HL Deb 12 November 1991 vol 532 cc492-508

3.57 p.m.

Debate on Second Reading resumed.

Baroness Robson of Kiddington

My Lords, I join the noble Lord, Lord Carter, in thanking the Minister for her introduction of the Bill. It is non-controversial and noble Lords on all sides of the House agree with its proposals.

It must be right to remedy a number of the defects in the Nurses, Midwives and Health Visitors Act 1979. Those were highlighted in the Peat Marwick McLintock report and have been pressed for in the past by the UKCC. The Bill will provide a better legislative basis for the council to fulfil its regulatory functions more efficiently. It is not often that all professional bodies and noble Lords in all parts of the House welcome a Bill and are in general agreement with it. Perhaps the consultation that took place prior to its introduction is something from which we can learn.

One or two points need to be clarified. The noble Lord, Lord Carter, has touched on some of them. There is concern about responsibility for financing nursing, midwifery and health visiting education being transferred to the health authorities and the health boards. We are all aware that when cash becomes tight education very often suffers. It has to because the service has to go on. We therefore welcome the Government's intention to ring-fence the sum of money necessary for education. However, can the Minister say for how long that ring-fencing will continue? I ask that question because ring-fencing is not a method which is very much liked by the Government or indeed by health authorities. Therefore, we wish to receive some reassurance about the length of time it will be in place. We should also like some guarantees that the fact that nurse education and training will be the responsibility of and funded by the RHAs in the future will not lead to a loss of momentum in the development of nurse education.

On Clause 7, as mentioned by the noble Lord, Lord Carter, all the bodies welcome the new power of suspension granted in the Bill, in addition to the power of removal from the register. However, I should like to join the noble Lord in asking that a further remedy should be made available to the UKCC; namely, that of cautioning persons, especially where the allegations of professional misconduct made against them have been proved or admitted and where removal from the register might be considered an excessive penalty. I understand that the idea of cautioning was included in the consultative document published on 30th September this year. I wonder why it is not embodied in the Bill.

I said that all three professional bodies are in agreement with the Bill. However, the Royal College of Midwives has a special concern which I should like to highlight and upon which I ask for the Minister's reassurance. The college feels that there is a weakness in the 1979 Act which has not been remedied in the present Bill. The central council has to consult the midwifery committee on all matters relating to midwifery. The college believes that that relationship should be strengthened and that it should go further to ensure that not only consultation takes place but also that the council should not unreasonably reject any recommendation of the midwifery committee. As the Royal College of Midwives considers itself to be a minority group, I wonder whether the Minister can reassure its members that they need not feel threatened by the new legislation.

I welcome the Bill. We shall do our best to ensure that it passes speedily through the House.

4.3 p.m.

Baroness McFarlane of Llandaff

My Lords, I too should like to thank the Minister for her presentation of the Bill and to speak in its support. I am a nurse, a midwife and a health visitor. Therefore, I have a personal interest in each of the professions named in the Bill. Further, prior to the 1979 legislation, I was chairman of the Joint Board of Clinical Nursing Studies, which was one of the nine bodies amalgamated under the 1979 Act. On the passage of the Act, I had the honour of being asked by the Secretary of State to be the first chairman of the English national board and, by virtue of that, a member of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. It is from that background and experience of what the situation was like prior to the 1979 Act, with the overlap of functions among nine statutory and governmental bodies, the problems of working through the provisions of the legislation and the division of work between the council and the boards, that I should like to support the Bill wholeheartedly.

The noble Lord, Lord Carter, paid tribute to the contribution of the professions named in the Bill. I think that it is right and proper, as we are here this afternoon, to say that the education and the regulation of those professions is of paramount importance to the health service and to quality assurance in the National Health Service. Unless nurses, midwives and health visitors are adequately prepared for their roles and unless the professional practice is regulated, the quality of the National Health Service will suffer accordingly.

I believe that there is probably no need to remind your Lordships of the increasing sophistication in medical care these days and of the commensurate need for sophistication in nursing care. We have the impact of high technology and the demographic trends, with increasing numbers of elderly people in the population and their needs and dependency. We then have all the matters stressed in the government publication The Health of the Nation and the need for health promotion and prevention of ill health. Because of all the sophistication, nurses and midwives are playing increasingly important roles.

I have only perhaps to mention a few of the specialties in those professions to indicate the need for their adequate preparation and control. For example, if one looks at the advances in oncology nursing and palliative care, the work of midwives in special care baby units and the work of health visitors in special stress counselling clinics, one sees that they are the backbone of the National Health Service.

Therefore, preparation for those roles is essential. I must pay tribute to the way in which the present UKCC has tackled the needs of the professions. The recommendations contained in the report on Project 2000 for the training and education of nurses to take their place from the year 2000 are now being implemented. I believe that exciting changes are taking place in nursing education which are preparing them for the future. More recently, the UKCC has produced its report on post-registration education and practice and on the future of community education. So the present bodies have been playing an important role it raising the standards of nursing education and in the regulation of the profession.

I believe that the provisions of the Bill outlined by the Minister have great strengths. That the UKCC should become the directly elected body means that the professions will be those to whom the UKCC will he accountable. That strengthens the whole question of self-regulation. The boards will be streamlined and I believe that, through that process, they will become far more effective and efficient. I also believe that, through the provisions of the Bill, the confusion in the division of work between the UKCC and board will be clarified and the whole of the professional conduct work will he taken over by the UKCC.

Not unnaturally, in a profession where Professor Judge called a report on nursing education fissiparous, reservations have been expressed about some of the provisions in the Bill. We have already heard some of them rehearsed in the House this afternoon. I have heard reservations as to the size and power of the boards and their ability to be innovative and responsive to national needs. I believe that the national boards took great pride in making provision for particular national needs. The Bill caters for that by making the UKCC accountable to the professions and therefore responsive to actual needs.

Secondly, I have heard reservations expressed about the loss of joint committees as provided for in Clause 3. In a profession such as health visiting, which before 1979 had its own statutory body, there is a feeling of loss at no longer having a joint committee. I feel that the Bill meets those needs because the council has power to set up committees and it must consult the professions when so doing. We have already heard about the apprehensions felt about the financing of nurse education and of the assurances sough" over ring-fencing.

This Bill gives me the opportunity to raise a matter that I mentioned on 13th February in our debate on the long-term objectives of the NHS. Whereas great progress is being made with Project 2000 and increased efficiency is being achieved with the consolidation of schools of nursing into colleges of nursing, the capital charges involved in bringing together colleges, for instance, in one building, have not been identified. I should be interested to hear an assurance on that point.

Our most important misgiving relates to the role of the UKCC in the regulation of professional conduct and its power not simply to suspend or remove from the register but to issue a formal caution. I regard the Bill as being uncontroversial. Given some clarification, I shall accord it my full support.

4.12 p.m.

Baroness Cumberlege

My Lords, I should also like to thank my noble friend the Minister for introducing the Bill. I wish to give it my strong support. I have been a member of the UKCC since 1988 and I have taken part in professional conduct committees. I know from first hand experience that the standards that nurses, midwives and health visitors set themselves are extremely high. I support them in their struggle to shake off the image of being angels or handmaidens. We know that they constitute a large. highly trained and scrupulously monitored professional body.

British nursing has laid the foundations for nursing education and practice in many countries. Nearer to home it has spearheaded attempts to improve professional practice within the EC, and as Europe continues to undergo change British nursing will have a key part to play in sharing its considerable achievement and skills.

The noble Baroness, Lady McFarlane, said that in this technological age nursing skills require a high degree of sophistication. I agree, but like the professions and indeed the council itself, I also strongly believe that good quality care embraces not only technical skills but compassion, gentleness and respect for one another. British nursing in my view succeeds in maintaining that very delicate balance. I am therefore mystified by the apparent reluctance to introduce limited prescribing for nurses. I think that everyone acknowledges that terminal care sisters and Macmillan nurses are the experts in caring for dying people, and yet they are not credited with the sense and skill to vary the rates of pain-relieving drugs.

Community nurses are not allowed to prescribe the simplest remedies, and they have to suffer the indignity of obtaining a doctor's signature, which also causes the patient prolonged and unnecessary suffering. Some doctors, I know, recognise the nonsense of the situation, and, perhaps one could say wrongly, leave a pile of signed prescriptions for the nurse to fill in. That is clearly not a desirable situation, but I think that it is an understandable practice, given the circumstances in which we find ourselves. I know that my noble friend the Minister will tell me that Touche Ross has been commissioned to report on nurse prescribing, but I wonder what is holding up that measure. Today we are dealing with a Bill of the most responsible nature, but we are absolutely failing to give nurses the responsibility and trust that they deserve.

We should appreciate that many people who need medical attention and advice neither want nor need to see a doctor. When we did a Marplan poll we found that 60 per cent. of people would prefer to see a nurse rather than a doctor for certain matters. I agree with the noble Baroness, Lady McFarlane, about the innumerable nursing problems faced by the increasing number of elderly and handicapped people for whom we have to cater at home and by their carers. There are few health centres and surgeries where people are offered direct access to a nurse; yet we know that seeing the doctor is not always the best solution.

Often people need and want time to talk and to be listened to. A busy GP cannot always give them that time. That has long been recognised in other parts of the world. Nurses here want to extend their brief to meet that demand. In this country we have a handful of nurse practitioners, and we urgently need many more to relieve GPs and to extend the choice of advice available.

I know that concern has been expressed today as to the problem with the funding provisions of the Bill; that they are perhaps not sufficiently robust. I also sense a healthy scepticism about the regions; that they are not to be trusted and that if money is not ring fenced, it will be spent elsewhere. I understand those pressures. When I was a district chairman, I experienced the temptation to raid the education and training budget to keep open a ward or a theatre or to progress new developments. But regions are now once removed from the intensity of operational pressures, and the new system, which is bureaucratically defined as Working Paper 10, is designed to ensure that education is protected from short-term expediency of that sort.

From my experience as chairman of the regional health authority for South West Thames, Project 2000, the new educational training scheme, has taken RHAs by storm. It has generated excitement and interest, and some of the best debates in my region have centred upon nurse education and training. In the past two years we have invested over £2 million in Project 2000. Some of that money has come from the centre, but some we have funded locally.

At present we have the ridiculous situation of regions being responsible for ensuring that sufficient skilled nurses are available to work in hospitals and in the community but part of the education budget for the training of the nurses to enable that to happen is being held by the educational boards. I welcome revision of a situation which means that in the North of England we are training too many nurses. That is extravagant not only in resource terms; it is a personal tragedy for young students who have completed years of training only to find that there is no job for them. There is real merit in bringing together the needs of the service and the resources available to ensure that the best quality of health care is given. There is also merit in allowing greater flexibility between pre-registration and post-registration education. On average, nurses used to spend only seven years working in the profession; today they spend 14; and so their needs for post-registration education are different. The NHS must be flexible enough to meet those changing needs. I believe that responsibility at the regional level is about the right level. It is not too far removed from the service and it is not too close to be pressurised.

I hope that we shall give the Bill a safe passage but I share the reservations expressed that there is no provision for a person whose registration has been neither removed nor suspended and who is not subject to a formal caution. I know that the backlog of cases coming before the UKCC is disturbingly long. Some people have to wait over two years to have their cases heard and that is unreasonable. Only 45 per cent. of those who come before the professional conduct committee are removed from the register. We require more flexibility, and I hope that the Minister will respond.

The Bill goes very far, but it does not recognise the demand for nurses to be able to prescribe, to become practitioners even more in their own right. I hope that in the future we shall have a measure before the House that will not only include such a provision but will also provide a nationwide nurse-practitioner service and thereby give a tangible expression to more patient choice as embodied in the Patient's Charter.

4.20 p.m.

Baroness Cox

My Lords, I am delighted to welcome the Bill and I offer it my strong support. I believe that its provisions represent significant milestones in the history of nursing, midwifery and health visiting. I wish to commend the Government for bringing forward the legislation, which I believe will be warmly welcomed by all the professions concerned.

As my noble friend the Minister has already indicated, the essence of the Bill is to provide for effective professional regulation based on the principles of professional responsibility and accountability. My noble friend has given such a clear exposition that I do not wish to add to it, but merely to highlight a few of the changes which I believe are particularly to be welcomed.

They include, first, the change in composition of the UKCC so that the majority of its members will be elected by the professions. This is a significant reflection of the principle of self-regulation. Secondly, there is the rationalisation of key regulatory functions relating to the maintenance of professional standards and conduct by bringing them together within the remit of the UKCC. Thirdly, there is the streamlining of vital educational functions by vesting important responsibilities in the four appointed national boards.

In my contribution I wish to pay tribute to my professional colleagues whose work has enabled the Government to recognise the profession's maturity in this way. First, I wish warmly to commend the UKCC under the leadership of Dame Audrey Emerton and Mr. Colin Ralph. The functions of the UKCC as laid down in the 1979 Act have been: to establish and improve standards of training and professional conduct for nurses, midwives and health visitors". The council has responded magnificently to those challenges. It has brought into being the entirely new scheme of education for nursing known as Project 2000. This is designed to enable student nurses to have a professional education rather than a basic training; to enable them to understand the theory underpinning practice; and to have the opportunity to think about and to think through the assumptions and implications of their professional responsibilities.

If I may say so, this is a world away from the situation during my training a generation ago. I shall never forget my first ward report from a marvellous ward sister whom I remember with admiration and affection to this day. After giving me what I am pleased to say was a good report, she offered me a kindly word of advice. She said, "In your own interests, nurse, as you go through the hospital, please do not ask so many awkward questions". My noble friends on the Front Bench may think rather regretfully that I have not changed much.

I am pleased that in our professional education we are now providing both pre-registration and post-registration students with an opportunity to think independently and critically about their own professional practice. The UKCC is to be congratulated or the way in which not only Project 2000 has been introduced but also the work it has accomplished on post-registration education designed to improve the knowledge and clinical competence of qualified practitioners. This underlies the philosophy of both the Government and the profession that every nurse, midwife and health visitor should be properly and adequately qualified to fulfil their professional responsibilities.

On the issue of professional standards, the UKCC has issued a number of key documents on professional conduct, confidentiality and accountability. As the noble Baroness, Lady McFarlane, mentioned, as professional practice in health care becomes ever more complex in terms of clinical, ethical, legal and social aspects of care, there will be an indisputable need for better educated and more ethically aware practitioners, a need which the UKCC has been keen to meet along with colleagues on the national boards.

I therefore wish also to offer a brief tribute to the work of the national boards. In my capacity as chairman of the Health Studies Committee of the Council for National Academic Awards, I have had the privilege of undertaking many joint validations of new courses together with national board colleagues. If I may do so without sounding patronising, I wish to express my appreciation of the high standard of work undertaken by board colleagues during validation visits which are often arduous and challenging, given the complexity and the seriousness of the issues at stake. I am therefore pleased that the importance of the continuation of their work is recognised in the Bill.

Before I conclude, perhaps I may turn to three questions which I wish to ask my noble friend. All have been anticipated in the contributions from noble Lord; earlier in the debate. The first relates to the issue of professional conduct and discipline. I think that this was raised by every noble Lord who has spoken so far. I know that colleagues on the UKCC and from the Royal Colleges of Nursing and Midwifery share this concern. I hope that my noble friend will be able to help us.

I refer to the lack of provision on the face of the Bill for the UKCC to have the option of issuing a caution as part of a disciplinary procedure. I understand that this is not deemed to be technically necessary as it may be implied by the provision of more serious sanctions. I also understand, however, that the situation is not clear-cut and could be challenged. Therefore, my colleagues on the UKCC would greatly appreciate this unequivocal and essentially benign provision. They would particularly value it as it would provide them with an appropriate response to situations which do not represent grave misdemeanours and also because it would help to ease the backlog of cases currently awaiting consideration. If my noble friend could offer reassurance on the matter, which I do not believe is contentious, perhaps in the form of a government amendment, I know it would be greatly appreciated and give much relief.

The second query refers to anxiety expressed by the Royal College of Midwives. It was anticipated by the noble Baroness, Lady McFarlane, and also the noble Lord, Lord Carter. I refer to Clause 5(5), the subsection which removes a duty placed upon the national boards in Section 6(2) of the 1979 Act to, have proper regard for the interests of all groups within the professions, including minority representation". As a group with minority representation on a non-elected body, midwives are concerned that nothing should be left to chance. The words were included in the 1979 Act to ensure proper recognition of smaller groups of health care staff outside mainstream nursing. Similar words remain in the 1979 Act relating to the UKCC. The Royal College of Midwives suggests that there is no logic for removing this responsibility from the national boards. I know that any clarification or reassurance my noble friend could give would be most welcome.

Finally, I have a query concerning funding for professional education. Again, this is a point that has already been anticipated by the noble Baroness, Lady Robson of Kiddington, and other speakers. Clause 5 of the Bill brings to an end the boards' responsibilities for financing nursing, midwifery and health visiting education, transferring it to health authorities or health boards. The Royal College of Nursing—here I must declare an interest as a vice-president of the college—has expressed concern over the proposal. It is concerned because in the past there has been a fear that education is vulnerable, particularly in times of financial cutbacks. The college therefore welcomes the Government's declared intention to ring-fence education funding in England at regional health authority level. However, as I understand it, this commitment is not prescribed in legislation. Can my noble friend therefore give some indication as to how and for how long such ring-fencing is to be ensured and protected?

I reiterate my overall delight in and unequivocal support for this important Bill. In its recognition of the professional maturity of nursing, midwifery and health visiting and in its principled provisions for the extension of their powers of regulation, I believe it will not only enhance the standing and practice of those professions but will also enable them to enhance the quality of care they provide for those for whom they are professionally responsible.

I end by congratulating the Government on bringing this initiative into Parliament, where I hope it will be received with enthusiasm. I also congratulate my professional colleagues on the UKCC and the national boards for their achievements, without which this Bill would not have been possible.

4.30 p.m.

Lord Meston

My Lords, I should declare an interest as a legal assessor to the UKCC. It is by serving as such an assessor that I have come to know something of the work of that body and also come greatly to admire its efficiency and high standards. Professional standards are constantly protected, defined and raised not just for the sake of it but for the sake of the patients and public being served by these professions. All that is not just a polite platitude but a real reason for saying that if this legislation is wanted by the UKCC we should respect its wishes and speed it on its way.

This Bill reflects the fact that the UKCC well knows its own business and is willing and able to control the affairs of these professions. It is worth raising a cheer for the work of the UKCC during the Gulf War when it enabled nurses to verify and update their registrations. With my limited perspective and with the authoritative speeches that have already been made, I shall not trespass into areas that I do not properly understand. However, I hope the Minister can enlighten us on the timescale of this measure. It seems that the changes proposed in Clause I have to be triggered by approval orders for both a proposal and a scheme under Clause 2. Presumably the existing regime continues unless and until approval orders are made. How long is all that expected to take? In that context, as regards Clause 16, will the Minister confirm that other changes will not be held up while the Clause 1 mechanism is being put into operation?

I now turn to the other proposed changes. As has already been mentioned, Clause 5 provides for a sensible transfer of functions relating to the investigation of misconduct. That has already been described as a streamlining measure. It is to be hoped that it will deal with some of the delay in getting cases before the appropriate committee. Previous speakers have referred to that matter.

Clauses 7 and 8 are also welcome. From my own experience and that of other legal assessors, I can inform the House that the conduct and health committees of the UKCC deal fairly and firmly, but also sympathetically, with a great variety of cases. These often involve detailed consideration of evidence and of almost every type of human weakness, both momentary and long-term. I stand second to none in admiring the way that task is carried out. In cases of misconduct it is never seen as just a punitive exercise; more often the committee tries hard to help the nurse concerned back on to the rails, if at all possible. At the same time the committee pays proper regard to the need to protect the public in general and vulnerable patients in particular.

Hearings are also often an opportunity for the committees publicly to explain and reassert professional standards. Clause 8 is useful in that context as it permits outside representation on the committees. That is a valuable if not an essential measure. I am glad to note that Clause 8 provides that the lay membership of such committees—I hope I may describe them in such terms—will not form a quorum. That reflects the fact that in certain cases technical matters are discussed which have to be left to the professionals to decide.

Clause 7 has already been mentioned. It provides for an additional power of suspension from the register. It adds a useful measure of flexibility to the Bill. However, I am not sure whether it is intended that suspension should be used as a sanction, or as a protective measure pending investigation where a strong prima facie case is raised, or possibly for both purposes. As almost every speaker has mentioned, what is still missing is an express power to caution or reprimand. As things stand, a conduct committee can remove a nurse from the register or make no order at all. There are cases where removal from the register, thereby depriving a nurse of her livelihood, is too severe. However, the alternative of making no order seems too feeble and sends out the wrong signal. We all know that for some years the UKCC has wanted the power to caution or reprimand. Other professional bodies have such a power.

It is frankly absurd that the UKCC should have to put up with conflicting advice. When it wanted the power to caution to be put in the rules it was told it could not have it because there was no basis for it in the primary legislation. Then when it wanted to put the power in the primary legislation in this Bill, the message came back that that was unnecessary as such a power was implicit in the greater power to remove. Lawyers can disagree about almost anything, I am glad to say. However, the lawyers who disagree in this case are not those who will have to pay for the test case to sort this matter out. The position is highly unsatisfactory. To remove all doubt and debate on the topic, there should be a power expressly stated in the Bill to caution or reprimand. When I speak of a power to caution or reprimand, I speak of a power with the formal status of a sanction to be recorded as such. I am not merely talking about an informal ticking off.

Subject to those observations, I join others in welcoming this Bill. I wish it a speedy passage.

4.37 p.m.

Lord Harmsworth

My Lords, in making this, my second speech in your Lordships' House, I expressed the view early this morning to one who must surely be the greatest authority in your Lordships' House, that one's second parachute jump is worse than the first. He gave me no encouragement. He said, "One's first speech is like jumping from a balloon, one's second is like jumping out of an aeroplane".

The Government have a proud record in the field of nursing. Since 1978–79 not only has the number of nurses and midwives in the UK risen by 69,000, but nurses' pay has increased by 48 per cent. in real terms. Nurses now have an independent pay review body, a modernised career structure and a modern graduate training system. Through Project 2000 there is a new system for training nurses which gives more weight to the process of learning and less to sharing the workload of hospital wards, valuable though that still is.

This Bill is much to be welcomed. It is welcomed by the Royal College of Nursing. That should come as little surprise. In the regular Treasury programme of reviews on non-departmental public bodies, Peat Marwick McLintock made recommendations which were the outcome of thorough research and consultation. That consultation continued formally on the issue of the report, to be followed by informal discussions thereafter between health departments, statutory bodies and NHS management. The result was a radical change in the structure and role of the UK Central Council on the one part and the four national boards on the other.

Two-thirds of the UKCC, its maximum size expanded, is now to be appointed by the Secretary of State on being elected under a new and self-determined electoral scheme proposed by the professions. Only one-third is to be appointed directly by the Secretary of State, and then only from among nurses, midwives, health visitors and medical practitioners, or from among people with qualifications that are considered of value to the council. That is in contrast to the position in the 1979 Act, under which all the 45 members are either appointed by the Secretary of State or nominated by the national boards. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting has come of age. It has had its adulthood acknowledged.

I like this Bill. It is right that these professions should be self-regulating. It is right that the Secretary of State should play a lesser role in the affairs of these professions. It is right that he and Parliament should limit themselves to the safeguarding of the public interest and that there should be a limit amounting to a general reserve power of veto over detailed constitutional and procedural issues. That is efficient and cost-effective management.

Apart from the tidying up of the 1979 Act, the Bill acknowledges the high level of expertise and ability in the professions, and, through it, the Secretary of State professes his faith in their ability efficiently to regulate their own affairs. He has delegated important professional functions to those best able to perceive their needs. Again, in contrast with the 1979 Act, the four new slimline executive national boards will now be appointed by the Secretary of State in each of the four countries. In keeping with the philosophy behind the provisions of the 1990 health Act, they will continue to be accountable to them. Here again, in their clearly defined role of approving institutions, validating courses including further training for those already registered, the boards afford a new and more efficient method of ensuring that appropriate professional training is delivered; and who better than the profession itself to judge what is proper training for itself?

Throughout the NHS there is a new spirit of enthusiasm and self-confidence. My belief is that it is born out of the trust that the Government have placed in the. marked and widespread ability to be found throughout the NHS: ability to stand on one's own feet, to run one's own affairs without unnecessary control from the centre, and to make decisions uncluttered by bureaucracy. The Bill mirrors those concepts so powerfully established in the new National Health Service and Community Care Act. I commend it to the House.

4.43 p.m.

Lord Auckland

My Lords, at a time when the National Health Service is the victim of some untidy and almost uncouth political wrangling, it is good to welcome a Bill that is virtually non-controversial. It is a highly technical Bill. I speak with some trepidation because, although my family has been involved in the administrative side of medical care for seven generations as I have mentioned to your Lordships before, only our younger daughter has had experience of the nursing profession. I have not consulted her regarding the Second Reading of the Bill, but I shall no doubt receive some information from her as we progress towards the remaining stages.

Our daughter is currently a practice nurse for a general practitioner in south-west London. I echo the views of my noble friend Lady Cumberlege who said that practice nurses should be given more responsibility. It is good for them to be able to put into practice the comprehensive training at their disposal to help out hard-pressed and harassed general practitioners, of whom there are certainly many in the London area and in the large conurbations, by performing duties that they have learnt during their training.

Clause 4 goes a long way towards establishing a realistic programme for nurses, midwives and health visitors. I have always been against large committees. The Bill gets the matter about right. It is essential to have on a committee of this kind people who have had experience of, and currently have experience of, the nursing profession.

Perhaps I may say a few words about Clause 7, the part of the Bill that has been most discussed during our Second Reading debate. Nurses, midwives and health visitors perform extremely responsible duties. They become tired; they may at times become irritable. Mistakes are bound to occur. As one who has spent all his working life in the insurance industry, I know of some of the appalling cases of malpractice that have occurred, particularly in America. However, such cases are rare in this country and, although at present we have an adequate supply of nurses, particularly in the conurbations, we cannot afford to lose good nurses and midwives who have made a mistake which was not serious and not intentional. I therefore believe that the Government's intention to introduce a cautionary procedure will be implemented so that cases which do not involve a serious act of misconduct are treated with reasonable leniency. Obviously, there may be a few cases in which harsher penalties are needed.

We have here a Bill which will help the nursing and midwifery profession as a whole. We come back to the question of nurses' pay and accommodation and nursing shortages. The problems are not confined to this country. I recently spoke at a conference in Copenhagen when the question of nursing shortages, particularly with regard to elderly people, and midwifery shortages, was raised. We have all been here before, but the Bill will go a long way towards establishing a proper organisation for those hard working and dedicated people.

4.47 p.m.

Baroness Hooper

My Lords, this has been a most interesting debate on a Bill of great importance to the nursing professions. We have had contributions from people who know what they are talking about, perhaps best exemplified by the noble Baroness, Lady McFarlane of Llandaff. I had not realised that she represents all three branches of the profession to which the Bill applies. I am also glad that my noble friend Lord Harmsworth decided to try jumping out of an aeroplane, having so successfully landed from his original balloon jump.

I am also grateful for the general welcome given to the Bill and for the many valuable points made, all of which have demonstrated your Lordships' interest and concern in the future of nursing and your understanding of the valuable role that the professions play and will continue to play in the challenging times ahead. I join wholeheartedly with all your Lordships in saying once again that we all acknowledge and appreciate the work of nurses, midwives and health visitors.

Turning to specific issues and questions, perhaps I may start with the point made by the noble Lord, Lord Carter, who suggested that we might write into the Bill a requirement for consultation with regard to Clause 1(4)(b). Such appointments are already subject to the provisions of Clause 1(5). Given the extensive consultations, which worked so well in the preparation of the Bill, my right honourable friend the Secretary of State would hardly wish to make appointments of such importance without proper consultation with those who have an interest. I can and do undertake that he will do so. That undertaking therefore is clearly on the record. However, in our view, it is undesirable to prescribe in legislation whom he should consult on particular appointments. We feel that there is a need for maximum flexibility. That is a basic principle underlying all the provisions of the Bill.

The noble Lord, Lord Carter, and all noble Lords who contributed to the debate referred to the power to caution in relation to Clause 7 of the Bill. Our legal advice is that the council, as the body charged with hearing and determining proceedings for a person's removal from the register, already has the power to caution. We are therefore advised that it is not necessary to write anything into the Bill. I understood that the council also received further legal advice which corresponded to that of parliamentary counsel. As a fellow lawyer, I bow and do not wish to disagree with the views expressed on this subject by the noble Lord, Lord Meston, except perhaps to quote again the dictum of an ancestor of one of his noble friends, the noble Viscount, Lord Falkland, who in a slightly different context said: "When it is not necessary to change, it is necessary not to change". Presumably, if it is not necessary to write something in, it is necessary not to write it in. Bearing in mind the force of the arguments that have been expressed in the course of today's debate, I undertake to look again into the question.

Still on the subject of Clause 7 and the reference made by the noble Lord, Lord Meston, to the power of suspension, in addition to the present power to remove from the register, it is intended that this power should be used where a nurse, midwife or health visitor is deemed by the health committee of the UKCC for medical reasons to be unfit to practice.

A number of noble Lords raised the point about midwifery representation on the boards in connection with the provisions of Clause 4(4), which specifies that the Secretary of State shall secure that the majority of members of a national board are registered nurses, midwives or health visitors. We have made every effort to make clear throughout the negotiations with the statutory bodies that the Government will wish to ensure that the interests and expertise of each of the three professions are adequately represented. However, it is also necessary to provide for boards of wider expertise, not only clinical but teaching and management expertise. It may not therefore be appropriate to guarantee that a practising midwife or a health visitor must be a member of each board. I recognise the preoccupations voiced by my noble friends and other noble Lords about minority representation on the boards and the references to the amendment which is made by Clause 5 to Section 6(2) of the 1979 Act.

We know that the statutory bodies are concerned about the impact that that could have on minority groups. They may, and clearly some of them do, feel vulnerable and disadvantaged without the protection previously provided. Nevertheless, the amendment was made because, in the view of the health departments, the phrase no longer has any relevance when boards cease to be bodies elected by the membership. National boards are required to exercise their functions in accordance with the rules of the council, which itself is required to have a proper regard for all minority interests. In our view that provides sufficient protection for all groups within the professions.

With regard to ring-fencing or funding of education and training, which we all acknowledge is of great importance, my noble friend Lady Cumberlege was very reassuring as to the role of the regional health authorities, particularly as considerable change is taking place in the whole area. The Secretary of State's announcement of government decisions on the two consultation exercises—one on the Peat Marwick McLintock review of UKCC and the four national boards, and the other on Working Paper 10—made it clear that it was for employers to determine their needs for qualified nursing, midwifery and health visiting staff. That is why regional health authorities, in consultation with employers, identified the education and training costs required to produce key, qualified staff in those areas and have protected them at regional level.

The ring-fencing aspect enables those costs to be removed from the contracting arrangements between purchasers and providers under the National Health Service reforms. In reply to the specific question asked by the noble Baroness, Lady Robson, and by my noble friend Lady Cox, the length of time that the ring-fencing will be in place will be as long as it proves necessary. We are satisfied currently that regional health authorities are taking very seriously their responsibilities under Working Paper 10 but I can assure your Lordships that we shall continue carefully to monitor the position.

Perhaps while I am on the subject of education and training, I may refer to the other question asked by the noble Baroness, Lady McFarlane, about the capital costs for merging colleges of nursing. She suggested that they should be met by the department. We have limited centrally top slice funds to transitional costs of moving to Project 2000, not the costs of merging colleges as such, which health authorities themselves must meet. But a special one-off grant was made this year to the regions to help with the miscellaneous costs of moving to Project 2000. Again, that did not include capital as such but it included a contribution, for example, to additional library costs.

My noble friend Lady Cumberlege also asked about the need for many more practice nurses. We agree that the role of nurse practitioners is vital and should increase, if not perhaps within the scope of this Bill. But we are aware of the need, and their numbers will undoubtedly increase. The current work being carried out in the UKCC on the subject of post-registration training, mentioned in its consultative document on community nursing, will, we believe, contribute to that increase.

The noble Baroness, Lady Robson, suggested strengthening the power of the UKCC midwifery committee. At present there is no evidence that the current situation, whereby the UKCC is required to consult the midwifery committee on midwifery matters, which does not restrict its powers any further, has not worked. Since the Bill is not intended to change the UKCC's role vis-à-vis any of the three professions there is no need to make any additional arrangement in that respect.

My noble friend Lady Cumberlege raised another matter which is outside the scope of the Bill, namely, limited prescribing by nurses. We understand the anxieties about delay, but consultations with relevant agencies are continuing. We hope and expect that an announcement will be made in the not too distant future. Although it is not a matter for this Bill I shall pass on my noble friend's remarks to my colleagues in the Department of Health.

Finally, the noble Lord, Lord Meston, mentioned implementation. We hope that if the Bill is enacted as speedily as possible—and I understand that all of your Lord hips hope that it will be—the reconstituted bodies will take office in April 1993. That is a tight timetable. I can confirm that Clause 14 provides that the existing council and board can continue in office until the new arrangements take effect.

In its reconstitution of the statutory bodies for nursing, midwifery and health visiting, the implementation of which will provide increased efficiency and effectiveness in the administration of those bodies and more direct accountability to the nursing professions which they represent, I believe that the Bill marks a milestone in the history of nursing. It can truly be said that it also represents the coming of age of the professions, and in that I echo the remarks made by some of my noble friends. I commend the Bill to the House.

On Question, Bill read a second time, and committed to a Committee of the Whole House.