HL Deb 28 February 1992 vol 536 cc533-46

2.19 p.m.

Baroness Cumberlege

My Lords, I beg to move that this Bill be now read a second time.

It gives me unusual pleasure to introduce to the House this short Bill. My honourable friend in another place Mr. Roger Sims, who is a recognised champion of nursing and nurses, steered his Private Member's Bill through another place with the utmost speed and dexterity, and he has charged me to do the same. With great skill and success he resolved, with the help of my honourable friend Mrs. Bottomley, the Minister for Health, all doubts and concerns, so that any objections and amendments were put on one side and support from all quarters gladly given. The Bill flowed unimpeded. I am aware that it is asking a great deal to give it equal and exceptional treatment in your Lordships' House but I hope that that will be the case. Perhaps exceptions are in order when a Private Member's Bill has been given total support by the Government, Opposition parties and all the professional bodies involved.

There are nearly half a million nurses in this country. They are heartily tired of being referred to as handmaidens and angels. The Bill refers to them as practitioners. That is as it should be, for years of training amply qualify them as nursing practitioners and have put them in a position of great trust.

In 1985, I chaired a review team to advise the Secretary of State on the future of community nursing. We spent three months touring the country, visiting community nurses and GPs in their practices. It became obvious to us that time was wasted and delays experienced by nurses having to request modest prescriptions to be signed by a doctor. We had sympathy for those GPs who signed blank prescriptions for nurses to fill in, because those doctors trusted nurses implicitly. But those doctors were transgressing. We found other nurses, with years of experience and exceptional skills, frustrated by having to wait, sometimes days, for a doctor to sign a prescription, knowing that in the meantime the patient in their charge was suffering needlessly.

In our many visits we found no one who questioned the skill and experience of, say, Macmillan nurses in their ability to care for terminally ill people. Most people we met were aware of and respected the midwives' skills. As one who has had two babies at home, delivered by community midwives, I endorse that. Most people acknowledged that the district nurse was the recognised professional in home care. So often it is the nurse who puts us back together again, physically and mentally, after the doctor has had, perforce, to take us apart. But it is not all tender loving care, nurses need ointments, sprays and dressings, and no one knows better than they do what they need.

As we move to more day surgery and shorter hospital stays, so nurses in the community take on more responsibility. They must be well equipped to do that task. The Bill, although important, is simple. It contains five provisions. First, it specifies that registered nurses, midwives and health visitors, are appropriate practitioners for the purpose of prescribing a limited number of prescription-only medicines under Section 58 of the Medicines Act 1968. It includes a power for the Secretary of State to limit the categories of nurses who can prescribe prescription-only medicines by reference to qualifications and training.

Secondly, the Bill makes a technical amendment to give the Secretary of State additional powers to make secondary legislation under the Medicines Act. Thirdly, it enables community pharmacists to dispense, on the NHS, a specified range of medicines and appliances which have been prescribed by particular categories of registered nurses, midwives or health visitors who have satisfactorily completed a prescribed programme of appropriate training. Fourthly, it applies the provisions to the United Kingdom. Lastly, it includes a provision enabling the Secretary of State to bring the Act into force by order.

By conducting proper consultation, through an expert advisory group, the Department of Health has gained the support of all the nursing professions and organisations. The national training boards are arranging the necessary training courses. There will be nothing slipshod or left to chance. Nurses have always been responsible for their professional actions. I know, from being a member of the United Kingdom Central Council Disciplinary Panel, that that regulating body will allow no nurses to sully their profession.

The BMA has given support to the measure, and after a considerable cost-benefit investigation by Touche Ross, the well-known firm of chartered accountants, even the armoury of the Treasury has been pierced. Touche Ross concluded that nurses make effective use of available resources entrusted to them. They estimate a saving of 2.84 million nurses', carers' and GP hours. To me, that is really significant: all that time wasted fiddling about getting prescriptions when it should be spent caring for people. That is a tangible benefit and it is what people want. The Bill slices through unnecessary bureaucracy and will benefit an estimated 7 million patients every year.

But above all, a highly responsible, highly trained professional group will have the reasonable dignity of being allowed to decide what it needs in order to do the job properly. This transcends all other considerations. The whole nursing profession will benefit from this rightful, professional recognition.

I must pay a tribute to the work of the department's advisory group, the experts who hammered out the implications of nurse prescribing. There are six core recommendations and they are very important. The first and second general ones are that prescribing nurses should be well qualified; that they will prescribe in clearly defined circumstances from a limited list and be able to adjust the timing and dosage of medicines within a set patient-specific protocol.

The third specifies that district nurses, health visitors, and practice or private nurses who have had the necessary additional training should be able to prescribe items for people in their care. The fourth is specific to nurses with specialist training who will be able to prescribe for stoma care and continence, and school nurses for lice control.

The fifth recommendation deals with adjusting the timing and dosages by nurses of medicines prescribed by doctors and covers medicines for diabetics and psychiatric patients and nurses working with terminally ill people who need to adjust pain-relieving drugs. I know that my noble friend Lord Mottistone wished to be here today but was unavoidably detained in another part of the country. He is concerned that community psychiatric nurses should not be allowed to prescribe drugs. Under the Bill, they will not be able to do so, thus my noble friend can rest assured that the Government have no intention of introducing such a measure. Paragraph 3.6 of the advisory group's report makes that plain.

The last recommendation is that nurse prescribing should be ready for introduction on 1st April 1992. However, this has been delayed for various reasons and the aim is now October 1993, when training will have been completed.

The suggested formulary covering the range of drugs which nurses will be allowed to prescribe contains only three medicines which cannot be bought over the counter. The formulary will be updated every two years, after wide consultation among the professions by the joint formulary committee. Nurse prescriptions will be distinctive and will be subject to close scrutiny and budgetary control, either by an employing GP or the local district health authority or, where it exists, the local community trust, which employs the community nurses.

The Royal College of Nursing which has done so much to promote the professionalism of all nursing, but in this case of community nurses, makes a special plea for nurses working in rural areas. The RCN can see great benefits to elderly and chronically disabled people, people suffering from a mental illness, those who have diabetes and people who are homeless or dying.

It is now over six years since my review team first made this recommendation; there have been six years of negotiation and evaluation. In other words, 16 million nursing hours have been lost; not needlessly, perhaps, because we have to get things right. But it would be most disappointing if the House were instrumental in causing another delay, because without the legislation nothing can happen. It might be a fairly long delay if a general election intervenes and this Private Member's Bill is lost.

I know that there are many Members of your Lordships' House who have great knowledge and expertise in these matters. They may be tempted to improve the Bill, although I gather that at the Committee stage in another place it took less than one minute to pass.

In effect the department has drafted the Bill. My honourable friend in the other place, Mr. Roger Sims, and I have gone through the text with a fine-tooth comb. We have taken advice from many quarters. We hope that your Lordships will feel able to pass this enabling Bill as it stands with no need for further amendment. However, I very much look forward to hearing the debate on this Second Reading of the Bill. I beg to move.

Moved, That the Bill be now read a second time. —(Baroness Cumberlege.)

2.30 p.m.

Lord Rea

My Lords, like the noble Baroness, Lady Cumberlege, and many others I welcome the Bill. I congratulate the noble Baroness on the very clear and succinct way in which she introduced it. She is the appropriate person to take the Bill through this House because of her major contribution to community nursing, which is well known to all of us.

The Bill is particularly timely now that, at long last, the primary health care team is receiving the recognition in kind that it has had in words for as long as I have been in practice, which is now most of a professional lifetime. As the noble Baroness hinted, the Bill in effect recognises in law the practice which has long existed in my own case and that of many other doctors. Nurses, particularly district nurses, have virtually prescribed the dressings and appliances which they need for the care of their patients. Prescriptions are sometimes written on a list by nurses and subsequently copied and signed by the doctor. Occasionally, they are written directly on the prescription form by the nurse and signed by the doctor. I do not recommend as a practice the pre-signing of prescriptions by doctors although I know that it occurs sometimes. A high degree of trust exists, as the noble Baroness pointed out, and suggestions from nurses are seldom, if ever, turned down. I know that district nurses are the experts in home care. I value their suggestions.

In hospitals some of the items requested by district nurses from general practitioners are available directly from hospital stores without a prescription being necessary. Even so, I can see that there may well be items which a hospital nurse of appropriate seniority and training, as laid down in and enabled by the Bill, should be able to prescribe, thus saving an over-worked junior hospital doctor considerable routine work. Here I differ from the British Medical Association which strongly objects to hospital nurses being given prescribing rights. After all, only a limited list of items would be permitted, although that may well grow as both professions begin to use the provisions of the Bill effectively over the years. I am sure that my noble friend Lord Walton will explain why the British Medical Association is opposed to the provisions of the Bill applying to hospital nurses.

In my practice in anticipation of the Bill we are developing our own list of drugs—and we hope that it will be the same—which our practice nurses, according to a strict protocol and after training and full discussion, will be able to prescribe. That may well be more extensive than the initial list of drugs which the regulations provided for by the Bill may define. We shall watch that aspect with interest.

The professional training of nurses and their ethical code is, in my view, enough to ensure that indiscriminate or unwise prescribing would be extremely unlikely. The provisions of the Bill ensure that only nurses of an appropriate category will be allowed to prescribe. That means that some additional training in prescribing the categories of drugs which are listed will have to be given before any nurse can prescribe. That will act as an appropriate safeguard. I am sure that my noble friend Lord Walton will go into greater detail about the discussions which the medical and nursing professions have had, separately and together, with the Department of Health.

I was surprised that it has been estimated that additional costs of £17 million would accrue as a result of the Bill, because most of the drugs which nurses will prescribe are already prescribed by doctors at the request or suggestion of nurses. However, I understand that that sum has been at least partially calculated to cover the costs of training. Perhaps the noble Baroness will be able to explain that.

It is a good Bill. It will enhance the professional satisfaction and status of nurses; it will save doctors and nurses much time; and, as the noble Baroness has pointed out, it will avoid delay in supplying very necessary items for patients.

2.35 p.m.

Lord Walton of Detchant

My Lords, I am sure that the House regrets that the noble Baroness, Lady McFarlane of Llandaff, a nurse, has been unable to take part in the debate. It took me nearly four hours to reach here from Oxford this morning. I imagine that the journey from Manchester made it quite impossible for her to reach the House as I am sure that she would have wished to have done.

Perhaps I may echo the comments of the noble Lord, Lord Rea, in saying how clearly the noble Baroness, Lady Cumberlege, introduced the Bill which I too warmly welcome as a member of the medical profession. For many years doctors and nurses have worked in close association both in hospital and in the community. As the noble Baroness said, many nurses now work in general practices or in association with general practitioners fulfilling the role of a nurse practitioner to the mutual benefit of the patients and of both the medical and nursing professions. The quality of training and experience which many of those community nurses have achieved has increased the level of responsibility which they are able to assume in relation to patient care.

It is some years since I had the opportunity as president of the General Medical Council, with some of my colleagues, of sitting down with nursing members of the United Kingdom Central Council and with the Royal College of Nursing to discuss the issue of nurse prescribing. At that time we hoped very much that it would become a practical reality. The noble Baroness was one of those who has been most instrumental in making the arrangements possible which have led to the introduction of the Bill.

As the noble Baroness and the noble Lord, Lord Rea, said, the British Medical Association welcomes the proposal that suitably qualified nurses working only in the community should be able in clearly defined circumstances to prescribe from a limited list of items and to adjust the timing and dosage of medicines within a set protocol. All nurses working in the primary health care team, including practice nurses, should be eligible for the necessary additional training which would enable them to achieve the qualifications allowing them to prescribe from a nurses' formulary. The arrangements for nurses' prescribing will, under the Bill, ensure that a doctor clinically responsible for the patient is in agreement with the treatment given and that the doctor must ultimately take the final decision if there were to be any disagreement over the treatment of the patient. Good communication with the doctor about variations in dosage will be essential.

All those factors to which I have referred are made possible under the Bill. I trust that your Lordships will agree to give the Bill a Second Reading and, as the noble Baroness suggested, will agree that the Bill has been carefully drafted and is not in need of amendment.

Having made that point, if the Bill becomes an Act, a number of issues may arise regarding the regulations which will be made by the Secretary of State. Certainly, the nurses who would be able to prescribe would include those visiting patients in certain cottage hospitals. However, unlike the noble Lord, Lord Rea, I believe that it would be unwise for that provision to be extended to nurses working in major general hospitals if only because, first, in such hospitals doctors are readily and constantly available to prescribe; and, secondly, the very nature of the illnesses which are being treated in such general hospitals makes it likely that the drug requirements of the patients will be much more complex and that there are potential dangers unless a qualified medical practitioner is available. Those dangers are not only medical. If the extension of the nurses' prescribing powers were to go into such general hospitals, there would be dangers of potential side effects and of those which are medical/legal.

The Bill would give discretion to nurses to take a new degree of independent action, and that is to be welcomed. However, it is important to note that under the regulations which will stem from the Bill there could well be medical/legal implications. If the nurse is an employee of a general practitioner, the GP will be ultimately responsible for his or her actions. If the nurse is an employee of a health authority, the authority will be responsible. The medical defence organisations believe that it should be strongly recommended that nurses who will be involved in the new prescribing arrangements should have their own indemnity cover. The clarification of legal liability for nurses, doctors and health authorities will need to be addressed once the Bill becomes an Act, as I hope it will.

Like the noble Lord, Lord Rea, I was surprised by the figure of £17 million in view of the fact that the drugs being prescribed would have been prescribed in any event by the doctors. However, I am sure that the sum covers nurse education and training as well as the cost of producing and distributing a nurses' formulary. Nevertheless, we shall need clarification of the figure. It is also important to bear in mind that in the regulations which will stem from the Bill when and if it becomes an Act we need clarification of the legislative and administrative changes which might enable dispensing doctors in rural areas in particular to dispense items prescribed by nurses. That is not an issue which to the best of my knowledge has been addressed.

The points that I have raised need to be given further consideration only after the Bill becomes an Act. As I said at the outset, as a member of the medical profession I warmly commend this important Bill to the House.

2.42 p.m.

The Viscount of Falkland

My Lords, I rise to speak on a subject which would normally have been dealt with by my noble friend Lady Robson of Kiddington. She would have congratulated the noble Baroness, Lady Cumberlege, on her work and on her clear presentation of the Bill. It appears to have universal support not only from Members of another place but from medical practitioners, nurses and other interested people.

We on these Benches support the Bill because, principally, it adds to the care of patients in the community. It also adds to the status of nurses, which has lagged behind in recent years. The training given to nurses has fallen behind the increase in their responsibility and capability as regards taking what the noble Lord, Lord Walton, described as discretionary and independent action.

The party for which I speak has a great deal of its representation in rural areas where the new freedom for nurses to prescribe will be clearly appreciated. It has been greatly needed because often there has been a delay which is worrying for patients and frustrating for nurses. They have not been able to prescribe medication which will be included in the new list of drugs available to them as a result of the Bill.

I wish to mention the hospice movement, which I have witnessed in action to some extent in recent times. Admirable developments have been made in the movement, which cares for people who need quick access to medication. There has been evidence of delays which have caused discomfort, pain and anxiety to patients. The Bill will improve that situation.

I now turn to the amount of additional money that is required to implement the provisions of this Bill. That money has been calculated at £17 million for the United Kingdom as a whole. From what has already been said, I understand that training will account for a large part of that expenditure, but we do not know that that is the case. I wonder why something was not stated on that point in the paragraph of the Explanatory and Financial Memorandum dealing with financial effects. We are left with an unnecessary degree of doubt about how the money will be allocated.

However, I congratulate those who have promoted this Bill on persuading the Treasury to agree to the necessary expenditure. I have no doubt the figure is accurate, but it would be interesting if the noble Baroness in her reply could tell us a little more about the costs and the proportion of those costs that will be taken up for training. What is expected to be the increase in prescribing which will result from this Bill?

We on these Benches thoroughly approve of the Bill and of the consensus it has achieved in all quarters. We wish it speedy progress to the statute book.

2.46 p.m.

Lord Carter

My Lords, like other noble Lords, I wish to thank the noble Baroness, Lady Cumberlege, for introducing this Bill. She has explained it with her usual lucidity and therefore there is no need for me to go through it in any detail. I should follow the convention that applies to those who speak from this Dispatch Box and make it clear that my remarks reflect my personal view. However, my party obviously would agree with my remarks. This Bill is a sensible measure and I would advise my noble friends to support it.

Before I discuss the Bill I should remark that there is a procedural matter that interests me. I believe that this is the fifth Bill on health that has been introduced recently as a Private Member's Bill. We have had the Nurses, Midwives and Health Visitors Bill; the Osteopaths Bill and this Bill. We shall shortly deal with the Still-Birth (Definition) Bill which is also a Private Member's Bill. The Bill on community care and residential accommodation was also a Private Member's Bill. All those Bills have been welcomed by the department. I believe that most of them have been drafted by the department. In that case why are they not Government Bills? I shall not take up the time of the House in discussing that. I hope that the Minister will write to me about it and place a copy of the reply in the Library for the benefit of other noble Lords who may be interested in the matter. Perhaps the Government's business managers have their business in rather a muddle and have to rely on private Members to get these Bills through.

We have certainly promised the Bill a fair wind and we shall not table any amendments in Committee. The Touche Ross report is a valuable analysis and it underlines a point that was made by my noble friend Lord Rea that nurse prescribing is already happening informally. Like all analyses of this kind, the Touche Ross report is a cost benefit analysis and it depends on assumptions. Page 42 of the report contains an excellent summary of the measure that we are discussing. It states: We conclude that the nominal value of time saved and the gross costs of nurse prescribing are relatively close, before allowance is made for benefits not evaluated in this study, namely: faster treatment, at times, for patients; benefits from additional items prescribed; increased job satisfaction for nurses". That quotation leads on to a point which has been made by a number of speakers as regards the financial effects of the Bill. The Explanatory and Financial Memorandum of the Bill states: Clauses 2, 3 and 4 will result in an increase in prescribing and dispensing … The cost to the Exchequer has been estimated at about £13.3 million per year for England alone and £17 million for the United Kingdom as a whole". That clearly implies that the extra cost is due to the extra prescribing and dispensing that will occur. Like other noble Lords I thought that perhaps the Explanatory and Financial Memorandum was ambiguous on costs and that it included training. However, I note that the Touche Ross report states on the page which precedes page 1: We have quantified the costs of nurse prescribing that arise from: monetary costs to Family Health Service Authorities for additional prescribing by District Nurses and Health Visitors". The report then states that there is: an annual cost to Family Health Service Authorities, following full implementation of nurse prescribing, of £11.7 million for additional prescription items and £1.7 million for dispensing fees". It goes on to deal with the costs of the prescription for the pricing authority. We all find that difficult to understand because one assumes that those medicines, bandages and dressings would have been prescribed by doctors which will, after this Bill becomes enacted, be prescribed by nurses. An increase in the number of prescriptions can only mean that doctors have been underprescribing. I find that hard to understand and perhaps the Minister will explain it.

I have only two queries as regards the detail of the Bill and I informed the Minister before the debate that I should be raising these matters. I believe that she is aware of the BMA's anxiety about the effect of the Bill on dispensing doctors. The BMA says that clarification is needed on the legislative and administrative changes required to enable dispensing doctors to dispense items prescribed by nurses. As far as we are aware, that problem has not been resolved by the Department of Health. The BMA says that it is possible that an amendment may be needed to the Bill. I hope that an amendment is not needed, but perhaps the Minister can clarify the position.

The other question concerns the growth of the prescribing of generics and pack dispensing, which will increase over time. As the formula is updated and changed, presumably proper account will be taken of the use of generic drugs.

Apart from those two points of detail, we welcome the Bill and we shall do our utmost to ensure that it reaches the statute book before the election.

2.50 p.m.

Baroness Denton of Wakefield

My Lords, I thank my noble friend Lady Cumberlege for bringing forward this Bill. I welcome the support that it has received. Many of your Lordships may know, of course, that the Government have supported the principle of nurse prescribing since it was the subject of a recommendation in the 1986 report on community nursing by my noble friend Lady Cumberlege. The report recommended that: The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well-defined circumstances". Since then a great deal of work has been carried out. As a first step, the Government set up the advisory group on nurse prescribing to advise on, how arrangements for the supply of drugs, dressings, appliances and chemical reagents to patients as part of their nursing care in the community might he improved by enabling such items to be prescribed by a nurse". The advisory group report recommended among other things that nurses working in the community who had district nurse or health visitor qualifications should be permitted to prescribe items from a limited list of products needed for the nursing care of their patients and to supply medicines, or vary their timing and dosage, within agreed protocols.

The Bill of my honourable friend Mr. Roger Sims in the other place provides the primary legislation to enable the prescribing aspect of the recommendations to be implemented. I should, however, mention that we are at the same time taking forward the recommendations concerning supply and changing timing and dosage. However, I understand that they do not require primary legislation.

The advisory group also recommended that a more thorough study of the benefits and a full assessment of the costs of nurse prescribing were needed before final decisions about implementation could be made. As a consequence the Government commissioned Touche Ross to carry out a cost-benefit analysis, copies of which are available in the Library.

The noble Lord, Lord Carter, and other noble Lords raised the issue of financial costs. The Touche Ross report considered that, apart from the one-off costs of implementation, nurse prescribing will cost the Exchequer £15 million per year in England. Most of those extra costs —approximately £11.65 million —are estimated to arise from additional items prescribed. I can understand noble Lords finding that rather strange. I do not believe that those costs will arise as a result of doctors underprescribing in the past. However, I understand that nurses can reach people such as travelling and rootless people. That will be of great help to individuals. Also, they will have greater contact and quicker recognition of symptoms and, one hopes, for the benefit of the people concerned, quicker resolution of the illness. I can assure the House that it is not a figure costed lightly; it will bring benefit to the patients. In addition, there are the costs of pharmacists' dispensing fees, costs at the Prescription Pricing Authority for pricing nurses' prescriptions and monitoring them, the cost of providing copies of the nurse prescribers' formulary, the drug tariff and prescription pads, and various other administrative costs.

Against these costs must be set the considerable benefits from introducing nurse prescribing. Nurse prescribing would do away with the need for doctors to spend their time signing prescriptions for items which nurses need for the care of patients. Appropriately trained nurses would be able to sign them instead. Also, community nurses would no longer have to make trips to the surgery to get prescriptions signed. On an individual basis such time savings are not substantial, but taken as a whole, as my noble friend Lady Cumberlege said, a considerable amount of time will be freed up which community nurses and general practitioners could devote to patient care.

More important, however, are the benefits to patients and their carers. Patients will be able to obtain their medicines and appliances more speedily, which may often mean quicker resolution of problems. In addition, they and their carers will be saved journeys to their doctors' surgeries—not always easy for someone who is ill. And there are other benefits. Community nurses will have the satisfaction of being allowed to take full responsibility for the nursing care they are providing. That is right and proper.

The products which the advisory group thought should be available for appropriately trained community nursing staff to prescribe are listed in Appendix E of its report. Again, copies are available in the Library. Most items on the list can be bought over the counter by patients, if desired, except for the following prescription-only medicines: Nystatin, for oral fungal infections; Clotrimazole, an antifungal preparation; Iodosorb, a medicated dressing, and Varidase, a desloughing agent.

That list is, of course, only illustrative. However, we expect that the final nurse prescribers' formulary will cover roughly the same range as the illustrative one. It is for the nurse prescribers' sub-committee of the joint formulary committee, which produces the British national formulary and the dental practitioners' formulary, to produce a nurse prescribers' formulary. Medical, nursing and pharmaceutical interests are represented on this sub-committee, which has already met twice, and plans to complete its work in the summer.

I said earlier that in line with the advisory group's recommendations nurse prescribing will, at least initially, be limited to those nurses holding a district nurse or health visitor qualification. It is only after monitoring and evaluation of this that other areas may be considered. I hope that that reassures the noble Lord, Lord Walton.

Before such nurses may prescribe, they will of course need training in nurse prescribing. At present the health departments are working with the UKCC and national boards to develop a free-standing module for appropriately qualified nurses. Longer term, it is intended that such training will be incorporated into the curriculum for district nursing and health visiting training. The UKCC has advised the Department of Health about standard, kind, content and length of courses, and the national boards are now organising discussions with course tutors. The courses will cover the items on the nurse prescribers' formulary, drug interactions, reporting adverse reactions, communications with other professionals, good practice in prescribing, budgetary accountability and monitoring, and all other relevant issues.

I am pleased to be able to report that extra money has been made available for this training module. Government have provided funds in 1992–93 for setting up the courses and producing training materials, and funds for the subsequent two years for running the training modules. We envisage that about 23,000 nurses will attend the special courses between April 1993 and April 1995. Nurses who have satisfactorily completed the training module will have their details submitted by the national boards to the UKCC, who will identify them as nurse prescribers on the UKCC register. Eligibility to prescribe can then be checked by bona fide enquirers with the UKCC at any time.

I would like in passing to mention the arrangements for budget accountability and monitoring. More work needs to be done in this area and the Department of Health is working closely with the Prescription Pricing Authority to develop suitable mechanisms. Where nurse prescribers are practice nurses—that is to say, employed by general practitioners —we envisage their prescribing costs being linked to their general practitioners' indicative or actual prescribing budgets. Where, however, nurse prescribers are health authority employed, we envisage each provider unit being responsible for prescribing costs. But, as I said, more work is to be done in this area before final decisions can be taken.

The noble Lord, Lord Carter, kindly gave me notice of the fact that he was questioning the "possible muddle" of government legislation. I am delighted to say that that is not the issue. The issue is that there is no way in which this Bill could have been brought forward before the cost-benefit report was available. That was in November and therefore it could not have been part of the gracious Speech. It is felt that the benefits can be obtained more quickly by taking advantage of my honourable friend Mr. Sims's ability to bring the matter forward.

As regards other matters raised by noble Lords, as has been rightly said it is not necessary to discuss them in detail at this stage. I can only assure them that they will be comfortable with the answers on all those issues. I am sure that my noble friend will draw specific attention to them.

Given the strength of commitment to nurse prescribing that exists on all sides of the House and with professionals, patients and their carers, I hope that I have convinced all your Lordships that the Bill of my honourable friend in the other place is a positive step forward and one that the Government are fully committed to implementing.

I thank my noble friend Lady Cumberlege for bringing the measure forward today. There is still much that needs to be done and the work required to train nurse prescribers, prepare secondary legislation and make the developments needed at the Prescription Pricing Authority means that implementation cannot take place before October 1993. We are working hard to ensure that this implementation date will be met.

3.2 p.m.

Baroness Cumberlege

My Lords, I thank all noble Lords who have taken part in this debate and for the generous remarks that have been made about my personal efforts in trying to get this particular measure enacted. I again pay tribute to my honourable friend in another place, Mr. Roger Sims, and also to the nursing profession which has been unceasing in its attempts and efforts to ensure that this Bill becomes a reality.

I am grateful but not surprised by the overwhelming support for this measure, which I believe is a very common-sense one. It will be effective. It will not only enhance the professionalism of nursing but perhaps, more importantly, it will benefit sick and suffering people.

Perhaps I may pick up one or two points made by noble Lords. I very much welcome the views expressed by the noble Lord, Lord Rea, who is, I believe, the only active practitioner in the Chamber today. He may be the only active practitioner in the House, but perhaps there is one other. I know that the noble Lord is very effective in his practice. I know his practice. It combines the elements of efficiency, effectiveness and compassion. It sets the highest standards in patient care in central London, which is not easy.

The noble Lord raised the question of hospital nurses being allowed to prescribe. Although I share the sentiments and the intentions expressed in that view, I favour the views expressed by the noble Lord, Lord Walton of Detchant. It is early days. We have to experience what this measure will mean for both doctors and nurses before we consider further widening the categories of nurses who are allowed to prescribe.

I share with all noble Lords their views on costs. I have listened very carefully to what my noble friend the Minister has said on the subject, and as always she has been most lucid and persuasive. However, I do harbour the suspicion that perhaps costs have been over-estimated, but that is a fault on the right side. So often costs are underestimated, to the annoyance of the Treasury.

The noble Lord, Lord Walton of Detchant, who has had such a distinguished and inspiring career, raised the question of legal implications. As I understand it, the well-known principle of employers' vicarious responsibility remains. But nurses will, of course, have their own professional indemnity. I understand that this is an area where the department intends to issue covering guidance before nurse prescribing is introduced to enhance clarity. I hope very much that we shall be able to satisfy the concerns of the British Medical Association. If this Act is to work properly it needs partnership in its broadest sense between doctors and nurses.

I should like to thank the noble Viscount, Lord Falkland, for passing on the kind thoughts of his noble friend Lady Robson who was my predecessor as regional health authority chairman in South West Thames. Her reputation still enhances the work of the authority. I very much agree with the noble Viscount that rural areas will greatly benefit and I share his admiration for the hospice movement.

The noble Lord, Lord Carter, brought to the debate the support of his party for this Bill. I should like to thank him for that and for his undertaking not to amend the Bill further.

My noble friend the Minister has given the Government's support. That is of course crucial, for I fear that we shall be overtaken shortly by events beyond our control. In conclusion, I welcome the support that has been given this afternoon to give this Bill a speedy passage. That we are able to enact the Bill. I am sure that the nursing profession throughout the country will be very grateful. Finally, I formally request this House to give the Bill a Second Reading.

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