Nurses and the NHS Reorganisation

HL Deb 04 March 1986 vol 472 cc131-62

5.56 p.m.

Baroness Cox rose to ask Her Majesty's Government what is their reaction to the concern expressed by the Royal College of Nursing over the effects of the reorganisation of the National Health Service on patient care and on the nursing profession.

The noble Baroness said: My Lords, it is with great regret that I feel it is necessary to initiate this debate tonight. Would that I could say that I speak more in sorrow than in anger. Unfortunately I speak as a nurse both in sorrow and in anger. However, perhaps I may begin by saying how grateful I am to those Members of your Lordships' House who have shown interest in this Question by putting down their names to speak in this debate. I greatly look forward to their contributions, and I am also grateful to other noble Lords and noble Baronesses who have told me personally of their concern and support but who are unable to take part this evening. I have in mind in particular my noble friend Lady Vickers and the noble Lord, Lord Richardson.

Perhaps I may begin by clarifying the nature of my concern, which is also the concern of the Royal College of Nursing. This concern has different but interrelated facets. First, there is concern about the principles involved in nursing's contribution to policy formation and decision-making in the National Health Service. Secondly, there is acute dismay about recent reorganisations following the Griffiths Report. In particular, there is serious anxiety about the actual and potential effects of some of these reorganisations on the quality of patient and client care. Finally, there is widespread distress, fear and anger in the nursing profession about the treatment meted out to some of its own members and the uncertainty in which many now find themselves, often after numerous years of professional service.

However, before I speak briefly to each of those dimensions of concern, I wish to say a few words about the Royal College of Nursing's original response to the recommendations of the Griffiths Report. The Royal College of Nursing never disputed the need for more cost-effectiveness, and in so far as reorganisation would achieve this the college was willing to co-operate—if the quality of care provided for patients and clients did not suffer. However, the college also made no bones about its fears that situations might develop where greater cost-effectiveness might be attempted at the expense of less care-effectiveness. Some of the college's worst fears seem to be being realised.

What are those fears? First, there are those relating to nursing's contribution to policy formation and to decision-making. Perhaps I may say that when I use the word "nursing" I include of course the related professions of health visiting and midwifery. Health care is an immensely complex and rapidly changing arena of activities and responsibilities. The nursing input is major in terms of resources and manpower. Nursing is responsible for about 50 per cent. of NHS manpower and 45 per cent. of the average district manpower budget. But perhaps even more relevant is the fact that it is the nursing profession which has the most direct continuity of care for patients and clients.

It is nurses who are responsible for round-the-clock care and on whom patients depend for their most fundamental needs. It is also nurses who are significant in creating the environment of care for patients in hospitals, nursing homes, or other kinds of residential institutions. Indeed, for long-stay patients such as the elderly, the mentally handicapped, or the young chronic sick, nurses are in effect their world. Patients in high-dependency units or in intensive care depend entirely on nurses for their very lives. A nurse in an intensive care unit is responsible for maintaining life support systems, and for giving psychological and emotional support to patients and their relatives in situations of ultimate need. Therefore, nurses are uniquely placed to speak with authority on patients' most intimate needs and to evaluate the effects of health care policy as they affect patients most directly.

It was Lord Briggs, in his report on nursing, who called nursing "the major caring profession". This does not imply, and no nurse would ever wish to imply, that other health care professionals do not care about their patients or their own professional responsibilities, but in the sense of direct patient care as well as in terms of resources and numbers nursing justifies Lord Briggs's accolade.

It therefore surely makes sense for nursing to be represented in the decision-making processes which affect the fulfilment of its own professional responsibilities for providing care. It is precisely because some of the developments which have occurred in the reorganisations following the Griffiths Report have not respected this principle of the need for a nursing contribution to the management of the National Health Service, that the Royal College of Nursing is so alarmed.

May I briefly outline some of the developments. In the early days assurances were given that nursing's contribution would be honoured. Mr. Roy Griffiths himself was reported on 18th November 1983 in the Daily Telegraph as saying: The proposals don't threaten nurses at all. The nurses are doing a good job and the changes that are being talked about aren't designed to affect them, except beneficially.

Mr. Barney Hayhoe, as recently as 20th November 1985, in a letter to all regional health authority chairmen, wrote: … most district management structures provide for medical and nursing membership of the district management board or similar body. Where this is not the case, I believe it is important that alternative arrangements command the confidence and commitment of all the medical and nursing interests locally".

It is the discrepancies between these intentions and the realities of reorganisation which are the burden of our concern. We are not worried in terms of professional self-interest, and in particular we are not worried about the small number of nurses appointed as general managers. I cannot emphasise that point too strongly, because it is a point that seems to have been misunderstood. What we are worried about are the principles and practices which have adverse effects on the provision of care.

Let me illustrate by example. The Royal College of Nursing has been collecting information on the changes which have already taken place. Its survey covers 146 district health authorities in England, which is about 75 per cent. of the total. The findings show how, in many places, the wholesale scrapping of nursing manager posts at the level of director of nursing services has taken place. That is the equivalent of the old-style matron. They have been replaced by a variety of new posts in which the decision-making component has been replaced by a purely advisory role. In a third of these posts even the advisory role is peripheral and may only be used at the behest of the general manager. Thus the principle of enshrining a nursing contribution to the decision-making process has been scrapped.

More specifically, 28 district health authorities in the survey have done away with the former chief nursing officer post. There is no nurse member of the management team, and professional advice to the health authority has been delegated to a director of nursing service of one of the units, or to a director of nurse education, or to the holder of some other post. The Royal College of Nursing argues that this situation is not satisfactory. It does not match up to the assurance given by Mr. Norman Fowler in his letter of November 1984 when he claimed: we would expect that authorities will need a nursing adviser, at senior management level, whose main responsibility is the provision of nursing advice to the authority".

How can a nurse with responsibility for her or his own unit (itself an arduous job), or for education (a comparably demanding role), have time or opportunity adequately to represent the professional requirements of a range of colleagues, often in very diverse fields, as well as fulfilling the responsibilities of his or her own post?

Fifty-seven other district health authorities have hybrid posts, sometimes with ghastly titles such as "Quality assurance manager". Would not Florence Nightingale turn in her grave to think of her respected matrons being reduced to that? Such posts retain a chief nursing officer role but they also bring other responsibilities, perhaps such as domestic, catering or laundry services. The Royal College of Nursing can welcome some of these, as such functions impinge directly on patient care and on the ward environment for which nurses are responsible, but others are much more dubious, such as responsibility for the ambulance service or for public relations.

Nursing management is one of the most demanding jobs in any health authority, accounting, as I have already said, for about 50 per cent. of health authority staff. It really seems astonishing, to put it mildly, to expect a chief nurse to perform all these roles and to give top priority to developing and managing the nursing services. However, at least those district health authorities retain a nursing input, but in nine district health authorities the chief nursing officer is not a member of the management team and has a purely advisory role with no direct line management responsibility for nursing. In other words, she or he is totally excluded from decision-making, with a contribution dependent on a grace and favour basis.

However, exclusion of nurses from decision-making bodies, or the awesome accumulation of incompatible responsibilities, is not the end of our tale of woe. One of the most serious and least reported effects of management reviews has been the amalgamation of units in ways which may be detrimental to patient care. In the past it was a well-recognised, even notorious, fact of National Health Service life that certain services were the Cinderellas in terms of resources and facilities. They included, for example, the care of the elderly, the mentally ill, and the mentally handicapped.

One of the reasons for their relative deprivation was the situation where they had to compete for scarce resources with the acute hospital services. In recent years a solution had been sought by arranging for such units to be managed separately so that their resource needs could be considered on their own terms and not in direct competition with other priorities. Now in many reorganisations hasty amalgamations are regrouping such units so that they lose management, autonomy and priority. Nurses in some of these situations are already finding difficulty in competing for resources, say, for the care of the elderly against the demands of a medically oriented acute unit. Moreover, many of these new amalgamated units are very large and geographically dispersed.

It appears that administrative and financial convenience has taken priority Over patient and client group orientation. In theory good management could cope well, without falling into the traps of the past. But the early signs are not propitious in some places.

This leads me into a brief discussion of some examples of the effects of reorganisation on patient and client care. Clearly it is early days, but some examples will illustrate the nature of our concern. Let me begin by reading an extract form a letter from a senior sister which describes the cost in human terms of decisions being made in the interests of cost effectiveness without an input by professionals such as nurses who can see their effects on patient care. I quote: The first instance when Griffiths started to affect us was in July 1985. My ward was closed; this was a specially adapted ward for the disabled. The patients were moved to the hurly-burly of surgical wards … which were totally unacceptable in design and equipment … for example, no lifting aids for the bathroom; nurse call buttons and radio controls mounted behind the beds and out of reach of these patients; toilet doors too narrow for wheelchairs; door handles and taps inaccessible … and a general atmosphere not at all conducive to the slow rehabilitation of the disabled".

In another notorious case an administrative decision was made to share a defibrillator between two hospitals. A defibrillator is a piece of equipment which is needed within a matter of minutes if it is to be effective in saving a life. The manager has since defended his judgment by claiming that a nurse was present when the decision was taken. But it should perhaps be noted that the nurse in question had just been axed from her post and was not in the most effective position for arguing any points.

In another district nurses have been asked to undertake laundry duties because of problems with the provision of laundry services. Dirty laundry has been accumulating and nurses, including ward sisters, have been requested to work in the laundries. This is hardly an effective way of using qualified professional staff, even if this is during off duty periods. Staff tired from nursing patients are hardly likely to find appropriate recreation working in hot, steamy laundries. If they are to be paid overtime rates this hardly fulfils the criterion of cost effectiveness.

This misuse of professional nursing staff raises the last concern I wish to discuss. This is the impact of reorganisation on the profession itself. I come to this last because the College's overriding concern is the effect on patient care rather than on the interests of its own members. But the adverse effects on nurses are incalculable. Many senior nurses have just been sacked after years of professional service. One chief nursing officer of a London health authority was summoned by the general manager and the chairman of the unit authority and summarily dismissed. She was told that her post was being abolished, that she would be given eight months' salary and was to be sent on "gardening leave".

The regional nursing officer of another region was told in front of other people, I am informed, that her role was not needed and was to be reduced to a token one day a week. When amalgamations occur literally hundreds of existing directors of nursing services lose their posts and are having to reapply for the newer, fewer posts. The figure may rise to literally thousands when we are thinking of the same situation applying to ward sisters and to charge nurses.

In one unit recently all existing ward sisters and charge nurses have been told that they will have to reapply for their posts. Perhaps even more disturbing, if that is possible, is the proposal from one health authority which recommended the abolition of the post of ward sister and its replacement by managers who might not be nurses. It is not known whether that proposal has been accepted, but that it should have been submitted is surely deeply shocking. If Florence Nightingale would have turned in her grave at the replacement of matrons or their equivalents by non-nurse managers, she would surely return to haunt those responsible for recommending the abolition of ward sisters.

Throughout the nursing service there is now fear: fear for the quality of patient care and for the future of the health service and for the future of nursing. Many nurses had been willing to believe the Government's assurances that the future of the National Health Service is safe in their hands. I think I might find it difficult now to find a nurse who still believes that. But there is also fear for the future of the profession and of each individual in it. Sackings and the wholesale annihilation of posts is poor recompense for a profession that has fulfilled its professional responsibilities consistently, often in very difficult cirumstances and despite poor recompense.

Through that terrible winter of discontent it was nurses who kept the hospitals going. Often nurse managers would finish their days' work, roll up their sleeves and do all the tasks which no one else would do, from serving meals and disposing of dirty laundry to removing the bodies of patients who had died. In one hospital where the strike had affected the mortuary, nurses used their own sitting room for the bodies of deceased patients. I hope we do not have another winter of discontent, because there will not be nurse managers in post to hold the fort again.

Similarly those responsible for nurse education are deeply worried about the effect on students and on recruitment to a profession where prospects have deteriorated and where morale is at rock bottom. Some 20 per cent. of nurses on the wards are students and they are entitled to adequate supervision and support. The syphoning-off of senior nurses will endanger the quality of teaching and back-up which will be available for them. It could also cause real stress to the students and maybe even danger to patients.

Finally, I cannot talk about morale without very brief reference to salaries. The thorny and perennial problem of nurses' pay has been eclipsed by other disputes. But may I remind your Lordships that nurses are still apallingly underpaid. A staff nurse's salary is still only about £6,000, although she is likely to carry responsibility for a ward while sister is off duty.

In more personal terms I shall tell your Lordships about a staff nurse I know well. A fully qualified nurse and a graduate, she recently undertook some agency nursing in a well-known hospital in the Home Counties. She was put in a ward in charge of confused elderly patients and was the only qualified nurse on duty, helped by two excellent auxiliaries. There were 26 very confused and physically dependent patients who needed every kind of care and attention, and who were sometimes, inevitably, unco-operative and aggressive. After carrying the responsibility for their care for a shift which was physically exhausting, professionally demanding and emotionally wearing, her take home pay was £2 an hour.

How long will our country go on treating its dedicated nurses like this? Will the Government take seriously the representations made by the Royal College of Nursing? I have only had time to touch on them very briefly and not to do justice to the full range and extent of examples.

I should like to conclude by asking my noble friend the Minister four questions. First, will she indicate whether the Government will consider issuing a circular with guidelines to ensure that health authorities comply with the assurance given by her right honourable friend the Secretary of State that authorities will have a nursing adviser at senior management level whose main responsibility is the provision of nursing advice to the authority? I am aware that there is a reluctance to issue guidelines but there are precedents, for example, with regard to competitive tendering. I hope that my noble friend will give some assurance on this point.

Secondly, will those responsible for implementing the Griffiths reorganisation be encouraged to respect the principle that there should be nursing management for clinical nursing; in other words, that any nurse who holds a position of responsibility for direct patient care is accountable and answerable to a senior colleague who can evaluate her clinical competence and offer clinical support and advice when necessary? To have situations where front-line nurses responsible for looking after patients only have a non-nurse senior colleague for accountability and support is professionally unacceptable.

Thirdly, can my noble friend give some guidance on the thorny problem of provisions for retirement and pensions for senior nurses who might wish to apply for managerial posts in the new structures? I have been given to understand that one reason why more nurses have not been applying for these posts is that they would lose their right to retire at the age of 55. Were they to be given such a post, they might find themselves in financial difficulties. For example, if their tenure of the post were to expire for any reason they would no longer be entitled to retire at the age at which they could have retired but would have to try to return to some other post in the NHS for an extra five years.

A final question, for interest and clarification, is this. Can my noble friend inform us as to where in the Griffiths Report or in Circular HC 84/13 the authority can be found for such massive and radical reorganisation of the National Health Service, even down to unit or ward level? We realise that managers were to be given considerable autonomy, but the degree of root and branch reorganisation which is occurring in some places appears to have no mandate in the original report. Had this been presaged, the Royal College of Nursing would have made known its representations earlier and would have tried to forestall some of the developments which it perceives as most damaging to patient care and to its own members.

I am grateful for this opportunity to present the concerns of the Royal College of Nursing, which are also my concerns and those of nurses up and down the country. I sincerely hope that the Government will take them very seriously, because what is at stake is inestimably precious: the wellbeing of the National Health Service and the future of nursing as we have known it in this country. As I have already said, the nursing profession has shown outstanding patience and tolerance in the face of abysmal salaries and tough conditions of service. They have set an example to the nation in putting the interests of those whom they serve before their own interests. But if they feel that the interests of those whom they serve are being jeopardised their patience and self-restraint may be strained beyond endurance. It is my earnest hope that the Government will demonstrate their good faith by proving that the National Health Service is safe in their hands by taking seriously the worries expressed by the Royal College of Nursing. I also hope that they will demonstrate their appreciation for a profession which has proven its dedication to that National Health Service but which is now fighting for its professional life.

6.23 p.m.

Baroness Robson of Kiddington

My Lords, I am desperately sorry that we are not allowed to applaud this House. May I thank the noble Baroness, Lady Cox, first of all for raising the subject of our discussion this evening and also for outlining in such a professional and moving way the problems that face the nursing profession. I had put down a Question similar to that which the noble Baroness has asked today in the category "No Day Named" and I was contemplating at what moment it would be right to raise the subject. I must say that the noble Baroness, Lady Cox, has chosen the perfect moment. It really is a great tragedy that we should have to have this debate today. I doubt whether Mr. Griffiths realised the upheaval the implementation of his report would cause. I am sure that he did not intend it, and in a way it is rather a pity that he is not a Member of your Lordships' House so that we could hear him personally express his concern at the outcome of the implementation.

I myself supported the idea of a general manager, just as did the Royal College of Nursing, and I supported it particularly at unit level because there, I believe, it is essential that decision-making is done fast and urgently. I have some doubt about its importance at regional and district level, but I never imagined that the introduction of a general manager in the structure of the National Health Service should mean the breaking up of the underlying structure of balanced input from all sections of the immensely complicated body of the NHS.

I had thought in my innocence that a general manager is something in the role of an executive chairman; that he has all the advice that is needed from all sections of the service and that, if there is disagreement, there would of course be occasions when the general manager would have to take the decisions. That is not such a different position in some ways from that which was held by regional chairman and district chairman under consensus management by the officers of the authority. It happened quite often that the officers were not in agreement and that the chairman of the authority had to be the arbiter. In my innocence I thought that, apart from an input of urgency by the general manager, that was basically the way the problems of the health service would be treated.

However, it appears that I was wrong. I should like to go back a little in history. I have been connected with the health service since long before the 1974 reorganisation. I was a member of a board of governors and I was chairman of another board of governors. In those days we did not have the problems that we seem to be facing now. All your Lordships must have read many letters and articles in the press about the desire to have the matron back. I must say that if you look back to pre-1974 it was the matron and the hospital secretary or house governor who were the two people who ran the hospital. But we must also remember that in those days they were running a hospital service and not the National Health Service as we know it now.

It was purely a hospital service. In those days, a house governor or a secretary to the board who had the courage to ignore the matron's point of view was really a very courageous man and he did it, I would assume, very rarely except when for some financial reasons he had to override what the matron wanted to achieve. Then we had the reorganisation of 1974 and the health service became to a very large extent what it is now, taking in the community services, and as we know it today. That was really the first time that nurses were put on an equal footing in the management teams of region, district and area. I admired enormously in 1974 the way the nurses accepted that challenge. It was an unusual position for them. They had not experienced that kind of management before. We all know that nurses—it does not apply to the noble Baroness, Lady Cox—are a little diffident in relation to the medical profession. They tend to whisper a little instead of clearly stating their point of view.

I have watched the development of district, regional and area nursing officers in my region. Although they started by being fairly diffident it soon became obvious that they were invaluable members of the team. In many cases the nurse became the chairman of the team. Whenever a nurse was the chairman, the meetings were run more efficiently because a nurse tended to talk less than the men when chairman. Nurses took on a tremendous responsibility.

In the 1982 reorganisation, that position for nurses was retained. They have worked at creating a position for themselves. They were listened to in planning matters. Most members of the other professions at team level have accepted that the contribution nurses have made to the development of the National Health Service, as we see it now, has been enormous. That did not change in 1982.

We then had Griffiths and the whole picture changed. It did not change because nurses failed in the managerial positions they had achieved. It changed because there is a desire to have financial control over the National Health Service to ensure that no money is wasted. I also believe in that. I am sure that every Member of your Lordship's House believes in that, but it does not mean cutting out the nursing input.

I am an enormous supporter of the Royal College of Nursing's present campaign. Like the noble Baroness, Lady Cox, I am becoming very worried about what will happen to the National Health Service because the importance of nursing advice is not recognised.

The noble Baroness referred to the district health authorities and gave various figures. I also have those figures. She mentioned the problem of not having proper nurse representation. Perhaps one of the most appalling examples she gave was that of the nine district health authorities where the nurse has a purely advisory position and is not a member of the team or of the day-to-day management. In other words, she is there should the general manager feel like calling on her. If she is unhappy about what is happening within her district she has the right to go to the health authority, but that is like appealing to a tribunal against a sentence that you have already been given and where there is no chance to state your case or defend your point of view among your peers in the service. I believe that is a desperately dangerous position

There are 46 district health authorities where the adviser to the health authority is the director of nurse education. How can someone, however eminent a director of nurse education, be responsible at the same time for all aspects of nursing within the district—nursing in the hospital and the community? It is not physically possible for someone to do that as well as be the director of nurse education.

We come to unit level which is where I believe a general manager appointment would probably be a good idea. If the unit has no nurse with the appropriate level of authority, the unit and the patients in it are in great danger. It is proposed that in some units the ward sister should be the adviser to the general manager. No one has greater admiration for ward sisters than I have—they are a dedicated part of the service—but in the modern National Health Service, with its shortage of staff, they are desperately busy. They are more than overworked merely running their own wards. It is essential that the wards be run properly. I do not believe that a ward sister can take into account all the problems of the other wards and the community services and serve her own ward adequately. That is probably one of the most dangerous developments in the health service at the moment.

How will a nurse who is doing her own full-time job and who is asked to act as an adviser to the authority keep up to date with all the problems of the service? I fear that the nurse appointed to represent all the specialties within the National Health Service is likely to be the nurse in charge of the acute wards because she happens to be in the hospital near the central office. What will happen to the Cinderella services for which for many years we have fought so hard to be given a fair share of the National Health Service cake?

We cannot blame the nurse in charge of the acute wards wanting the best for her side. Obviously acute wards are terribly important. I fear that if we do not have a director of nursing services responsible solely for the running of the nursing service within each unit and district patient care will further deteriorate. That is what frightens me about the present problem.

Letters from the department and discussions with the Secretary of State and the various Ministers for Health, as they have changed, have always claimed that the whole idea of Griffiths was that each unit should have greater freedom of decision-making and that the Department of Health and Social Security did not want to be involved. I wonder how logical that is. Why is it necessary for regions and districts to submit not just their management structures to the DHSS for approval but all the advisers that they propose to appoint?

I know we do not want circulars. I was in the service long enough to know that I was buried in circulars in those days. Things have improved in the DHSS, but we do not want just letters from Ministers to chairmen of authorities which say, "The Ministry would expect" or "The Ministry hopes". What we want, whether it is in a letter or a circular, is something saying, "The management structures must include a nurse representative". I think the authorities need firmer guidelines from the DHSS, even at the risk of another circular. I believe, therefore, that every unit in this country must retain a head of nursing services working with the manager. Clinical nurses would then be managed by trained nurses, which in my view is the only way to safeguard the interests of the patients.

6.41 p.m.

Baroness McFarlane of Llandaff

My Lords, I wish to thank the noble Baroness, Lady Cox, for providing an opportunity for your Lordships' House to discuss this matter of very grave concern to nurses and to all those who I believe have the standards of patient care in the National Health Service at heart. I would congratulate her on her very eloquent presentation of facts, with which I should like to align myself.

In rising to speak, I feel I should apologise to your Lordships' House for the fact that I am not able to be here as frequently as I would wish. That is because I hold a full-time teaching appointment in the University of Manchester. I am a nurse and a professor of nursing, so that I have the welfare of students very much at heart, together with the learning environment in which they learn to nurse and also the job satisfaction in their future career opportunities. With that I would align the job satisfaction and career opportunities of many National Health Service colleagues. But most of all I am concerned for the quality of patient care. I believe that, as one who is slightly outside the health service but is daily visiting and having contact, going into the wards, the departments and the community with students, I have some insight into what is going on and maybe I can see it a little more objectively than perhaps someone who is in the heat of the situation.

It is my experience that young people come into nursing—and increasingly mature people also come into nursing—with a very high degree of motivation to give high-quality care. Nowadays, as the noble Baroness has indicated, that includes competence with intricate machinery and increasingly with computers and with high technology of every kind. It also includes the more elusive and less easily quantifiable aspects of care: making people comfortable who are uncomfortable, preserving human dignity in all sorts of stressful situations and giving psychological and spiritual support in threatening situations. These are the things that are the very essence of nursing.

It is because these are under threat at the present time that I believe the concern of the RCN merits consideration—a concern which I believe is shared by many other professional organisations. Only today, for instance, I was contacted by the Health Visitor Association about the effect of the Griffiths reorganisation in community care. The concern is also shared with the statutuory body for nursing education in England, the English National Board for Nursing, Midwifery and Health Visiting. That is evidenced by a letter recently sent by the chairman of the board to health authorities about the need for student nurse training.

I have to remind your Lordships' House that the Royal College of Nursing is a organisation which has on repeated occasions reaffirmed a "no-strike" policy in the interests of patient care. I would suggest that an organisation which has demonstrated its commitment to care to such an extent really deserves to be heard when it expresses concern for patient care. I would reiterate that the main focus of that concern is not the proportion of nurses who have achieved top management posts—some 10 per cent. in general management posts—so much as the loss of expertise of many senior members of the nursing profession and the effect that has on the quality of patient care.

I think the overall objective of efficient management and the economic use of resources is an objective with which none of us would disagree. Yet we can look at some of the various myths that have grown up about the management of the nursing service and the management of the health service. I had the privilege of serving on the Royal Commission on the National Health Service between 1976 and 1979, and we looked at some of those myths. There was an idea abroad then that the proportion of nurses in management had increased greatly and that many very efficient clinical nurses has been sucked out of the clinical situation into management posts. When we looked at the figures, that was not borne out: there had been no increase in the proportion of nurses in management.

We also looked at consensus management, and many members of the commission came to that discussion with great misgivings about the subject. But we took voluminous evidence and in fact the evidence was that that was working very well after the few years that it had been in position. The delays in decision-making, we found, were delays in passing information up and down between various levels of the National Health Service, between region, area and district. We recommended that one level of management should be lost.

However, I do not wish to enter any particular argument tonight about the virtues or otherwise of consensus management. The only thing I would say is that in a service as intricate as the National Health Service balance between the varying interests and the competition for resources in that service has to be achieved by consensus. One of my great misgivings is that in the present reorganisation the assets, the people who can contribute towards decision-making about the allocation of resources, have been stripped away.

Why has this happened? In 1983 Sir Roy Griffiths said in his report: A general manager should be identified within the existing team or elsewhere according to the chairman's view of the local requirement. This is not intended to weaken the professional responsibilities of other chief officers, especially in relation to decisions taken on matters within their own sphere of responsibility". So the Griffiths Report did not recommend the wholesale restructuring of the National Health Service at local level that we are now seeing; nor the restructuring of professional responsibility which has taken place in the name of Griffiths. The extent to which that has taken place has, I believe, been very amply rehearsed by the noble Baroness, Lady Cox. I am concerned, therefore, at the effects on patient care of the rather blind and thoughtless attempts at economic savings that are presently being made.

I wish to look at our methods of measuring efficiency. I suggest that the methods of making savings by the sacrifice of experienced professional posts and cuts in clinical staff in many places are a false form of economy. The measures of efficiency used neglect some of the most important aspects of nursing care. We tend to measure efficiency in quantitative terms, in those rather unfortunate phrases of "patient turnover" and "patient throughput", rather than the quality of care or even the effectiveness of care.

How does less than adequate staffing affect the nursing care given? In a district general hospital on my doorstep a seven-day survey of the pattern of nurse staffing was carried out recently on 114 wards with 2,487 beds. The minimum staffing requirement to give basic care and to carry out the average work of the wards was determined for each of three shifts. Then they looked at what the failure to achieve the minimum staffing ratio resulted in with regard to the pattern of nursing care. A whole lot of essential nursing care had to be reduced. For instance, nurses were unable to turn patients who were bedfast two-hourly, one of the essential features of preventing pressure sores. The frequency of toileting for old people was reduced. Old people were told that they could be toileted only two-hourly. Some patients were prescribed hourly fluids to keep up their fluid balance. Nurses were able to give those fluids less than at hourly intervals.

These were increased mistakes in drug administration. Many of the rehabilitative measures in nursing care were eroded. It is far quicker to dress a patient with a stroke yourself than to encourage that patient to dress himself and therefore to encourage his rehabilitation. When a nurse is in a hurry when the staffing ratios are short, she will dress the patient herself and thus the whole objective of rehabilitation is lost. So we can say, "Oh, yes, the ward was managed with fewer nurses", because in nursing there seems to be a moral virtue of making do, but the measures for prevention of pressure sores, the promotion of continence, the promotion of mobility and the keeping of the patient hydrated were all reduced.

Why was the study carried out? There has been a suggestion that there was an unnecessary overlap of nurses at certain times of the day and that reduction of this overlap not only in this hospital but over the country could achieve tremendous savings nationally. I am old enough in the nursing profession to remember that it was in the 1960s, after a lot of discussion, that a period of overlap of nurses in the afternoon was instituted. It was instituted as an educational measure so that student nurses could learn and could integrate the theory that they were learning in the classroom with the practice that they were getting in the ward. True, by taking away the overlap one could achieve an economy in nurses, but the nursing education would be eroded. But in this study in the district general hospital, if one excluded that overlap period, at other times there was a total deficit of 205 nurses during that week if a minimum staffing ratio was to be maintained. Ninety-seven out of 113 wards were below the minimum staffing ratio. So in a place where there was apparent overlap, where savings were being demanded of the nursing staff and where there had been a cutback of nursing staff because the authority was overspent, the minimum staffing requirements to maintain basic care were not present.

I have spoken of the way in which necessary physical nursing care is eroded by low staffing ratios, but the measures for comfort, for dignity and for psychological and spiritual support are those which are eroded most quickly. There is less time to talk to patients if one is understaffed; less time to talk to relatives; less time as a community nurse to educate the family about how they should care for the patient in the absence of the nurse. Not all this "cruel absence of care", as we could call it, is directly attributable to the Griffiths reorganisation, but these are examples of things that can happen when economies are made—looking at the surface of what is apparent and looking for ways in which staff can be cut without any recourse to the expert nursing advice that needs to be fed into that decision-making.

I know that it will be argued that there has been an overall increase in the numbers of nurses. There is a fascinating account of this from the Centre for Health Economics that indicates just where in the health service these extra nurses are being used and the type of work in which they are being used. But I want to go on and touch briefly on the effects on nursing education.

The learning environment in which students learn to nurse is of supreme importance. In the school the student will learn now of a great deal of research that is going on contributing to many innovations in patient care, some of which I have mentioned. The student then goes on to a ward, where the demands are such that continence and mobility cannot be promoted; the confused cannot be orientated to reality; the anxious cannot be reassured; and the patient who needs teaching about his care cannot be taught. So the school is teaching standards of good patient care, yet we place students in positions of conflict where they cannot carry out the care that they have been taught.

What happens? I believe that the service picks up the cost of poor care. There are studies which show how much the care of bedsores costs the nation; yet we are putting nurses in positions where they cannot give the preventive care that will prevent those bedsores occurring. What a false economy!

I wish to comment not just on the standards of care which we see undergoing an erosion but on the loss of nursing expertise that is taking place. The noble Baroness referred to the erosion of the work of a regional nursing officer. To my way of thinking, she was one of the most innovative nursing managers that this country has seen for a long time. We lose her expertise, and that has a cost attached to it.

The divisional nursing officer for the community in the district next to where I work and the divisional nursing officer for acute care are both taking early retirement. The district nursing officer is now a personnel officer. In the county borough where I am domiciled, the community nursing officer is taking early retirement. Not only are all those people lost to the health service but so too is their expertise lost to the nursing service and to patient care. The lack of their replacement means that any advice on nursing is being pushed further and further down in the level of the nursing service. I know that our colleagues in the community who are now in megaunits are feeling that very keenly.

The concern of the profession is seen in the growing volume of anecdotal evidence that there is about what is happening. Daily I receive stories in my office. One general manager suggested that if staff nurses could relieve ward sisters when they were off duty, then there must be no real need of ward sisters. Some of those gentlemen come from concerns such as the Royal Navy, Tesco's and Woolworth's. I suggest that such would be an interesting principle to apply in other places.

Another general manager demanded that the director of education should cost the meetings that she held with her staff. I suggest that that is a very good idea, and I have adopted it myself. But then there was an edict that the director of education should hold no meetings with her staff; that there should be no communications in the school of nursing. In another place a unit manager is an anaesthetist. I understand that he rushes out between cases and carries out the work that the matron once carried out in managing the nursing service. What a way to run a health service, let alone a nursing service!

Next year I shall celebrate 40 years of association with the nursing service, both pre- and post-National Health Service. I do not believe that I have ever experienced such a time of stress and such a time of wastage of this country's resources.

At the beginning, upon the introduction of the Griffiths proposals, during the course of a short debate initiated by the noble Lord, Lord Molloy, I raised certain issues about the effects on nursing and the nursing service. In reply, the noble Baroness the Minister gave assurances. I went away from that debate feeling happy. The noble Baroness said: The purpose of the Griffiths recommendation is… to bring the best possible service to patients… At unit and district level the chosen manager could well be a nurse. Even if that is not so, nurses will be managed by nurses".—(Official Report, 9/11/83; col. 913.) In the light of the concern felt by the Royal College of Nursing, and in the light of so much anecdotal and factual evidence that is being amassed, I wonder whether the noble Baroness will give the House an assurance that Her Majesty's Government will give active consideration to what is happening in the National Health Service and that nurses will indeed be managed by nurses.

7.4 p.m.

Lord Wallace of Coslany

My Lords, after three expert speeches, I can only comment as a consumer and also perhaps as one who fought for the National Health Service long before it came into being. I am very grateful to the noble Baroness, Lady Cox. In my innocence, I had previously put down a Starred Question for yesterday. However, one morning at breakfast I received my copy of the Minutes of Proceedings and noted that the noble Baroness had put down her own Unstarred Question, and then I realised that it was far more important.

Something else happened that morning at breakfast. I received through the post two very attractive leaflets from my bank which informed me that as an Access cardholder, I could obtain 15 per cent. discount on membership of BUPA. I then picked up the local newspaper, and the headline that greeted me was: No money, no nurses, no beds". It is to that particular situation that I want to refer briefly before making my general points.

That reference in the newspaper refers to the situation at Queen Mary's Hospital in Sidcup—a hospital with which I have been linked for many years since it came into being. Because of illness among nurses at that hospital, 42 beds have been closed to "ensure patient care". The reason for those indefinite closures was that no money was available for agency nurses and staff—and I understand that agency nurses cost at least 25 per cent. more. Nursing recruitment has been restricted and the present nursing staff are already under strength. I say quite emphatically from my own experience that the situation at that hospital is becoming absolutely intolerable.

The action taken at that hospital, including the previous temporary closure of a GP ward (now likely to be permanent), was taken, it is alleged, to maintain patient care under difficult financial circumstances. To illustrate those difficult financial circumstances, that hospital has just had an X-ray tube go "west" and it does not have the money to replace it. Not yet—but we hope to get the money one day. Nevertheless, as a result GPs cannot send their patients to be X-rayed and, at the moment, only people who are in hospital can be X-rayed. In the meantime, and after all that, the lists of people awaiting beds and patient care will get longer and longer and longer.

Faced with a major shortage of cash in the next financial year, the district health authority is confronted by acute problems and has set up a think tank to try to resolve them, as further reductions of services are absolutely in evidence. Bexley Health Authority, faced next year with an overspend of £1.6 million for 1986–87, is already in debt and is desperately trying to cope with providing a service.

The reason for that problem is a strange one. It is that that hospital happens to be successful. It is inundated with patients. The workload—which means more work for nurses—has increased by 15 per cent. but there has been no increase in the nursing staff. Another ridiculous situation is that more consultants have been appointed but nobody has thought to provide adequate nursing staff to cover the work of those consultants—and consultants cannot do their jobs properly without adequate cover and nursing care.

Nursing care, as we have already been told, covers 24 hours each day. The increased high workload has meant increased pressure on nursing staff, which in turn increases illness among them. Consultants rely on nurses for their 24-hour cover, but stress impedes good nursing and patient care. With the increased workload—and the noble Baroness, Lady McFarlane, mentioned nursing strength—student nurses are heavily engaged on duties within their training experience, but (and this is a very important point) it means that nurse training itself suffers because the young student nurses are too busy elsewhere. That in itself is a serious matter.

Anyone who has escorted a person to an outpatients' department, as I have to do fairly frequently, and who has seen the masses of waiting patients, seen the nurses protecting the harassed doctors, and has seen them soothing and calming patients, will wonder how on earth they manage to cope and keep their cool. There must be stress reaction when they are off duty. That is where illness arises. Pay awards are not part of this debate, but health authorities have added to their financial worries because of the system imposed upon them.

There is another point. There are many people who say, "Yes, privatise". They say that we should privatise this and that in the health service to save money. But do not forget that every time you privatise redundancy payments must be made and the health authority has a further financial burden. The situation at Queen Mary's Hospital, Sidcup, is financially criticial because of inadequate funding. Our two Members of Parliament, Mr. Heath and the Member for Bexleyheath, Mr. Townsend, are at present actively chasing the Ministers.

The general position of overwork and, to some extent, chaos as far as nurses are concerned and the facts I have given are not unique to Queen Mary's Hospital. It is widespread throughout the National Health Service. Small wonder that good, trained nurses are being lost to the private sector and to industry.

Some strange things seem to be going on. I understand, for instance, that a chief nursing officer has been sent to British Leyland in order that she should acquaint herself with quality control. Are we to assume that patients are items on a production line? Almost all decisions taken in the National Health Service affect patient care, either directly or indirectly. It is essential that there is an experienced nurse manager at each level of decision-making. The Griffiths Report on the management function clearly stated that nurses will still lead nurses. In each management structure there must be clear lines of professional accountability and leadership.

There is a further point which is extremely important so far as the Health Service is concerned. To maintain and encourage nurses and midwives to be both recruited and retrained within the NHS a recognisable career structure with professional management and expertise needs to be retained, in the interests of nurses and midwives but essentially in the interests of patient care. As I have already indicated, and others have, it is only nurses and midwives who give patient care on a continuous basis over each 24-hour period.

I assume that those of us taking part in this debate have received letters from the BMA and the NAHA. The efforts being made by the BMA to ensure that their members are represented at district and unit management level are most impressive. What strikes me is that in the BMA letter there is no mention whatever of the value of round-the-clock nursing care in ensuring the success of the doctors' skills. The same representation given to doctors under pressure from the BMA should be given to nurses. Nursing is only mentioned incidentally in the opening paragraph in reference to this debate.

However, the letter I received from the director of the National Association of Health Authorities is more like a script from "Yes, Minister". It is quite chauvinistic and it made me extremely angry until I saw the funny side of it. I quote one example: No one could possibly disagree that nurses are best placed to make professional decisions about professional nursing matters. But management of the NHS is much more than that. It is about ensuring that, in a multi-million pound enterprise, the most effective decisions are made, thereby ensuring that the service given to patients is of the highest quality". Tell that to the people in Sidcup and the patients who are on the waiting list for treatment. It is not management; it is downright mismanagement. I quote again: The Griffiths Report and its subsequent implementation offer a bright new future for the NHS and its patients. Quicker and better decisions, resulting from more decisive management and stronger leadership, will create an improved service". It continues: Managers cannot expect to operate effectively in a climate where they are constantly being told what to do by Whitehall". Strong and decisive leadership and decisions leading to an improved service can be secured only if backed by adequate financing. As for being told by Whitehall what to do, well, after all, that is where the money comes from via the taxpayer; and do not forget the masses of circulars and directives emanating from the Elephant and Castle.

The management of the NHS at both district and unit level involves two highly skilled professions—doctors and nurses. We are not dealing with a supermarket chain, but an area of professional skills affecting people's lives and welfare. It is an extremely sensitive area. Therefore, it is essential that the skills of both the doctors and the nurses should receive adequate representation to enhance management and certainly give us a better service than we have at present.

7.16 p.m.

Baroness Lane-Fox

My Lords, like other noble Lords I am much obliged to my noble friend Lady Cox for tabling this Unstarred Question. It is a natural but regrettable fact of life that when you are in good health you have little that goads you on to consider the lot of the nursing profession, whereas when you are ill, immobilised or elderly perforce you think about the nurses a great deal.

During two recent spells in hospital and a close involvement with an assessment ward and a long-stay ward at a geriatric unit I have been heartened by the high standard of care, the skills and duties of the nurses, and by the warmth of their hearts. In case my last remarks suggest that I am just an aged sentimentalist let me recount a recent piece of hard evidence to support them.

The patients' association of one unit where I was accommodated is trying to raise £1 million in order to move to better and safer accommodation. Knowing the struggle made by their patients to raise the funds the nurses, despite their hard work, organised a sponsored bike ride. They were accompanied by many of their admirers on a 40-mile route from Clapham to Tunbridge Wells. Triumphantly they returned with £1,400 to contribute to the fund. The next day they were on duty again providing their therapeutic brand of hope and happiness, no matter what their own personal problems.

I make a point of this event because it came when the morale of nurses was low. They were dispirited to find that their take-home pay compared unfavourably with that of persons having far less vital responsibilities. Given the present sophisticated machinery and methods used on the wards, lives depend perhaps more than in any other era on the skill and vigilance of the nurse. The remaining portion of the last increased pay award I believe has just been implemented. I only hope that this time it will not, as it usually does, coincide with higher deductions for food, emoluments, insurance and tax, leaving them still with a level of take-home pay that would be sneered at by many industrial workers.

Nurses have said to me that, knowing current Government spending on hospital and community health services stands at £10.4 billion, growing next year to £15.5 billion, they wonder why recognition of the part played by nurses is so far down the line. That is why it is imperative that this year's review body award, when it appears, should be realistic and designed to take account of the greedy clawback at source.

There are nurses who say, generously, that they see their chosen career as rewarding and fulfilling apart from the pay aspect. But they do not and cannot believe that they are seriously expected to work their hearts out for poor pay and uncertain prospects. Some of them try to subsidise their pay by agency nursing in their off-duty hours, and thereby probably undermine their health; others are lured abroad or into other jobs where the work and the environment are less to their liking but where the money seems worth the sacrifice of their training. Those who just cannot make both ends meet, often because of family commitments, leave the profession disillusioned and bereft of their earlier aspirations.

As a layman it seems to me that in the Griffiths reorganisation very close attention should be paid to reducing the hassle that nurses have to undergo. We know that many hospitals are economising hard, and that creates an atmosphere which can stifle good work. There is a difference between that situation and a thrifty routine, which surely is the right balance to be struck. Nurses deserve all the help that they can get on the wards, provided that it can be offered within the limits of sensible housekeeping—and this goes for the provision of up-to-date equipment. It amazed me to find no hoist on the wards of a famous London hospital. This meant that two nurses and the patient were locked in what to me seems an obsolete method of lifting, which puts nurses' backs at great risk and causes patients much anxiety. To someone like me who regularly makes use of a hoist, this struck me as at least very unfortunate.

In order to cope with the current method of discharging cases from hospital into the community as early as possible, it is really important that the domiciliary services should be closely integrated. Social services departments have a very heavy task in providing home helps, who are invaluable and can prevent many a disaster, as is the case with the meals-on-wheels service and, where relevant, the occupational therapists; but the district and community nurses are the closest link with hospital treatment and care.

As a consumer I can vouch for the fact that the district nurses get me up, dress me and put me in my wheelchair every day of the year. The clinic from which my nurses come serves several areas. Almost always it is short-staffed and the nurses are hard-pressed. They come from many homelands, and they wear a blue, green or brown uniform depending on their qualifications. To those of us who so much admire and value their professional services and approach, it is interesting to see how they work over a very wide area and carry considerable responsibilities. Only a few of them drive a car; some bicycle; and the rest cover wide distances on foot. The normal morning case-load appears to be eight or nine visits, some of short duration and others taking up to one and a half hours.

In the recent bad weather walking has meant a great deal of trudge and sludge. I sincerely hope that any modernisation of the nursing services will include consideration of this invaluable branch, and of its travelling problems in particular. It is not so bad if the pay is good at the end of it all, but I find it mystifying and alarming that highly-qualified nurses in this service receive a take-home pay which compares unfavourably with that of a secretary or a civil servant whose prime responsibility is not the actual lifeline of a human being, as is the case with nurses.

With society's ever-increasing demands for care in the community, we must realise that domiciliary nurses have a most important role to play. This is a service of which this country can be proud, and we should guard it. Obviously, nurses are best placed to make professional decisions about professional nursing matters. Nevertheless, they are worried at the idea that they could be excluded from management decisions within health authorities, as we have heard. Under the new recommendations it is surely intended that the new managers will obtain the best for everyone out of the improvements that are now taking place in the National Health Service. It will be for management to take the professional advice of the nursing profession. Those of us who are concerned must devoutly hope that every effort will be made on all sides to reach accord.

The object of my intervention is to plead with my noble friend the Minister, and through her to the Secretary of State, that the efficiency, dedication and loyalty of the great nursing service shall never be taken for granted. Then, with its great traditions and with the leadership of such distinguished ladies as my noble friend Lady Cox and the noble Baroness, Lady McFarlane, the highest quality and standard of nursing will be deservedly honoured and maintained.

7.25 p.m.

Baroness Masham of Ilton

My Lords, I am grateful to the noble Baroness, Lady Cox, for giving us the opportunity of trying to bring to the notice of Her Majesty's Government some of the anxieties felt by the nursing profession due to the most recent reorganisation of the National Health Service, which in turn is having an effect on patient care.

On the way here I was questioned by my taxi driver who wanted to know what I was going to do in your Lordships' House. I told him that we were going to discuss the effects of management reorgnisation of the National Health Service on nurses and patients. He asked: "Is that the Government bringing in businessmen to run the National Health Service?" and he added, "I would not want them looking after me". My imagination drew a picture of Mr. Victor Paige, the general manager at the Department of Health and Social Security, running around a ward with a bedpan.

Who knows best what patients need and how to organise their care? While in hospital, the people who are closest to the patients and in whose care they are 24 hours a day seven days a week, are the nurses on the wards. The Government has said, "The National Health Service is safe in our hands". I would rather they had said, "Patients being treated by the National Health Service are safe in our hands".

The National Health Service is a very large organisation. I am concerned that the further away from the patients that the top management goes, the more the patients will suffer. It is natural that employees at whatever level try to justify their positions. The National Health Service has often been criticised for too much administration and too little direct patient care. Many people agree with the idea of having general managers so that there is an identifiable person who can be singled out to be accountable and responsible for decisions. In the past there has been too much buck-passing and cover-up.

A general manager at the DHSS, at regions and at districts, seemed acceptable but it now appear that there are general managers emerging at every level—more and more managers—and this adds up to yet more administration. The nurses have realised that they may no longer be directed by nurses, perhaps because general managers are trying to justify their own existence. Nurses have been told by the Government that they themselves can apply to be general managers, but most of them do not want to manage other parts of the health service. They have chosen nursing as their vocation and their profession. That is what I think is not fully understood.

Nursing is a caring profession. It also has a highly technical side, with many specialties. If the manager who manages nurses does not fully understand the many aspects of nursing and has to deviate to other aspects of running a hospital, it seems that standards could well drop and many needs of a patient be overlooked. Nurses feel that unless they have a direct line to the district general manager via a director of nursing their many vital requests may be overlooked.

Everyone knows that the National Health Service could be a bottomless pit, with its many demands, and all people who are interested in the NHS should welcome the schemes which have given better value for money. But I have witnessed real concern from some very experienced and dedicated nurses, some who themselves are retired and no longer have a financial interest. They are worried that their profession will be damaged by people who do not fully understand it. It is now easy to witness petty rules being implemented in the name of cost-efficiency savings. It is sometimes the little things in life which can mean a lot.

Some months ago I mentioned the fact that many nurses were concerned and unhappy to the Minister, the noble Baroness, Lady Trumpington, who should personally value the vital need for good nursing care. A few weeks ago I personally witnessed the day that a very experienced sister from the obstetrics and gynaecology department of a London teaching hospital took early retirement. Everyone, especially the doctors, seemed dismayed. She had worked at that hospital for 30 years. The straw which broke the camel's back was that the general manager had made a ruling that staff no longer could have a kettle to make a cup of coffee or tea. Machines, where people pay for a revolting cup of something and which generally get jammed so that they lose their money and get nothing, had been installed. I wonder what would happen in your Lordships' House if, for instance, the hardworking staff in the Whips' Offices could no longer make their cup of coffee.

A dedicated and experienced sister who has skills of life gives confidence to patients and trains both nurses and junior doctors. Such people do not leave in the middle of a difficult delivery just because the time has come to go off duty. If the general managers behave in the way I described in that example, the new generation of nurses may well change their attitudes, and heaven help the patients and hospital morale! There must be senior staff to direct and teach juniors. There should also be a worthwhile career structure.

Another example that I heard of only last Wednesday was told to me first-hand by an ex-patient of St. Thomas's Hospital. A journalist from one of the influential women's magazines went in for an operation. The ward sister went off duty and there was no replacement. The ward routine deteriorated and the patient's brother, who is a solicitor, complained to the management that the patients were not receiving adequate care. The hospital responded, but the nurses made life too unpleasant for the patient. She discharged herself early, and will not forget the experience in a hurry. This is the sort of very disturbing incident which happens when staff do not have the direction of a sister and back-up cover. The backlash always lands on the patients.

I have been told by a nursing officer from a nearby health authority to Milton Keynes that Milton Keynes health district may dispense with individual ward sisters and only have a few in charge of a group of wards. That this idea of floating sisters was ever suggested is very worrying. I hope that this is only a rumour, and I think that the idea has now been dropped. But I hope that the Minister can give an assurance tonight that this will never happen in other districts. In some districts recruitment of nurses is not very good. That sort of insecurity would only make it worse. Nurses now seem to prefer to work in the community. Could pressure in hospitals be becoming too great?

The Government must do something to help patients, because it is patients who will suffer. The nurses can at least work elsewhere if things become impossible. They can go abroad or work in the private sector. Many patients are at the mercy of the Government. The patients who cannot afford private health care have no choice. The Government must step in before it is too late. It is no good just saying that it is up to the health districts or regions to do what they think best. It was the Government who approved the appointments of the general managers, as has been said by the noble Baroness, Lady Robson. They must surely now see that they do not destroy our much sought after British nursing profession.

Many people up and down the country mourn the disappearance of the matron, the figure who all patients and nurses knew and whose authority they respected. Now we have new and worrying dangers facing the hospital service. Nurses and patients have to cope with several dangerous infections and cross-infections, and nurses have to brace themselves for the increasing violence in accident and emergency departments. The rule in hospitals should not be one of fear and of not having enough equipment and staff to do the job well. It should be one of teamwork and co-operation, with support and guidance from the top, right down to the most junior nurse.

7.37 p.m.

Lord Auckland

My Lords, this is one of the most important debates that this House has had for a long time. It is a great pity that it comes in the form of an Unstarred Question, because it puts my noble friend the Minister, who is dedicated to her department and to the National Health Service, in the difficult position of having had a number of questions and brickbats thrown at her.

I take part in this debate because last July I was a patient in a national health hospital for the first time in 37 years. The time before that was 1947, when I spent two periods in a military hospital during my national service with the British Army in Austria. That hospital had a matron, and, by jove, we knew it! She came from Scotland, which was fortunately the home of my mother and my grandparents and so I got to know her fairly well. But that hospital was run very much by the matron, as those noble Lords who have been in military hospitals will know. Even the commandant went in fear of her. She was wholly dedicated, and if one was seriously ill, as I and a number of my colleagues were for some weeks, the treatment and the nursing were absolutely first class and the whole hospital was extremely well administered.

If ever there was a case for having noble Baronesses in your Lordships' House, this is the day! We have already had several quite outstanding speeches. I am sure that we have at least one more to come.

One of the problems at present is the fact that in hospital one does not know who is the matron. There are area and district nursing officers and principal nursing officers. That makes it difficult, particularly for young nurses who may have a personal problem to know to whom they should apply.

During my time in your Lordships' House, I think that we have had at least seven reorganisations of the NHS. I am bound to say that when the reorganisation came in during the tenure of Sir Keith Joseph (who was again a dedicated Minister of Health) a great deal of damage was done. At that time I was a member of a house committee of a long-stay mental hospital. Many of our Lordships will have known the late Lord Grenfell to whom I have referred previously in your Lordships' House. He was chairman of the hospital management committee of that area. If there was any problem, the hospital management committee, often through the house committee, could get to grips with it. They would not necessarily solve it. If it was very serious it obviously had to go to a much higher authority. The noble Baroness, Lady Robson, was very much concerned with that area at the time and gave impressive service.

My experience recently in hospital was one of extremely dedicated nursing. At night there was a shortage of nurses. On many occasions there was not a ward sister. The staff nurses had to take on big responsibilities. But the service given to the patients was quite exemplary, as I believe it always will be. From time to time we hear a great deal about ill-treatment of patients in our hospitals. This cannot, of course, be justified. But if there is a shortage of nurses it may well inevitably happen. This is one of the problems that we have to face at present.

I am not necessarily against reorganisation. I am not against managers. I do not believe that the Royal College of Nursing, with which I have had a great deal of contact, is against managers. This late hour is not an appropriate time, at least for someone like myself, to develop that argument, but it will have to be faced in the future. There is much concern throughout the health service over the present rates of pay, as my noble friend Lady Lane-Fox, and others, have mentioned, and about extreme shortages in some hospitals and the long hours that nurses often have to work.

This is happening not only in the smaller hospitals. It affects the London teaching hospitals. My younger daughter trained in one of the well-known London teaching hospitals. After a few months' training she was confronted by an elderly man having a very serious heart attack. The two ward sisters had been called to an emergency. She coped as best she could. The man died. This was no fault of the hospital, because clearly he was terminally ill. But how many similar incidents have occurred, not only in teaching hospitals but also in district hospitals and general hospitals? It cannot always be avoided. But with the present state of staff shortages in the health service there is an on-going danger.

I have always been dedicated to the National Health Service. I have always used it. The present Government, I believe, are spending more on the National Health Service than has been done previously. At the same time there is the question of whether more money needs to be spent on the nursing service. We tend to spend, I believe, in our health care too much on administration. Of course, one must have administration. If, however, we are really to have a dedicated nursing team in the future, as we have now, we have to face the realities of what the Royal College of Nursing has said and treat the health service in a much more generous manner.

7.45 p.m.

Lord Ennals

My Lords, this has been a very remarkable debate. All your Lordships are deeply grateful, I believe, to the noble Baroness, Lady Cox, for opening the debate and for the manner in which she did so. The noble Baroness made a remarkable speech, exemplary in every way. It was, as I believe the noble Baroness who has to reply to the debate will recognise, a damning indictment of the way in which the nursing profession is being treated in the National Health Service today. No one can accuse the noble Baroness of irresponsible talk or of playing party politics with a dedicated profession. She cannot be accused of over-dramatising the situation. And certainly she cannot be accused of talking about a subject of which she does not know very much. She knows much more than I do and much more, with due respect, than most of the men who have spoken in the debate.

It has been a remarkable debate. I was delighted that it brought the noble Baroness, Lady McFarlane of Llandaff, to us. Even though she is not here as often as we would wish, the noble Baroness has made, and continues to make, an outstanding contribution to nurse education. She speaks, as does the noble Baroness, Lady Robson, with great experience and authority. It was very notable that Lady McFarlane said that after 40 years she had never experienced such stress in the nursing profession as exists now.

I do not believe that anyone would disagree with Lady Lane-Fox who said that nurses are wonderfully caring people. I certainly share the view of the noble Lord, Lord Auckland, that the quality of nursing is still extraordinarily high. But this has been a debate of great criticism in depth. I hope that the message has got home to the noble Baroness, Lady Trumpington. If not, let me go over it again.

Today's argument about management is perhaps unfortunate but probably inevitable. Some of us warned the Government that the business principles that would probably guide the general managers, appointed under the Griffiths reorganisation, were likely to, if not bound to, create conflicts and tensions with the professions such as doctors and nurses. But, as stated by two or three noble Lords, no one thought that the reorganisation would be as fundamental as it has turned out to be.

Let us remind ourselves of the colossal role that nurses fulfil in the whole of our health service and especially the hospitals. They form the largest single part of the workforce, accounting for over 50 per cent. of the staff—around half a million people. It accounts for 40 per cent. of the budget. As my noble friend Lord Wallace said, nursing is the one service that is truly responsible for patients 24 hours a day, seven days a week, all the year round. If anyone asks where the buck stops, the buck stops with the nurse on duty at the time the problem arises.

I should like to quote Mr. Trevor Clay, general secretary of the Royal College of Nursing: The voice of nursing has to be heard and acted upon every day at every level in the health service, not just once a month at a health authority meeting. That will not work. The nursing voice must carry authority and not simply be advisory". That was a profoundly wise statement to make. I say to Trevor Clay that his fulfilment of the role of general secretary of the Royal College of Nursing shows a standard of leadership that is worthy of anyone in this House.

The noble Baroness, Lady Cox, was I believe right to say that the principal concern was not the number of nurses who had been appointed to health authorities. The figures are certainly very disturbing. They are less than 10 per cent. But that is not the principal point. I think we should all have been a little happier if more nurses had been appointed at district level than has been the case. A very small percentage of nurses have been appointed at district level. But what is much more significant and disturbing to the Royal College—and I must say I share their concerns—is what is happening at district level with the role, the effectiveness and the voice of the nurse being heard at the time when decisions are taken.

The Royal College of Nursing conducted a survey and covered 138 district health authorities. I want to give one or two examples. They found 28 district health authorities in which there was no chief nursing officer post at all. In this situation there was no nurse member of the management team at district level and the professional advice to the health authority was delegated either to a director of nursing services from one of the units who could not be expected to understand the needs of all the units—perhaps the director of nursing education, who, if she was concentrating on education could not be expected to understand all the service needs—or the chairman of the professional advisory committee.

The Secretary of State, Mr. Norman Fowler, in a letter which he wrote in November to Trevor Clay—and I am quoting—said: In practice … we would expect that the authorities will need a nursing adviser, at senior management level, whose main responsibility is the provision of nursing advice to the authority". That was an authoritative statement, and it has not happened. Certainly it is the view of the Royal College of Nursing that none of the structures to which I have just referred is satisfactory or matches up to that description. As the noble Baroness, Lady Robson, said, placed in such a position a director of nursing services in one unit would find it difficult to have an over-view of the work of all nurses in the whole authority.

If I may take another group, nine district health authorities have a chief nursing officer who is purely advisory. The individual is not a member of the district management team and will have no direct line management responsibility for nursing. They are excluded from participation in day-to-day management which would give them real influence over decisions being taken.

If I may give my third example, 46 district health authorities have a chief nursing officer who is adviser to the health authority but who also has a direct responsibility for the management of nurse education—nurse education having generally been run on an authority-wide basis. This is another post which is essentially advisory, with all the problems that have been outlined.

The scope of an effective chief nurse should encompass the whole authority and all aspects of nursing particularly the practice in the hospitals and the community. The chief nurse who is directly responsible only for nurse education will in time come to focus on education rather than practice and will be seen by the health authority as the voice of nursing on education alone rather than on the whole of nursing practice.

All district management structures have had to be approved by the DHSS. I emphasise this because the whole question comes down to one of responsibility: who is to do what about this situation? First, we know that the decisions about the appointment of all general managers from top to bottom were approved by the Secretary of State. This is an issue which several times has been raised in this House as to why certain managers who had been appointed by their authorities were then turned down by the Secretary of State. However, that is past. All managers are appointed by the Secretary of State.

It is also true, as I have said, that all district management structures have had to be approved by the DHSS. Therefore, if there has been a system within a district or a region which has been unsatisfactory, which has denied to the chief nurse the main opportunity of representing his or her profession and of having the authority that he or she is entitled to have, then that system has been approved by the Secretary of State.

One has to say that the situation as we now see it is a very serious one and runs quite contrary to that which was set out in the quotation which I read from Norman Fowler's letter of 16th November, 1984. If one listens to everything that has been said—and I address the noble Baroness—from the beginning of this debate to the end, it all suggests that there is a major problem to be tackled. We have to assume that if the problem of management and the role of the nurse and the voice of the nurse in management is not put right then the morale of nurses within the profession, which, as has been said, is very low, will get lower and we shall see more of those distinguished people who have served the service for 20 or 30 years leaving before retirement age because they are dissatisfied with the structure under which they are forced to work. I therefore say to the noble Baroness who has the responsibility of replying that she must get this message over to the Secretary of State and must do so "pdq", because he has to get this matter straight.

We were talking earlier about circulars. The noble Baroness, Lady Robson, said that she was used to receiving circulars. Some of them were sent to her by me, and I do not regret many of them. Perhaps one or two of them could be shortened—we all expect that. But a new circular is now required. The noble Baroness said that there needs to be from the Government a new circular on nursing which sets down some minimums, such as having a director of nursing services as the head of nursing in every unit; such as ensuring that the first line of accountability for a clinical nurse is to a nurse manager who can fully understand the whole range of complex problems and give professional advice and support. These are principles which should be adhered to by every unit manager.

We also want a statement which emphasises compassion and humanity as being just as important as cost-effectiveness and throughput. I get fed up, I have to say to the noble Baroness, that every time we raise a question in this House we are told that more patients have been pushed through, that more money has been provided; but we are not very certain that a better service is being provided as a result of what is being done.

I often think that patients are being pushed through the health service too quickly and often they have to come back again as new patients because of that. This is not just the fault of the hospital which wants to achieve its turnover, and the general manager who wants to produce his facts and figures to show what a rapid turnover he has, but it is also due to the inadequacy of the services in the community to support the patient who is discharged.

That is what we are asking about. There is no point in saying at this stage that we should scrap the Griffiths Report. The Griffiths Report is here to stay, whether one likes it or not. What we want is that it should work effectively in the interests of the patient; and there is no profession more directly related to the daily interests of the patient than that of nursing.

At the very beginning Lady Cox put four questions to the Minister, I shall not add any new questions because those were the fundamental ones. There was another question put by the noble Baroness, Lady Masham, which makes five. I want the noble Baroness the Minister to reply as best she can, but, more than anything else, I ask her to convey to the Secretary of State, who I think does not yet understand, the extent to which in the nursing profession up and down the country, from responsible organisations like the RCN to the trade union organisations representing nurses, there is now a deep concern about the role of nurses in management at every level, and that this is something which must be put right because otherwise the National Health Service will suffer even more severely than it is suffering now.

8 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Baroness Trumpington)

My Lords, I am glad that my noble friend Lady Cox has instigated this debate, if only, I hope, to clear the air. I have listened with considerable interest to what has been said and I shall try to answer all the points that have been raised. I hope at the same time to answer the original Question that my noble friend Lady Cox has asked.

The Government's reaction to the Royal College of Nursing's campaign is to regard it as a sadness that they decided to present their views in this way. It is particularly disappointing in view of the fact that my colleagues and I have always been more than willing to meet with the Royal College of Nursing and discuss any concerns that they may have, and I know that health authority chairmen feel the same way. As my noble friend Lady Cox said, it is early days.

I fully appreciate that change always causes concern for staff; and with 14 regional health authorities, 191 district health authorities and over 600 units all undergoing management change, I am hardly going to pretend that there will be no local hiccups anywhere. There are bound to be a few. As a member of a regional health authority, I am sure that the noble Baroness, Lady Masham, through her experience, will agree with me. I also acknowledge that some nurses feel bruised by the experience of putting in for, hut not getting, general management posts. However, I also believe that the best way forward is through constructive and forward-looking discussion rather than through expensive campaigns in the media. I should like to think that many nurses are looking ahead in anticipation of seeing many more nurses filling management posts as further opportunities arise over the next few years.

The noble Baroness, Lady McFarlane, raised the question of economies. I must make clear that economies have not been our principal concern in introducing the concept of general management. Right from the start—and I feel that it is important to stress this point in answer to my noble friend Lady Cox—the key objective in introducing general management to the NHS (as recommended in the Griffiths Report) has been to improve service to patients. Perhaps I may quote from the guidance sent to health authorities in June 1984 which set the ball rolling in the National Health Service: The primary objective for health authorities in implementing the Report's recommendations must be to achieve changes at Unit level and below. If there were no observable improvement in services at that level, in the eyes of patients and the community within three to five years, then there would be no point in making changes at District Health Authority level and above". Our primary aim is still to see improvements at the point where the patient receives a service. I remain convinced that this will be achieved by, first, improving the way and the speed with which decisions are made; secondly, by ensuring those decisions are taken as near as possible to the services and patients they affect; and, thirdly, by ensuring doctors and nurses are as fully involved in management as possible.

I must respectfully tell the noble Baroness, Lady McFarlane, that it is nonsense to suggest that managers who know nothing about nursing are taking over nursing affairs. In the first place, at the important unit level more than three times as many doctors and nurses have been appointed as general managers than people from outside the NHS; and those from outside will have the benefit of first-class medical and nursing advice. Indeed, a senior nurse of my acquaintance said to me last week that any manager who did not consult with nurses is a "damn fool". I can assure your Lordships that we are certainly not in the business of appointing "damn fools" as managers.

In the second place, it has been made clear that professional nursing matters remain the exclusive province of nurses. Nurses will still monitor their own professional standards and make professional day-to-day nursing decisions. That is entirely right. What the Government have done is ensure that the profession is drawn into the mainstream of general NHS management rather than left to wither in glorious isolation.

The RCN is pressing for a centrally-imposed management model at unit level. It wants to see a director of nursing services appointed in every unit. Obviously there are many units where such a model will fit perfectly. Indeed, I gather that some are proposing to use the good old-fashioned term "matron" in this context, a term which I must confess I like very much; and I agree with the noble Baroness, Lady Masham, on that point. However, I must also say that I find it hard to believe that the one model will be appropriate for every single unit. They come in different shapes and sizes. As I said before, there are over 600 units round the country. They range in budget size from just over £1 million to £46 million. Different units serve completely different groups of patients and employ different types of staff. It is surely better at that level to let local health authorities make sure that the system in each unit really does meet local needs rather than for the DHSS to prescribe a model from the centre.

The noble Baroness, Lady Robson, spoke about the reduction of units. The overall number of units is likely to be reduced from about 850 to around 600. The final number will not be known until the last district has completed its review of management arrangements. I have no doubt that, in reducing the number of units, authorities have sought to reduce the overall costs of administration and management so that more resources can be released for direct patient care. However, I am sure that, in making choices about the structure of units, careful regard has been taken of the need to ensure that the development of mental illness, mental handicap and other services deserving priority is secured. Most authorities have advised us that districts' new unit arrangements will be kept under close review. If this shows that some districts have not got it quite right, perhaps for the reasons to which the noble Baroness referred, they may have to think again.

The noble Baroness, Lady Robson, asked a question about the approval of structures. This is a matter of lines of accountability. The department approves regional structures; regional health authorities approve district structures after consultation with the DHSS. It is a matter for the health authorities locally to consider and approve local unit structures. Surely it is not suggested that we should adjudicate literally about hundreds of local unit structures from the centre?

The noble Baroness, Lady Masham, referred to Milton Keynes and the rumours that ward sisters were being dropped from some wards. As I have said, local arrangements must be worked out at local level. However, I am aware of the point the noble Baroness has raised concerning this particular district, and I am able to confirm that through local consultation the situation that concerned her will not arise.

Some noble Lords expressed concern about nurse career development. The Government share that concern. The vast majority of nursing posts will not be affected. Careers in nurse education and training, and in many places nurse management, will continue as before. For those who do not wish to enter management, there will be careers in the developing clinical nurse specialisms. My noble friend Lady Cox questioned the wisdom of nurses being appointed as directors to their health authorities' management groups in such diverse fields as personnel, quality assurance and consumerism. Clearly it has been important for health authorities to be sure that such nurses have adequate back-up support to discharge those functions in addition to the all-important provision of professional nursing advice. Such arrangements must be kept under review, but my own view is that these roles can provide an ideal training ground for the next generation of nurse general managers.

My noble friends Lady Cox and Lady Lane-Fox referred to nurses' pay. Here I must say that the Government are proud of their record on nurses' pay which has risen, on average, by 111 per cent. since 1979, more than 30 per cent. over and above inflation. During the same period the working week of the nurse was cut as well. For next year we await the recommendations of the independent pay review body. Within the constraints of the interests of the health service and the economy as a whole, I can assure noble Lords that there will be a positive response.

The noble Lord, Lord Ennals, and others stressed the importance of a nursing input into decision making. I agree that this is of crucial importance, and every step has been taken to ensure that it takes place at every level. Every health authority has a member who represents nursing interests, so decisions made at that level will have a nursing input. Every health authority has been required to appoint a single nursing adviser who will not only supplement the advice of the nursing member but will also be charged with providing the authority's general manager with advice for decisions that he will be making. There has been no prescription from the centre about arrangements at unit level, but health authorities have been told that provision must be made for adequate nursing advice.

In a recent letter to all regional health authority chairmen my right honourable friend the Minister for Health reminded them that, proper arrangements for the provision of professional advice to authorities and managers are of considerable importance. He went to to say that it was, necessary to take full account of the need for effective professional involvement in management. I am quoting this to emphasis that we are not washing our hands of arrangements at local level but making absolutely clear to health authority chairmen the vital importance of the proper involvement of nurses and doctors in management.

Furthermore, Health Ministers hold annual review meetings with regional health authority chairmen at which the chairmen are held to account for their performance over the previous year. I can assure noble Lords that the satisfactory implementation of general management throughout the health service certainly does feature when appropriate on the agendas of those meetings.

Only a very small minority of districts have not proposed to have their nursing adviser on their management board, or equivalent officer body. Where this is the case regional chairmen have been asked to ensure that the arrangements command the confidence and commitment of the profession locally. My noble friend Lady Cox and the noble Baroness, Lady Robson, referred to cases where arrangements have been made for professional advice to be given by a director of nursing services or a director of nurse education. We have made it clear that in such cases the giving of such advice is a substantive role which is district wide, needs proper support, and in respect of which the nurse has direct access, when required, to the health authority itself.

Some local examples where problems had occurred were cited by my noble friend Lady Cox. Such cases are best pursued and resolved locally. Clearly, however, where the process of local discussion and consultation fails of course I would be prepared to look at particular cases. As I have said, there will be local difficulties here and there but these are being raised by the RCN locally, and I am not being made aware that problems are not being discussed through and resolved. I cannot accept that further guidance is needed.

My noble friend Lady Cox concluded her speech with four specific questions. I have covered a number of these points, but let me now address them one by one. The question of nursing management is covered in, we expect, the structure of general management and nurse management in each unit to take account of the need for proper supervision of the work in wards and departments. This is a matter which really must best be left for local decision, taking account of the views of local professional interests.

To turn to radical reorganisation, the Griffiths Report and the circular to which my noble friend Lady Cox referred undoubtedly heralded a completely new approach to management throughout the health service. The change from consensus management to general management with responsibility for decisions being vested in one person had to mean big changes in management. What the Griffiths Report said was that unless this led to real changes at unit level—meaning improved services to patients—the changes would have been to no avail. It was inevitable and necessary that management change penetrated through, indeed even especially, to unit level.

With regard to the question of retirement and pension, I should like to inform my noble friend Lady Cox that the RCN is in correspondence with my right honourable friend the Minister for Health on these very issues. I think I have already answered the fourth question that she asked. If I did not, I shall write to my noble friend.

The noble Lord, Lord Wallace, spoke about Bexley and Sidcup. He referred to the financial difficulties in the Bexley health authority area. This is of course primarily a matter for the South East Thames Regional Health Authority. I appreciate the noble Lord's concern, however, and I am aware that the regional health authority is discussing these matters with the new general manager of the Bexley district with a view to finding a solution to their difficulties.

The noble Lord, Lord Ennals, of course spoke at the end of the debate, and he charged me to tell my right honourable friend the Secretary of State "pdq". My right honourable friend will of course read this debate and Lord Ennals' golden words. I do not think that the noble Lord, Lord Ennals, is in any position to level criticism. The Government's record of expenditure on the National Health Service, to which my noble friend Lord Auckland kindly referred, speaks for itself.

What we have also had the courage to do is grasp the all-important nettle of management in the National Health Service, and dismantle the weaknesses of consensus management, which have so often in the past fostered indecision and delay, and replaced it with a management style which pins responsibility for decisions and actions on individuals, the prime aim of which is to see direct improvement in patient care, and the noble Lord will surely agree with that. As the noble Lord said, I am giving him that message "pdq".

I am glad that my noble friend Lady Lane-Fox drew our attention to the role of community nurses. I pay tribute to their invaluable contribution to health care. In closing, I should like to join with those who have spoken this evening in paying tribute to the excellent and invaluable work carried out by all nurses throughout the National Health Service. They are held in the highest regard by this House and by the public at large, and deservedly so.

Looking ahead, as we progress further down the all-important road of care in the community, I am sure that we all recognise the new challenges that this will increasingly present to our nurses, particularly in the fields of care for the elderly, mentally handicapped, and mentally ill people.

To end on a note of harmony, the Government and the RCN are in broad agreement on two key points: the needs of patients must come first, and more involvement of nursing in management is essential. I trust that I have been able to reasssure this House today of the Government's wholehearted commitment to those important principles.