild asthma. Not unnaturally, we visit the practice nurse every two months. 1212 My child blows into the blower and sucks from the sucker and, once every six months or so, the nurse says, "You're coming on fine. That's great, but you have run out of the lozenge which has to go into the machine." When I say, "Right, I'll take some away now", she says, "Ah, I can't give you more because I cannot write a prescription". The doctor is busy next door—probably seeing one of my other children—so he cannot write the prescription right away. Therefore, I have to go away and come back the next day. That is the kind of inefficiency that the Bill can break through. Does my hon. Friend the Minister envisage that practice nurses will be able to write prescriptions if their GPs so wish? Will the Bill or the subsequent regulations that the Department will bring into effect allow that or will we have to agree amendments in Committee?
Everything in this country takes time. As my hon. Friend the Member for Chislehurst is aware, this modest measure has taken a long time. The first report from Baroness Cumberlege appeared in 1986. Considering the most rapid progress that the Bill might make, it is proposed that the regulations will be in place by the autumn of 1993. With a little slippage, we are talking about 10 years between the birth of an idea and its practice.
However, that is the birth of this idea only in Britain. We must not forget that we are not reinventing the wheel. Nurse prescribing is practised widely in other countries that abhor bureaucracy and practise economic liberalism and which believe in having no layers of the onion skin between the patient and the doctor or nurse. Nurses prescribe in Canada and in most of the states in America. I hope that we will not set out on another study in the years ahead, but will act on this Bill with all speed and dispatch.
§ Mr. Michael Stern (Bristol, North-West)
I am grateful to you, Mr. Deputy Speaker, for calling me to speak on this important measure. I join all hon. Members in congratulating my hon. Friend the Member for Chislehurst (Mr. Sims) on bringing forward this welcome measure. We know that this will be a truncated parliamentary Session. Therefore, the difficulties facing any private Member's Bill are even greater than usual. The Government's support for the measure is welcome. Indeed, the support of the Opposition, despite their somewhat reduced numbers today, is also welcome. We need all that support, and support in another place, to give the measure even the slightest chance of success in a shortened time scale. I am sure that all hon. Members wish it well.
At the outset, I stress that the points that 1 wish to make in no way detract from my support for what will be a welcome measure not only in rural areas, which are one of the wellsprings for it, but in heavily urbanised areas such as the one that I represent. I wish to draw attention to a couple of aspects of the proposed restricted list of drugs and the formulary which the Bill will set up under regulations. I congratulate my hon. Friend on drafting, or allowing the Bill to be drafted, to permit much of the detail of the Bill to be dealt with by regulation rather than being in the context of the Bill itself. There is a considerable history of successful regulation by the Department of Health. The idea of a limited prescribing list began in the teeth of considerable opposition to the Department of Health, and it has proved 1213 to be far more successful than the medical profession and Her Majesty's Opposition thought at the time. Because of the rapid change in the work demanded of nurses within the community, there will be a need for equal flexibility within the Department of Health in respect of the powers given to nurses under the Bill.
My hon. Friend is entirely right, albeit that most of us normally deprecate legislation that effectively hands over substantial additional powers to Departments rather than them being within the review of the House. My hon. Friend is entirely right to pass that power to the Department and effectively take it from Parliament.
A regulated list of drugs or preparations under the control of the Department finds support in some rather surprising quarters. The Department's work in preparation for the Bill parallels work that has been done in the pharmaceutical world over many years, in particular leading up to the campaign which started a few years ago for pharmacists to be able to sell and advise on certain drugs without a prescription. I hope that the passage of the Bill will not damage that campaign by pharmacists to be able to use their professional knowledge and expertise to a greater extent and that the movement toward non-prescription will not be damaged by the movement towards greater freedom of prescription.
That work has received support from some surprising sources. I remember a pamphlet from the Institute of Economic Affairs some years ago—not a body to which one would normally look in such matters—which argued strongly for greater freedom for pharmacists to be able to sell without prescription. I hope that my hon. Friend the Minister will reassure me that the movement toward greater freedom of non-prescription will not be harmed by the Bills.
The Bill refers to appropriate training for nurses in the use of the restricted list. It is worth dwelling on that for a moment. What may be appropriate training for a district nurse in a rural area may not be appropriate for a health visitor dealing with an area of urban stress. The demands on their time and their abilities to prescribe are likely to be totally different. I hope that, when considering the training schemes that will be set up under the Bill, my hon. Friend will give appropriate weight to the flexibility that will be needed to ensure that nurses are trained for the many tasks that will become necessary under the Bill. I suspect that that suggestion would lead to an unacceptably wide and demanding training course. Alternatively, I hope that my hon. Friend will look at some form of modular training so that a nurse who wishes to take on prescribing rights in, say, an urban area will be able to receive specific training in, for example, dealing with the homeless and areas containing a large number of people with tranquilliser dependency, such as occurs in at least one area of my constituency. Those demands will be totally different from those on a nurse who is training for the right to prescribe in some rural areas or, indeed, urban areas which do not suffer the same social stress.
I now refer to the signature of prescriptions which will be permitted under the Bill. I ask my hon. Friend the Minister how that will relate back to doctors, health authorities or other bodies responsible for a certain aspect of patient care with which the nurse will be dealing when the prescription is generated. In that connection, I draw 1214 my hon. Friend's attention to an organisation which, so far, has not been mentioned. My hon. Friend will know it well. I refer to the Prescription Pricing Authority, a body which is centered on Newcastle upon Tyne. One's first acquaintance with it would indicate that it is a great contributor to the welfare of the warehousing business in Newcastle upon Tyne, because it stores and sorts, under a system called PACT—prescription analysis and cost—every prescription that is ever written. That body does much unsung technical work to a very high level of professional expertise. Any family health services authority which wishes to inquire into the prescribing habits of a doctor or a practice will be able to go to the Prescription Pricing Authority and obtain from it, with appropriate safeguards, all prescriptions issued by that doctor or practice over a certain period. I do not have to tell the House the extent of the work that is necessary to provide that service.
At the moment, the Prescription Pricing Authority will work to a certain doctor, so the sorting mechanism at the PPA is determined by the need to sort by doctor or, frequently, by type of preparation. I wonder how the PPA will have to adapt its work. A district nurse or a nurse on the official list will sometimes work with a certain doctor or health authority. There may be other circumstances in which the ultimate responsibility for a validity of a prescription will not be relevant to a certain general practitioner. I hope that my hon. Friend the Minister can reassure the House that, under the Bill, the standards of control and the "findability" of prescriptions will be no less than those for prescriptions currently issued by a registered general practitioner.
Recommendation 5 of the Crown report refers to the type of work of nurses for whom prescribing could become useful. The recommendation states:In addition to nurses with a district nurse or health visitor qualification, certain community nursing staff who have successfully completed appropriate specialist education, training and assessment should be able within a patient specific protocol".I emphasise the phrase "patient-specific" as it is underlined in the recommendation—to adjust the timing and dosage of medicines which are prescribed by medical practitioners.That is an important recommendation.
The recommendation continues:At present we propose that community psychiatric nurses, community mental handicap nurses, specialist nurses for terminally ill patients and diabetic liaison nurses should be given this authority.I entirely agree with that recommendation. It shows a breadth of understanding of the specialist work of the nursing profession which is highly commendable. However, one aspect of nursing is not covered by the recommendation. I refer to the case of qualified nurses who, under the general training provisions of the Bill, qualify for prescribing, but have chosen a career path that has led them to become matrons in nursing homes, especially for the elderly in the private sector. I have come across cases in my constituency where such matrons who in every way qualify to issue a prescription under the Bill are debarred and may continue to be debarred from issuing a prescription to a patient under their care because those matrons have no direct relationship with the general practitioner who has responsibility for the elderly patient in the nursing home.
The case of an elderly person living in my constituency who was urgently admitted to a nursing home on the other 1215 side of Bristol has recently been drawn to my attention. That patient's GP practised in my constituency and was, therefore, unable to provide an immediate service to the patient. Shortly after the patient was admitted to the nursing home, and before there was time to transfer the patient to the care of a GP close to it, the patient needed a prescription. However, the matron was forced to say to that patient's children that she was sorry but was unable to help other than to arrange for the patient's admission to hospital so that an urgent prescription could be given. It would be helpful if matrons of nursing homes could, as of right under the Bill and subject to proper training, be given the same powers of prescription as will be given to other groups of nurses.
Clause 2 of the Bill rightly extends the duty of family health services authorities in England and Wales to cover the prescription duties. I should declare an indirect interest as my wife chairs such an authority. I assume that, under the Bill, when any nurse is acting for or working with a GP to issue a prescription, any complaint of an offence on the issue or non-issue of a prescription will be related to the nurse and the doctor by the family health service authority. I should like my hon. Friend the Minister to clarify that assumption. One assumes that a disciplinary hearing, which at present can be brought only against a doctor, could in future be brought against a nurse.
However, how will a family health services authority carry out a similar duty if there is a complaint about prescription by a nurse when he or she is acting for a health authority, for a home run by the social services or a privately run home that provides services to the social services authority? How will the family health service authority conduct a disciplinary hearing when the case does not relate to a practitioner who is registered with that authority? That may seem a technical point, but disciplinary hearings cause much anguish both to the practitioner and the patient. It is worth while to reassure all health service users and all nurses that there will be adequate mechanisms for coping with what I am sure will be very few disciplinary or complaints hearings.
There have been a number of comments in the debate on the Treasury's attitude to the proposals. Unlike my hon. Friend the Member for Eastleigh (Sir D. Price), I do not regret that the Treasury has not adopted an open-handed attitude as, by their very nature, Treasuries are debarred from so doing. I congratulate the Treasury on making available, through the money resolution and the Government's support for the Bill, the not insubstantial sum of money that it will cost to implement the legislation. Many apparently equally deserving proposals that would have cost less than the estimated cost of the Bill have been put to the Government and, regretfully, the Treasury has had to refuse. Treasury Ministers deserve praise, not grudging acceptance, for the fact that they are prepared to make available the necessary money.
The notes attached to the Bill make it clear that the sums involved will fall on the budget of the family health service, which generally seems entirely appropriate. But I hope that we may be assured that, when the regulations are drafted under the Bill, the budget of the family health service will not be unnecessarily put upon from either health authority budgets or social service budgets. That could happen as services are provided under the Bill that would otherwise have been paid for by health authority or social service budgets. I speak as an accountant and foresee a difficult accounting problem that should be 1216 addressed early. Inevitably, even given the greatly expanded funding that the Government have made available to the health service generally, there is still—rightly—considerable pressure of competition on all aspects of budgeting for resources in the health service. So the Minister should account in advance for some of the issues that will occur between budgets as a result of the Bill.
I underline some of the points made in the Touche Ross report about the likely costs of the measure. My hon. Friend the Member for Eastleigh pointed out that much of it was guesswork, which means that the report must sometimes, inevitably, put figures to guesswork. Even so, those figures are based on the best analysis available. They take into account all the known factors, so that, although we must accept them with caution, it would be unwise to discount the figures. Although we recognise—I appreciate that my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) takes issue with me on this—that there will be considerable savings in time resulting from nurses not having to travel backwards and forwards to get prescriptions filled out and redeliver them to patients, that degree of time saving, though welcome, will manifest itself not in cost savings but in the more efficient use of nursing time and, one hopes, in less delay in patients receiving the drugs that they need.
§ Mr. Arbuthnot
My hon. Friend is making the case for the inevitability of the extra time being made available by the Bill to district nurses being taken up by extra work by those nurses. Is that acceptable? We shall have many options to consider when the measure becomes law, including a reduction in the number of district nurses and the channelling of the resources so saved into other areas of health care. It would be unwise to reject those options at this stage of the Bill.
§ Mr. Stern
I accept that, and my hon. Friend is underlining in many respects the strength of the Bill in that it draws together the support of hon. Members who look at the issue from the standpoint of the greater service that will become available, for example, in some of the most stressful inner-city areas such as that which I represent. That advantage will apply right across the spectrum, through to the services that other hon. Members expect to receive in more rural or less stressful urban areas. I do not anticipate there being any reduction, as a result of the Bill, in the numbers or costs of the services in the area that I represent. But I expect a higher level of service and, I hope, slightly less stress on the providers of that service.
I welcome the Bill because it is about supporting the nursing profession and giving its members more facilities and greater ability to do their job. In that way, we shall not only assist the members of the nursing profession in a difficult and dangerous part of their work, but give them additional responsibilitiess which add to their problems.
I think of one area in my constituency, the walk-up flats in Lawrence Weston. I was recently taken round the area and during my visit, which lasted a day, saw some of the cases and problems that people face on a day-to-day basis. The Bill will not reduce the physical danger in which nurses sometimes find themselves, but it will help them to provide a better service in areas of high stress. It will also 1217 help them to plan their day better, so enabling them se their time more effectively, for the benefit of their patients.
While we have been in office, there has been an unprecedented increase of about 68,000 in the number of active nurses in the profession. I welcome a measure which, I hope, will not decrease those numbers but will strengthen the hand of the profession in dealing with its problems.
§ Mr. James Arbuthnot (Wanstead and Woodford)
I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on coming high in the ballot and on choosing a subject that is close to the hearts of us all. We are all subject to the vagaries of health, and he has made it possible, by introducing the Bill, to improve the care that is available to the public at large and to make it more effective and efficient at the point of service.
I echo what was said by my hon. Friend the Member for Harlow (Mr. Hayes) in congratulating Christine Hancock on all the work that she has done in helping to bring the Bill forward. Before moving to her present position, she was the general manager of the Waltham Forest health authority, which covers my constituency. She may have been the first such general manager to occupy her present position, and her work has been extremely valuable.
In May last year my hon. Friend the Member for Kensington (Mr. Fishburn) introduced a Bill under the ten-minute rule which was discussed on the Floor of the House on a Friday morning. It was unusual for such a Bill to come so close to achieving legislative effect. He managed it in a way that is almost unique to him, for he has introduced many ideas that have been taken up only after he thought of them. In that respect he is an admirable successor to his predecessor, our late-lamented colleague, Sir Brandon Rhys Williams. So not for the first time has my hon. Friend the Member for Kensington brought forward fresh ideas that have helped not only his constituents but the country as a whole.
Several reservations were registered to the Bill that my hon. Friend introduced last May, some of which I raise again in the hope that they will be answered. I spoke briefly when that Bill was debated on 3 May 1991, and at that time the Minister did not have an opportunity to deal with some of the issues that I raised.
It is crucial that nurses who are given power to prescribe have proper training, and obviously the power to prescribe should be limited to those who have had that training. It is essential for that not simply to involve going through various courses, but for those who go through them to prove that they have an understanding of, and achievement in, what was contained in the courses. Merely to have been sent on a course should not be sufficient proof that a nurse has grasped all the principles involved in this important and delicate matter of prescribing. Training is crucial. I suspect that it should be limited to a relatively small number of nurses, at least at the beginning.
The important question that needs to be addressed is precisely what nurses should be allowed to prescribe. My hon. Friend the Member for Eastleigh (Sir D. Price), in his excellent speech, read out a paragraph from the report of the Social Services Select Committee in which it was said: 1218many witnesses believe that nurses should have freedom to prescribe a limited range of items, such as dressings, ointments and medical sprays, and that they should be able to use their professional judgment on matters such as the timing and dosage of drugs prescribed by doctors for pain relief.If that report is accepted, the implication is that the Bill should cover only dressings, ointment and medical sprays, and the amount and timings of drugs already prescribed by a doctor.
I am not sure whether the Bill would allow nurses to prescribe new drugs. If it has that effect, we must consider it extremely carefully in the light of the negotiations and discussions since my hon. Friend the Member for Kensington introduced his Bill. That innovation would present dangers and problems. What would happen if a patient were prescribed two drugs that interacted with each other? I raised that problem in my few remarks on 3 May.
Frequently patients do not tell their doctor or nurse what they are taking. Therefore, a nurse could prescribe one drug which would react with another to provide a dangerous effect in the patient. We must guard against that. Doctors are well able to guard against that by reason of their training. If the Bill becomes law, as I sincerely hope it will, nurses, too, should be trained to deal with that. That probably applies even to an increase in dosage, to which the Select Committee report refers.
The next question raised during this morning's debate is precisely where nurses should be able to prescribe. There has been a difference of opinion on that. My hon. Friend the Member for Chislehurst said that health visitors and district nurses who travel a lot in the country should be able to prescribe. They do not want to have to go back to the doctor for a prescription for something about which they may know more than the doctor, then travel to a chemist and back to the patient. All the time that that procedure takes up would be saved.
If the circumstances are expanded to include nurses in hospitals writing prescriptions, altogether different questions arise. My hon. Friend the Member for Chislehurst said that it was not necessary for nurses in hospitals to prescribe because doctors are on hand and, with all their training, should be available to make the necessary prescriptions. He told us that that circumstance was, therefore, not covered by the Bill. I questioned my hon. Friend the Member for Kensington, who suggested that that circumstance should be covered in the Bill on the ground that if it was necessary for nurses in hospital to prescribe, as circumstances might suggest that it would be, the law should allow them to do so.
My hon. Friend is an eloquent proponent of liberalisation of all sorts, but we must be exceptionally careful with the prescription of drugs. Although they can bring great benefits, they can also cause great tragedies. We must be careful about the extent to which we liberalise our drugs regime.
My hon. Friend the Member for Bristol, North-West (Mr. Stern) gave an example to show why it was necessary to consider at least the possibility of some hospital prescribing. He referred to the matron of a nursing home or some similar establishment and related how someone could not obtain a prescription from a doctor as there was no local link with a doctor. That tipped the balance in my mind between the views of my hon. Friend the Member for 1219 Chislehurst and the views of my hon. Friend the Member for Kensington. We should consider whether an amendment should perhaps be made in Committee.
This century matrons have acquired a respect. They were noticed only when they began to disappear as a result of some health reforms some time ago. I am delighted to say that matrons are now coming back, partly because of our health reforms. They are increasing our respect for the health service. Those who would prefer a doctor to a matron to give a prescription would often be considered to be rather odd.
§ Mr. Arbuthnot
I have read the Bill, and it deals with amendments to other legislation which one then must follow through and follow through and follow through. It is complicated to work out precisely the effects ofafter the words 'exemption conferred' there shall be inserted the words 'or modification made'".I am grateful to hear from my hon. Friend that that could be done by regulation. If that is so, I hope that my hon Friend the Member for Kensington will consider it.
The Bill will create for the first time—I am open to correction on this—two different forms of prescription: those produced by nurses, district nurses or health visitors, and those produced by doctors. An essential aspect of the Bill is that chemists must be able to tell at a glance which prescriptions are being presented to them. They must be able to ensure that nurses' prescriptions are limited to the drugs or appliances that are permitted by the regulations introduced under this legislation.
I am not sure how it is proposed that those prescriptions should be differentiated. Perhaps they should be on two different coloured prescription pads so that chemists may know that a white prescription comes from a doctor and a green prescription from a nurse. In that case a green prescripton would not permit a chemist to give over the counter to a nurse drugs that only a doctor can prescribe. That, of itself, would mean that not only nurses but chemists would need training as a result of the Bill. That is to be welcomed. Contrary to the belief of my hon. Friend the Member for Bristol, North-West, I believe that the Bill may well produce financial savings as well as savings in time and effort. The training of chemists in that respect could easily be absorbed within the money resolution.
The Bill will save district nurses and health visitors time and journeys now wasted on going to the doctor, writing out the prescription for the doctor, persuading the doctor to sign it, going to the chemist, and taking the appliance, or whatever, to the patient. But doctors, who are very highly paid, will also experience a saving: they will no longer have to spend time dealing with prescriptions for patients about whom they propbably do not know very much.
My hon. Friend the Member for Bristol, North-West feels confident that the savings in time would be absorbed immediately by the extra work done by district nurses and, probably, by doctors. I disagree. One of the benefits of the health reforms that we have introduced is the fact that health authorities are being literally forced to be sensible about priorities, and to allocate resources accordingly. If 1220 they find that district nurses or health visitors have more time available as a result of the Bill, health authorities will have not only the ability but a positive duty to consider whether to reallocate the resources that have been saved —to hip replacement operations, for instance. In the constituency of my hon. Friend the Member for Bristol, North-West, those resources might be used to increase the amount of productive work done by district nurses.
§ Mr. Arbuthnot
On that note of harmony, I shall move on to another point. The hon. Member for Peckham (Ms. Harman) said that trained nurses were leaving the national health service at a rate of 80,000 a year. I am not sure whether that statistic is correct, but I understand that there are now 69,000 more nurses and midwives than there were when the present Government took office. That may be a result of a pay increase of nearly 50 per cent. in real terms.
Nevertheless, the retention of nurses is essential. One advantage of the Bill is the increase in job satisfaction that it would give nurses. At present, a district nurse is forced to say to a patient, "I am sorry, but I cannot provide you with this ointment. It is silly, but I will have to go to a doctor who knows nothing about your case and get him to sign something that he probably will not read. I will then have to take the prescription to a chemist—who probably will not be able to read it—and bring the ointment back to you."
Not only is that process a waste of time; it humiliates the nurse or health visitor, and makes her feel that her job is menial—which it certainly is not, and which it should never be considered to be. The Bill would give that nurse or health visitor the responsibility that—in practice—she already exercises: she would be seen to have that responsibility. I believe that such an increase in job satisfaction would contribute greatly to the retention of district nurses and health visitors. Their job is already rewarding, but the Bill would make it more rewarding.
That valuable increase in the responsibility of district nurses and health visitors would also involve a valuable decrease in the burdens borne by doctors. I do not know whether the retention of doctors has been a problem, but, if so, the Bill might help to solve it.
Still more can be done to improve job security for nurses. We can increase the provision of training, not just in regard to prescriptions but in regard to other matters.
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. I very much hope that the hon. Gentleman is not using a Second Reading debate to make a general speech about the nursing profession, and that he will adhere more closely to the terms of the Bill.
§ Mr. Arbuthnot
I was going to say that I hoped that the Bill could be used to increase nurses' job satisfaction. Training is an essential aspect, and one reason for it is that increase in job satisfaction. I hope that the Bill will be used almost as a platform to give nurses the status of highly qualified medical practitioners—not quite on the same level as doctors, but more respected than they are now.
§ Mr. Gordon McMaster (Paisley, South)
I do not wish to detract from the importance of what the hon. 1221 Gentleman is saying, or from the value of the Bill, but I was interested by his remarks about giving people a better quality of life and more job satisfaction. The next Bill on the Order Paper—the Civil Rights (Disabled Persons) Bill—is also very important, and many of us hope that we shall reach it today.
§ Mr. Arbuthnot
I am aware of that, and I shall end my speech shortly.
It is pointless to restrict the prescribing of medicines, ointments and appliances to doctors, given that the number of prescriptions with which they must deal makes it inevitable that they will sign forms without giving them proper attention, and without exercising the required clinical judgment. The same applies to Ministers: if they have to sign about 100 letters each day, they will inevitably sign some without reading them.
In many cases, nurses might well be better at prescribing than doctors. A district nurse with 25 years' experience would have much more knowledge of individual patients' needs and circumstances than a newly qualified doctor who did not have the same opportunity to get out and about.
I welcome the Bill. I am glad that both the Government and the Opposition support it, and I wish it every success.
§ Mr. Roger Moate (Faversham)
Although I am sure that we all appreciate the importance of reaching the Civil Rights (Disabled Persons) Bill, I have no doubt that every hon. Member also appreciates the importance of this Bill, small though it is. It gives us the opportunity to comment both on the use of nursing resources generally and on the implications of the Bill for our constituents.
I apologise to my hon. Friend the Member for Chislehurst (Mr. Sims) for entering the Chamber towards the end of his speech; I was inadvertently delayed. As I came in he was saying, in effect, that the Bill need not be extended to cover hospital nurses, because doctors were normally in attendance. Would that that were the case.
I welcome the Bill. Like many others, I have long believed that the medical skills of our experienced nurses are an underused resource. The more that we can utilise their skills, the better it will be for patient care. The Bill is a small step in the right direction. It inches forward when perhaps we could have taken a giant step for mankind, but I hope that it will be used to go further, perhaps within the regulations that might follow.
I hope that we shall not lose the momentum to develop further the use of skilled and experienced nurses for services where the patient is not getting that speedy and rapid service that he or she desires, There is a long way to go. I do not go as far as my hon. Friend the Member for Kensington (Mr. Fishburn), who wished to apply Mr. Samuel Brittan's rules of economic liberalism to prescribing. I accept some of his economic prescriptions, but not his medical prescriptions.
I accept, too, that we must be careful of simplistic solutions. As my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) said clearly and concisely, not only benefits but risks will be conferred by easier prescribing.
One understands why the medical profession moves carefully and slowly, but it can go too slowly and I suggest 1222 that it has done so. Although the Bill is welcome, the Cumberlege report was published in 1986 and it will be a long time before the benefits of the Bill are conferred on midwives, community nurses and patients. I hope that the medical profession will try to speed up the process whereby we extend the use of nursing skills into other areas.
I am sorry if I missed the more detailed explanation that my hon. Friend the Member for Chislehurst gave of why it is not necessary to extend prescribing rights to hospital nurses. Perhaps we shall hear more from my hon. Friend the Minister about that.
I feel strongly about the Bill because in my constituency—I am sure that this experience is shared in other constituencies—the services of smaller hospitals have been progressively cut. Services have been concentrated on general district hospitals. The acute services and other facilities of smaller hospitals and, indeed, of medium-sized hospitals have been cut. Those cuts have been made under every Government in the past 25 years. To a large extent, it has been a question not of resources but of changing medical practice. In areas such as the Isle of Sheppey—this is echoed elsewhere in the United Kingdom—acute local hospital services are now denied to local people, who must travel further afield for urgent medical attention.
A welcome new trend is the greater emphasis on primary care hospitals, community hospitals or GP hospitals, whichever is the preferred term. Some of the primary care hospitals will be substantial. None the less, we cannot expect them to be manned constantly by consultants, trainee doctors or GPs, who might be on call. Many emergencies and minor matters will have to be treated at a district general hospital many miles away.
It is extraordinary that a highly trained but relatively inexperienced paramedic ambulance driver may take a patient to hospital, but a senior nurse at that hospital with 20 or 30 years' experience cannnot use the same equipment to the same degree as the paramedic. That does not make sense.
There is a new senior grade of nurses—nurse practitioners. I am unaware of the extent to which they are being encouraged to practise. My impression is that their use is not widespread, but it would be a tremendous step forward if nurse practitioners, with the ability to prescribe and use the emergency equipment, were encouraged to practise in smaller primary care hospitals. All nurse practitioners should certainly also practise in the larger new health centres operated by general practitioners.
That seems such common sense that I suspect that it would receive widespread support, as long as it was done within the proper disciplines and standards that we expect of the health service. But it all seems to be taking so long—and time that we do not have—when the speed of change in the hospital service is so great and when facilities are being closed rapidly to meet the increasing demands of modern technology and science. We should be moving quickly to release the tremendous resources and skills of those nurses.
Are there any impediments to developing the nurse practitioner facility in the hospitals that I am talking about? Close to my heart is Sheppey general hospital, which has lost many acute services. It will soon be redeveloped as a fully fledged substantial community hospital. The same applies to Sittingbourne hospital. It would mean much to my constituents if nurse practitioners were able to use their skills and resources in a 24-hour minor casualty service. If the problem is extending 1223 Prescribing powers—I think that it might be—would the Bill allow the extension of prescribing powers to nurse practitioners? Or is the problem money? If many nurses are promoted to higher grades to carry out those services, is there a problem of relativity within the nursing profession and, if so, could it be resolved by extra resources? If that is so, it is an issue which we must tackle.
I return to what I said at the beginning. The real problem is that in many hospitals doctors are not on hand at all times and must be called in, which takes time. For that reason, casualties are often directed to other hospitals many miles away. That is an unsatisfactory situation which could be solved by the philosophy contained in the Bill.
I have said how far I should like the Bill to go and why it is important, but I regret that it has taken us so long to get this far. However, I welcome the Bill for what ii says explicitly and I congratulate my hon. Friend the Member for Chislehurst on introducing a measure which will help the elderly and chronically disabled people in my constituency and elsewhere. It will help people in rural areas—such areas are a large part of my constituency—and it will encourage nurses and give them greater job satisfaction. Many of them undoubtedly have great skills which should be better used. The Bill will save their time because they will no longer have to go to the surgery to get a prescription signed. It is in general a good measure which should be warmly welcomed. I wish it a speedy passage, but I hope that we shall use it as a foundation stone on which to build more extensive involvement for senior and experienced nurses in the delivery of good patient care.
§ Mr. Harry Greenway (Ealing, North)
Like my hon. Friend the Member for Faversham (Mr. Moate), I shall be brief because I appreciate the importance of moving on to the next Bill. I join him in congratulating my hon. Friend the Member for Chislehurst (Mr. Sims) on the introduction of this important measure. It is right that it should be properly debated, especially when one bears in mind the fact that the three categories of health service workers mentioned in the Bill perform a very important task.
I pay tribute to the work of nurses, midwives and health visitors. I have had a great deal of contact with them during my 23 years as a teacher, during one or two spells in hospital and during my constant hospital visits o my sick constituents which I and all my hon. Friends and all hon. Gentleman make.
It must be said that nurses, midwives and health visitors already undertake virtually the duties set out in this valuable Bill. They cannot do so by law, but they have a good knowledge of the drugs that patients need. They are in constant contact with patients
at least in hospitals—and are well aware of any changes in a person's health. Like most doctors, they know what medicines are needed in a particular situation. In my experience of hospitals, I found that nurse would tell patients that they needed this, that or the other and that they would write the prescription. They could not sign it but they could produce it.
It seems absurd that such health workers do not have the written and delegated legal authority to sign prescriptions when they have the knowledge to suggest a prescription. They also have the detailed knowledge that 1224 only a nurse can have—in many cases, more so than the doctor—of the way in which a patient reacts in the short and in the long term to a particular medicine. Such workers are in an almost unique position to suggest sudden changes in medication and it would be right and proper if they had the authority to authorise such changes.
Hospitals are well geared to handle nurses' prescriptions just as they are geared to handle doctors' prescriptions. After all, there is a pharmacy in most hospitals and nurses' prescriptions could be used or cashing in—so to speak—in such pharmacies as well as anyone else's. Therefore, the health service is well geared to responding to the measures set out in the Bill should it be enacted.
What about midwives? Surely they, more than almost any other category of health service official, operate on their own. When my three children were born I was present on each occasion. We did not see much of any doctors; the midwife was the figure—the health service representative—with whom my wife and I continued to deal afterwards. She must have had a unique knowledge of the health or otherwise of our children and must have been in a position to suggest and authorise any medication required. Happily, none was required in our case, but we all know that, sadly, in many instances midwives have to suggest to doctors particular medication for mothers and babies if doctors are unable to get to them. It is ridiculous that midwives do not have the final authority.
§ Sir David Price
My hon. Friend will be aware of the fact that under separate legislation midwives today have limited powers of prescribing.
§ Mr. Greenway
I am aware that they have limited powers of prescribing. They always have had such powers, but why should they be limited? My grandmother was a midwife and as children we used to walk around with her and she would point to some enormous man or woman and say that he or she was one of her babies. She would then give a detailed explanation of the parent of that child and the medication needed. She could do a great deal even all those years ago, but midwives still do not have the full powers for which we are arguing.
Health visitors also have limited powers. I should not want anyone in this country or anyone else in the world to have unlimited powers, because that is unhealthy. However, health visitors should have fuller powers than they have at present. I have had much contact with health visitors in schools and the work that they do with mothers and children. There are not many parents who do not have more than one child and a child's school attendance is often affected by the health or otherwise of a younger child, especially when the parents have to go out to work. In those circumstances, the younger child is often visited by the health visitor who will advise parents on how to handle the particular case. It does not make sense for health visitors not to have the full authority to dispense prescriptions.
From every point of view, the Bill has a great deal to offer. It will resolve a problem that should have been dealt with long ago, perhaps even when the health service first came into being but certainly shortly afterwards. For nurses, midwives and health visitors not to have the authority and powers set out in the Bill is, in a sense, a slap in the face for them. It is a denial of their professionalism and their contribution and of the fact that their 1225 contribution could save the valuable time of doctors and sometimes of consultants and others. I strongly support the Bill.
§ 12 noon
§ Mr. John Browne (Winchester)
I shall be very brief because I am conscious that hon. Members are waiting to debate the Civil Rights (Disabled Persons) Bill. I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims), first, on winning his place in the ballot, and, secondly, on what I think will be viewed as an excellent choice of subject for health care, especially by the patients. I declare an interest in the medical field, as listed in the Register of Members' Interests.
This is an excellent Bill, which is long overdue. The fact that nurses cannot prescribe does not keep up with today's world and the level of education that nurses have reached. That fact militates against patients because doctors and others who prescribe are overloaded. It also decreases the efficiency of nurses.
I agree with my hon. Friend the Member for Faversham (Mr. Moate) that the Bill should be seen as the thin end of the wedge for future legislation.
My constituency is a rural area. In addition to the City of Winchester, we have the towns of Alton, Bishop's Waltham and Arlesford, but there are also some 74 villages. The Bill will be given a special welcome in rural areas because it will greatly increase the efficiency of nurses and midwives. It will also increase the efficiency of doctors, because a load will be taken off them. The Bill will also increase the morale of doctors, midwives and nurses. It will greatly benefit patients in the NHS, especially those in rural areas where the inefficiency and inconvenience of travelling backwards and forwards to surgeries are so manifest.
I wish the Bill all success on its passage through the House.
§ 12.1 pm
§ The Minister for Health (Mrs. Virginia Bottomley)
Many hon. Members have made clear in the debate their strong commitment to the introduction of nurse prescribing. I warmly congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) as well as my hon. Friend the Member for Kensington (Mr. Fishburn), who has played such an important part in these matters. It is perhaps fitting that my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) paid a tribute to the predecessor of my hon. Friend the Member for Kensington, Sir Brandon Rhys Williams, whose wife is chairman of the family health services authority in that area, and she does a magnificent job.
My hon. Friend the Member for Chislehurst paid tribute to the work of our noble Friend Baroness Cumberlege. He hopes that she will steer the Bill through another place. Her work for community nurses is second to none. That work, which she is now able to carry forward as chairman of a regional health authority, ensures that right at the heart, in the leadership of the NHS, there is someone with special knowledge and authority in this area.
I wish to remind the House of the context of the debate, both the development of the service and the status of 1226 nurses, into which nurse prescribing fits. It is a step of great significance, which I believe will mean that the status of nurses, which is so fundamental to the health service, is reinforced and enhanced.
Our commitment to the health service is based on our determination to improve services for patients—nothing more, nothing less. That is why in the health reforms outlined in the patients charter we have spelt out our commitment to patients, especially the commitment to have a named nurse so that patients know to whom they should turn in times of difficulty, whether that be a midwife, a nurse or a health visitor. We are already seeing remarkable results. The maximum use of those who work in the service is fundamental to our being able to deliver further and improved patient care.
I am grateful to those hon. Members who have seen the Bill in the context of our introduction of care in the community. It is essential that those community nurses make a maximum contribution to enhancing the care of patients once they have left hospital. We know about the improvements in hospital care for the elderly—the 43 per cent. rise in geriatric consultants and the 84 per cent. rise in the number of elderly patients treated. However, patients are increasingly treated in the community and the support of community nurses is important.
I appreciate the comments of my hon. Friend the Member for Harlow (Mr. Hayes), who spelt out the three long-standing aims of the Royal College of Nursing, all of which have been achieved. He referred to the work of Trevor Clay, and then paid tribute to his successor, Christine Hancock. I thank my hon. Friend for his warm remarks about Dame Anne Poole, who, as chief nursing officer, has made an important contribution and has ensured that the interersts of nurses, midwives and health visitors are kept in the forefront of our considerations.
One of the first decisions of my right hon. Friend the Secretary of State was to appoint the chief nursing officer to the policy board so that, as we considered reforms and changes, we had her advice at the centre of our considerations.
Nurses have achieved an independent pay review body. As hon. Members have made clear, their pay has risen by 48 per cent. in real terms, ahead of inflation, since 1979. Pay is important, but so is training. Again, I thank hon. Members for their reference to Project 2000. Some£207 million has been put into that new form of nurses' training, to provide the qualified nurses that we need for the next century. We need those dedicated professionals, and we must get a better balance between classroom skills and hands-on care.
We have provided a better career structure under the new clinical grading structure introduced in 1988. Nurses now have better opportunities than ever before if they remain in clinical practice. Last year, we introduced a new senior nurse structure, which provides greater flexiblity and access to performance-related pay. Just this week the Nurses, Midwives and Health Visitors Bill completed its Committee stage. It will strengthen the professional self-regulation of nursing. Again, we worked closely with the professions to ensure that we have the mechanisms in place that can best enable self-regulation and the control of training. Those are very important steps. The hon. Member for Peckham (Ms. Harman) was wrong to suggest that nurse prescribing could have been appended to that important and significant Bill.
1227 I must mention the work of the nursing development units and nursing audit. In a number of areas there is a practical commitment to recognising and enhancing the role of nurses. Nurse prescribing fits well into that background. It will be a significant and worthwhile improvement in the services for patients. They will be able to get their medicines and dressings more quickly, and so have speedier treatments. Nurses will have greater responsibilities as professionals in their own right. The Bill builds on our determination to ensure that nurses achieve their rightful status in the health service.
§ Mr. John Marshall (Hendon, South)
One of the important issues in nurse prescribing is the number of nurses who work for general practitioners. I congratulate my hon. Friend the Minister on the fact that in 1979 there were only 990 nurses in general practice, whereas in October 1990 there were 7,700 full-time equivalents—making 13,520 nurses in general practice. Is not that a remarkable achievement, which underlines the case for the Bill?
§ Mrs. Bottomley
My hon. Friend is right in his figures. I am grateful for his comment. The role of the practice nurse is important. Primary health care has been transformed beyond recognition. More general practitioners are using computers. The whole area of general practice is developing. The practice nurse plays a vital role in that. If my hon. Friend will bear with me, I shall explain how we envisage the increasing involvement of practice nurses.
It is important to go into the details, even if only briefly, because it is a significant and important step. A number of comments during the debate show that there is some misunderstanding about precisely how the new arrangements will work.
We have long supported the principle of nurse prescribing. In 1986, the Cumberlege report on community nursing recommended:The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well-defined circumstances.The Government accepted that recommendation in principle and, through our standing medical nursing and midwifery and pharmaceutical advisory committees, set up the advisory group on nurse prescribing to advise ushow 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.The recommendations of the advisory group included a considerable number that required further work. One of the key aspects was the economic implications. Now that we have completed that further work, we are in a position to support nurse prescribing in practice as well as in principle.
I share the feelings of many hon. Members who wish that we had been able to make speedier progress. However, it is important to ensure that we have examined all the aspects—costings, cost-effectiveness, the mechanisms of how the prescriptions will be organised and referred back, and how the other professional groups have responded.
One of the reasons why we have received such warm and wide support for the measure is that we have been able 1228 to take the time to consult effectively and to take people with us. The advisory group report recommended that certain groups of nurses working in the community should be authorised to prescribe from a limited list of products and to supply medicines or vary their timing and dosage, within agreed protocols.
My hon. Friend's Bill provides the primary legislation to enable prescribing aspects of the recommendations to be implemented. Those are the aspects of most interest to community nurses, GPs, pharmacists and—most important—patients and their carers. I should also mention—this has been raised in the debate—that at the same time we are taking forward the recommendations concerning supply and changing timing and dosage. That aspect does not require primary legislation; it is a question of agreed protocols.
In its recommendations about prescribing, the report considered that nurses working in the community who had a district nurse or health visitor qualification should be permitted to prescribe the items that they needed for the nursing care of their patients. That is the basis on which we have worked in preparing the secondary legislation needed to turn my hon. Friend's Bill into a reality.
My hon. Friends the Members for Eastleigh (Sir D. Price) and for Faversham (Mr. Moate) and others have said that they support the idea with regard to community nurses and asked, "What about hospital nurses?" The advisory group reported in the context of community nurses, but the Bill would establish a framework whereby the concept could be extended to hospital nurses.
I was interested in what my hon. Friend the Member for Eastleigh said about people working in ophthalmic casualty. Before we took that further step, however, careful consideration and consultation would be required.
§ Mrs. Bottomley
At this stage our view is that we welcome the Bill and would like to see it translated into practice, but we do not envisage community nurses being able to prescribe until October 1991 Then there is further work to be done in considering what other items may be made available and how other groups may be incorporated. Special consideration should always be given to the role of groups such as community psychiatric nurses and others, and to the items that they may be able to prescribe.
A move such as that envisaged by my hon. Friend the Member for Faversham is therefore a considerable way off. We must be sure that we have established the right framework for the first group before opening our minds to the question whether others might have an important part to play.
My hon. Friend made a point—perhaps I should deal with it now rather than later—about the changing role of the health service and the development of community hospitals. He spoke of the combination of acute high-tech medicine in district general hospitals, alongside more effective and sophisticated comprehensive care in the community. The point was well made and we certainly wish the role of the nurse, whether in the hospital or in the community, to be developed and maximised.
1229 As I have said, we want appropriate nurses to be able to prescribe the items that they need for the nursing care of their patients. There will be a formulary of items that they may prescribe which represents the items that nurses in the community with district nurse and health visitor qualifications might need for the care of their patients, and which it would be appropriate for them to prescribe. Some hon. Members may have envisaged that nurses will be able to prescribe a far wider range of items than is proposed.
The Joint Formulary Committee, which produces the British national formulary and the dental practitioners' formulary has set up a sub-committee to produce a nurse prescribers' formulary. Medical, nursing and pharmaceutical interests are represented on the sub-committee, which has already met twice, and plans to complete its work in the summer. We are very grateful for its urgent help.
Hon. Members who are interested in the types of product that nurses will be allowed to prescribe should refer to the illustrative formulary in the advisory group report. Items include laxatives, stoma care products, pain killers such as aspirin and paracetamol, skin preparations, and a wide range of appliances and dressings. Most items can be bought over the counter by patients. The illustrative formulary lists a number of prescription-only medicines: Nystatin, for oral fungal infection; Clotrimazole, an antifungal preparation; Iodosorb, a medicated dressing; and Varidase, a desloughing agent. We anticipate that the final nurse prescribers' formulary will cover the same range of items, or similar items.
Other aspects have been raised by hon. Members—about the full implications of the Bill, about the nurses who will be able to prescribe and about their qualifications.
The advisory group gave very careful consideration to which groups of community nurses it would be appropriate to allow to prescribe and recommended that, at least initially, prescribing should be limited to those holding a district nurse or health visitor qualification. Secondary legislation under the proposed Act will, therefore, limit prescribing to appropriately qualified district nurses and health visitors working in the community. Before such nurses may prescribe, they will, of course, need training in nurse prescribing. In future, nurse prescribing will be integrated in district nurse and health visitor training courses, but at present we are working urgently and closely with the UKCC and the national boards to produce a nurse prescribing training module for those currently employed.
Many hon. Members will know a great deal about the work of the UKCC and the national boards, as we have spent some hours in Committee discussing their work. Hon. Members will be pleased to know that extra money has been made available for the training module. We have provided funds in 1992–93 for setting up the courses and providing training materials. We have also provided funds for 1993–94 and 1994–95 for running the training modules at the various centres around the country that run district nurse and health visitor courses. In England, taking account of practice nurses with district nurse or health visitor qualifications there are about 25,000 potential nurse prescribers. Some of those will leave or retire before implementation, and they will usually be replaced by 1230 nurses who have received nurse prescribing training as part of their initial training, so we anticipate that about 23,000 would-be nurse prescribers will attend the special course between April 1993 and April 1995.
The UKCC has advised us about standards, kind, content and length of courses. The national boards are now organising further discussions with course tutors. I know that my hon. Friends will want to be satisfied about the courses, because we are taking a new step and it is important to consider all the aspects.
The courses will cover, of course, the items on the nurse prescribers' formulary—drug interactions, reporting adverse reactions, communication with other professionals, good practice in prescribing, budgetary accountability and monitoring and all the other relevant issues. The courses will need to meet the criteria set by the UKCC and to be approved by the national boards.
At the end of the courses, potential nurse prescribers will be assessed and only if they reach the required standard of knowledge will they be allowed to prescribe. Nurses who have satisfactorily completed the training module will have their details submitted by the national boards to the UKCC which will be able to identify them as nurse prescribers on the UKCC register. Eligibility to prescribe can then be checked by bona fide inquirers with the UKCC at any time. It has been important to ensure that we consider all those angles to ensure also that, as we start the new move, it is carefully monitored and properly prepared for.
Budgetary accountability and monitoring were mentioned, scarcely surprisingly, fairly thoroughly by my hon. Friend the Member for Bristol, North-West (Mr. Stern), as well as by a number of other hon. Members. My hon. Friend has expert knowledge in these questions and a close awareness of the working of the family health services authorities. I made it clear that one of the areas that would-be nurse prescribers would need to address was budget accountability. We plan that the cost of nurses' prescribing, specifically the net ingredient cost of the items that they prescribe and the pharmacist fees, will be met in the family health services budget.
It is not appropriate to meet the costs from the hospital and community health services budget because, on the whole, nurse prescribers will be prescribing for general practitioners' patients and if the community nurses were not prescribing for them, the general practitioners would be doing so.
If nurse prescribers are practice nurses—that is, employed by GPs— we envisage their prescribing costs being linked to their GPs' indicative or actual prescribing budgets. If nurse prescribers are health authority employed, we envisage each provider unit being responsible for prescribing costs. More work is needed in that area before final decisions can be made. Through the Prescription Pricing Authority, GPs and community nurse managers will be able to monitor the patterns of their nurses' prescribing.
My hon. Friend the Member for Wanstead and Woodford raised the question whether there would be a differentiation between GP and nurse prescriptions. We intend that nurse prescriptions will be a different colour from GP prescriptions. I am sure that my hon. Friend is aware that pharmacists already manage to distinguish between GPs' and dentists' prescriptions, so there will be 1231 no difficulty in identifying a nurses' prescription. Apart from the different colour, the prescription will haw the nurse prescriber's name on it.
My hon. Friend the Member for Bristol, North-West also raised the question of the Prescription Pricing Authority and its work. The PPA, which does not always get the tribute it deserves, is a remarkably efficient and effective body. It will be able to identify the nurse prescribing undertaken by a particular group of nurses attached to GPs or by nurses prescribing in the community. It intends to identify the amount spent on nurse prescribing, not by individual nurses, but only according to a nurse's unit of employment.
Mention has been made of the Touche Ross report. I am the first to acknowledge that these questions are complex.
§ Mr. Arbuthnot
Would not it be beneficial to have the prescribing practices of individual nurses identifiable, if purely from a budgetary standpoint?
§ Mrs. Bottomley
That is a matter to which we have given careful consideration. My hon. Friend's point would introduce an extra layer of complexity. We are talking to health authorities and especially to those in the family health services about the further steps that we need to take in monitoring the prescribing practices of, particularly, community nurses. Our judgment is that the most helpful way to take the matter forward is to be able to identify the nurse prescribing undertaken according to the GP practice in which the nurse is employed or according to her employment in the community. We can, no doubt, consider that aspect further as we finalise details.
According to the Touche Ross report, apart from the one-off cost of implementation, nurse prescribing, as my hon. Friend the Member for Chislehurst said, will cost the Exchequer£15 million a year in England. Most of the extra costs—£11.65 million—are estimated to come from the cost of additional items prescribed. In addition, there are the cost of pharmacists' dispensing fees, costs at the PPA for pricing nurses' prescriptions and monitoring them, the cost of providing copies of the nurses' formulary, the drug tariff and prescription pads, and various other administrative costs.
Against those costs, we must consider the considerable benefits available from introducing nurse prescribing. There will be concrete benefits in terms of community nurses and GPs being able to save time. Nurses will no longer have to make trips to the surgery to get prescriptions signed, as several hon. Members eloquently described. GPs will no longer have to sign those prescriptions. Those time savings are considerable in total, although none of us believes that those time savings have the significance that the benefit of the measure would have in improved service for patients and for the convenience of those who are in the community.
There will be improvement in terms of the satisfaction of community nurses who will know that they can take full responsibility for the nursing care that they provide. It is ludicrous that district nurses with years of experience must bother GPs to get them to sign prescriptions for the nursing care of patients. I am very pleased that, through the Bill, we can recognise the skills and competence of community nurses.
The safety of patients will not be compromised. I have already outlined the special training that will take place. I 1232 mentioned the nurse prescribers' formulary which will mostly contain medicines and appliances that patients can buy over the counter. We also fully recognise the importance of good communications between nurse and doctor to ensure good-quality care for patients and to maintain patient safety. We shall issue further guidance before implementing nurse prescribing on the handling of adverse reactions and on the maintenance of patient records.
My hon. Friend the Member for Chislehurst rightly asked about implementation. Having reached this stage, he, like my hon. Friend the Member for Kensington and many others who have championed the cause so excellently, wants to ensure that we achieve our implementation date of October 1993. We are working to a good timetable. We shall begin work on the regulations as soon as the Bill becomes an Act. There should be no problem in preparing the regulations in accordance with that time scale.
There is more to be done. There is the secondary legislation under the Medicines Act 1968 and under the National Health Service Act 1977 to specify the types of nurses, the training and the circumstances. We are already consulting all interested parties before we can make the statutory instrument under the Medicines Act.
Clearly, the question of legal liability is important. Nurses are professionally personally accountable for their actions. In terms of legal liability for actions carried out in the course of their duties, their employers take vicarious responsibility, so that health authorities will be responsible for the prescribing activities of health-authority employed nurses and general practitioners will be responsible for their practice nurses' prescribing. My hon. Friend the Member for Bristol, North-West referred in particular to the family health services authorities and their service committee hearing proceedings. It will be the GP who is subject to such proceedings because it is the GP who is answerable, but all nurses are subject to the control of the UKCC, so in cases of professional misconduct, whether involving a practice nurse or a nurse in the community, should there be difficulties, proceedings could be taken by the UKCC.
Hon. Members have made it clear that they take a close interest in the role of pharmacists. My hon. Friends the Members for Wanstead and Woodford and for Walthamstow (Mr. Summerson) will know that we are already working on the wider role of community pharmacists. I can advise my hon. Friend the Member for Harlow (Mr. Hayes)—without whose contributions a debate on health matters would be almost empty—that recent information was sent to community pharmacists on the vital question of head lice, which he brought to the attention of the House. I hope that that reassures him on that front.
We are also working to consider those items that could more appropriately be provided over the counter. Obviously safety is the key criterion in deciding whether an item should be prescription-only or whether it should be available over the counter. The Secretary of State acts on the advice of the independent Committee on the Safety of Medicines and the Medicines Commission in reaching such a decision. I am grateful to my hon. Friends for their comments.
I want to comment briefly on the importance of retention and recruitment and the role of nurses in the service generally, to which the hon. Member for Peckham 1233 referred. We were the first Government Department to sign up to Opportunity 2000. We were congratulated only the other day by Lady Howe on our work towards ensuring that we continue to enjoy the excellent retention rates that we have now established. I can report to the House that the average length of stay for any nurse in the service is now 14 years as against the seven that it was some years ago.
We have explicitly stated our goals under Opportunity 2000. We in the health service have given ourselves eight goals that we shall achieve before 1994, and two of them particularly relate to nurses. First, we should not allow the number of midwives, nurses and health visitors leaving the profession to increase. We are proud of the position that we have reached and we want to maintain it. Secondly, those returning after a career break or maternity leave should be able to return to their job at the same grade as they were in when they left it.
We want job-splitting and job-sharing to be the norm in the service. It is up to employers to explain why women should not job-share rather than for individuals to seek to negotiate the arrangement. We are well in the forefront of developments, seeking to ensure that the NHS is not only the largest employer of women in Britain but the most enlightened. We know that it is our ability to use our staff to the full and to ensure that we have flexible employment patterns that will enable us to achieve the health goals to which we are all strongly committed.
My hon. Friend the Member for Ealing, North (Mr. Greenway) mentioned midwives. The Bill has the support of many midwives, some of whom are with us today. My hon. Friend the Member for Eastleigh drew attention to the special role of midwives since 1902. They already have 1234 satisfactory arrangements for obtaining the drugs that they are allowed to supply and administer, but it is important that the Bill's provisions should include them, as we may need to extend to them the ability to prescribe, which they do not have at present. I hope that, as we make good headway on the Bill, we shall be able to extend and develop its provisions through secondary legislation.
We all welcome my hon. Friend's determination to ensure that all the necessary measures are in place. We all believe that the role of nurses is fundamental to the health service. We wish the Bill extremely well and congratulate my hon. Friend. I hope that, on the many important points of detail, I have been able to satisfy my hon. Friend and the House of the rigour, care and commitment surrounding this most important measure.
§ Mr. Sims
With the leave of the House, may I first apologise for not being present when my hon. Friend the Minister began her speech. I had to leave the Chamber for a few minutes to meet a group of district nurses who wanted to tell me how very much they support the Bill and to express their anxiety that it should pass through all its stages before the end of this Parliament.
I thank my hon. Friend the Minister for her remarks about the Bill and for her support for it. I thank also hon. Members on both sides of the House for their kind remarks about me and, in particular, for their support for the Bill. That augurs well, and I hope that the Bill will now make rapid progress and that the district nurses who came to see me, and who do such a wonderful job, will not be disappointed.
§ 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).