HL Deb 26 November 1991 vol 532 cc1277-99

3.10 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.—(Baroness Hooper.)

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Clause I [Changes to constitution]:

Baroness Robson of Kiddington moved Amendment No. 1:

Page 1, line 18, after ("State") insert ("after consultation with those professional bodies and other persons representing the interests of nurses, midwives and health visitors,").

The noble Baroness said: I understand that Amendments Nos. 1 and 2 have been grouped together. The purpose of Amendment No. 1 is to ensure that the Secretary of State takes the opportunity, prior to appointing members to the United Kingdom central council, to consult with representatives of the relevant professions.

The Government's stated aim with this Bill is to ensure that as many detailed matters as possible regarding the conditions and procedures for the UKCC should be determined by the professions themselves, acting through the UKCC. Clause 1 of the Bill states that the UKCC will have a membership of 60 people, of whom two thirds will be elected and one third appointed by the Secretary of State. The timetable for those appointments, as set out in the Bill, is six months.

There is no doubt that the professions themselves will undertake detailed consultations within the three branches of the profession as laid down in the Bill. That is recognised. As that body will be regulating both standards of practice and codes of conduct of —what is the word I want?

A noble Lord

Conduct?

Baroness Robson of Kiddington

I have already used the word "conduct". The matter is important because the body has complete power over both standards of practice and professional conduct. It therefore makes sense for the Secretary of State, too, to give careful consideration to the one third of the representatives to be appointed by him.

Apart from appointing a balanced number of representatives from the professions, the Secretary of State also has to take into account the geographical distribution and expertise of those appointed. I should have thought, and it should be written into the Bill, that the Secretary of State should consult the professions. That should not be assumed; it should be written into the Bill before he nominates the one third of the members of the UKCC he has the power to appoint. I beg to move.

Lord Carter

I was glad to add my name to the amendment. It is a subject which we touched on at Second Reading, and there is no need for me to go into detail as the matter has been explained very well by the noble Baroness.

The changes to the 1979 Act which we are considering dictate the operation and constitution of the five bodies which govern nursing, midwifery and health visiting. The next amendment deals with appointments to national boards. We feel that it is important that there should be proper consultation. Without being in the least political, I should point out that there has been some anxiety about the nature of the appointments to boards of hospital trusts, for example. This is a different situation, but there is a general feeling among the professions concerned that they would be encouraged if the nature of the consultation was written on the face of the Bill. They would then not be anxious that the Secretary of State would not carry out the consultation which we all agree is so necessary if the Bill is to be effective.

Baroness McFarlane of Llandaff

In speaking in support of the amendment I should like to express my confidence in the appointments that have been made by the Secretary of State over the years. I believe that I am right in saying that this is the 50th year in which there has been a nursing division at the Department of Health. Through those years we have come to rely on the advice which the Secretary of State receives from a department of high integrity.

Nonetheless, I recognise the sensitivities of the professions named in the Bill. Through the UKCC they will be responsible for standards of practice and codes of conduct. Therefore it is arguable that consultation with those professions would be in the interests of the work of that council.

Baroness Hooper

Of course I remember the anxieties which were expressed in connection with this issue at Second Reading. I believe that my right honourable friend the Secretary of State's record on consultation is excellent. In regard to the Bill before us, the announcement of intention was made in a consultation document in February this year. That resulted in a very thorough period of consultation with a group which comprised representatives of the four UK health departments, the UKCC and the four national boards. Very thorough consideration was given in that forum to the composition of the council.

In making his own appointments to the council the Secretary of State will in any case be required under Clause 1(5) to select people who are either registered nurses, midwives, health visitors or medical practitioners or who have such qualifications and experience in education or other fields as in his opinion will be of value to the council in the performance of its functions.

I happily take the opportunity to reaffirm what I said at Second Reading, namely, that I undertake that my right honourable friend will consult those with an interest before making his appointments. As has been said, under the present arrangements nominations are invited from a very wide range of professional organisations. Whether such arrangements will remain appropriate in the context of the new style UKCC will need to be considered carefully. We may wish to consult an even wider range of groups and organisations. My right honourable friend will need to take particular care in making his appointments, given the fact that two thirds of the council will in future be directly elected by the professions. It is clearly more important than ever that the wider public interest in the regulation of the professions should be adequately reflected in the appointed membership.

Therefore, the amendment we are discussing, by restricting consultation to professional interests only, implies a rather narrower focus than I believe would be desirable. I do not believe that statutory prescription is required in this matter any more than it has been in the past. Legal arguments about who should or should not be consulted on a particular appointment would not be desirable.

I hope that in the light of that explanation and the very clear undertakings that I have been able to give, the noble Baroness and the noble Lord will feel able to withdraw their amendment.

Lord Carter

Before the noble Baroness decides what to do about the amendment I should like to raise a point which has aroused some anxiety. Subsection (5) (a) includes the words: the need to secure that the members of the Council include registered nurses, midwives and health visitors". I assume that one could interpret that as meaning that those appointments will be in the majority of the appointments made on the Bill. It merely states that it will include them. It is important that they will be in the majority of the appointments that are made.

Baroness Hooper

We are talking here about appointments for the purposes of subsection (4) which relate to only a third of the membership of the body. A wide range of interests must be considered and consulted in relation to the appointments to be made by my right honourable friend.

Lord Carter

I am sorry to prolong the discussion. Subsection (4) states that the appointments will be made "from among persons". Subsection (5) states that the appointments will include those people. We assume that those professionals will be in the majority of the appointed members. It would he helpful if the Minister could confirm that point.

Baroness Hooper

The noble Lord can take that as read.

Baroness Robson of Kiddington

I thank the Minister for her reply. However, we must keep in mind the fact that this body is being given new powers and that it controls the standards of practice and codes of conduct of the professions that we are considering. It is not difficult for the Secretary of State to appoint, within the number that he is entitled to appoint to the UKCC, members of the profession who are geographically spread; nor is it difficult to find members with educational expertise.

I take the Minister's point that there should be a proportion of outside interests on any body, but consultation with the professional bodies should take place. I accept her statement that the majority of the members would be members of the three professions. Until I have read her reply in detail and thought about it a little further, I beg leave to withdraw the amendment.

Baroness Robson of Kiddington moved Amendment No. 3:

Page 3, line 19, after ("made") insert ("after consultation with those professional bodies and other persons representing the interests of nurses, midwives and health visitors,").

The noble Baroness said: This is another amendment about which I feel strongly because it relates to the national boards, appointments to which are completely in the hands of the Secretary of State. It is important that the members appointed to the national boards are the kind of people who can create the right relationship between the UKCC and the national boards. That is the most important part of the new structure. The Government have stated that they intend to ensure that the interests and expertise of the profession are adequately represented on each board.

It is even more important in this amendment, regarding the appointments to the national boards, than in the previous amendment, that the Secretary of State should take the opportunity to consult the relevant professions. When the appointments are made, if the Secretary of State commits himself to consultation, the working relationship between the national boards and the UKCC will be immeasurably improved and the confidence of the three professions enhanced. I beg to move.

Lord Carter

The only point to add to those made by the noble Baroness, Lady Robson, is that the boards will have no elected members. They will all be appointed. It is therefore important that consultation is carried out as suggested in the amendment. We have discussed this matter in relation to many Bills. There is always a reluctance on the part of departments to spell out in the Bill the nature of consultation. The Government give assurances that they intend to consult but, as we all recognise the need for proper consultation, one wonders why there is a reluctance to spell it out in this Bill as in many others.

Baroness Hooper

I accept that different considerations apply to the national boards than to the council in that all the members of the national boards will in future be appointed by the responsible Secretary of State. Once again, I am happy to give an undertaking that my right honourable friend will consult those with an interest before making appointments.

However, as I said before, statutory prescription in that area is inappropriate. We made it clear that the new national boards will be smaller executive bodies appointed by and accountable to the responsible Secretary of State, even though they will have a majority of professionally qualified members and will be required to discharge their functions subject to and in accordance with the council's rules. As I said, the Secretary of State will certainly wish to consult those with an interest, particularly professional organisations, before making appointments. We are happy to consider any suggestions about how the mechanics of that might work. But a formal and statutory requirement to consult representatives of particular interests would cause unnecessary inflexibility and risk blurring the responsibility which the Bill confers upon the Secretary of State.

I hope that, in view of the fact that wide consultation took place before the recommendations of the Peat Marwick report were incorporated in the Bill and in view of the undertaking that I gave regarding consultation, the noble Baroness will withdraw the amendment.

Baroness Robson of Kiddington

I thank the Minister for her reply, but I should like to draw her attention to the fact that communication between those various bodies in the past has not always been very good. Perhaps she will reflect on whether those communications between bodies that are appointed purely by the Secretary of State, without a written-in need to consult the profession, would be improved. After all, knowing how government works, to write in the need to consult is not necessarily the same as accepting the responses to consultation, but it would allow the professions to feel that they had something to contribute to the appointments to those national boards which are important to them. It would help to improve the relationships between the national boards and the UKCC.

I hope that the Minister will ponder those arguments. I may return to the subject at a later stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Carter moved Amendment No. 4:

Page 3, line 21, leave out paragraph (b) and insert: ("(b) have such qualifications and experience in the teaching of nursing, midwifery and health visiting, or other fields as in the opinion of the Secretary of State will be of value to the Board in the performance of its functions.").

The noble Lord said: This is a probing amendment. It may look at first sight to rest on a rather pedantic distinction between education and teaching. Clause 1(5) (b) refers to: the need to secure that qualifications and experience in the teaching of nursing, midwifery and health visiting are adequately represented on the Council".

Clause 4(3) (b) refers to persons who: have such qualifications and experience in education or other fields".

We feel that the two subsections should march together. As the functions of the national boards are to ensure that the requirements of the UKCC are met regarding the standard, kind and content of education programmes, it is important to ensure that at least one nurse, midwife and health visitor teacher is appointed to each national board. This requirement reflects a desire to ensure that to assist the work of the boards there are adequate numbers of appropriately qualified nurses, midwives and health visitors, able to contribute to educational policy-making related to the professions of nursing, midwifery and health visiting.

We want to ensure that teachers rather than theorists, people with experience of teaching nursing, midwifery and health visiting, are specified. It is not entirely clear why the Government have chosen to emphasise teaching in Clause 1 and referred to education or other fields. It is an alternative. The whole of Clause 4(3) states: Appointments … shall be made from among persons who … are registered nurses, midwives or health visitors, or … have such qualifications and experience in education or other fields".

This is an attempt to improve the drafting of the Bill, which we are always anxious to do. It is a probing amendment to discover whether the intentions of the Government in this area would be clearer if the wording of the Bill were to specify teaching rather than just education. I beg to move.

3.30 p.m.

Lord Meston

I wish to speak briefly in support of this amendment, if only to invite the Government to look at the phraseology used in the existing Clause 1(5) (b) which seems to have been lifted verbatim from the 1979 Act. The phraseology does not strike me as particularly happy. It may be that as a matter of simple drafting it should be looked at again.

Baroness McFarlane of Llandaff

I also should like to speak in support of this amendment. The functions of the boards are to approve institutions in relation to the provisions for nursing education set down by the council. It would be unthinkable if on those boards there were people experienced perhaps in general education in many fields but with no expertise in the teaching of nursing. I feel that the boards need to have among their number those who have had down to earth experience in the teaching of nursing.

Baroness Hooper

I am most grateful to the noble Lord, Lord Carter, for explaining the effect of his amendment. It is true, as the noble Lord, Lord Meston, said, that Clause 1(5) (b) incorporates some of the words from the existing Section 5(6) of the 1979 Act; namely, that: the Secretary of State shall have especially in mind the need to secure that qualifications and experience in the teaching of nurses, midwives and health visitors are adequately represented on each board". Those words have now become part of the revised Section 5.

There is a similar provision in the existing Section 1(5) of i he 1979 Act relating to the Secretary of State's appointments to the UKCC. That is substantially reproduced in Clause 1(5) (b) of the Bill. There is clearly a need to give the Secretary of State the duty to ensure that nursing and midwifery teaching are adequately represented on the new council, as the noble Baroness said, as it cannot be guaranteed that the electoral arrangements will automatically ensure elected members with adequate expertise in these areas.

In fact those considerations will no longer apply to the national boards, given that in future they will be wholly appointed bodies. The Secretary of State's fail-safe or fall back powers in the existing Section 5(6) will no longer be required, as he himself will be able to ensure when he makes his appointments, that all the necessary expertise is represented as a result of the consultation exercise that we have been discussing.

Therefore, in the light of what I have said, I hope that the Committee will agree that the amendment is unnecessary. In making their appointments, clearly my right honourable friends will in practice need to ensure that qualifications and experience in the teaching of nursing, midwifery and health visiting are adequately represented. But they will also, as they do now, want to look more widely at the broader education field. That is the message of Clause 4(3) (b) of the Bill as it stands, which in this regard reproduces the wording of the existing Section 5(5) (b) (ii). Narrowing the scope of that provision, as the amendment seeks to do, might give the wrong kind of signals. Nevertheless, we shall look at the wording in the light of the comments that have been made, as indeed we always endeavour to do. I hope therefore that the proposer of the amendment will feel able to withdraw it.

Lord Carter

I certainly intend to withdraw the amendment and not to press it. We are puzzled over the drafting and the distinction between the first clause which mentions teaching and this clause which mentions education. We felt that it would be clearer if both said the same thing. We are grateful to the Minister for her commitment to look at it and consider whether it needs rewording. In the light of that assurance, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn

Lord Carter moved Amendment No. 5:

Page 3, line 28, at end insert: ("( ) In making appointments to a National Board, the Secretary of State shall bear in mind the need to secure that the members of the Board include registered nurses, and practising midwives and health visitors.").

The noble Lord said: This amendment deals with a very important point. I know that the Minister is aware of the disquiet felt, certainly by midwives and health visitors, about the fact that they should not be swamped by the larger profession and by the way in which the new structure will operate. The Minister will know that the Royal College of Midwives is anxious that membership of the national boards should not be without a guaranteed place for a practising midwife. As we understand it, there is no guarantee at board level of midwife membership (or indeed of health visitor membership), or provision for the means by which midwifery matters will be dealt with by the boards. We shall come to midwifery matters a little later in another amendment.

We know that the board will continue to have a specific and influential responsibility relating to midwifery education, midwifery practice and supervision of midwives. Therefore those who advise us feel that those responsibilities present a strong argument for the need to have a guaranteed midwife membership of the boards. I am sure the Minister is aware that some alarm was aroused at Second Reading when she said: It may not therefore be appropriate to guarantee that a practising midwife or a health visitor must be a member of each board".—[Official Report 12/11/91; co1.508.]

That statement set up some alarm in the midwifery and health visiting professions.

It would appear that it would be inappropriate for a body with a specific remit relating to a specific profession not to have guaranteed in its membership a member or members of that profession. Whatever the change in the status and functions of the boards, they will remain the statutory bodies exercising responsibility for nurses, midwives and health visitors. The involvement of each of the three professions in the decision-making process relating to the work of the boards should be guaranteed.

There is a feeling that the framework for midwifery will be considerably weakened if this matter is not addressed within the Bill. The same applies to the anxiety expressed by the Health Visitors' Association. We know that the joint committee will cease to operate under Clause 6(b) of the bill. There is a feeling that as a result, health visitor representation has been eroded. We understand that in discussions between the Health Visitors' Association and the department, it was said that this was largely a technical point made on the insistence of the parliamentary draftsman. It would be interesting to know why it was felt important to emphasise the omission of health visitors as a technical point of drafting. Health visiting is experiencing an alarming and unprecedented change on the education and practice side and a profound change in the management and delivery of care in the community as a result of the implementation of community care plans in April 1993. For all those reasons it would be helpful if the Minister would state clearly why the department has adopted the line that it has and does not feel able to guarantee membership for the minority professions, if I may use that phrase, in the three professions referred to in the title of the Bill. I beg to move.

Baroness Robson of Kiddington

I support the amendment. On many occasions in the past the midwifery profession felt that it had been excluded. It is important under the new structure that the national boards have proper representation of practising midwives.

Whatever the changes of status of the boards they still have responsibility for governing all three professions. It is important that all the professions should be properly represented.

Baroness Hooper

I am of course aware of the anxieties that have been expressed in particular by the midwifery profession about the boards' role in relation to the minority professions. I wish to take the opportunity of clarifying what I said at Second Reading about midwifery membership of the boards. Perhaps it would have been more felicitous if my reference to the guarantee had been elaborated upon: that it was not necessary to have a guarantee in legislation, as opposed to a rather more general form of guarantee. However, I hope that we have made it clear throughout our discussions 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.

I accept that in practice the membership of each board will have to include, either as an executive or a non-executive member, a registered nurse, a registered health visitor and a practising midwife. I should like to put that clearly on the record. I am not personally aware of the meeting between the Health Visitors' Association and the comments with regard to the technical drafting requirement. However, I shall look into that matter.

I do not believe that it would be appropriate for there to be statutory provision setting out which groups within the profession should be represented on the national boards and in what numbers. That would cause unnecessary and perhaps unhelpful inflexibility. In the light of the commitment that I have given, I hope that the proposers of the amendment will feel able to withdraw it.

Lord Carter

That is extremely helpful. Before the next stage of the Bill, perhaps the noble Baroness will write to me and to others interested in the technical drafting requirement which puzzled the Health Visitors' Association. That would be helpful with regard to the next stage of the Bill.

I am grateful to the Minister for the explanation that she gave. I am not sure that it was a guarantee. It may assuage a little of the alarm that I believe she realises that she caused by the rather bald statement she made at Second Reading. I shall read Hansard with care. However, having exchanged views between now and the next stage of the Bill I hope that we shall not need to come back on the issue. In the meantime, I beg leave to withdraw the amendment.

3.45 p.m.

Lord Carter moved Amendment No. 6:

Page 4, line 31, at end insert: ("( ) In subsection (2) the words from "including" to the end shall be omitted.").

The noble Lord said: I shall speak also to Amendment No. 7. Amendment No. 6 is similar to the previous amendment. It seeks to protect the interests of all groups which will be represented, both majority and minority. We are amending another Bill. Therefore we have the problem of referring to both the 1979 Act and the Bill before us.

We believe that it would make the functions of the national boards absolutely clear if we removed the words, including those with minority representation",

in Section 6(2) of the 1979 Act. It would then state: The National Boards shall discharge their functions subject to and in accordance with any applicable rules of the Council and shall have proper regard for the interests of all groups within the professions".

That makes the position absolutely clear. If that form of wording were adopted it would be clear that all groups were included in such proper regard. In that way each of the three professions which have to act within the ambit of the Bill will be absolutely clear.

There is no need to repeat the functions of the board relating to validation, approval of training arrangements and so on. If the proposed wording were adopted and the Bill were amended to take into account the 1979 Act, the position would be much clearer. It is not simply a drafting point. We believe that it would emphasise that all the groups will be represented and their needs and wishes clearly understood in the operation of the new structure. I beg to move.

Baroness Hooper

A number of noble Lords expressed concern at Second Reading about Clause 5(5). I said at the time that I recognised their preoccupations, and we have subsequently had the opportunity to reflect further on what was said.

I should say at the outset that we remain of the view that Section 6(2) of the 1979 Act is not, as it stands, consistent with the new constitution and role of the national boards. The new boards will not have the same representative function. That will be for the UKCC. Therefore the reference to "professions … with minority representations" would, at best, look rather odd. I do not believe, therefore, that it is appropriate to accept Amendment No. 7 as it stands.

Having said that, I recognise the concerns that have been expressed, in particular as they apply to the boards' role with midwifery. With the disappearance of the statutory midwifery committees at board level, there will now no longer be any, as it were, organisational focus at that level to ensure that the special position of midwifery is adequately reflected in the way the boards carry on their day-to-day operations. I acknowledge that the boards will need to continue to have a special concern for midwifery, if only because of their continued responsibility under Section 16 of the 1979 Act for issuing advice and guidance to local supervisory authorities for midwives.

I therefore agree that there should be some provision in Section 6 of the 1979 Act dealing with the boards' functions requiring them in discharging their functiors to take into account special considerations which apply to particular groups within the professions, including midwives. The extent to which such provision might reflect, at any rate in part, the existing wording of Section 6(2), as proposed in Amendment No. 6, is a matter that we wish to consider further. If noble Lords agree, and if the proposers feel prepared to withdraw their amendments today, I undertake to ensure that an appropriate government amendment is brought forward at a later stage

Lord Carter

The Minister's reply was extremely helpful and most encouraging. It is difficult to redraft one Bill during the course of another, but the Government have resources which are not available to us. I am grateful to the Minister and beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 7 not moved.]

Baroness Robson of Kiddington moved Amendment No. 8:

Page 4, line 33, at end insert: ("( ) After section 6 of the 1979 Act (functions of national boards) a new section shall be inserted as follows.

"Funding of nurse education.

6A.—(1) The Secretary of State shall, with the approval of the Treasury, make grants out of money provided by Parliament towards the cost of providing courses of training with a view to enabling persons to qualify for registration as nurses, midwives or health visitors and for courses of further training for those already qualified.

(2) Grants made in accordance with this section shall be used solely for the provision of such courses as defined under subsection (1) above.

(3) The Secretary of State shall, not later than 30th November in the year preceding any financial year lay before Parliament his estimate of the total amount of grant likely to be distributed under this section in respect of that financial year and forecasts for the amount for the following two years.").

The noble Baroness said: In my view this is one of the most important amendments tabled today. The Bill ends the responsibility of the national boards to fund nurse education and enables the Secretary of State to transfer it to health authorities and to health boards During Second Reading we received a partial reassurance that such funding would be ring-fenced. However, we received no assurance about the length of time that it would continue. The amendment aims to give that promise a statutory force.

It is interesting to note that most of the proposals in the Bill have been taken from the recommendations in the report compiled by Peat Marwick McLintock. However, the report did not recommend the transfer of funding for nurse education from the national boards to the regional health authorities. It stated that the allocation of resources by the RHAs to individual schools would provide some guarantee as to their use. However, the RHAs have a serious problem: they must divide the resources for training and strategy between the number of people whom they believe they must train and provide funding for resource allocation and management. The national boards must provide professional advice and approve and monitor courses. I believe that it is wrong to split those two responsibilities.

The Government have decided that the RHAs should be the funding bodies and one hopes that the ring-fenced amount will be the minimum that is required. The RHAs will be considering the number of nurses whom they believe they will need to train. However, there will not be the same impetus and need to safeguard money for further education—that is, post-registration education. We shall need a large number of post-registration courses as we move from one type of National Health Service to another which is more community based. I am extremely anxious that the funding for such education will not be forthcoming from the RHAs to the same degree.

There have in the past been problems within the National Health Service in providing specialist training for the type of nurses that we shall need in the future. That need is now even greater. I hope that the Government will guarantee that ring-fencing will continue and will not be limited to only one year. If it is limited the threat to nurse education will be great. I beg to move.

Lord Carter

I was pleased to add my name to the amendment. I am sure that like me the Minister has a sense of déjà vu when discussing ring-fencing. We spent many happy hours discussing the National Health Service and Community Care Bill. Members on this side of the Committee were able to persuade this Chamber of the merits of ring-fencing but unfortunately we could not convince another place. We welcome the announcement that the Government will ring-fence these funds, but we have tabled the amendment in order that they might stiffen their resolution.

The Minister gave the game away when on Second Reading she said: 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".—[Official Report, 12/11/91; col. 509.] I should have intervened then to ask who will decide when it is no longer necessary. The Minister must answer that crucial question. We are glad that the Government have seen the need to ring-fence the funds at the outset. We hope that it will be a permanent feature. The arguments were expressed extremely well by the noble Baroness, Lady Robson; we fear that the budgets will be eroded if they are not ring-fenced. The Minister will satisfy all Members by answering that simple question. We believe that it will be necessary to keep the ring-fencing arrangements in place for a long time, but we should like the Minister to confirm that.

Baroness McFarlane of Llandaff

I speak in support of the amendment. There are real fears that in passing the budget for nursing education to the regional health authorities it could be eroded by the need for cuts in the allocation of budgets. Those fears are real because within the profession live memories of the problems of Birmingham in recruiting a sufficient number of paediatric intensive-care nurses. The problem arose because not enough were trained. At present there is a reduction in the number of district nurses and health visitors who are being trained for important roles in the community. In such key professions within the health service there is a need to train not only to the level of registration but at post-registration level with many specialised roles being taken up. Therefore, we believe that there is a need to protect the budget for nursing education against any possible erosion.

In response to a question I asked on Second Reading the Minister indicated that a special grant had been made in moving towards Project 2000. It included a contribution to additional library costs in the implementation of that project. The grant was made in order to meet a crisis need for library costs. Project 2000 implements a much broader-based curriculum for the nurses of the future. That is necessary if they are to take an intelligent place in the service. I believe that the library is focal to all the work that nurses will have to undertake in that broader foundation programme of education. In addition, library resources are essential in post-registration courses.

I look to the future with the boards approving colleges and centres to run those courses. However, the boards will not be able to do so unless library facilities are adequate. Library resources in certain schools and colleges of nursing have been pathetic. Not only are the stocks of books and journals inadequate for the new curriculum, but the library staff are also inadequate. Many colleges of nursing no longer have a trained librarian. In looking to resources for the future it is essential that those needs are identified.

4 p.m.

Baroness Cumberlege

As I understand it, there are three elements to the new education budget. First, there are the bursaries that are awarded to student nurses which amount to about £100 million per year. That is allocated to regions to build into contracts with health authorities. Secondly, there is the costs of the individual colleges in terms of their fabric and day-to-day maintenance. That cost used to be borne by health authorities and is now transferred to the principal of the college. I welcome that because it strengthens local management.

The third element is the costs of nurse tutors and their support staff. As the noble Baroness, Lady Robson, said, from 1993 that budget, which is now held by the ENB, will be devolved to regions. Therefore, for the first time ever we shall be able to match the size, experience and skills of the teaching faculty with the number of students. I think that everybody agrees that that makes sense.

For the system to work smoothly regions must draw up a workforce plan with other purchasers; that is, the health authorities at district level, the family health service authorities and to a lesser extent GP fund holders. Regions will have to assess the health care needs of their populations and forecast the number and skills of all staff required to meet those needs. That will include therapists, technicians and other support staff. It will include the need not only for those coming into the profession for the first time but also those who need post-basic education.

Once agreement is reached on the size of the budget, district health authorities will then need to allocate those finances and convert them into contracts with individual colleges of nursing education on an annual basis to ensure that there are sufficient numbers and quality of staff.

Health authority contracts in turn must be linked into the ENB approval mechanism, so really it is a triangle, with all three points firmly connected. It seems to me that one of the chief benefits of the system is that there will be local assessment of the work needed to be done, unlike the proposal in the amendment, which seeks to place responsibility for quantifying the numbers and skills of nurses on to the shoulders of the Secretary of State, or more realistically the Department of Health. In my view that is not possible. I do not believe it is possible for the centre—for Whitehall—to assess the detailed needs of a population of 56 million. We are required to do that at regional level, and even to do it for 3 million is quite a task.

The Project 2000 proposals recognise that we need a new type of nurse to meet the demands of the 21st century: someone who will lead a clinical team, who is a practitioner in her own right, who is better educated and who will assess and supervise health care for individuals. As a nation we have invested large sums in the training not only of nurses but more recently of health care assistants. We have established a national vocational qualification. I believe it is essential that those people are sensibly and effectively used. It may be that in order to provide sensitivity and appropriate health care, flexibility will have to be exercised within the total region training budget.

I know that there are strong views among members of the nursing profession that we must have initial stability; and I agree with that. But I believe that that can be achieved not through ring-fencing, which rather smacks of an old-fashioned command economy, but through the corporate contract which regions negotiate annually with the management executive. We should make the best use of the new management tools which are incorporated in the reforms. However, we also need to maintain maximum flexibility since health care is such a dynamic discipline, with fast moving consumer demands, highly sophisticated new technology and tragically the introduction of new diseases such as AIDS. Therefore, with great regret, I cannot support the amendment.

Lord Carter

The whole area of corporate contracts is new and everybody must try to feel their way. Is the noble Baroness suggesting that the Government should not ring-fence the RHA budget at the outset? I am not entirely clear whether she suggests that ring-fencing is wrong in principle; whether she feels that we need it at the beginning while we are working things out and—if so, for how long?—or whether she feels as some of us feel that because these matters become eroded overtime that protection should be in place for quite a long time.

Baroness Cumberlege

I am against ring-fencing in principle but I want to ensure that there is initial stability because I understand the fears. I am suggesting that we have a management tool, which is the corporate contract between regions and the management executive. That is monitored very closely on a quarterly or half-yearly basis. We should use that tool rather than ring-fencing because it is much more pertinent and sensitive to the needs of the individual regions. There is an overall view from the management executive that it allows the fiexibilities which I think we need in the future for health care.

Baroness Hooper

This is an important topic. We take education and training very seriously since it affects the quality of care of patients, which at the end of the (lay is what the National Health Service is all about. Therefore, I am grateful to the noble Baroness, Lady Robson, for explaining the thinking behind her amendment, although, as drafted, the effect of the amendment is unclear. It states that the Secretary of State is to be required to make grants for nursing and midwifery education and training. However, it is not clear to whom he is supposed to make those grants, although we have a good idea as a result of this afternoon's exposition.

The Government's policy on the funding of nursing and midwifery education and training was explained by my tight honourable friends the Secretaries of State responsible for the health departments in a Statement made in another place on 4th February this year, which does not appear to have been repeated in this Chamber. It may be for the convenience of the Committee if I reiterate the main features of that Statement as it relates to the matters raised in the amendment. I shall relate my remarks primarily to the position in England. The position in Scotland and Wales is broadly similar having regard to the different organisational structure of the NHS in those countries.

In the Government's view there are two main principles which should underlie arrangements for organising and financing nursing, midwifery and health visiting education. The first is that decisions governing the supply of trained nurses, midwives and health visitors should be taken as close to the point of service delivery as possible to ensure that such decisions are responsive to local needs and to the changing requirements of employers.

Secondly, the Government have a duty to ensure that overall there are mechanisms in place to ensure an adequate supply of properly trained nurses, midwives and health visitors to meet the health needs of the nation. The financial arrangements in force since April of this year under which the health service purchases services through contractual arrangements with providers do not jeopardise that supply.

Against that background it is our policy that regional health authorities, in consultation with employers, should have the main responsibility for identifying the level of demand for qualified nurses and midwives which needs to be met, for deciding the number of students who need to be recruited and trained and for funding pre-registration nursing and midwifery training. My noble friend Lady Cumberlege, as chairman of a regional health authority, described the responsible attitude of the regions in that respect. To enable that to happen, Clause 5(2) removes the existing duty of the national boards to provide or arrange for others to provide education and training courses. In future, that function and the funding which goes with it will be transferred to regional health authorities. In that context, library costs, to which the noble Baroness, Lady McFarlane, referred, will be one of the items which regions will need to take into account in setting their top-sliced bids.

In the Government's view, however, it is important that the resources to be allocated to pre-registration nursing and midwifery education should be specified in a clearly defined budget. It is moreover important that the budget should be protected; in other words, once regions have decided on the sum to be allocated to pre-registration nursing and midwifery education, that budget should normally stand for that full financial year, and commitment to existing students should in any case always be honoured. We shall continue to monitor regional provision for training in this sphere in order to ensure that our overall responsibility for safeguarding the supply of nurses and midwives is adequately discharged. The exact mechanisms for this monitoring are still under consideration. They will be important.

So far as concerns post-registration training for nurses, midwives and health visitors, our view is that, while general in-service training—for example, management and IT training—should continue to be the responsibility of individual employers, post-registration education and training designed to produce specific professional skills should, for the time being at least, be funded from a separate and protected regional budget, managed in a similar way to that for pre-registration training. We have made it clear that these specific arrangements for post-registration training will be subject to review in the light of experience. But I can assure the Committee that, as in the case of the protected budget for pre-registration training —in respect of which I gave the commitment at Second Reading quoted by the noble Lord-the current arrangements will continue as long as is necessary. How long that will be, will be a matter of fact at the time.

I hope that I have adequately explained to the Committee the Government's commitment to ensuring that adequate resources are made available for this area of education and training and that in the light of what I have said the proposers of the amendment will feel able to withdraw it.

Lord Carter

Before the noble Baroness decides what to do with the amendment I should like to congratulate the Minister on producing the best post hoc argument I have ever heard. She said that this, will be a matter of fact at the time". Of course it will be a matter of fact at the time. We all know that. But when is the time? The noble Baroness said at Second Reading "as long as it proved necessary". She has just said "for the time being at least". How long does she think this ring-fencing is likely to last? It is causing a good deal of anxiety among the professions. They would like to have some idea of the time scale that the Government foresee.

Baroness Hooper

I have indicated that we are doing this initially on an annual basis and that we shall review it on an annual basis. It must be clear that for the first few years it will be reviewed on an annual basis.

4.15 p.m.

Baroness Robson of Kiddington

I am not very happy with the Minister's reply to the amendment. For some years I was a regional chairman, and I had the greatest admiration for my successor at the South-West Thames Regional Health Authority. However, it has been my experience in the health service and in every other walk of life in which I have been involved, including industry to a slight extent, that when there is a shortage of money, education and training are always chopped first. It has happened in this country, which is why we are in a mess at the moment. We do not have enough skilled labour. We are just waking up to the problem.

The noble Baroness said that the RHAs would have to take into account matters such as library costs when they make their top-sliced bids. She said that they would have to have a clearly defined budget for nurse education. She added that it would normally stand for the financial year. What does "normally stand for the financial year" mean? What if something untoward happened on which the RHA preferred to spend the money? That is why we are asking for the education slice to be ring-fenced. It is desperately important that there should be some guarantee.

We are living in a greatly changing world. Nurse education is changing enormously with the development of Project 2000. It has already changed. It is possible that nurse education will be taken out of the health service altogether. It may become the responsibility of the Department of Education and Science and be funded quite differently. If that happened it would be tremendously important for the amount of money transferred to the Department of Education and Science to be ring-fenced.

The issue raised in the amendment is important for pre-registration nurses, post-registration training and postgraduate education and training. The issue is important not only for the nursing profession but for the whole of our society. I am sure that we shall return to this amendment. If the noble Baroness does not like the wording perhaps we can come back with an amended form. We shall try to make it clear that it is one subject that we should like to see written into the Bill. I beg leave to withdraw the amendment.

Clause 7 [Suspension]:

Baroness Cumberlege moved Amendment No. 9:

Page 5, line 6, leave out ("and") and insert: ("(bc) a person whose registration has been neither removed nor suspended may be made the subject of a formal caution; and").

The noble Baroness said: This amendment concerns the very modest widening of the powers of the United Kingdom central council to administer a caution in appropriate circumstances. It has received all-party and cross-party support. I am grateful to the noble Lord and to both noble Baronesses whose names appear with mine on the Marshalled List. I am also aware that other noble Lords support the amendment. In particular, my noble friend Lady Cox wishes me to say how much she regrets not being here today to support the amendment.

The wisdom of enshrining an additional power to enable the United Kingdom central council not only to remove or suspend from the register but, in appropriate circumstances, to caution those practitioners who come before the professional conduct committee was widely appreciated and supported at Second Reading, and not least by my noble friend the Minister, who undertook to look again at the issue. I understand that after further consideration she is very sympathetic towards its aims. Because of that I shall not re-debate the issues but merely make four points.

First, the members of the United Kingdom central council, the registrar and his officers are deeply concerned at the length it takes for a case, once reported, to be heard by a professional conduct committee—anything up to two and a half years—which results in a disturbingly long backlog of cases. This amendment, in conjunction with the other measures in the Bill, will reduce the time to six months and eliminate the backlog.

Secondly, without the power to caution, cases have to be pursued, with a view to removing the practitioner from the register".

In fact, only 45 per cent. of the cases heard result in this draconian sanction. To remove a qualified practitioner from the register not only debars that person from practising their profession, but in many cases results in years of unemployment with subsequent misery and deprivation. Removal from the register is surely the final sanction. There needs to be flexibility and interim disciplinary measures as is the case with many other professional bodies.

There is of course incorporated in the Bill an additional power of suspension which the UKCC has not had previously. But that too can have the same effect as removal from the register albeit for a shorter period. My third point is that without the power of caution, cases are inappropriately brought before the professional conduct committee because of a rightful concern that if the case is not brought, although it is recognised that the ultimate sanction is inappropriate, the profession and the public believe that unprofessional misdemeanours are being condoned and the wrong message is sent out to the public and the profession. That was a point very well made at Second Reading by the noble Lord, Lord Meston.

The fourth and final reason is that the measure is not included in the Bill because of a difference of opinion between lawyers. Parliamentary counsel states that inclusion of a specific power to caution is unnecessary. But on two previous occasions the UKCC has sought to make rules introducing the caution under the existing Section 12(l) of the 1979 Act and has had its request rejected. The UKCC recently sought counsel's opinion to clarify the matter once and for all and was strongly advised that the power should he incorporated in the Bill and appear on the lace of the Act.

Disagreement between lawyers is expensive, but a test case carried through all its stages is not only an unfair financial burden to be borne by hardworking nurses whose subscriptions support the UKCC, but is also totally unnecessary given the opportunity afforded in the Bill. I hope that my noble friend the Minister will give us hope and bring forward a government amendment to ensure that these goals are reached. I beg to move.

Lord Carter

I am pleased to support the amendment from these Benches. The arguments in its favour have been expressed extremely well by the noble Baroness. I believe that it is the first time that she has moved an amendment to a Bill. I understand that the Government are going to accept it in principle although they may want to reword it. Before the noble Baroness becomes too excited I should warn her that if my experience is anything to go by, that situation will not last although it perhaps helps to start on the same side as the Minister.

The arguments have been well put. I understand that there has been a technical legal argument (we hear them often during the passage of a Bill) as to whether this matter needs to be on the face of the Bill. I understand that the Government now accept that it should be, although they may wish to have their own wording. I am pleased to support the amendment.

Lord Walton of Detchant

Perhaps I may also speak briefly in support of the amendment. In the very comparable situation of the medical profession, governed as it is by the medical Act and the rules derived therefrom, which were approved by the Privy Council, any medical practitioner appearing before the professional conduct committee may, at the end of the hearing, be subject to five possible alternative disciplinary sanctions.

The first is admonishment; the second is to attach formal conditions to the doctor's registration; the third to postpone judgment which is a little like putting the doctor on a state of warning as to his or her future conduct; the fourth is suspension; and the fifth is erasure from the register. This amendment would have the same effect as the General Medical Council admonishing a doctor. Therefore, it is something which the Committee should support.

Lord Meston

I too support the amendment, which is important and required by the UKCC. It is difficult not to repeat points made at Second Reading. It is also difficult not to express the disappointment which was then felt at the Government's unwillingness to accept the need for the power to caution to be stated expressly in the Bill. I am glad to hear hints that the Government have had a change of heart.

The need for such an amendment exists if only to avoid any uncertainty about whether the UKCC has such a power. It is apparent that the Government do not oppose it in principle. We all seem to want the same thing. The fact is that the UKCC has had conflicting advice from government lawyers as to the necessity for an express statutory power. The risk is that the omission of an express power to caution might be regarded by the courts as a deliberate omission. Therefore, there must he a risk that the courts would not feel willing or able to hold that there was an implicit power to caution. In reaching that conclusion the only people to benefit would be the lawyers. Undoubtedly, as has been said, it would be to the detriment of nurses. On this occasion I am happy to speak against the interests of my own profession. To adopt the phrase of the Minister earlier today, the omission might cause "unhelpful inflexibility". Therefore I ask the Government to put the matter beyond all doubt.

Lord Auckland

Without going into legal technicalities I am sure that the amendment will be welcomed by the profession for bringing it into line with, for example, the armed services where a soldier or other member can be admonished or reprimanded as opposed to being cashiered or sentenced to a term of detention or imprisonment. With its very reasoned terms this amendment will undoubtedly be very much welcomed by the profession concerned.

Baroness Hooper

A number of noble Lords strongly represented at Second Reading that there should be a specific provision on the face of the Bill for a matter which we believed was implicit. In the light of those views, I undertook to look at the issue again. Since Second Reading, officials from the department have had useful discussions with the UKCC about the details of how the proposed power to caution might be exercised.

I understand that most if not all of the Members of the Committee may have seen the helpful note which the UKCC has now circulated about this matter. We have looked again at the legal position in the light of this clarification and in particular at the way in which a caution would be administered at the initial investigation or preliminary proceedings' stage of the process. I can say to the Committee that we now accept the principle that there should be specific reference to the power to caution in the legislation.

The noble Lord, Lord Meston, said that the UKCC had received contrary advice from government lawyers to the effect that there was no power to administer a caution under the existing Section 12. Unfortunately, neither we nor the UKCC have been able to find clear documentary evidence for such advice. However, it appears that the question at issue on the earlier occasion was whether or not the national boards, not the UKCC, could be given powers under the rules to administer a caution as part of its duty under Section 6(1) (e) of the Act to carry out initial investigations in professional misconduct cases. That power is repealed by Clause 5(4) of the Bill. The UKCC is in future to be responsible for all stages of the investigation of professional conduct cases. That is relevant to the question of how the powers available under Section 12 should be interpreted.

In view of this happy agreement that we should accept the principle of the specific reference, nevertheless I would like the opportunity of considering further exactly how that can best be achieved. I have been advised that the amendment before us does not quite do the trick. It seems to imply that the administration of a caution is a formal and an appealable penalty on a par with removal or suspension from the register rather than what I understand is in fact intended that it should be—a warning, albeit a formal one, as to future conduct.

There are a number of technical difficulties arising from the drafting which need to be clarified. Therefore, if Members of the Committee are in agreement on the withdrawal of the amendment at this time, I undertake to ensure that a government amendment meeting the intentions of this amendment is brought forward at a later stage.

Baroness Cumberlege

In the light of the remarks made by my noble friend the Minister, it gives me pleasure to withdraw the amendment. We look forward to reading the exact wording which she brings forward from the Government. I should also like to thank those Members of the Committee who spoke in support of the amendment. In the circumstances, I beg leave to withdraw the amendment.

4.30 p.m.

Lord Desai moved Amendment No. 10:

Before Clause 9, insert the following new clause:

("Consultation between Council and Midwifery Committee . In section 4(2) of the 1979 Act (which requires the Council to consult the Midwifery Committee) after "consult" there shall be inserted "with and not unreasonably reject any recommendation or and after "relating to" there shall be inserted "or in any way affecting".").

The noble Lord said: The object of this amendment is to ensure that there is adequate consultation with the midwifery committee by the UKCC. As the areas of responsibility are shifting we are doing here what my noble friend Lord Carter has already mentioned: we are amending another Act in the course of passing this Bill.

The purpose of the amendment is to amend Section 4 of the 1979 Act. As amended, the section would read: The Council shall consult with and not unreasonably reject any recommendation of the Committee on all matters relating to or in any way affecting midwifery". Consultations used to be concerned only with matters relating to midwifery. We are seeking to widen the scope of consultation to cover matters "affecting" midwifery. I am sure that this amendment will be welcomed by all sides of the Committee. I beg to move.

Baroness Hooper

Perhaps I may reaffirm what I said on Second Reading (at col. 509 of Hansard); namely, that there is no evidence that the current situation whereby the council is required to consult the midwifery committee on midwifery matters, but which does not restrict its powers any further, has not worked. It is not our intention to use the Bill to make any changes in the council's constitutional role in respect of any of the three professions which it regulates. It would, therefore, be inappropriate to make this particular amendment at this time, given that the existing provisions have not caused any problems.

I believe that consultation and consideration of recommendations are areas where a great deal depends on a constructive and mutually respectful relationship between the bodies concerned. It would appear that the amendment could erode rather than enhance that relationship. In the light of that explanation, I hope that the noble Lord will feel able to withdraw his amendment.

Lord Desai

I am happy to beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clauses 9 to 12 agreed to.

Clause 13 [Central Council rules: consultation]:

Lord Desai moved Amendment No. 11:

Page 6, line 12, leave out from beginning to ("after") in line 13 and insert:

("(1) Section 22 of the 1979 Act (duty of Central Council to consult about rules) shall be amended as follows.

(2) At the end of subsection (3) (b) there shall be inserted "and, insofar as the proposed rules are relevant to the Boards functions prescribed in section 6 of this Act."

(3)").

The noble Lord said: Again, this is a matter which relates to consultation. Certain functions of the national boards are being transferred away from them to the new health authorities but they will still be responsible for validation of courses and other matters. The purpose of the amendment is to ensure that the UKCC continues to consult the national boards and that there will be a positive requirement for such consultations to be carried out. There is not much more that one can say about the amendment. I beg to move.

Baroness Hooper

I am aware that concern has been expressed that the words which this amendment seeks to replace appear to give too much discretion to the council in determining what is and what is not relevant to the boards' functions. I must say that I do not consider that this really amounts to a point of substance. Someone has clearly got to be given the job of formally determining the matter and it is difficult to see that the body could be anyone other than the council. To leave the issue rather in the air would be unsatisfactory.

If a doubtful case did arise, it would be most unlikely that the council would not in practice consult the board on the issue. Moreover, at the end of the day, if the council acted unreasonably in not consulting the board, it would of course be open to the board as a last resort to seek redress in the courts. But that seems to me to be a most unlikely scenario. In view of that explanation, I hope that the noble Lord will feel able to withdraw the amendment.

Lord Desai

I am most grateful to the Minister for that assurance. In the circumstances, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 13 agreed to.

Remaining clauses and schedules agreed to.

House resumed: Bill reported without amendment; Report received.