NHS Nursing Staff

HL Deb 11 May 1988 vol 496 cc1129-57

3.2 p.m.

Lord Molloy rose to call attention to the conditions of employment of nursing staff in the National Health Service; and to move for Papers.

The noble Lord said: My Lords, on behalf of the noble Baroness, Lady Cox, perhaps I may immediately express how deeply she regrets that she cannot participate in this debate as she would have liked. We all know the valuable and knowledgeable contribution which she could have made. She is not here because she is attending a nurses' event elsewhere.

Perhaps I may also explain that events have moved rather quickly since I tabled my Motion. It has been on the Order Paper for some time and the Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine has now submitted its report. There can be little doubt that we all agree—those of us who have had time to read it—that it is a momentous review and has been received with a great deal of happiness among all the professions involved in medical science.

Therefore, I believe that it behoves us to take a glance at some of the primary points in this review. When one examines it one realises the unhappiness in the past four years in the nursing profession at the rundown of the National Health Service, or at least what people thought was a rundown. The profession believed that we were in the worst possible situation, spending more on a service that was becoming worse. Therefore, this review is very welcome.

Perhaps it behoves us to take a cursory glance at the history of the nursing profession in this country. The nurse demand was first created over 100 years ago. Now, as then, the family provided its own nursing service. When a child is ill with the measles or whatever, it is the mother or elder child who is the nurse. Therefore, the family provided its own nursing service. It is fundamental for us to acknowledge that all forms of illness create a dependency. The sick need not only medical treatment but personal service. We have steadily moved to that in this country. Indeed, by the middle of the 19th century a group of women was developed with skill and knowledge in the care of the sick. They had been carefully selected and trained. In short, the nurse had emerged. Before that the situation was totally haphazard.

Now, as then, demand for the nurses' services increased with demand for medical services. It would be quite impossible in this House not to mention the magnificent role in furthering the cause of nurses of Miss Florence Nightingale, OM. She made bitter attacks on the quality of recruitment of nurses. She pointed out that those people recruited as nurses were poverty stricken themselves. It was the work of Florence Nightingale that had such a marked effect. Her description of some hospital wards was significant. The nurses' quarters in the wards were nothing more than wooden cages where they lived and cooked their own food. There is not much doubt that Miss Nightingale was the most influential reformer of her time. Certain ladies in the Department of Health and Social Security like Mrs. Currie might do well to take note now and then and to read a little about Miss Florence Nightingale, OM.

The range of doctor specialisations also has a valuable role, and they recognise the valuable role of the nurse and the health visitors. They include general practitioners, doctors practising in community medicine and community health—that is, family planning and child health clinics—those who are community physicians with health authorities, clinical medical staff, those contracted with universities to teach students, doctors working in our armed forces, in our Civil Service and in our occupational health services and those working for companies. In all those instances every doctor acknowledges that the nurse is invaluable.

The creation of the National Health Service enhanced the life of our nation and also enhanced the medical profession. The growth of professional and medical trade unions like the Whitley Council have also made a remarkable contribution. We now have this vital body, the Nursing and Midwifery Staffs Negotiating Council. There is very little said about it, but throughout the past 20 years it has been negotiating all sorts of conditions and pay. By and large it has gone unsung. The only time it is brought to anyone's notice is when there is a collision, and everyone regrets that.

Perhaps I may say that the evidence submitted by the staff of the council to this pay review body could bring about profound changes in the structure of nursing and midwifery. For the nursing profession it is the most striking contribution since the days of Miss Nightingale herself. The Confederation of Health Service Employees, which covers all grades of nurses and auxiliaries, considers that this report will constitute a most profound change in the nursing sevice. However, it is concerned about neighbourhood schemes and the emergence of nursing practitioners. It also feels that education has to be improved. It takes pride in the fact that we have maintained a free health service.

Likewise, the confederation says that there are masses of details which it has given in evidence and that is true, as anyone will see if he reads the report. This contribution by CoHSE is a work of factual statistics allied to prevailing conditions. Indeed, it is a valuable assessment of considerable scholarship, and I believe that CoHSE is to be congratulated. There has been research from the broad membership of nurses on pay conditions, the relevance of market forces, the role of comparability—equal pay for equal value—and relativities with other groups of the NHS staff. It is quite a remarkable contribution.

The Royal College of Nursing has done a superb job in submitting evidence. It says: The Royal College of Nursing believes that there is a growing problem of recruiting and retaining nursing staff within the NHS. Whilst we welcome the recent pay settlement"— and so does CoHSE— and agree that this will help to resolve some of the staff shortages which have been highlighted, particularly in specialist areas, many problems still remain regarding the working conditions of nurses, and it is now urgent that action should be taken to alleviate the situation". No Carlton Club proposals are acceptable to the Royal College of Nursing or the Confederation of Health Service Employees.

What is equally and vitally important is that the great and humane role played by our health visitors should be recognised and due acceptance and acknowledgement given to the remarkable contribution which they make. They wish the health service still to be funded from taxation. Like the Royal College of Nursing and CoHSE, the Health Visitors' Association believes that the health service must be free at the point of delivery. The association also supports the Royal College and CoHSE in that there should be decent rewards reflecting justice for health visitors as well as for other forms of nursing. There is one disappointment that each association feels ought to be mentioned. There has been no increase in London weighting for nurses. I ask the Minister to say whether the Government are prepared to look again at that point.

I wish to pass very briefly to some very important statements of the review board. It states, for example, that it appreciates that it may take some time to bring about the changes which it has recommended because the data for which it has asked, particularly at a time when new data have been introduced in the National Health Service, remain unsatisfactory. I hope the Minister will note that point. It is a superb report by the review body but it believes that the submission of the data that it required was unsatisfactory.

The review body continues by saying that there are important issues in themselves but that consideration of them has taken place during a wide-ranging public debate on the future of the National Health Service. This was prompted in part by growing concern about the problems of recruitment and the retention of key staff. The review body states: As Chapter 8 indicates, our recommendations will result in a substantial increase in the paybill. This flows largely from the exceptional circumstances associated with the introduction of the new clinical grading structure, which will affect the vast majority of the nurses, midwives and health visitors covered in our review".

There is one other aspect that I feel I should bring to your Lordships' attention. It worries the review board, it is worrying everyone in medicine and I feel sure that Ministers are equally concerned. This relates to midwifery and nursing posts in special care baby units. Those units are having some harassing moments because among the highest vacancy rates are posts for specialist nurses who can deal with special care baby units. Other specialities with average vacancy rates include mental illness nursing and nursing of the mentally handicapped. There we have it; and it is worth repeating. Special care baby units, mental illness nursing and mentally handicapped nursing are all suffering from a shortage of staff. Something should be done about that, and I hope that the Government are prepared to say that something will be done.

The staff side provided a reasonable breakdown, compiled from newspapers, of wards closed and beds lost as a result of the shortage of nursing staff in the period 31st August to October 1987. The survey indicated that there are shortages in all regions and that they are not confined to London and the South-East. The staff side also referred to the independent surveys carried out by the Royal College of Nursing, the Royal College of Midwives and the Health Visitors' Association. They found evidence of substantial shortages across the country. The Health Visitors' Association discovered that out of 105 districts where health visitors are urgently required, nearly 50 to 60 per cent. were short of health visitors' visits. Therefore, the Health Visitors' Association needs more help.

The review states: We are concerned that the Health Departments have been able to provide little detailed and up to date statistical evidence to support their statement that there is no general recruitment and retention problem for nurses". All the professional organisations, every doctor, every specialist, every group of nurses say that there is a serious shortage. The only body which does not agree is the DHSS. I find this to be quite remarkable. It is a massive challenge for the DHSS to tell the Royal College of Nursing, the Confederation of Health Service Employees, the doctors, the British Medical Association and the Health Visitors' Association, "You are all wrong and we are right". My point has to be made forcibly. I wished to put it mildly but I feel very deeply about it.

The review states: The Health Departments said that there were no problems in the recruitment and retention of unqualified staff, and that those nursing auxiliaries and assistants who would be placed in grade A should receive no more than a relatively modest cost of living increase". The review body states that it is folly—and I agree—for the department to make such a disgraceful statement. I hope that the Government will note that folly is often more cruel in consequence than malice can be in the intent. It would be awful for us to throw out the recommendations of this remarkable review.

There are many other matters which I can raise but I hope I have said enough. This review board has worked magnificently and it has provided a superb report. I hope that it will be the basis upon which the Government will see that the DHSS advances. It is on this basis that it must advance or it must reject what the board has said.

Britain's medical profession, together with the great advocacy of Aneurin Bevan, created the health service. If I may say so, they were well aided by his then PPS who is now in this House, my noble friend Lord Bruce of Donington. He played a great role. At the time I was engaged on staff side work and I know what a magnificent part my noble friend played in assisting Aneurin Bevan in the creation of the National Health Service. We all know that they had to fight tooth and nail. The NHS Bill was fought clause by clause, line by line, amendment after amendment. At all phases of the parliamentary procedure it was opposed. When it was triumphant it became the envy of the world.

The point I wish your Lordships to note is that we created our NHS only a few years after the greatest war in history. For this nation of ours that in itself was a tremendous, civilised achievement. Britain's entire medical profession is a monument to civilised devotion and duty. It is an example of our capacity for practical and emotional concern for individual life, and that is the most significant quality of a civilised human being.

Perhaps I may be permitted to conclude with these words on behalf of all grades of Britain's nurses, male and female. Our nurses serve medicine and our people in the most sensitive area of human emotion—in the care of the sick and the suffering. They have a noble record and they deserve the support of this House. I hope that my short debate will give us an opportunity to pay a massive compliment to this noble profession for the assistance it gives to medicine and for the comfort it provides for the benefit and good of our nation.

My Lords, I beg to move for Papers.

3.20 p.m.

Lord Trafford

My Lords, I am sure that we are all grateful to the noble Lord, Lord Molloy, for the opportunity of discussing this important subject. It is customary to declare one's interest when making a speech in this House, and mine in this respect is quite simple. I love nurses. I have worked with them for more than 30 years, and my admiration and respect has if anything increased. In fact, I even married one, and I can recommend that to those who are considering such a step.

My view of nurses is not just a starry-eyed one of angels floating about, for it must be remembered—and it is an important point to bear in mind—that out of uniform a nurse is the product of her generation. Those now entering nursing aged between about 18 and 20, just like other 18 year-olds today, are doing many other things as well. I make this point because it does not help nurses if, apart from a proper respect for their professional activities, one tries to make them something special, which of course they are not, in all respects.

For example, a nurse like any other girl will look closely to her pay, her accommodation, her terms and conditions of service, the work interest with which she is presented, the type of discipline she has to undergo and the sensitivity with which she is managed and treated. Those are the factors she will consider in evaluating her job satisfaction and her happiness, or otherwise, with her lifestyle.

There has been a significant change over the past 20 years which particularly affects young girls. Perhaps I should point out that, although we often refer to nurses as being young girls, many nurses are male. I have to be careful because yesterday in this Chamber we were picked up about three times for referring to headmasters and not to headmistresses. Today one should make the point that a large minority of nurses are male, and very good nurses they are too.

There has been a change over the past 20 years. Many more opportunities are now presented to young school-leavers, especially young females, than was the case some years ago. It is comparisons of the kind I have just made that will dictate to a large extent who is recruited to what is an arduous profession requiring considerable discipline and commitment.

I shall not say much about pay because it has been very much in the public eye recently. The noble Lord, Lord Molloy, mentioned the report and asked one or two questions. I shall add one, if only to clarify a point. I refer to whether or not the conditions of the pay increase apply to community and district nurses as well as to other nurses. My understanding is that they do, but I should like confirmation from my noble friend. There has been a certain amount of apprehension on this point though I am not absolutely clear why that should have arisen.

I should like to turn to recruitment. It is often said that 30,000 nurses a year leave the National Health Service. That is a true statement, but as a bald statement it means nothing. A large number of those nurses are retiring or are leaving the profession for excellent reasons like getting married, having children and all the things that people do. It was no problem and was not raised very much in the previous 10 or 15 years for the very simple reason that on average we were then training between 25,000 and 30,000 nurses a year. We are not training that number of nurses now. Of the 25,000 nurses taken in for training—at least 1,000 were trained but did not register or did not work in the National Health Service—some 7,000 dropped out, which represents more than one-fifth and nearly a quarter of that total. There is a shortfall, and we must therefore look carefully at the question of recruitment.

Surely the shortages which the noble Lord mentioned are related not solely to the general level of recruitment but to specific areas and to specific training facilities within the profession. For example, five or 10 years ago paediatric intensive care, which the noble Lord mentioned, was hardly very extensive in the country. The one unit that trained these nurses provided more than enough. However, a sudden expansion by the medical profession in this field, a sudden burgeoning of the number of paediatric intensive care units around the country, has led to a shortage. It is inevitable.

It could be argued that we should not have expanded in that way and instead should have set up the nurse training establishments, then set up the anaesthetic training establishments, then increased the number of paediatric doctors and at last opened the units. Unfortunately, as most noble Lords will know from experience in their own fields, things do not happen in that way. One could say "Thank God they don't", because the result would have been half as good as it actually has been. So despite some of the high decibel complaints, if I may so describe them, that were launched by the noble Lord, some of the complications have been due to the very success of the National Health Service rather than to its failures.

I now turn to two other points relative to recruitment. The first concerns recall schemes. It is estimated that there are about 750,000 trained nurses in this country. Some 300,000 or 400,000 are occupied in the National Health Service and a few thousand are in other fields. It is believed—and I do not think that one can go further than say it is believed—that of the remainder it is possible that 200,000 may be available for return to the profession of nursing.

How do we get them back? In some districts, but in far too few, systems of recall by direct questionnaire and direct approach and short courses and short reintroductions are being operated to attract them back. In such circumstances it is important to remember the psyche of people who have been out of nursing—and especially high-tech nursing—for 10 years. They are nervous of returning to this function. How nice it is to find that the next six people with whom you are conducting a course are equally nervous because they are equally out of touch. It is reassuring from their point of view, and therefore there is a great deal to be said for recall in groups. It appears to have been most successful in returning a number of nurses to the profession.

Another question is completely overlooked. We are short of nurses. Some are going to Australia and to America, and they are doing so for all kinds of reasons. If I were a young girl, which obviously I am not, I should very much like to have the initials SRN after my name. It would take me to New Zealand, Australia, parts of Africa, Asia and America. It is a world-wide passport. They can go anywhere and be given a job for a period of time. What a wonderful way it is to proceed. I am all in favour of that. I understand it and I should not like to stop it.

However, there is a counterflow. In the town of Londonderry, or Derry, or whatever people like to call it nowadays, they have actually cut the intake for nurse training. They have a superfluity of nurses and they cannot even offer full-time jobs to those they do train. My question is: if our nurses are going to Australia, why the devil are their nurses not coming here? They do not seem to want to go to Australia, thank goodness! Secondly, there were 2,000 applicants last year in Derry for 450 places. Where are our recruiters for the remaining 1,550—if my mathematics is correct—that were turned down? Obviously some of the applicants were unsuitable, but assuming that 1,000 were suitable, they would have made quite a considerable difference to the problem had we trained them in this country and offered them proper facilities.

My next point concerns accommodation and facilities. It is perfectly true—as we all know, and repeating it does not help the situation—that something like 70 per cent. to 80 per cent. of all buildings in the National Health Service are pre-1918. Naturally such buildings do not make the most attractive settings for young girls to live in. We must also remember that the changes in the housing market—flat prices and where you live—have made a great deal of difference as to whether nurses want to live in or out of the hospital. Just recently because of rising costs, especially in the South, nurses have once again returned to wanting to live in.

On the management side we must be adaptable and take account of that situation. We must provide nurses with the incentives and the facilities, just as one would, in my view, if one was running any other business and wished to acquire a short supply of labour: one must raise the price. Of course for national reasons we may not be able to raise the price in terms of the actual wage, but we can raise it in many other ways. For example, there is no reason why tennis courts, swimming pools, squash clubs and so on should not be dragooned—the local ones I mean—into offering nurses free access. That should not be too difficult to arrange. There are not many institutions which would refuse to give, if not free, special rates. There are many endowment funds in nearly every hospital which could pay to make access free for nurses. That concession would help considerably.

We must also take a far more businesslike approach—if I may use that expression—in our attitude to property in the National Health Service. However, I do not wish to pre-empt what I believe will be a debate on a subsequent occasion on the management of estates in the National Health Service. Nevertheless, we are desperately conservative in our approach to this matter and far too stick in the mud in its regard. There are plenty of ways of doing this and plenty of ideas in this connection. It is interesting to note—many noble Lords will no doubt have read about this—the approaches among building societies, the nursing profession and the medical profession to obtain the necessary accommodation. It is most important that this should also be done.

However, there are many other factors apart from accommodation. For example, nurses are most concerned with their working conditions—their safety and occupational health. Twenty-five years ago I used to spend a whole afternoon in the Nurses Health Service, as we called it. The fact that it was called the Nurses Health Service was not to downgrade all the ancillaries who work in the health service—that is, the porters, the scientists and the technicians. It just happened to be called the Nurses Health Service. Today there is no such thing in most places, and in some there is an inadequate or partial occupational health service. Nevertheless it is somewhere, something and some way of showing that one is taking a special interest in a vital part of the profession.

If tomorrow we sent all the doctors out of the hospital in which I worked it would still be useful. However, if we sent the nurses out, it may as well have to shut its doors the next morning. That is the difference. Nurses form a critically important part of the service which we expect to receive and take for granted. Therefore every conceivable effort should be made to meet their reasonable requirements as regards facilities, safety, health and accommodation.

I turn to another critical issue as regards nurses: their status and their education. At the present time Project 2000 has been put forward. It is a wide scheme which I understand from the DHSS is now under consideration. Therefore I shall not ask my noble friend to make too many comments on it because I am sure that when the time comes he will do so. It is like the curate's egg—good in parts. However, I am worried about the slight disregard, the almost looking down the nose attitude, it has towards enrolled nurses who are a most important part of the nursing profession. Nurses have many anxieties about this. There are many ways in which one can raise status. I hope that we have taken the lead in Sussex by drawing together the regional health authority of the South-East, the University of Sussex and the Brighton Polytechnic to form on a tripartite basis at the university an institute of nurses. By itself of course the project achieves nothing. However, what it can do with a little imagination and some effort is to galvanise people into research into nursing.

There has been remarkably little research into nursing—on the effect of what nurses actually do, on the services they should be providing or on the way in which they should be deployed. All other matters are ancillary to that. The project could also raise the status and level of nurses in terms of the way in which they are trained, the methods of education and the breadth of such education. In other words, it moves some way along the lines of part of Project 2000, which I fully support. However, I am dubious about one matter—because I favour the apprentice system in training—and that is the reduction from about 75 per cent. to something under 50 per cent. of the time that would be spent on training in the wards.

Finally, I turn to management. We must manage, as we do in all other spheres, but in this one especially, with sensitivity. I am afraid to say that all too often at local and sometimes national level the degree of sensitivity is deplorable. The way that the nurses are often treated by patients—and doctors, I regret to say—the abuse and the injuries they sustain, especially in accident centres, is quite unacceptable. There would be no harm in running what I would call a courtesy drive throughout our hospitals and our general practices where nurses work to improve the way in which we treat such an important group of people. That drive should start with the medical profession.

There is now a good chance on the basis of the new report, with the increased pay awards (which, as I said, I have not gone into), with the possibilities as regards education and with improved sensitivity in management, that we can build on this concept and continue to have a committed, admired, respected and loved profession which will look after us when we most need it.

3.40 p.m.

Baroness Robson of Kiddington

My Lords, I should also like to thank the noble Lord, Lord Molloy, for raising the debate. I think that all of us from all sides of the House welcome the Government's acceptance of the review body's recommendations, especially the agreement fully to fund the increase in nurses pay. I believe that if that had not happened the NHS would have collapsed. Therefore we are most grateful to the Government for agreeing to those increases.

Nevertheless we should ask ourselves why the nurses demonstrated to such an extent prior to the publication of the review body's recommendations. I do not think that their grievances were solely about pay. Of course they are concerned about their income. They are perfectly normal human beings who want a reasonable standard of living. But I believe that they were equally concerned about their working conditions. However, above all, they were concerned because they care deeply about the National Health Service and they could see so many shortfalls within it. They felt that unless they took a stand now it would be too late.

Reference was made by the noble Lord, Lord Trafford, to the fact that 30,000 nurses leave the NHS each year and that 6,000 out of 27,000 recruits fail to complete their training. We must also ask, as has been said, why 200,000 or 300,000 qualified nurses do not work while there is a 20 per cent. shortfall in staff in inner London. We must consider those figures. Irrespective of the obvious reasons for which nurses leave, which have been referred to, such as getting married or moving out of the profession for various personal reasons, there are other reasons. We must look at that matter against the background of what is happening to the population of this country.

By 1992 there will be many fewer school leavers. It is estimated that, in order to recruit enough nurses, the NHS would have to recruit 45 per cent. of all qualified young people to staff the NHS. That means young people with five O-levels and two A-levels. It is inconceivable that we shall be able to do that. We must do everything possible to keep nurses in the service and to encourage others to return.

We should consider student nurses. There is a problem. Why do 6,000 students fail to complete their training? It is largely because they are overburdened with responsibilities before they are ready to accept them. After only eight or nine weeks of initial instruction they are asked to accept responsibility on the wards. That is all right so long as there is plenty of supervising, qualified staff on the wards. Due to the shortage of qualified staff in the big conurbations it frequently happens that a student nurse is left in charge of a ward for an hour or two. None of us with only eight or nine weeks' initial training would enjoy that responsibility. It puts an unnecessary strain on young students.

We then have to think about the way in which we look after young student nurses. People who go in for nursing are inevitably caring people. They tend to become involved with their patients, especially on long-stay wards. Someone will inevitably die on the ward. For the first time the young nurse comes up against death. She feels disturbed by it. At the moment, at the end of her shift she gets on the bus and goes back to wherever she lives. There is no proper counselling service for that young student nurse. If one is working in a stressful profession such as nursing, that is what is needed when one is young, and it must be improved if we are to keep our nursing students. That does not apply only to student nurses. Even adult nurses who acquire an affection for a patient might need counselling when something like that happens.

I agree with the noble Lord, Lord Trafford, that the only way we can solve the problem of nurses having to take on responsibility after only eight or nine weeks' training is to introduce Project 2000 as soon as possible. We know that 30,000 qualified nurses leave the NHS each year. Apart from the natural causes for leaving, in many cases they leave due to the poor conditions in health service premises, as the noble Lord, Lord Trafford, said. It is estimated that about £2 billion is needed to bring all our hospitals up to a top-class standard. Another problem is that most of the medical equipment that nurses have to use is outdated and over-age. Both those factors militate against the feeling that one can give of one's best.

Nurses lack backup such as ward clerks. Nurses and sisters spend too much of their time filling in forms and doing the paperwork. The increased throughput of patients, without an adequate increase in staff, also creates problems. Some people think that the NHS takes an enormous slice of the GNP. Lately enormous efforts have been made to make it more efficient and cost-effective. One of the ways of doing that is by competitive tendering which in 1986, I am told, saved the NHS about £86 million. We all think that that is good because that £86 million will go on patient services, but we must also look at the standards and whether they are being maintained in the hospitals.

If the domestic services are not being fulfilled, there is only one person to do the job—the nurse; but it is not her job. She should not have to do jobs such as washing, cleaning and apologising for meals that are late and because clean sheets have not arrived on the ward. Those are all additional tasks with which the nurses have to cope under present conditions.

When outside contractors are being employed in the hospitals it is necessary that the nurses on the wards are intimately involved in setting the standards for the contractors to fulfil. The nurses are the only people who know how the domestic side fits into the ward-caring side so that they do not interfere with each other. The nurses are the only ones who know the standards that are required in the wards.

Nurses come up againsts all kinds of problems. For instance, if a nurse goes on maternity leave a locum is not employed. The other nurses have to absorb all the extra work. There is a lack of childcare facilities. The working hours are inflexible and do not take account of nurses' domestic responsibilities. There is hardly any job-sharing in hospitals. In many other walks of life job-sharing, especially for married women, has become the thing. There is no reason why job-sharing should not be used in the health service.

The noble Lord, Lord Trafford, referred to the problems of residential accommodation. That is something with which I have been intimately involved since I have been a governor of UCH. We had two large nurses' homes in the centre of London. They began to empty because their homes were single rooms along a corridor without a carpet and with the bathroom and loo at the end of the corridor. It was not an ideal place to live. Even sisters had no better accommodation if they wanted to live in. As a result, as has been said, nurses moved out into flats. They joined together and rented a flat. Even in those days I suggested that we should turn the nurses' home into a block of flats where two or three nurses would share a unit and run it themselves exactly as if they rented a flat further away.

Lord Molloy

My Lords, perhaps the noble Baroness will allow me to intervene. This idea has been accepted by nurses. What put an end to it was that some DHSS or regional management evicted nurses to do just that—to build flats and then let them privately.

Baroness Robson of Kiddington

My Lords, that does not make it right. I am sorry, I want the nurses to have those flats, so we have no argument about that. It would have the additional benefit of the nurses living within walking distance of their place of work.

If I were a young, newly qualified nurse I may want to live in a flat, perhaps sharing it with a couple of friends. What I find frightening is that in order to be able to afford to live somewhere in London I should have to move such a long way out. That is all right, but we must also remember that nurses work very unsocial hours; sometimes they do not leave the hospital until 11 or 12 at night. They have to come in very early in the morning. I wonder whether noble Lords would like their daughters to travel home on the Underground with the chance of being mugged and robbed. Hospitals are not doing enough to arrange transport for the nurses whom they employ. Therefore instead of selling off the nurses' homes for profit I believe that it would be best to turn them into blocks of flats for the nurses to rent. We should then keep many more nurses in the centre of cities.

The nursing profession has become a high powered, very skilled profession. We cannot survive without it. However, despite their increased skills, nurses are still the main caring group in the NHS. Noble Lords may talk to any patients who have been in hospital and ask them what they thought about their surgeon and what was his name. The surgeon can be fantastically brilliant and of course, patients are grateful. But what they remember when they leave hospital is the nurses who looked after them. They are the most important caring group within the NHS. Without creating the conditions within which the nursing profession can find satisfaction in its work, there is no future for the NHS.

3.52 p.m.

Lord Hunter of Newington

My Lords, perhaps I may also add my thanks to the noble Lord, Lord Molloy, for giving us the opportunity to debate this important topic. I have a vivid memory of the nursing situation 50 years ago when I was a house physician. For the visit of the consultant in charge, the patients were all in bed with the bedclothes neatly folded and the wards were inspected by sister before the consultant's arrival.

Now things have changed but, most important, the doctors and nurses have realised what a powerful and dangerous weapon bed rest is. It has to be used in small doses, the stay in bed has become minimal. All governments have made full use of the statistical results: turnover has increased, output is greater, and so on. We have listened to this many times in the House.

One of the consequences is the additional pressure, particularly on beds, and the strain on nursing staff. As has been said, instead of having the job satisfaction of seeing another human being recover, nurses have to turn their attention to the next problem. Moreover, the tempo of change is increasing. There is a need for continuing education and additional training if jobs are to be done properly. The Select Committee of the House of Lords, looking at medical research, learned something about this and research in nursing.

What are the consequences of the quick throughput? The patients spend half their time recovering at home and often require specialised nursing attention, particularly in paediatrics. Are such nurses with the specialised training available in the community? The paediatrician's view of this and the Cumberlege Report differ in this regard. Specialised services in the community need to be provided if patients are to leave hospital sooner. As we have found with the return of the mentally handicapped to the community, there may not be a dramatic reduction in costs. In other words, returning patients to the community from the hospital may incur substantial additional costs, particularly in staffing.

We may also find that the family practitioner organisation has to be changed to meet patients' needs, as it will have to be altered to meet the public health need. Perhaps we should be thinking of the development of secondary care centres, apart from hospitals, where this kind of thing could happen at a reasonable cost, if it is not available in small general practices.

Noble Lords will remember the 1970s and the Briggs Report on nursing, the disappearance of the medical officer of health, the reorganisation of local government and, most important, the introduction of consensus management, which has now been abandoned. How did the nurses fare in all this turmoil? The Briggs Report was mainly concerned with training and was very soundly based. But what were the consequences for nurses in hospitals and their job opportunities? In contrast to the situation in the past, the ward sister was no longer in charge of the ward in all its aspects; she was no longer the manager. There was considerable attraction in the new proposals and in being promoted out of the wards to higher echelons of administration.

To people sitting on committees looking at the health service, this may have seemed very reasonable. But what have been the consequences? In the earlier days to which I referred the sister was the most important person, consulted by staff, patients and relatives alike. Somehow that is no longer so. The discipline and co-ordinated running have somehow become flawed. Many nurses have left the service to take jobs in private medicine and to go elsewhere. One hoped that with the introduction of managers into the health service the sister would once again be recreated and become the manager of the ward. But that does not seem to have happened.

What of the future and the training programme? I feel that the most urgent matter in the whole of this debate is to try to ensure that the ward sister's job becomes more attractive. It should be the ambition of many nurses to become a ward sister, and that would be the job which the nurse looks forward to carrying out for many years. The patients need it and I think that the patients largely want it.

As the noble Baroness, Lady Robson, has said, we must consider carefully the more stressful jobs: theatre staff attending major operations for many hours; premature baby intensive care units; the abortion services. Young people cannot stay in these stressful jobs for long. Perhaps they have been specially trained for them, but should they be given training in community nursing so that they can take their essential skill into the community but keep the larger salary? If so, they would provide an important link between the hospital and the community. That is only one suggestion in this debate.

3.59 p.m.

Lord Auckland

My Lords, I should like to join in the thanks accorded to the noble Lord, Lord Molloy, for initiating this debate. Although we have had in past months a number of debates on the National Health Service in both this House and in another place, the National Health Service is a matter with which Parliament must always involve itself even though, as the noble Lord admitted, this debate has been somewhat pre-empted by the publishing of the findings of the pay review body.

No doubt in due course your Lordships will be able to have a debate on that matter. At the moment the whole matter is under study because there are bound to be regional problems here, as there are obviously certain areas which the noble Baroness, Lady Robson of Kiddington, particularly mentioned where accommodation is very expensive if it is obtainable at all.

The pay review body will, on the figures which I have tried to digest, award an increase of approximately 44 per cent. in nurses' pay, and that is to be welcomed. But I should like to devote a moment or two to the question of accommodation because I believe that this is vital. Many noble Lords will have families working either in a therapeutic capacity in the National Health Service or in some branch of health care.

As I have mentioned to your Lordships before, our younger daughter who is now married with three small children, has returned to nursing. When she eventually obtained a place in a creche through the Lambeth Health Authority the prices for the creche shot up. When this kind of thing happens any increase in pay is immediately negatived to a certain extent by the increase in the cost of creche facilities. I am not necessarily saying that the price for creche facilities can never be increased. Devoted people have to look after the small children and they have to be paid. But it is nevertheless a rather frustrating disincentive for a nursing sister, or staff nurse in my daughter's case, to find that almost immediately that she obtains a place in the creche the price goes up.

I hope that my noble friend the Minister will bear that in mind because I believe that that is a positive disincentive to older women returning to nursing. It is very often the older women, and indeed men, particularly in long-stay nursing, who are so badly needed.

We can all quote from personal experience about the accommodation facilities of the nurses' homes attached to some of our hospitals. I have been round a certain number of nurses' homes. My younger daughter trained in a very well-known and much respected teaching hospital in the East End of London. I must say that when she was a student nurse about 12 years ago Charles Dickens would have condemned the accommodation that she was living in.

Nevertheless, there was a great esprit de corps. As has been said, nurses do not stay in the nurses' homes. They want to get accommodation outside the nurses' home. They want to entertain their families and friends and that is much easier if they can obtain a flat or some other such accommodation. There is much to be said for the comments of the noble Baroness, Lady Robson, with her experience in the health service, as regards the fact that these nurses' homes could in some cases be turned into flatlets. I hope that this is something which the DHSS will look into. There may be administrative problems here but it would help to make these places somewhat more habitable and somewhat more personal. After all, not all nurses working in St. Bartholomew's Hospital may live in Essex or Surrey. Some may come from Northern Ireland and some may come from Northern Australia. As my noble friend Lord Trafford said, there is an almost ongoing exchange in nursing.

When I was a patient two years ago in my local district hospital in Surrey, one of the team of nurses was an Australian girl and two or three came from the Middle East. The only difference possibly is that our own nurses go to Australia and New Zealand and very often stay there, whereas the Australian and New Zealand nurses who nurse here may go back to their own countries. From my own experience gained on a visit to Australia at the end of 1986, when I went round a new general hospital in Canberra, I know that about one in every five members of staff came from this country. They had been out there in some cases for several years. It is true to say that the pay rates and certainly the accommodation in Australia, which is a much less populated country than our own and where there is probably much more land on which to build nurses' homes and flats and hostels, act as a positive incentive to nurses to stay there.

One of the greatest tragedies, if I may put it that way, of the National Health Service was the ending of the hospital management committees and the house committees. I served for a number of years on a house committee of one of the long-stay mental hospitals in Surrey. At that time there was communication between the nurse, the nursing sister, the physician and the management of the hospital. I am very sceptical of the present situation. The whole thing has become too big but not very beautiful and there is a remoteness about it.

I believe that the status of the nursing sister is vital, as the noble Lord, Lord Hunter of Newington, stressed in his admirable speech. The sister or in former times the matron was an all-important figure. But there is the disturbing situation too of the young student nurse who is left in charge of a ward. This happened to my own younger daughter in a teaching hospital in London. She was left in charge of a ward for about an hour and an old gentleman died of a heart attack. She was very upset. The sister eventually returned and took charge. She said to my daughter, "Look, my dear, that is what it is all about. It is a great tragedy but that is what you are nursing for. Get on with it". And my daughter did. Obviously, hard as it may seem, that is the right approach.

However, student nurses are for all practical conditions not really students. An art student, a language student or any other kind of student would not have to take on those responsibilities. All right, the latter kinds of student are not paid and they pay to learn, whereas student nurses are paid. I also believe that the recommendations of the new review body will result in student nurses being paid reasonably well. But it is asking an awful lot of a girl of 18 or 19—this is particularly true in the long-stay hospitals where there are more serious staffing shortages than in the general hospitals—to take on that responsibility.

Finally, I should like to say a few words about the weighting system. The London weighting system leaves an awful lot to be desired. My noble friend the Minister will correct me if I am wrong, but I believe that the average payment in London is about £968 per year. In Epsom, which is 19 miles away and where the accommodation is possibly even more expensive than in some parts of London, the figure in what I believe is the Mid-Surrey Regional Health Authority is roughly £392. The figure for Leatherhead is barely £200. We all welcome the pay review body. However, unless something is done about accommodation for nurses of all grades—staff nurses, nurses, and nursing assistants—any plan to enhance recruitment will suffer. We have reached desperation point in some areas as regards accommodation.

This has been a very useful debate. Obviously the matters I have mentioned, will be studied by the pay review body and they will be matters for future debates. However, I believe that our debate today has enabled the House to study them. Even in an ideal situation, those problems will never go away.

4.10 p.m.

Baroness Masham of Ilton

My Lords, I shall speak only briefly today. Over the weekend, I was out of action and I have not had time to gather my thoughts together. I thank the noble Lord, Lord Molloy, for initiating our debate. It gives us a chance to say, "Thank goodness the Government saw sense at last and gave nurses a reasonable pay award".

Nurses have been leaving the National Health Service at an alarming rate. Pay is not the only aspect of life which is important to nurses. I should like to give one or two other examples of conditions of employment. First, when nurse recruitment and morale is low, patients suffer. Nurses are not all angels and we rarely hear much about what patients sometimes have to put up with. When there is a shortage of nurses, it may happen that some nurses who do not possess ability or authority are put in positions of leadership. When leadership is poor and weak, a ward can be turned into chaos. That is disturbing for patients and for junior staff. Such bad practice as nurses talking across patients about their boyfriends and totally ignoring the existence of patients may go unchecked. Good nurses may move to other wards, and again the patient suffers.

Some decisions which are taken by health authorities may seem difficult to understand. At one central London hospital, there was a good obstetrics department. Against the wishes of the obstetricians and the nurses, the department was moved to a grotty hospital further out where the nurses have to walk down a dark and dingy alley way. Nurses are attractive targets for rapists and molesters. It is that sort of unthinking decision which is likely to create low morale.

Another aspect of the problem is the lack of reasonable accommodation in many places. The encouragement to sell off nursing accommodation is very unwise. That has been one of the major problems in the recruitment of nurses at the world-famous hospital at Stoke Mandeville in Aylesbury, which the Minister visited a short time ago. Nurses come from long distances to work at that hospital, especially in the spinal unit which has an interesting post-graduate course. The available nursing accommodation badly needs upgrading. The alternative—a flat in Aylesbury—is very expensive, as Aylesbury is now a dormitory town for London and has high employment.

Over the years, living standards and expectations of nurses have risen. However, accommodation has deteriorated. Many valuable spinal beds have been closed because of a shortage of nurses, and seriously ill patients with infected pressure sores have been treated in general hospitals which do not always manage to cope with complex conditions which can cause sepsis and anaemia. Such sores can take months to heal. If the correct techniques are not used, the sores may break down after surgery. That situation is far from cost-effective to the National Health Service. It is also very demoralising for patients who may have to spend many extra months in hospital.

Many hospitals have been recruiting diligently, especially those in Ireland. It is important that nurses, once recruited, should obtain job satisfaction and that they should not be overfaced with so many tasks that they leave after a few weeks. When there is a serious shortage of staff on a ward and the list of duties is long, some nurses simply give up and go off sick. At one hospital, a very experienced sister who had worked for many years in the National Health Service left after she was told by an administrator that she could no longer have a kettle to make a cup of coffee. That was the straw that broke the camel's back. Another sister left because the clinic where she worked was so out of date. She went to Canada, not for the extra pay but for better working conditions.

Nothing is more important than our excellent National Health Service. It serves the majority of our population. It tries to keep the hazardous viruses and infections which afflict society under control. No matter how many doctors we have, their work is rendered useless without nurses.

A very important problem which is connected with nurse recruitment is that of the falling birth rate. Our birth rate fell after 1964. In 1976–77, it reached a staggeringly low figure—the lowest since 1940. In the 18 year-old recruitment group, there will be fewer 18 year-olds during the 1990s. There will be a fall of 30 per cent. To illustrate that, I shall give the figures for the 1990s. If for 1985 one takes the number as equalling 100, in 1990 the figure will be 87; in 1991 it will be 81; in 1992 it will be 77; in 1993 it will be 72.5; in 1994 it will be 70; in 1995 it will be 68.5; in 1996 it will be 71.6; in 1997 it will be 77; in 1998 it will be 79; in 1999 it will be 76.3; and in the year 2000 the figure will be 75. The worst years for recruitment of 18 year-olds will be 1994–96.

In 1977 we had the lowest number of births which had been recorded for 50 years. What will make it even more difficult will be an increasing demand. If we are to have an increasing and thriving economy, which we all hope for, there will be more competition for jobs for the small number of 18 year-olds. We must put our house in order so that the National Health Service can recruit and keep entry to the nursing profession open in a very competitive market. With an ageing population and growing demands on the National Health Service, the nursing profession is of paramount importance.

4.20 p.m.

Lord Harvington

My Lords, by courtesy of the remaining three noble Lords who are down to speak in the debate, I should like to take the opportunity offered to address a few words of thanks to the noble Lord, Lord Molloy, for the way in which he opened this debate and for the speech he made.

I was particularly thrilled by what he said about the nurses who went to the Crimea with Florence Nightingale. That is because prior to 1970, when I became Chairman of Ways and Means in the Parliament then elected, I was for eight years chairman of the board of management of the hospital of Saint John and Saint Elizabeth. The nursing sisters there are the direct lineal successors to the community which went out to the Crimea with Florence Nightingale to cope with the tremendous task that was so well set out by the noble Lord opposite. Having myself been associated for so long with this hospital, I felt that your Lordships would not mind if, on behalf of the community at the hospital, I said a few words of heartfelt thanks for the kind way in which the noble Lord spoke of those nurses, considering the community from which they came.

I am also glad to tell your Lordships that the hospital is flourishing and rebuilding. We aim to spend a huge sum of money: how we shall get it we do not quite know, but I expect that we shall get it somehow. I thought that your Lordships would wish to know that the community which provided the nurses who went with Florence Nightingale still exists.

4.21 p.m.

Lord Prys-Davies

My Lords, I have to thank my noble friend Lord Molloy for having chosen such a worthy Motion as the basis for this debate and for giving us this opportunity to discuss the conditions of employment of nursing staff in the NHS. As one would expect, my noble friend has spoken with deep feeling and conviction about the National Health Service.

I should like to begin by bringing together the few facts which have been mentioned in the course of the debate. I think that that is a good starting place. About 300,000 nurses and 100,000 student nurses work in the NHS. About 30,000 nurses leave the NHS each year, although I would accept that that in itself may not be significant. Nevertheless, it is a fact. About 13 per cent. of student nurses discontinue their training, which is a high discontinuance rate. About 200,000 qualified nurses are not working in nursing; according to the NHS, about 85,000 of them are thought to be available to return to nursing.

In a sense these facts tempt one to ask the question: nursing shortage—what nursing shortage? It would be a misleading question, because there is a shortage of nurses within the NHS. We have been given the figures this afternoon. It is estimated that nursing vacancies, at least prior to the last pay award, were about 9 per cent., reaching 20 per cent. here in London. The number of school leavers who are entering the profession is falling and we have been told by the noble Baroness, Lady Masham of Ilton, that they will continue to fall for some years to come.

I think therefore that we are entitled to ask: why should there be this nursing shortage? Is there a relationship between the conditions of work and the number of student nurses failing to complete their training, or the number of nurses leaving the NHS or failing to return to nursing? We suspect that the conditions of work provide a clue to the predicament of the nurse, as it was described by the noble Baroness, Lady Cox, in a major debate on this subject which took place in your Lordhips' House on 23rd March last. At col. 209 the noble Baroness made this forecast: We are building problems for the future which may exceed those of today unless we can encourage and enable those who are willing to consider entering this demanding profession to do so, and if they do so to remain. When the Minister came to reply to the debate on 23rd March he had, in fairness, to keep an eye on the clock and, in commenting on the contribution of the noble Baroness, he concentrated on only one of the conditions of employment; namely, nurses' salary. Of course we all agree that that is a very important condition of employment but, as the noble Baroness, Lady Masham of Ilton, reminded us, it is only one of many conditions.

Since that debate took place the pay award has been announced, and there is really only one question for clarification I should like to ask about that award. If, following the clinical regrading exercise which is part and parcel of the award, the health authorities are left with insufficient funds to meet the additional salary bill as a direct result of regrading, will the Minister confirm that the Government will ensure that new resources will be available to meet those particular additional costs?

The pay award has been well received, but we shall have to wait about 12 months before we shall know whether it has led to a significant reduction in the number of nursing vacancies. However, we think that additional measures are required if a long-term solution is to be found for the country's nursing problems. I would suggest that those measures can be brought under three main headings. First, there is the need for modernisation and flexibility within the nursing profession itself along the radical lines set out in Project 2000, which was produced by the Central Council for Nursing, Midwifery and Health Visiting, and presented to Ministers 15 long months ago.

The health authorities submitted their comments before last September and I wonder whether the Minister is in a position to give us even a rough indication as to when we may expect to receive the Government's response to this major and radical initiative by the central council. Project 2000 has widespread support and indeed it has been referred to approvingly by a number of speakers in the debate this afternoon. We want to see it implemented at an early date and we think that the packaging of reform it contains would encourage managers and others in key positions in the NHS up and down the country to accommodate a more forward-looking approach to patient care, where there is still a need for such accommodation. The integration of nursing education with higher and further education would prevent the nursing profession from drifting into a cul-de-sac.

If and when the Government come to accept Project 2000 we would strongly urge that no attempt should be made to reduce expenditure on key areas of the project such as the student nurse contribution to hospital employee staff power.

Lord Trafford

My Lords, perhaps I may ask the noble Lord, before he moves off the subject of Project 2000—which I agree is most interesting—whether he could explain or enlarge upon one aspect of his demands to the Minister. How would he deal with the 50 per cent. reduction in ward staffing from the service point of view, which I believe is critical to the project?

Lord Prys-Davies

My Lords, when I pleaded with the Government not to attempt a reduction in expenditure in that key area of the project I was speaking with the authority of the nursing professions themselves. If the Government doubt whether that can be achieved in practice in the short term I invite them to address that question to the nursing professions.

I now come to the second heading, which I call the need for organic developments within the nursing profession. While Project 2000 requires a major political decision, nevertheless there are organic developments which the DHSS could and should encourage. I am advised by the Royal College of Nursing that it would be very beneficial if the department were to encourage two developments in particular.

It would be a small but important step forward if nurses working in the community could have the power to prescribe a limited range of drugs and appliances. That development was discussed in another place in the debate on the Health and Medicines Bill on 13th April. In that debate the Government acknowledged that they were sympathetic to the principle of nurse prescribing and announced that the professional and ethical issues involved were being referred to a joint working party.

Can the Minister tell the House when the department will be in a position to name the chairperson and the members of the working party? Can he also tell the House whether the working party will be encouraged to produce its report by a given date? Will it be given a suggested timetable for its work?

It would also be a significant step forward if the department were to go flat out in support of the concept of the nurse practitioner, or the specialist practitioner as she is named in Project 2000. I understand that it was the Americans who discovered that new and expanding role for the nurse. Although a project was set up in Birmingham about six years ago and thereafter a similar project was set up in Greenwich to test her role in a number of defined areas of work, we in this country have yet to adopt the concept.

Again in the course of the debate on 13th April in another place the Minister expressed his general sympathy with the concept. That is encouraging. It would appear from the Minister of State's speech in another place that the obstacle in the way of such a development is one of definition of the term "specialist practitioner" or "nurse practitioner". May I ask the Minister how long it will take before a draft definition will have evolved in the department? When does it envisage going out to the professions with draft wording?

It seems to me as a layman that a very strong case can be made out in support of both developments. I understand that they would be welcomed by many nurses as being worthwhile objectives enabling them to expand their skills and their role. I am told that the evidence from Birmingham and Greenwich and from certain opinion polls indicates that they would also be welcomed by patients, which is an important consideration. Those developments would greatly assist in providing improved health services in the community. The nurse practitioner in particular could provide surveillance of groups of patients in the community who are at risk—in particular the elderly, the mentally ill and children. Both developments would help managers to make better use of health service resources.

I hope that the department will not be held back from fully supporting both developments because it may be thought in some quarters that they will endanger the status of some other professionals within the health service.

I come finally and very briefly to the third area, in which management could make life a lot easier for many nurses. Management and doctors could show greater consideration for nursing staff in a number of small and helpful ways which have been instanced in the course of the debate this afternoon. It should be possible for managers to organise the working day so that shifts are more accommodating to working mothers. That is one suggestion. More could be done in some districts to liaise with local bus companies to work out convenient travelling times for nursing staff. We have heard how the managers could embark upon short schemes of study to attract nurses back to the NHS. So there are a number of small but significant initiatives which could be undertaken by management without involving excessive expenditure.

I want to base my closing remarks on an interesting reflection of the noble Lord, Lord Hunter of Newington, in the debate on 23rd March. He said that when he joined the National Health Service in 1948 there was a general air of optimism in the medical profession and beyond the medical profession. It is my impression that that optimism carried the NHS forward for over a quarter of a century notwithstanding a shortage of resources and a poor physical environment. There was an awareness that there was something very special about the National Health Service. That awareness led to a sense of loyalty to the team and an overriding sense of duty to the patient. For those reasons there was always a determination to get through in spite of difficulties. But if after 43 years the difficulties appear to be never-ending attitudes among the staff could begin to change.

Nurses constitute one half of the staff employed in the NHS. It is therefore important that their morale should remain high and that their loyalty to the team and their sense of duty to the patient should be sustained. Clearly the conditions of service within the NHS can help to foster or to weaken that sense of loyalty and duty. That is why this debate initiated by my noble friend Lord Molloy is important.

4.40 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Skelmersdale)

My Lords, I genuinely congratulate the noble Lord, Lord Molloy, on his fortuitous timing in raising the subject of conditions of employment of nursing staff in the National Health Service today. Perhaps I may poach from my noble friend Lord Trafford and say that we all love nurses. Without them the health service as we know it would collapse. If they did not exist, we should have to invent them. My noble friend with his on the ground experience as a doctor would no doubt recognise that more readily than most.

It could hardly be a more topical subject, for only three weeks ago the Government announced their decision to accept the recommendations contained in the fifth report of the review body on the pay of nursing staff, midwives and health visitors lock, stock and barrel. This means that the Government have undertaken to meet the full additional cost—some £566 million—of this pay award from the reserve. It averages 15.3 per cent. with the vast majority of nurses—well over 90 per cent.—getting basic pay rises of between 6.3 per cent. and 33.6 per cent.

This momentous award, as the noble Lord, Lord Molloy, called it, means that nurses will now receive the highest ever levels of real terms pay. I accept straight away the reproof of the noble Lord, Lord Prys-Davies, that it is only part of ensuring that nurses working in the NHS have the right incentives and conditions of employment to remain in the NHS carrying out the vital work for which they have been trained.

The noble Baroness, Lady Robson of Kiddington, was the first to try to set parameters for the debate. She talked about what we know of the problems in nurse recruitment and training, and why they do not come for training and disappear from training. The Government share the review body's desire to have data that are as comprehensive and up-to-date as possible. That is why a new data system is currently being introduced in the NHS implementing the recommendations of the Körner Report. As the review body acknowledged in its report, it takes time in an organisation the size of the health service to bring about the changes in the presentation that we all want to see. I know that the House does not approve of the British Rail slogan, but I believe that in this case the Government are getting there.

The numbers of female school-leavers with five O-levels and one A-level—the qualifications needed to enter nursing—will fall by 25 per cent. by 1992–93. It was of no comfort to me to be told by one official recently, "Never mind, Minister, we also have the highest number ever of women of childbearing age". This is a serious point, and I agree with what the noble Baroness, Lady Masham of Ilton, said. Taking account of the projected growth in demand for nurses, we need over half this group if current recruitment patterns continue. However, I think that this is an unlikely prospect. The answer must be to do more to tap the large pool of qualified nurses who are not working in the health service and to encourage them to move back to nursing.

There is little wholly reliable information on the vacancy levels in nursing, but we know that these have increased dramatically in the last four to five years. One of the ways of filling the gap is by the use of agency staff or nurse banks. I have said before in the Chamber that this is unsatisfactory, but it is not necessarily expensive. When health authorities are employing nursing agency staff, they must follow departmental guidelines that permit them to pay agencies a maximum of the mean of the appropriate pay scale for the grade plus agency commission and the employer's national insurance contributions. After allowing for directly employed staff's superannuation, annual leave, sick leave and so on there is little difference between the cost of employing agency nurses and directly employed staff. Directly employed staff are of course able to ensure their continuity of patient care, reduction of management and supervision difficulties and provision of clinical training for nurse learners.

Health authorities are encouraged to examine more flexible working arrangements to respond to recruitment and retention problems. The noble Baroness, Lady Robson of Kiddington, mentioned the idea of job sharing, which has been widely mooted in various quarters. That is one approach. Health authorities have been asked to examine a scheme for this and other arrangements that make it easier for trained staff to remain in the health service and to return to work after a break. There remains the problem observed by many patients, especially in hospital, that too many different nurses are caring for them. Nurse management would have to overcome this.

The Government have a basic philosophy on public sector pay, whether in or outside the health service, that salaries should reflect what is needed to recruit and retain staff in an open labour market. To that extent, we agree with the comments of CoHSE and the Royal College of Nursing as reflected by the noble Lord, Lord Molloy. Your Lordships have been seeking to persuade me ever since the election that there are not enough nurses in certain specialities. Noble Lords have not however been quite as happy when in my turn I have told the House that in many cases not as many patients have been treated as might have been, not because of a shortage of money but because of a shortage of nurses. These things do not happen overnight. They take a long time to arise and to cure.

I do not recall that noble Lords opposite made much of the fact that this Government's record on nurses' pay contrasts strongly with the position before 1979. In the five years before 1979, nurses' pay fell by 21 per cent. in real terms. That was a marked deterioration in conditions of employment for nurses. I do not intend to dwell on this, but I contrast it with the Government's proud record on nurses' pay. Since 1979 it has increased by almost 44 per cent. in real terms. Their working week has been reduced from 40 to 37½ hours without loss of pay. This increase would certainly be envied by many other groups in both the private and the public sectors. It recognises the outstanding contribution to the care of patients that has been provided by skilled and dedicated nurses, midwives and health visitors—care for which many people in the country have reason to be grateful. Those qualified nurses and midwives who are working as district nurses, community nurses, psychiatric nurses and health visitors in the community stand to benefit from the awards. I can confirm to my noble friend Lord Trafford that they are not restricted to hospital nurses.

Nurses are in a special position, and rightly so. The vast majority will not take industrial action because they refuse to damage services to patients. They have just reinforced this by a recent vote. The Government recognise this and accordingly themselves established the review body in 1983. Since 1983 five reports have been received. All have been implemented in full. As a result, during this period nurses' pay has risen by nearly 29 per cent. in real terms.

I have said that nurses are in a special position in relation to industrial action. That is so. It is only right to reflect that a very small minority of nurses took part in industrial action earlier this year. I know that there are those who have attempted to claim that fear of further industrial action by the nurses explained the Government's decision to implement and fund in full this year's review body recommendations. That is a nonsense perpetuated by some of their own curious political ends. For their part, the Government are much more influenced by the dedication of the majority than by the willingness of a tiny minority to damage services and harm patients. Those who wish to explain this year's award in terms of industrial relations would do far better to look at the decision in March by members of the Royal College of Nursing to vote by a majority of four to one to retain its no strike policy.

Improvements in pay are important. But this Government realise that satisfactory conditions of employment entail more than just getting the levels of pay right. I should like to use this opportunity to outline some of the wider changes in conditions of employment for nurses with which this Government are very much concerned.

Over the past 40 years many changes have taken place in the work carried out by nurses, midwives and health visitors. Developments in health and medical technology and an increased emphasis on health promotion have all meant that an increasing range of skills are required. Yet the way in which nurses, midwives and health visitors have been graded has hardly changed at all. A major review of nurse grading has been undertaken by the Nursing and Midwifery Staffs Negotiating Council. Management side and staff side representatives have together agreed a new clinical grading structure comprising nine new grades for staff at ward level.

This is a major opportunity to ensure that individual nurses and midwives receive recognition for the duties and responsibilities called for in each post and the rewards to match. It means that there will be far better opportunities to progress and the incentive is for nurses to remain in clinical practice rather than having to move into management to make progress—a problem which was undoubtedly rearing its ugly head in some hospitals. To digest Project 2000 while this is going on is more than management can cope with.

This new grading structure represents a major improvement for nurses in the health service. It takes full account of the changes which have taken place. It recognises and rewards increasing levels of skill and responsibility. For example, a skilled nurse working on a specialist renal unit and a sister in charge of a ward where students are training will both receive significant pay increases. If they were on the maximum of their scales the staff nurse I have just talked about would receive basic pay of some £10,650 a year and the ward sister £13,925. The new structure will provide better career prospects for all staff who wish to stay in clinical practice. Finally, this new structure should be important in helping to recruit and retain nursing staff in areas in which there have been shortages in the past.

In answer to one of the questions of the noble Lord, Lord Prys-Davies, the Government believe that the estimates of the costs of regrading are reasonable and the funds consequently provided are sufficient. The Government therefore do not intend to reopen this question.

All of us here will be aware of the economic growth enjoyed by London and the South-East over recent years. The present thriving labour market does, however, create its own pressures and for some time health authorities in London have reported recruitment and retention difficulties among their nursing staff over and above those found in the rest of the country. This year the review body has accepted the Government's invitation to look at this problem and has recommended London pay supplements for nurses.

In the circumstances I do not feel that the time is right to make adjustments to London weighting beyond the current offer. Noble Lords will recall that the management side of the London weighting consortium has confirmed that on the present basis of confirming London weighting settlements it cannot contemplate a higher increase than that of the 5.5 per cent. offer. I regret that the staff side continues to reject the offer. However, I can confirm that it remains on the table.

The review body awards mean that with the increases in basic pay this year, increases for staff nurses and sisters in inner London will be in the range of £27 to £57 per week. Starting pay for a staff nurse in inner London is now £9,677 and for a sister it is £12,048. In each case this is more than the previous maximum basic pay for the grade.

NHS spending continues to increase in real terms. It has risen by 38 per cent. since 1979. However, the important factor is that this Government's commitment to funding improvements in the health service has been accompanied by an emphasis on increasing efficiency and ensuring value for money.

I note the points made by the noble Baroness, Lady Robson. The facts are that more money is being spent on the health service than ever before and more patients are being cared for. This success owes a great deal to the efforts of nurses and other staff and the Government have recognised their contribution. Not only is the NHS better funded than ever before; it is also better staffed. The number of nursing and midwifery staff employed in the health service continues to increase. At 30th September last year there were some 405,200 whole-time equivalent nursing and midwifery staff employed in England. This is nearly 47,000 more than the figure we inherited.

For some time the Government have been encouraging more flexible recruitment policies. Health authorities are now seeking to attract more mature entrants and more men to what has traditionally been a female profession. This policy has been fully supported by the Royal College of Nursing. Over and above this, opportunities for part-time work and job sharing are growing. Nurses are being encouraged to return after a career break by provision of part-time training and retraining.

We intend to publish leaflets on nursing and other careers in the health service from 23rd May onwards following a complete revision. This is part of a campaign designed to increase the recruitment of nurses which will be focused in particular on London and the South-East.

Several noble Lords have mentioned accommodation. The suggestion was made that nurses are being made homeless due to the Government's policy of selling and reorganising National Health Service residential accommodation. I should be horrified to learn that this was borne out in practice. My right honourable friend the previous Secretary of State gave an undertaking that no one will be made homeless in such circumstances and we continue to stand by that undertaking. Of course residential accommodation for nurses is primarily a matter for individual health authorities. I have been around the country recently; I have been especially looking at the special health authorities in London.

I have discovered that hospital management includes a great chunk of housing management and accommodation for nurses. We believe that in the main it is better for health service staff to obtain their own accommodation in the normal way. However, we recognise that in certain areas such as greater London high cost can make this especially difficult. That is why we have welcomed the Nationwide Anglia Building Society scheme to provide low cost 100 per cent. mortgages to help nurses and other staff working in greater London to buy their own homes. In December of last year my right honourable friend the Secretary of State announced a comprehensive housing policy for staff. This will be especially important in areas such as London and the South-East. I believe that it will help those who wish to purchase their own homes but who, because of the high cost of housing, are unable to do so.

I take the point made to me by so many nurses that once they are into the 25 years and older age group they no longer wish to live in nursing hostels and other rented accommodation. They want their own home. I can report to the House that a number of properties are now being purchased with the aid of a partnership mortgage, and with a few, legal documentation is nearing completion. It is expected that the first purchase will be completed at the beginning of June.

Ministers welcome this as an excellent example of how collaboration with the private sector can benefit the National Health Service. In recent days we have heard of other suggested forms of co-operation between the public and private sectors for the benefit of those who work in the health service; and we welcome them all. The Government expect the scheme to continue to be successful.

But what about elsewhere? Worthing Health Authority and the Gateway Building Society have developed a preferential mortgage aimed at exactly the same thing, at recruiting and retaining staff. Under the terms of the scheme, employees may borrow up to three and a half times their income plus one and three-quarter times their partner's income. Normal interest rates apply, however.

There is another related provision. The Nationwide Anglia scheme will be assisted by a proposal put by the general Whitley Council management side as part of the review of the removal expenses agreement. This will give health authorities discretion to make an interest-free advance of salary to help staff wanting to move to their own accommodation, whether owner-occupied or rented, with legal and other costs, even where there is no change of employer. This facility will not be restricted to London or to any particular staff group. The advance will be repayable over 10 years, though there will be provision for employees to opt to defer repayment for up to two years from the date the advance is made.

This will help staff in London particularly, but elsewhere as well, to take advantage of the various building society schemes and make it easier for staff throughout the country to obtain homes of their own to rent or buy.

Lastly, I accept the comments of the noble Baroness, Lady Robson, on the increasing range of responsibilities that nurses carry; for example, counselling and the management of other staff groups and contractors. It is precisely because the role of nurses is changing, and their duties have in some areas expanded over the years, that the new grading structure is now being introduced. Clearly we shall have to ensure that this recognises and rewards the responsibilities that individual nurses now undertake and it must be designed to be capable of responding to developments in the future.

To sum up, nurses now enjoy record levels of real terms income—higher than the levels set by previous landmarks in nurses' pay: the Halsbury Report in 1974 and the Clegg Report in 1979. And there are more of them than ever before—nearly 47,000 more than in 1979. The Government have established the independent review body to get the levels of pay right and have agreed with the staff side the biggest restructuring in nurses' grading in the 40 years since the National Health Service began. This will ensure that there are better career prospects than ever before for nurses who want to remain in clinical practice.

But there are other moves afoot. The noble Lord, Lord Prys-Davies, to whom I am extremely grateful for giving me warning, commented on the White Paper Promoting Better Health, in which we said that we welcomed the interest shown in the idea of nurse practitioners; but we still have a number of problems to sort out, not least the definition of a nurse practitioner. He also commented on nurse prescribing, which I am not sure fits into this debate. If I may, I shall write to him on that subject.

I believe that the record I have outlined today is one to be proud of and a demonstration of the Government's commitment not just to nurses but to the National Health Service and the patients it serves.

Lord Molloy

My Lords, I thank the Minister for the measures he has announced which are designed to enhance the recruitment of nurses to the National Health Service. I also thank those who spoke with such knowledge and understanding. I also thank those who listened. The debate has been an honourable and deserved acknowledgement of the work and value of Britain's nurses within our National Health Service. I remind the House that the review explains that the next review is already urgent.

Many Members of your Lordships' House have great knowledge of the NHS, of medicine and particular aspects, and nearly all have indicated something which needs to be done but which is not mentioned by the review board. That will make the next review even more expensive. The review board has said that we must face up to the fact that to carry on the good work the next review will need more money and the NHS will need ever more money.

In conclusion, all I hope is that we in this country will never again fall into the myopic error of knowing the price of everything and the value of nothing. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.