Nurses in the NHS

HL Deb 16 June 1998 vol 590 cc1539-56

7.59 p.m.

Lord Morris of Castle Morris rose to ask Her Majesty's Government what action they propose to take to deal with the problems arising from the recruitment, retention and retirement of nurses in the National Health Service.

The noble Lord said: My Lords, I am not what I seem. I am No. 445590 Morris, Brian, d.o.b. 4.12.30, male, C of E. I know this because it was written on the little plastic bracelet placed on my wrist on 21st January last when I became a patient in The Royal Hospital, Chesterfield, whence I came this morning to ask the Question standing in my name.

The facts are not in dispute. We are facing the worst nurse shortage crisis in 25 years: the first ever shortfall in applications for nurse education places in England. In 1993/4 there were 18,100 applications for 12,000 places. In 1996/7 there were 15,400 applications for 16,100 places. Turnover among registered nurses was 21 per cent. in 1997, up from 12 per cent. in 1992. Vacancies remain unfilled. One report in 1997 suggested that there was a shortage of more than 8,000 full-time posts across Britain. The Royal College of Nursing reports that the number of nurses aged over 55 will double over the next five years, with 25 per cent. of registered nurses in the NHS eligible for retirement by the year 2000.

What a boring recital that is. How easy it is to ignore that set of percentages. It will be all right; someone will do something. The Government will find some money. After all, nursing is a vocation, is it not? Nurses will not take industrial action; they care too much about their patients. That is not good enough; it will not do. Try being one of those patients and see how you feel.

Last March the Nuffield Trust published Improving the Health of the NHS Workforce. That report said that the most commonly cited causes of psychological disturbance among nurses were high workload, workload pressures, the effect of workload on personal life, staff shortages, unpredictable staffing and scheduling, and not enough time to provide emotional support to patients. I have watched that happen every day since 21st January on a medical ward in a typical county hospital. On the morning I was admitted to The Royal Hospital, Chesterfield, my first impression was of nurses hurtling about, moving beds, answering telephones, dishing out meals like waitresses, making beds, dispensing drugs, or sitting at the nurses station writing up reports, requests and readjusting notes, endlessly rushing round or writing. One senior nurse said as she left the ward that she had done a nine-hour shift. She had not had time for a break. She had not had time to eat or go to the loo all day. The reference in the Nuffield Trust report to the "effect of workload on personal life" is euphemistically polite. It means: how does one cope with a physically and emotionally exhausting hospital shift and then go home and look after one's children or dependent relatives, or study for hours to get additional qualifications, or to keep up to date, and then do the housework? One young nurse who had been married for only a year or so summed it up cynically and succinctly when she said that these days nursing did not do much for wedded bliss. I could see what she meant.

In Shakespeare's "Troilus and Cressida", Agamemnon asks Ulysses: The nature of the sickness found, Ulysses, What is the remedy? My noble friend the Minister may well put the same question to me, since I have told her little that she does not already know and I have suggested no solutions. What we can all welcome is the Government's £2.15 million nationwide campaign to recruit nurses. I hope that when my noble friend replies she will be able to give the House an up-to-date report on progress in that initiative. A young woman, or now a young man, aged 18 considering nursing as a career must qualify via a three-year course given or validated by a university, which is equivalent to any other university first degree course. It is true that bursaries worth some £4,000 to £5,000 are available, but upon graduating successfully the nurse will start work with a salary of some £12,000 while her contemporaries entering other professions or businesses will immediately command a much higher figure. Those contemporaries will rarely be called upon to empty bedpans, clean up the incontinent, or mop up vomit in the earliest years of their employment; nor will they often carry life or death responsibility for their clients. A higher starting salary after registration may encourage potential students to view the prospect of nursing as a career with greater equanimity.

Better career development plans would help. Almost the only way to gain significant promotion is to leave the bedside and go into management or academic work. Is there not a case for establishing a new grade of top rank nurse? That is exactly what is proposed for really good teachers in schools who do not wish to become head teachers because that would remove them from the classroom teaching in which they excel. Something must also be done about the high drop-out rate in pre-registration training. Some areas report 30 per cent. and more. This is surely an avoidable waste of scarce resources. This is closely studied in the attrition formula described on page 123 of the report Project 2000: Fitness for Purpose by the Universities of Liverpool and Warwick. Perhaps the Minister can also bring us up to date on the prospects for that report's recommendations.

One thing comes through again and again about pre-registration training: practical clinical skills are not sufficiently achieved by the student. The clinical teacher role has gone and quite senior clinicians have to waste their time teaching new nurses how to do things on the wards. Perhaps an internship for the diplomates at the end of their course is necessary. After all, new nurses are in law accountable for their practice from day one.

The Project 2000 report also discusses the possibility of an entirely new structure for training health service professionals in which medical students, nursing students and others are taught together those basic, elementary things they all need to know, for example how to give injections correctly, and even how to wash hands correctly. I have seen several very dry thumbs in the past five months. An integrated preliminary course could lift the status of the nurse and aid recruitment considerably. Will my noble friend look kindly on the idea?

Turning to the problems of retention and the awesome 21 per cent. turnover rate, can my noble friend assure me that family-friendly employment policies are being fostered by her department? Forty-eight per cent. of nurses have caring responsibilities for dependent children. Twenty-five per cent. have caring responsibilities for dependent adults. How on earth do they cope? The RCN reports that some 66 per cent. of nurses have no workplace crèche or nursery facilities available. Surely, this must be given higher priority.

Related to this is the issue of so-called goodwill hours. In the past months I have watched very many nurses due to stop work at the end of a shift work on for several hours simply because there is work to do for one or more of their patients. They cannot and would not charge money for this time, nor could they demand time off in lieu because that would complicate the shift rotas. They simply work the extra hours for nothing. I tried to find out the national figures for this voluntary work and was told they were not recorded, no doubt on the fine old Civil Service principle of "do not ask a question if you think you might be appalled at the answer". Can my noble friend give us some idea of the extent to which the NHS is dependent on this free service?

I am sure that the retention of nurses is being improved by the developments that this Government are bringing in: skillmix, the NHS Direct Scheme, nurse prescribing, primary care groups and clinical governance. They will make the job more challenging and responsible, but there is still a long way to go.

To solve the retirement problem is in a way much simpler. Either you let most nurses retire at 55 and concentrate on recruitment and retention to maintain the workforce, which is simple but risky, or you make the final decade of employment a period in which the physical workload is reduced and these experienced nurses are given increased administrative, advisory and mentoring responsibilities. I suspect that what most of them want is not power or riches but job satisfaction.

All reassurances and good news that my noble friend can give in her reply will be gratefully received by patient No. 445590 and by every nurse in the nation.

8.9 p.m.

Baroness Cumberlege

My Lords, I start by declaring an interest as vice-president of the Royal College of Nursing, sadly, not a pecuniary interest; and I know that other Members of your Lordships' House here tonight are also vice-presidents. I wish also to thank the noble Lord, Lord Morris of Castle Morris, for the brisk and arresting way in which he introduced this important debate.

Nursing is probably as much an art as a science, for although nurses have embraced modern technology with flair and enthusiasm, nursing has also a scientific base. It is as much about good communication, advocacy, supporting carers and understanding complex family relationships as mending broken minds and broken bones. GPs now recognise that in addition to those skills nurses are fast becoming the experts in asthma and diabetic care and that with an increasingly elderly population we need nurses now more than ever before.

That is the dilemma which the Government face. Nurses' salaries account for 2.6 per cent. of total public expenditure. That is not NHS expenditure, but total public expenditure. One per cent. on nurses' salaries adds £83 million to the NHS pay bill. In terms of public expenditure, one suspects the Treasury feels that there are too many nurses. But the public beg to differ. There are too few.

This morning the Secretary of State announced another 2,000 hospital beds in order to tackle waiting lists. I, among others, rejoice in that. And, he added, we will recruit more doctors and more nurses". It takes three years to train a nurse. On a rough calculation, the Secretary of State is talking about another 2,000 nurses in the next few months. So my first question to the Minister is this. From whence cometh these nurses? The ENB statistics show a shortfall in applications for nurse education places. We know that 60 per cent. of employers report "current and significant problems" in recruitment; and the pay review body suggests a shortfall of 8,000 nurses across the UK.

My second question concerns the status of nursing. When I left school there were really only three careers open to young women unless they were pioneers. One could be a teacher, a nurse or a secretary. Today women are making successful careers in the law, the City, the media, medicine, accountancy and so on. This means competition to recruit to nursing has never been harder. In order to attract more of the very best candidates, I believe that we have to raise yet again the status of nursing. It should be a career regarded as fruitful as those I have mentioned, and that requires an all-degree profession. Of course the work still has to be done and there is an important role for those with national vocational qualifications. But we need the brightest men and women to join this all-important profession. Does the Minister agree, and would she like to comment on that?

My third question relates to retention. Nurses have a thirst for knowledge. The vast majority want to realise their potential and practise the art and science of nursing to their maximum ability. Doctors receive a postgraduate educational allowance. Most nurses have to pay for their postgraduate courses, and it is difficult when they require to be released from their duties by their employer, in particular when it is a GP. That seems to me unfair. Can the Minister consider this inequality in opportunity and ensure that nurses also receive an allowance for postgraduate courses?

8.13 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Lord, Lord Morris of Castle Morris, for asking this most important Question. Instead of one meagre dinner hour debate, the subject needs your Lordships' highest priority. I hope that the Government will treat it with the utmost urgency.

When I broke my back years ago and had multiple injuries resulting in a great deal of pain, my life was saved by the skill of excellent doctors and nurses who understood the specialty of spinal injuries. In the hospital there was a matron who was highly respected, and sisters who worked on the wards with the patients, junior doctors and nurses, and knew how to make a patient comfortable.

Those days have gone. Recently my husband, my noble kinsman Lord Swinton, was in hospital for three months. I saw the sister once, and that was when he had emboli in his lungs—a very dangerous condition.

The removal of senior staff from the wards was recently brought home to me when I visited a private hospital in Aylesbury. One of the very senior and best sisters from Stoke Mandeville Hospital was running the nursing in that private hospital. As a result of regrading, her senior post had been made redundant, just to save money. What about her years of experience, which were lost to the National Health Service?

For many nurses the only way to gain promotion is to leave the bedside and move into management or academic work instead, according to the Royal College of Nursing. I feel that not giving junior nurses the security and benefit of having senior specialised nurses to give them back-up and support is one of the many reasons that young nurses with very difficult patients to nurse feel unable to cope and leave the profession. It is even worse at night when a young, inexperienced nurse can be left in charge of very ill patients who are recovering from operations. She or he may feel overwhelmed and patients may feel insecure. Patients as well as nurses need emotional support.

When there are staff shortages and difficulties in recruitment, the wrong people may be appointed. With so many very seriously ill patients to nurse, more and more equipment—I refer to turning beds, low air loss beds, hoists and so on—is being used. Many agency and pool nurses do not know how to use the equipment and are frightened to do so. Why not have specially trained non-nursing staff, such as handymen or security staff, to work such equipment? This would save the nurses' time and their backs.

I come from North Yorkshire, where at the moment the turnover in nursing staff is low compared with many parts of the country. But all the chief nurses are concerned about midwifery. A new system is being introduced nationally from next April under which trusts will receive only partial reimbursement of the costs of midwifery training. Many fear that trusts will be put off from encouraging nurses into midwifery training. The main problem in York is a shortage of theatre nurses. That has an impact on the number of operations the trust can perform, and therefore influences the waiting list situation.

The workforce is ageing and retiring. We must find ways of attracting young people into the profession. The National Health Service cannot look after patients without good, reliable, well-trained nurses.

8.17 p.m.

Lord Hunt of Kings Heath

My Lords, I, too, thank my noble friend Lord Morris of Castle Morris for instituting this important debate.

As we celebrate the 50th anniversary of the NHS, it is an opportunity to reflect on the contribution which nurses are making in care, professional development, teaching and research, and, above all, in improving the quality of service that we give to patients. It is also appropriate to reflect on the extraordinary change in the role of the nurse in the past few years. Nursing practice has changed dramatically. Nurses have taken over many of the duties previously undertaken by junior doctors. Not only has the service been more effective, but many patients very much enjoy that and support it.

The shift towards primary care will also enhance the role of nurses. I refer to the increase in the number of practice nurses and nurse practitioners. I am anxious that primary care groups will give to nurses a strong leadership role. Perhaps some primary care groups will be led by nurses. I certainly hope so.

The agenda for the future is exciting for the nursing profession. We have to set that against the context of the problems in recruiting which have been so graphically described in the debate tonight. Some of those issues can surely be dealt with through good practice. We have heard about family friendly policies and initiatives to attract nurses back to the profession. But I am convinced that overriding that factor is the need to enhance the role of nurses in management and leadership. I take the point that those nurses who wish to stay in nursing and practise nursing at the patient level should be encouraged and rewarded to do so. But equally we must have strong leadership in management positions in the health service.

In the past few years we have seen many trusts remove a range of management posts so that between the ward sister and the director of nursing we have lost a number of nurse managers. That means that there is no clear progression for nurses who wish to pursue a career in management. Nurses on wards sometimes believe that their voices are not heard at high levels.

I commend the RCN approach in encouraging nurses to take up leadership positions and leadership projects. But the NHS must do much more. We need more nurses at the top table, whether in trusts, health authorities or at the Department of Health. We need more nurses leading debate not only about nursing issues but about the whole future of the NHS and the key priorities that we need to address. If we can do that I am sure that we can improve the quality of service and begin to improve the quality of support given to nurses in so many stressful situations. Above all, I am sure that we will then be able to recruit and retain more nurses.

8.20 p.m.

Baroness McFarlane of Llandaff

My Lords, we are all delighted to have the noble Lord, Lord Morris of Castle Morris, here tonight and we are grateful for the vigorous way in which he raised the Question. He promises to be the most cherished patient in the NHS from here on. He has given us the three Rs of nursing workforce deployment. I wish to focus on the relevance of educational issues to those three problems. Since 1932 and the Lancet Report on nursing, there have been successive reports at five or 10-yearly intervals. Perhaps the time is ripe to look closely at what is happening in the service, in particular nursing education.

The report which changed the face of nursing education was the UKCC report Project 2000, published in 1986. As the noble Lord said, since 1989 nurses have been educated in the higher education sector and take courses in diploma and degree level qualifications. Yet I hear criticism of the Project 2000 system and it is timely that we should examine that.

The major criticism I hear is that the newly registered nurse is no longer a confident practitioner when she comes to the ward. The noble Lord referred to that. The perception is that the amount of clinical practice has been greatly reduced to accommodate academic studies. I believe that that is a misconception. Dame Betty Kershaw has confirmed to me that 50 per cent. of the course is in clinical practice, as compared with her figures of 53–54 per cent. in 1989. The major difference is that 50 per cent. of that clinical practice takes place in the community, which is where the majority of patients are nursed. That is right and proper, but it may explain why nurses coming to a ward appear less confident. I join the noble Lord in recommending that we examine the possibility of an intern year.

Secondly, the consortia of trusts which commission nursing education rightly do so with an eye to workforce needs. But there is very tight control on the numbers and little ability for the students to change the branch of nursing into which they have been recruited. This may be a disincentive and we should look at whether some relaxation of that strict control by consortia is possible.

Thirdly, the Project 2000 system may create certain shortages. There is no longer a direct entry in psychiatric nursing. The student follows the foundation course and may never see a psychiatric nurse or psychiatric practice for the first 18 months. One can understand the increased wastage in that area. Therefore, there may be a case for looking at how we prepare psychiatric nurses. A course more allied to social work may be beneficial.

We have a widened date of entry, with people with BTEC and NVQ qualifications, but there is also greater wastage and academic failure in the courses. We need to address that problem and the causes of it.

8.25 p.m.

Baroness Emerton

My Lords, I thank the noble Lord, Lord Morris, for posing the Question arising out of first-hand experience of hospitalisation and treatment. I trust that the good progress made from his treatment will continue.

I declare an interest. I am chairman of a large acute trust, chairman of the Nurses Welfare Service and a nurse on the effective register of the UKCC. Furthermore, I must confess that I was chairman of the UKCC when Project 2000 was introduced. I wish to make a few suggestions relating to the recruitment, retention and retirement of nurses.

Recruitment and retention is cyclical within the health service. There is no doubt that there is now a real problem in the NHS. A multiplicity of factors have an effect on recruitment and retention and to a certain extent on retirement. We have already heard mention of the reduction in the number of entrants into nursing. However, this Government have invested more money in training and there has been an increase in the number of training places. The problem lies in attracting more young people and more mature entrants into the nursing profession.

Nursing is a caring profession. I believe that the ethos of caring needs to be developed in our young people. Will the Minister consider discussing with her colleagues in education using the school curriculum to influence more young people in community service during their final year in school, perhaps introducing caring skills into the curriculum? I am sure that we all agree that society generally is not a caring society and that we need to influence young people to enter the profession.

The attrition of students remains high and we need to examine selection procedures. Now that we have nursing education within higher education, perhaps we need to examine our selection procedures. I suggest that research is undertaken into what we are looking for in nurses entering the profession. While nurses need a good academic base, they need a good theoretical knowledge, too. They also need to be able to correlate that in delivering practical skills. We must be able to identify that in our selection process. I believe that we need a research project into selection techniques.

As regards retention, we in the NHS recognise that we live in a dynamic organisation with many changes. Nurses still give 80 per cent. of direct patient care. However, there is a worrying factor in relation to sickness and absence. Mention has been made of the recently published report, Improving the Health of the NHS Workforce. At present, 29–48 per cent. of nurses suffer from exhaustion leading to suicide. That is a high level and considered to be significantly higher in nurses than in equivalent professional groups. The trust that I chair sets a target of 3 per cent. sickness. We reduced the level from 6 per cent. to 3.5 per cent., but it has now risen to 5 per cent. I believe that we really could improve matters if the Government would take a lead on the points made by the Nuffield Trust.

Finally, the Nurses Welfare Service is caring for 166 nurses suffering health problems as a result of issues not picked up during their period of work. More sensitive management would probably enable those problems to be identified more easily.

8.30 p.m.

Lord Graham of Edmonton

My Lords, on hearing the noble Lord, Lord Morris, we were reminded of what the House has missed for four months. I had not realised how great a servant of this House he has been. On behalf of many colleagues who are unable to be with me tonight, I say to the noble Lord, Lord Morris, that we are delighted that he is here and in comparative good health because I know that he has been through a great deal during the past few months. I am pleased to see also that he is in good heart and fighting fit.

I have been fascinated by the amount of expertise and experience that has been demonstrated on all sides of the House. That must stand the Minister and her colleagues in good stead. Not for the first time, the noble Lord, Lord Morris, has rendered a great service to this House and to the nation by reminding the Minister and her colleagues of problems of which they may be aware but about which it does not do any harm to publicise the anxieties of members of your Lordships' House.

I suffered an illness and someone must have gone very carefully through my CV because when it was noted that I was a former Chief Whip, I was sent to Whipps Cross. It should have been Chief Whipps Cross and it is a cross that I have had to bear more than once. There is better to come!

From the experiences that I had, I thought that the noble Lord, Lord Morris, was describing my ward—which, incidentally, was called Peace Ward—when I think of the frenetic manner in which the servants of the nation, whatever their rank, were looking after their patients. I came away from my stay in hospital not only, as I hope most people do, with a deep sense of indebtedness for the professional care but I was grateful also for the calmness, steadfastness and the patience of all those who work in our hospitals.

What staggered me was that from seven in the morning until nine at night—and there were some who worked all those hours—the staff never seemed to have one minute's rest. The noble Lord referred earlier to someone working for nine hours. I formed the view that everyone who served in that hospital worked extremely hard. It was a Victorian hospital which the noble Baroness, Lady Cumberlege, will know from her experience as a Minister. It was one of those hospitals which was built to serve the needs of a large number of people over many years. It is loved by the people who look upon it as their hospital. The same is true of Chase Farm Hospital in Enfield, where I lived for many years. Those hospitals have a special place in the heart of the community. The North Middlesex Hospital, which I know very well from my constituency, is another example of that.

I hope that the Minister will be able to say this evening that she and her colleagues appreciate very much the dedication of the nursing staff. Of course they are entitled to a fair reward. As a trade unionist all my life, I believe that they should be vigorous in putting forward their case. But, even if no more money can be provided, there should be at least an acknowledgement—and the Minister may be able to give that this evening—of the care and comfort which the Minister and her colleagues must take from knowing that we, the nation, are served so well by extremely devoted nursing staff.

8.33 p.m.

Baroness Amos

My Lords, I too thank my noble friend Lord Morris of Castle Morris for introducing this important debate. I must declare an interest as a non-executive director of University College London Hospitals and also as chair of the Royal College of Nursing Institute. I should like to focus on recruitment and retention in London. The main issues are that there are not enough qualified nurses in the system, a point made already by the noble Baroness, Lady Cumberlege. London trusts are competing for the same staff and therefore they have difficulties working in partnership, although the Promoting London Campaign has begun to address that, as several London hospitals are now advertising collaboratively.

There are particular shortages in some specialist areas—for example, theatres, intensive care and renal nursing. Accommodation costs tend to be much higher in London in relation to comparative accommodation outside. Host-registration rotation programmes have been difficult to establish and maintain. Those problems might be resolved if rotation became an educational requirement as it is currently in the medical profession.

Over the past three years, UCL hospitals have made significant improvements in their recruitment techniques to increase effectiveness. But the retention of nursing staff has remained a problem. During 1997–98, the overall turnover was 30 per cent. and was particularly significant in the lower nursing groups of D and E.

So how have we sought to address our particular needs? Our trust board has ensured that recruitment and retention issues have been identified as a high level performance indicator, and on the recruitment front, like many trusts, we have sought to recruit abroad. We have targeted newly qualified staff and we were involved with a customised job fair in 1997 which had the additional benefit of promoting the trust and promoting nursing in particular. We are in the process of reviewing our publicity material to ensure that we are recruiting from as wide and diverse a group as possible.

I endorse the view of my noble friend Lord Hunt of Kings Heath that we must enhance the role of nurses among management and leadership. But it is clear that we need to change the image of the National Health Service and promote the benefits of working in the service if we are to attract and retain nurses. I am particularly concerned that although historically, ethnic minorities have been over-represented in nursing, many of those nurses would not recommend it as a career to their children because of the way they have been treated.

I turn now to retention. Initiatives have included extending the scope of appraisal and personal development planning, agreeing a study leave policy and being more flexible as regards working hours. I am aware that the Government's strategy is to increase training levels and to invest in initiatives to improve the recruitment and retention and return to the practice of trained staff. I have been encouraged by the national promotion of flexible and family-friendly working hours.

I am encouraged also by the continuing commitment and high quality of care demonstrated by our nurses. We need to find ways to support and sustain that commitment. At a national level, we need to continue to increase training levels; to encourage more trained nurses to return to the profession; and we need to focus on valuing, motivating and involving nurses by looking at working practices, stress levels in the work place, employment security and protecting staff from discrimination and harassment. Most important, we need a clear framework at national level for local autonomy, flexibility and accountability.

8.39 p.m.

Lord Addington

My Lords, first, I am very happy to take on—duty is not the right word—the task of saying how good it is to see the noble Lord, Lord Morris, back. I have always felt that he is one of the most forceful and entertaining speakers in your Lordships' House. No matter what else he has been through, I am extremely pleased to see that he has not lost his touch.

When one thinks of nurses, a series of images comes to mind based on personal experience. I usually think of a nurse desperately trying to get the damaged rugby player patched up and thrown out of the place on a Saturday before the real work starts. She tells him to go to see a physiotherapist and pushes him away. That is because there is always that horrible experience about to happen when the pub shuts. That is when the real work starts. That is when nursing staff encounter people falling over, or into, each other, often wielding bits of glass. That is when the sportsman will say, "I don't care if it's broken, I will come back tomorrow." One felt that one should not be there because something more serious was going on.

Nursing is a comparatively low paid profession that has never enjoyed a proper status, despite having to deal with a society literally red in tooth and claw. We do not pay the profession enough respect and never have done. Nursing's image has always been tainted by sexism and the view that it was for the worthy female. Nursing has always been the Cinderella of the medical profession.

Often, an experienced nurse is infinitely of more use, especially in a casualty ward—which is my only real experience of hospitals—than a junior doctor, who is usually rummaging around for help most of the time. Anybody who attended university with junior doctors had the feeling that they should not be allowed anywhere near patients for the next 10 years anyway.

The only thing we can really do for nurses is pay them more. It is easy for the Government to say, "We are spending more on the National Health Service and pay rises are coming." But when a government say that a pay claim is to be split and not implemented in full, that sends the wrong message. Unless we up pay standards for nursing, the profession will not retain staff—particularly in areas where work is hard and accommodation is expensive. The noble Baroness, Lady Amos, put her finger exactly on the point, but was probably too kind to members of her own Front Bench to follow through on the comment. We must pay for a quality service. Unless we are prepared to invest in those people, we will have problems.

The similarities between nursing and the teaching profession were pointed out by the noble Lord, Lord Morris of Castle Morris who referred to a super grade of practitioner who would be paid more. That will not do, even if it is introduced. We do not want one wonderful nurse running around; we want lots of good nurses. Overworked nurses will make mistakes, no matter how good they are. The real problem is status, and that is so closely linked to pay that one might as well put them in the same sentence. The problem of status is particularly acute where there is need for staff of the highest quality.

8.42 p.m.

Earl Howe

My Lords, the noble Lord, Lord Morris of Castle Morris, has shone a spotlight on the most important challenge facing the National Health Service—the need to recruit, train and retain sufficient numbers of nurses for every branch of health care. We are all immensely grateful to him, even though the time made available for this debate was so short.

There is little doubt that the pressures on the health service from nursing shortages are real and growing. Over the past few years there has been a steady decline in the initial entries to the UKCC register of about 25 per cent. since a decade ago. In 1985, student nurses numbered some 71,000—all of them employed in the NHS. By 1995 there were fewer than 40,000 student nurses—not all of them working in the NHS. Nursing shortages are apparent across the board, but obvious in specialist disciplines such as cancer care, paediatrics and mental health. The difficult recruitment climate is partly due to the smaller pool of potential recruits in the current demographic trough of 17 to 20 year-olds. It reflects also the stiff competition that nursing, as an increasingly graduate profession, faces in the employment market. As my noble friend Lady Cumberlege mentioned, young people see nursing portrayed in the press and elsewhere in a less favourable light than other professions and decide that it is not worth considering.

A welcome if only partial counterbalance is the enhanced appeal of nursing as a broader-based profession. As the noble Lord, Lord Hunt of Kings Heath, said, nurses now do many things previously done only by doctors. That widening of skills undoubtedly makes nursing more attractive to individuals—usually graduates—who relish a higher intellectual challenge.

If we are to improve the recruitment graph, the so-called entry gate must be as wide as possible so that not only graduates but bright, caring school leavers with motivation, as well as mature adults, are enabled to join the nursing register. Also, much more information needs to be made available to school children about what nursing is all about. I agree entirely with the noble Baroness, Lady Emerton. There needs to be specific targeting to attract new entrants and the projection of a positive image of nursing and patient care. There are numerous opportunities for universities and hospital trusts to target by way of job fairs, open days, work placements and links with specific schools.

In some parts of the country, the retention picture is worrying. As we heard from the noble Lord, Lord Morris, national turnover is around 21 per cent a year. Although that figure is bad enough, it is an average. I have visited trust hospitals where staff turnover is only just in double figures. Other hospitals have to manage what seems to be a never-ending haemorrhage of nursing staff and, simultaneously, a constant recruitment crisis. With the cost to a hospital trust of replacing a nurse estimated at £4,900, a high or even average staff turnover represents a substantial drain on resources.

There are many reasons for nurses leaving, but the most significant seem to be stress and lack of job satisfaction. Pay appears not to be an issue in itself but, when combined with other grievances, its importance tends to be magnified. The extent to which good human resource management in a hospital trust can make all the difference is striking. Trusts that adopt family-friendly policies such as flexible rostering and crèches seem to do a lot better. The same is true of trusts that provide automatic clinical updates for nurses and where emphasis is placed on professional development and career progression.

All too often, nurses find that the ability to do their jobs as they wish is hampered by competing time demands, not least from paperwork. Perhaps the biggest single source of stress is the shortage of nursing and support staff. From that perspective, the current crisis in nurse numbers has the potential to become self-fuelling, which must concern us. I am convinced that much can be done to improve the situation. We need to encourage nurses who have moved away from the profession to return. Hospitals should offer re-entry courses, preferably free of charge. Also, to alleviate the stress felt by qualified nurses that the noble Lord, Lord Morris, graphically described, we must examine closely ways of improving the skill levels of health care assistants, to enable them to take on greater responsibilities. The best way is a national register of qualified health care workers, to act as a lever for raising standards in hospitals and social care generally.

8.48 p.m.

Baroness Jay of Paddington

My Lords, my thanks to my noble friend, Lord Morris of Castle Morris, go beyond the normal courtesies. I am delighted that he was in his place to introduce this short but authoritative debate and to find him in such characteristically vigorous form. It is wonderfully characteristic of my noble friend not only to slip unnoticed into his place following his recent illness but to mark his return by opening a debate that clearly reflects his lifelong concerns for the caring professions and his capacity to identify the most important issues in our public services.

No one who participated in the debate needs reminding that without nurses there could be no National Health Service. The debate gives me a welcome opportunity to pay tribute, as I was encouraged to do by my noble friend, Lord Graham of Edmonton, to the one million staff of the NHS, particularly members of the nursing profession.

Everyone taking part in this debate has recognised the huge variety of roles that nurses undertake every day of the year. However, we all recognise that there are problems and tensions. We know that there are very real issues to address. Perhaps I may focus briefly on some of the key issues that have been raised which the Government feel are priorities to improve the essential three Rs encompassed in my noble friend's Question; namely, recruitment, retention and retirement.

My noble friend was right to call for a strategic approach to the 3Rs. The Government have recognised that a new overall development programme for nursing into the next century is vital and necessary in the short term. In our White Paper, The New NHS, published just before Christmas, the Government made clear their commitment to strengthen the nursing contribution to healthcare. To follow this, in April my right honourable friend the Secretary of State announced to the Royal College of Nursing congress that we would start a consultation exercise on the development of a nursing, midwifery and health visiting strategy. That is currently under way and we expect to see some results from a nationwide exercise involving widespread written and spoken consultation before the end of the year.

Our fundamental aim is to ensure that the nursing profession is given all the support that it deserves so that nurses can feel involved and can achieve their correct status, as mentioned by several speakers. Their efforts in delivering high quality healthcare to our communities must be both recognised and rewarded. For example, we are anxious to see nurses take their rightful leadership role in the organisation and governance of the new NHS. That will be especially important in the primary care groups where each board will be required to have a nurse representative.

We already have around 80 personal medical service pilots, as they are called, under the primary care Act. which are taking place. It is worth pointing out that 10 of those 80 are led by nurses and that they involve nurse practitioners and GPs working in partnership. In addition, two of the pilots involve nurses taking full responsibility for the practice contract and, indeed, employing a salaried GP. My noble friend Lord Morris may be interested to know that one of these, covering a population of about 2,000 people, is in south Derbyshire where a salaried GP is employed and the pilot aims to develop a nurse triage system for appropriate GP referrals.

We welcome those developments and we are of course seeking to encourage them, but to recruit and retain nurses who are willing to take on those leadership roles we must first address the things to which noble Lords have drawn attention tonight which are important to individual nurses—better promotion prospects, gaining broader experience, better training and development opportunities and better or more suitable working hours with less stress. We also recognise the need to address violence, employment security and discrimination as well as the need for a fair pay system. Just as important is the need to invest in nurses and to improve their training and development—the first of my noble friend's 3Rs, recruitment. I am pleased to tell my noble friend that we are investing £800 million this year on training nurses and on professions allied to medicine. Last year the numbers entering training increased by 1,700 places and a further increase is planned for this year. It is not enough, but it is a good start.

New students are of course the lifeblood of nursing and, therefore, the lifeblood of the NHS. It is essential that they are properly valued and supported while they are training. Their financial security is of course most important. The new funding arrangements being introduced this September in response to the Dearing Report are good news for them and for the other professions involved. After agreement last autumn between the Department of Health and the Department for Education and Employment, they, together with midwives and PAMS, will have tuition costs met and will have access to NHS bursaries, which have just been uplifted. We expect this to mean a better deal financially for nurses and for other healthcare students.

It is possible that these new financial arrangements are encouraging new applicants and that may partly explain the success of our latest recruitment programme, which my noble friend and other noble Lords mentioned. As my noble friend said, the £2.15 million initiative was announced in the autumn to boost recruitment and aid retention. It includes a national nurse publicity programme. So far I am pleased to tell your Lordships that the campaign has attracted 14,000 responses, which is very encouraging.

However, to take up the point made by the noble Baroness and the noble Earl, Lord Howe, we need to try to introduce the values of public service at an even earlier stage. I am pleased to tell the House that the NHS Executive will be running a competition in secondary schools in the next academic year with the idea of challenging negative and traditional stereotypes about health service employment, raising awareness about NHS career opportunities and encouraging a broad range of applicants from across society.

Of course, attracting young people to take an interest in the NHS is only the beginning. Retaining them, once they have been recruited, is the next of my noble friend's significant Rs. Perhaps I may quite frankly say that we are concerned that about 100,000 nurses who are on the UKCC register do not appear to be working. We need to provide much more imaginative and good career opportunities to help people return when often they have retired temporarily for very good reasons. They take career breaks because of their family responsibilities, as several Lords mentioned, but may want to return to a profession which they valued at an earlier stage.

My right honourable friend the Secretary of State announced at this year's RCN congress a further £4 million for local investment in return-to-practice initiatives; for example, to run projects which seek out nurses in the local community who are currently not practising to encourage them to consider resuming their careers on a personal basis and to prepare them for a return to work. In my personal experience of talking to trust chief executives who have been attempting new recruitment programmes, especially following up the waiting-list initiative, these local campaigns seem to be successful.

The NHS Executive recently sent out a resource pack called "Sharing Ideas" to all trusts. It is aimed at helping employers both to recruit and retain staff. The pack is called "Sharing Ideas" because that is simply what it aims to do. For example, a consortium of employers comprising 10 trusts pooled its investment of return-to-practice moneys to fund an area-wide initiative beyond the catchment basis of their individual trusts to recruit non-practising nurses living locally and outside the usual recruitment channels. That initiative resulted in 200 inquiries ranging from nurses who had last practised between six months and 20 years before. Indeed, 75 of them subsequently took up courses and a re-run of the advertisements produced a further 150 inquiries. We are also determined to exploit the added attractive employment opportunities of NHS Direct. These 24-hour nurse-led helplines are proving an enormous success in the three pilot sites already established. We are going to press ahead with the plans to make this a nationwide service as soon as possible.

The new system has advantages for some of the nurses we have been discussing, as well as for patients. I have in mind nurses who perhaps want to work different hours than those in traditional shift patterns, nurses who want less physically demanding roles than those on the wards or those who are often older women who want to revitalise their skills in a different environment. All of them can be very satisfactorily and satisfyingly enrolled in NHS Direct.

There are some concerns about a retirement bulge developing within the nursing profession. Although many nurses are in their 40s and 50s and are technically eligible to retire from the age of 50, I can assure noble Lords that the average retirement age is around 59. Rising numbers of retirements are expected from the turn of the century but we have this under review. The impact is being assessed as part of the workforce planning being undertaken by the NHS. We cannot alter the natural demography but we can develop a strategy for dealing with it; and we are doing so.

We are determined overall to make the NHS a better and more attractive place to work. The general human resources strategy which my honourable friend Alan Milburn is spearheading is directed towards a more co-operative culture where staff are listened to and where there is an evolutionary approach to management and change.

Trusts are already tackling a range of immediate issues. My noble friend Lady Amos gave examples from her own experience in London. However, those trusts include in their considerations the role of promoting health at work, recognising and dealing with racism, developing family friendly employment policies and ensuring that staff can speak out when necessary without victimisation. I was glad that my noble friend Lord Hunt raised that point. At a nurse leadership conference last week I spoke on the theme that people should not be afraid to rock the boat; indeed, they should be confident in speaking out about their concerns both as regards professional standards and their personal interests.

We understand that nurses need to work flexibly to combine careers and family responsibilities. We also understand the need not just for words and policies but for practical demonstrations. We have, for example, been piloting self-rostering IT software which allows staff much greater control over the hours they work while covering peaks and troughs in the workload. Pilots have been set up across 19 sites within 11 trusts. Early findings suggest that if the system is well managed there can be significant savings in casual absenteeism and staff can plan their work around their known personal commitments.

As regards the more general and less tangible problems that several noble Lords have mentioned of stress, work related illness and job satisfaction, my noble friend and others were right to draw attention to the Nuffield Report Improving the Health of the NHS Workforce. It is an important piece of work which confirms the need for the package of action we have started to put in place. We recognise that stress is a major cause of absence in the health service. We have issued guidance on the management of sickness; piloted a model to reduce organisational stress; and published practical ways of tackling stress at work. A task force of nurses, doctors and other health service workers has just been set up to advise Ministers on the way to increase staff involvement in improving services, thus, we hope, improving their job satisfaction.

The importance of pay was commented on—that point was taken up vigorously by the noble Lord, Lord Addington—and in particular the idea of a top ranking nurse. Rather than planning to establish a new grade of nurse, we have been looking at the whole NHS pay system. Exploratory talks have already been undertaken with the RCN, other NHS unions and the professional bodies, as well as with NHS managers. on how best to achieve a system of nationally determined pay which is fair, efficient and has appropriate flexibility.

All of the important issues that the Government are addressing, as well as the pay issue, were mentioned in the speeches of my noble friends and other noble Lords who have contributed to the debate. They are, for example, well run clinical placements; flexible hours; continuing professional development; encouragement and support from managers; less bureaucracy, and so on.

I realise that I have overrun my speaking time slightly but I say in conclusion that next month the health service celebrates its 50th anniversary. As I said at the beginning of my reply to the debate, the high reputation of the NHS in its history has often depended on the reputation of its nursing workforce. I hope that what I have said tonight reassures your Lordships that the Government recognise that the skills and dedication of our nurses are key components in maintaining the trust we want the public to enjoy into the next century. Once again I must say how splendid it is to see my noble friend Lord Morris of Castle Morris leading our discussion on this important topic. Long may he and the nursing profession continue to flourish.

House adjourned at two minutes past nine o'clock.