Nursing and Midwifery Order 2001

HL Deb 13 December 2001 vol 629 cc1495-517

8.7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)

rose to move, That the draft order laid before the House on 15th November be approved [10th Report from the Joint Committee].

The noble Lord said: My Lords, this order will implement important reforms to the system of professional self-regulation for nurses, midwives and health visitors. The order will establish a new regulatory body, streamline the present arrangements and deal more effectively with the complex range of issues affecting these vital professions.

The order has been the subject of extensive consultation going back over some years and, I am glad to say, of broad agreement. We have responded positively to many of the points made during the consultation process. A number of significant changes have been made along the way. I confirm today my view that the provisions of the order are compatible with European convention rights.

Under the order, the Nursing and Midwifery Council will replace the UK Central Council for Nursing, Midwifery and Health Visiting and the four national boards. These proposals represent a key component of our wider efforts, working in partnership with the professions themselves, to drive up and sustain quality throughout the health service. The public and patients are entitled to expect that those treating them are properly regulated and that there is consistency across professional boundaries. We signalled our intention to modernise regulation in the NHS Plan in July 2001 and set three tests for the regulatory bodies. They must be smaller, with much greater patient and public representation. They must have faster and more transparent procedures. They must develop meaningful accountability to the public and the health service.

These orders fully reflect those commitments. But this is only a part of the reforms which are now under way. For example, we have strengthened the GMC's powers to deal with allegations against doctors; and we are working with the council on a wide-ranging programme of reform covering governance, revalidation, registration and conduct procedures. We have embarked on reforms to the regulation of dentists. In addition, the NHS Reform and Health Care Professions Bill that is being considered in the other place will further strengthen and improve professional self regulation.

The proposals meet the tests set by the NHS Plan. They will provide for a streamlined structure of council, statutory committees and panels, allowing far wider lay participation and expert input from the professions; a flexible, enabling framework with much greater scope for the council to design efficient procedures; a wider definition of unfitness to practise and more powers to deal effectively with it; and a duty to work in partnership with key interests—for example, employers, education providers, the professions and other regulators.

I referred to the need for and the benefits of consensus. The proposals have been endorsed by the professional bodies most closely concerned—the Royal College of Nursing, the Royal College of Midwifery, the Community Practitioners and Health Visitors Association, and Unison. I suppose that I ought to declare an interest in Unison. Those organisations' concern—and surely that of your Lordships—is that the law should be translated into effective action.

The professions concerned are the backbone of the health service—635,000 nurses, midwives and health visitors—and delivering on our aspirations for the NHS depends critically on supporting those key staff and encouraging an active partnership between them and those they serve.

The new council's principal purpose is set out in Article 3. It will, for the first time, be required explicitly to treat the health and well being of patients as its prime objective. The council will have a duty to collaborate with and to consult all those with an interest in its work—the professions, patients and clients, employers, education providers and other regulatory bodies. The council will have to be open and proactive in informing the public and the professions about its work.

The new council's core function, at Article 5, will be to keep a register of qualified professionals. It will establish and monitor compliance with standards of education and training, conduct and performance. The measure will not seek to define those standards—nor should it, since that is properly a matter for the council. In that respect, the order continues the tradition of 150 years of professional regulation. It is designed to modernise that tradition by providing a flexible and enabling framework within which the council can respond rapidly and effectively to changes in the provision of services, education and practice, and in public expectations.

The council will no longer need to seek rule changes through Parliament before it can change its operational procedures, as the UKCC must do now. That will give it the tools to do the job properly. That freedom is rightly balanced by areas that must be subject to approval by the Privy Council that are key to the performance of the core regulatory functions. They are the parts of the register and the protected titles for each part.

In addition, the Privy Council will approve the fees that the council proposes to charge registrants; its election scheme for registrant members; and its forward business plan. The Privy Council will also appoint lay members and receive the council's annual report and accounts to present to Parliament. Both councils will have wider powers to deal with individuals who present unacceptable risks to patients. They are set out in Articles 22 to 33. The councils will have powers to deal with registrants whose fitness to practise is impaired through ill health, lack of competence or misconduct. At present, the UKCC labours under a wholly opaque definition of misconduct, as conduct unworthy of a nurse". The council will also have a wide range of powers and sanctions to apply to registrants who are found unfit to practise. They will include cautions; conditional registration while retraining is undertaken or health is regained; suspensions; and striking off the register in extreme cases where the practitioner needs to be removed from treating the public.

The council will also have a critical role in positively guiding and supporting the vast majority of practitioners whose fitness to practise is never in doubt. The council will be much leaner and more strategic than the current bodies. Its initial composition will be 23 strong, with an elected professional majority of one. There will be guaranteed membership from each of the professions regulated. The Nursing and Midwifery Council will also have statutory committees—including one specifically to advise on midwifery issues, to recognise the unique regulatory function of midwifery supervision. The council's structure allows for an equal number of nurse, midwife and health visitor members.

The council may establish any other committees and panels that it needs, so it will have extensive opportunities to co-opt non-members to advise on professional matters or national policy, or to undertake detailed casework within the strategic framework that it sets. The council will report to Parliament through the Privy Council, which will approve any statutory rules the council makes.

We have taken on board most of the concerns raised by those who responded to an earlier draft but I want to address the issue of health visitors, as there has been great concern about the order among some members of that profession. The Government consider health visiting an extremely important profession, on which the NHS and the public depend. Health visitors have a hugely important public health role. Many people know them best for the help they give to families with new babies and their support through children's early years.

Health visitors also work with the most vulnerable people in our society. Health visitors work with individuals and families, to help them to change their diet; to stop smoking or abusing drink and drugs; and to encourage healthier lifestyles. They work in communities to build support for those with no family and friends. That way, health visitors promote physical and mental well being, and help to keep people living in their own homes.

With the developments in primary care that will be introduced over the next few years, health visitors will be at the forefront of joint working with partners in social care. I make it clear that the order will regulate health visitors. The words "health visitors" do not appear in the order because we do not want to tie the new regulatory body to only the health visiting function as it is now. We recognise that health visiting is expanding into other areas of community and public health practice. We want to give the new council the flexibility to reflect that changing role.

The order is the culmination of many years' hard work and discussion. I pay tribute to the representatives of nurses, midwives and health visitors who have made such an important contribution to the preparation of the order. There have been compromises along the way. Not everyone is happy with everything contained in the order's 101 pages but there is broad agreement that the measure represents a sensible outcome that will enhance the professions, provide faster and more transparent procedures, enable greater patient representation and, above all, uphold and strengthen public interest in professional self-regulation. I hope that the House will support the order. I beg to move.

Moved, That the draft order laid before the House on 15th November be approved [10th Report from the Joint Committee].—(Lord Hunt of Kings Heath.)

8.18 p.m.

Lord Clement-Jones

rose to move, as an amendment to the above Motion, at end to insert "but that Her Majesty's Government should also lay an amended order containing a provision for a compulsory register of specialists in community and public health, including health visitors".

The noble Lord said: My Lords, I thank the Minister for his customary clarity. I declare a family interest in the order, in that my sister is a health visitor—which gives me some insight into the value of the work of health visitors and the deficiencies in the order.

The Health Act 1999 represented agreement that changes to professional regulations would be effected by the affirmative order procedure, not primary legislation—and there were assurances that there would be full consultation. I recognise that there will be a number of competing professional interests and that a government are not always in control of the intra-professional communication that is needed. However, there is an overriding need to ensure adequate consultation and that reforms are not steamrollered over a profession in a minority. That applies both to this order and to the Health Professions Order, which is the subject of our next debate. Examining the Nursing and Midwifery Order convinces me that health visitors are not being treated properly or fairly. No compulsory register will be set up specifically for them, as at present, and there is no reference to the words "health visitor" in the title of the order, as there was in the 1979 Act. In fact, there is not a single mention of health visitors in the order.

Let us look at the situation from the point of view of health visitors. They happily believed that their representative organisation was busily negotiating away on a new regulatory structure. Then they heard that in order to fulfil a "modernisation agenda" for the creation of a wider group of specialist community practitioners, they would need to give up their right to separate registration. In fact, they were told that they will have to subsume themselves within that wider group and, under Article 6, that there will not even be a compulsory register for the new wider group, only one that may be set up by the Privy Council on the proposal of the new council—the NMC. Their membership may be only temporary to that body and, even then, they will be in a small minority. That is hardly satisfactory.

The only groups with a compulsory register will be the nurses and midwives. How would that make me feel as a health visitor—a member of a profession that has been in existence since 1860 and separately in statute since 1919? I would feel that I had been badly represented and I would be justifiably angry with the Government for creating anxiety and uncertainty among my professional group.

I do not place all of the blame on ministerial shoulders. The representative body concerned, which purports to represent some 16,000 or so public health specialist nurses, district nurses, community nurses, school nurses and health visitors appears to date to have failed to obtain adequate assurances from Ministers and to have caused a great deal of unhappiness among its members by failing adequately to debate these matters.

The Minster and his colleagues have on previous occasions and in correspondence said that everything will turn out all right. They say that whatever the arithmetic of the new council—health visitors will initially represent four out of 23 council members—community nurses, including health visitors, will in due course be granted their own register.

But what evidence is there that that will happen or that health visitors will not simply be treated as specialist nurses without their own register? Both the RCN and RCM are hostile to there being a third register. They say that health visitors are a group within nursing and are not a separate profession. Indeed, the RCN said that separate regulation is "confusing" for the public and other specialist interests in nursing. The proposal may never actually come about. It is for that reason that, without wishing to negate the order, we on these Benches want to amend it.

We seek cast-iron assurances from the Minister in various areas. First, we want the register for specialist community and public health practitioners to be definitely set up under the terms of the order, and we want it to include health visitors as a specific registering group or class of registrants. Secondly, we want name protection to be given to health visitors as part of that compulsory register. Thirdly, we do not want the order to dilute the pre-registration standards of qualification that are expected of health visitors. Moreover, if review work that is now in progress recommends that longer training is required, we want there to be mechanisms under the order to allow for that.

We on these Benches support much of what the professions and the Government are trying to do in terms of giving greater status and qualification to specialists in community and public health. However, that must not be done at the expense of damaging the morale of health visitors or their professional standing and qualification. That would be highly counter-productive. Research papers have clearly demonstrated that there are difficulties yet to be overcome before the specialist community practitioner role can be properly dealt with. As part of the regulatory reforms, I want a strong and viable public health visiting profession. The Victoria Climbie case has already demonstrated that the role of the health visitor in the community should not be minimised. They assess the factors involved with placing children at risk. I hope that the Minister can give the necessary assurances. I beg to move.

Moved, as an amendment to the above Motion, at end insert, "but that Her Majesty's Government should also lay an amended order containing a provision for a compulsory register of specialists in community and public health, including health visitors".—(Lord Clement-Jones.)

8.25 p.m.

Baroness Noakes

My Lords, I thank the Minister for introducing the order so comprehensively and the noble Lord, Lord Clement-Jones, for the clarity with which he moved the amendment. This is a complex area of professional self-regulation. I pay tribute to all those in the professions who have worked hard with the Department of Health to bring forward the proposals.

I am aware that these proposals are supported by the Royal College of Nursing, the Royal College of Midwives, and the Community Practitioners arid Health Visitors Association. Those organisations have provided me and, I am sure, other noble Lords with some helpful briefing. Noble Lords should welcome much in the order, which improves the regulatory framework within which those professions work. However, there are aspects of the order that cause concern, as the noble Lord, Lord Clement-Jones, made clear.

The Nursing and Midwifery Council, which will be created by the order, is the successor body to the UKCC. We should remember that the UKCC, while usually known by the initials of the first four words of its name, was in fact the UK Central Council for Nursing, Midwifery and Health Visiting. The new body, however, takes within its title only the professions of nursing and midwifery, not that of health visiting.

Noble Lords may well ask: what is in a name? Names matter because they send powerful signals to the outside world. As the noble Lord, Lord Clement-Jones, said, health visiting has existed as a profession in statute for more than 80 years. The disappearance of the name from the title of the regulatory body could mislead the public as to the status of health visitors. More importantly, it could lead health visitors to believe that they are not a profession. That is important because the belief in, and practice of, specific professional standards is crucial to the delivery of high-quality care, the maintenance of standards and recruitment.

As the noble Lord said, just as serious as the omission of the name from the title is the omission of any mention of health visiting anywhere in the order or the Explanatory Notes. Conspiracy theorists would have had a field day. Health visitors have been amazed at the Government's fierce determination to refuse to mention health visitors. I was glad that the Minister took the opportunity today to place on record the Government's support for the profession of health visitors and their value in society.

The noble Lord, Lord Clement-Jones, explained that while the Community Practitioners and Health Visitors Association has supported the order, that is only part of the story. As he said, there is a strong body of opinion among health visitors that they have been sold down the river by the CPHVA. While the CPHVA claims that it has around 80 per cent support from its membership, it has never asked its members whether they are content with the terms of the order. The question that gets 80 per cent support is whether health visitors should remain part of the family of nursing. Health visitors have not been asked about the order, which contains no entrenched protections for the profession of health visiting.

A small group of health visitors, including a recent former chairman of the CPHVA, became disturbed at the development of the draft order and the absence of specific reference to the health visiting profession. They enlisted the support of a number of branches of the CPHVA and called for a special meeting of the association to discuss the matter. The council of the CPHVA refused that elementary democratic process. This group of health visitors, who have styled themselves the Grassroots Network, have contacted a number of individuals who are involved in the affairs of the association's branches. It does not claim that those people form a statistical sample. However, the overwhelming view of those to whom they spoke wanted to see "health visiting" in the title of the NMC. That is perhaps not surprising. But 80 per cent of the members expressed concern about inadequate regulatory safeguards in the order which they believed would adversely affect health visitor training and education.

The amendment put forward by the noble Lord, Lord Clement-Jones, refers to the compulsory establishment of a separate register for community and public health nurses. That is not the desire of the Grassroots Network, whose primary aim is to protect and enhance the role of health visiting. At present there is no recognisable profession of community and public health nursing, and it is not self-evident that such a register will provide the necessary protection for the health-visiting profession. But, on the basis that half a loaf is better than none, I am confident that if there were a requirement for a separate register for community and public health nurses the democratic processes of the CPHVA could be harnessed for the benefit of the health-visiting profession in that context.

Health visitors form a small part of the professions of nursing. As the noble Lord, Lord Clement-Jones, said, they fear that their larger cousins in the Royal College of Nursing and the Royal College of Midwives do not regard health visiting as an identifiable profession. While health visitors will initially have four out of the 23 council places, there is a fear that, once the NMC arrangements are in place, the other bodies will gang up on the health visitors, remove the separate register, resist the creation of a separate community and public health register, and thereby remove specific representation of health visiting on the council.

I do not believe that that is a flight of fancy. The general secretary of the Royal College of Nursing said in a letter to me that the name of the NMC—that is, excluding reference to health visitors— reflects the view of the majority of RCN members that it is appropriate that the regulatory body refer only to the professions, rather than groups within the professions, that are regulated". The RCN thus believes that health visiting is a group within nursing and not a profession.

Of course, if this were to come to pass, a majority of the council would have to be persuaded to remove the recognition of health visitors, and the Privy Council would also need to be involved. But I have been involved in professional bodies for a good part of my working life and I know how easy it can be to marginalise minorities. These are very real fears.

I want to raise a number of important questions relating to health visitors in addition to those put by the noble Lord, Lord Clement-Jones, to which I believe answers should be given. Is it the Government's intention that a part of the register will be maintained for health visitors, both transitionally and for the future? Do the Government believe that the health visitors' part of the register should not be closed without the consent of the council members who are health visitors? Do the Government believe that the health visitors' part of the register should not be closed unless a majority of health visitors themselves agree to closure? Do the Government believe that council representation for health visitors should not be removed; for example, if a majority of the council voted to close that part of the register but did not set up a separate community and public health register? And do the Government agree that the NMC must facilitate the protection and development of the professional knowledge of health visiting; for example, by updating its training rules?

If the answer to any of those questions is anything other than an unequivocal "yes", health visitors everywhere will fear for their profession. And noble Lords would rightly conclude that the amendment proposed by the noble Lord, Lord Clement-Jones, is an essential adjunct to the order before us today.

8.34 p.m.

Lord Hoyle

My Lords, in rising to speak on this matter, I declare an interest. I am an ex-president of MSF, which is the permanent body to which the CPHVA is affiliated. I also want to say that I speak for the vast majority in the profession. I speak for many thousands of people. I must also put into context the health visitors' Grassroots Network, which I believe has written to all of us about this matter. Having said that I speak for the vast majority of its members, I should add that they number 150.

There has been talk about consultation, and several figures have been quoted this evening. It was said that 81 or 94 per cent of health visitors wanted "health visiting" in the title. But only 88 per cent of the people were consulted, which means that the survey was based on only 81 people. Against that, the CPHVA consulted all its members. It held a ballot and 81 per cent of those who replied were in favour of the order as it stands. Since then, independent surveys have shown that 5,000 people have been balloted

Baroness Noakes

My Lords, I thank the noble Lord for giving way. When he referred to what the members were balloted on, can he confirm that they were asked specifically—I believe that this is what he said—whether or not they were happy with the draft order?

Lord Hoyle

My Lords, I said that they were happy with the way that matters had progressed in relation to this matter. I also said that 81 per cent had gone further than that. Independent surveys were carried out in which 5,000 people were canvassed—that is, 82 per cent of the total. Only recently—that is, this year when the matter came before us—3,700 people were contacted. Again, 81 per cent of those balloted were in favour. Therefore, I say to the noble Lord and to the noble Baroness, who have spoken from the Opposition Front Benches, that they are speaking for a minority—a vociferous minority, I accept. However, that is the group for whom they are speaking.

This order is not about titles; it is about what will happen in the future. In the future the order will not only bring together the professions; it will also involve the public far more. It is about protecting the public as well as the professions. Professions are important but we must not be hidebound by them or by their names. We must see what is being done.

There are more health visitors on the new council than there were on the old one. In addition, they will have equality. This issue has not arisen out of nothing. Not only has consultation taken place among the members of that profession; there has been consultation with Ministers and officials. It has taken six-and-a-half years to arrive at the point that we have reached this evening. I say to anyone who wishes to destroy what has been built up over six-and-a-half years that there is a pointer to the profession being better and more professional. Health visitors will become involved. Their profession is a very proud one. In addition, as has been said, the public will be protected in relation to community and public health, too. We are moving forward.

I do not want to see this matter unravel because of amendments, however well meaning. I hope that, on reflection, the noble Lord, Lord Clement-Jones—he says that a member of his family belongs to this profession—will take into account what has been said by those of us who speak not only for one person but for the vast majority of health visitors and other professionals, such as those who work in community and public health. I hope that the order will not be held up or even destroyed because of a good intention upon which the amendment is based. I believe that we have moved on and that the noble Lord speaks for a tiny minority.

Baroness Emerton

My Lords, I declare an interest having had 48 years experience as a nurse and 23 years of being involved in the professional regulatory system. I was chairman of the UKCC until 1993. It is true that a need for change in the nurse regulatory system and nurse education was identified in 1948 and it took until 1979 for legislation to be passed. From 1983 until now there have been great movements forward in bringing nurse education into further education and universities. There has been movement in terms of the profession coming closer together. However, there is no doubt that large bodies are not effective and efficient at working speedily. It has been apparent that professional conduct work has been slowed down by procedure.

After the review of the present structure by JM Consulting recommendations were taken on board. We know that primary legislation was urged by the profession. However, we were persuaded by Ministers at the time, because consultation would take place, to go for an affirmative order. The profession, which includes nursing, midwifery and health visiting, were resistant at that stage. However, it was finally persuaded and consultation took place. As stated by the noble Lord, Lord Hoyle, that took place over a period of six years.

I am mindful of the words used by the noble Lord, Lord Clement-Jones, in terms of the minority group. The noble Baroness, Lady Noakes, referred to the minority of health visitors—which is a small minority—who wish to contest the title of the order and the fact that they do not have a separate register. We live in a fast moving world of change in the health professions. I support the order. I would ask that the amendment before us tonight be revisited in the light of the fact that the draft order states that the council may set up a register and that there is representation on the council of an equal number of nurses, midwives and health visitors, as the Minister stated, with a majority of one professional.

I therefore support the draft order. I take into account the views of health visitors, who play an important part in the future of community and public health nursing. They have a proud profession on which to reflect. However, we have to look to the future in the provision of health care, both within hospitals and the community, which is fast moving. The delivery of the health professionals is extremely important. The draft order provides a facility in which there can be flexibility and whereby a register can be set up which could embrace all those that work in the community. I am sure that any council which well and truly reflects public and patients' interests will ensure that there is equal representation in terms of a need to set up a register.

8.45 p.m.

Baroness Turner of Camden

My Lords, I, too, declare an interest. The noble Lord, Lord Clement-Jones, said that his sister is a health visitor. My step-daughter is a health visitor and a member of the HVA. I was an official of MSF, which is the overall organisation to which the Health Visitors Association is affiliated. The HVA is a democratic organisation. It had its own elected executive and annual conference. The group that has been lobbying in favour of the amendment or against the order seems to be a tiny, maverick group. When consultation takes place, that must be with the elected leadership of those organisations. Who else should consultations proceed with?

The HVA is keen to have this order after six years. It thinks that it will help its members to move forward. It is anxious that the order should pass unamended tonight. It has pointed out to me that this will give the HVA stronger representation on the council than it has ever had before. It believes that the order will be helpful, and that it speaks for its membership except for a tiny minority. We do not have to take note of tiny minorities, no matter how articulate. What really matters are the elected senior representatives of the organisation. They are both elected and supported by the membership. I therefore hope that we shall vote tonight for the order unamended.

Lord Hodgson of Astley Abbotts

My Lords, the noble Lord, Lord Hoyle, had his finger on the button when he spoke of the key criteria being patient care and patient safety. Therefore, I understand the thrust behind the order which the Minister clearly explained. That having been said, I believe that the noble Lord, Lord Clement-Jones, has made a good point. I do not want to re-run the arguments put before your Lordships' House; they are clear.

Twenty years ago, as a Member of another place, I served on the Standing Committee which dealt with the Nurses, Midwives and Health Visitors Bill, which became an Act in 1997. Some of the issues that we are debating tonight are echoes down the years of the tensions that exist between the different professions—or different branches of the same profession, depending on how one looks at it—that we then had. As I recall, there was a long discussion within the then Labour Government about the short title of the Bill. As a result of that, it was concluded that "health visitors" should appear in the short title, as eventually happened. The reason given by the then Labour Government was that health visitors had a distinctive role in healthcare. More than any other, they operated in the community not within the structures of the NHS or the educational system. Theirs was an important and distinctive role, albeit a preventive one, but none the less important for that, as opposed to the curative role with which the other professions were concerned.

In the eyes of the Minister's predecessor at the time, Roland Moyle, it entitled them to a specific mention in the title of the Bill. There is a danger that if one is trained as a health visitor and called a health visitor one does not feel as committed to an order entitled "The Nursing and Midwifery Order" as a nurse or a midwife, or even a factory nurse or school nurse. I understand from official correspondence which I along with other Members of your Lordships' House have received that all parties, at least at an official level, are happy with the title of the order and what is contained therein. However, as the noble Lord pointed out, Clause 6(3) states "may provide". It does not require the register to be set up.

It is easy to talk of 19 or 20 per cent as being a vociferous minority. However, if we were to find a way to move from "may" to "shall", surely that would have the effect of calming the concerns of those health visitors who feel that their profession may be overwhelmed under the new structure and those who feel their distinctive contribution may be overlooked.

I hope that the Government will think about the noble Lord's amendment as a way of bridging the gap and ensuring that we move forward with the thoroughly praiseworthy reasons behind the order but that at the same time we carry not just 80 or 70 per cent of the health visiting profession with us but all of it, because it carries out such an important preventive role for the health of our society.

Baroness Howells of St Davids

My Lords, I feel compelled to speak in this debate. I am sure that noble Lords will not doubt me when I say that the one place in which the black community has excelled is in support of the profession that we are discussing. They have given unstinted help from the 1960s to now and have reaped the rewards. Nevertheless, I felt that it was important to find out from them what was really going on. They are in full support of the Royal College of Midwives, the Royal College of Nursing and the Community Practitioners and Health Visitors Association in welcoming the order.

All these organisations would have liked far more for themselves, but they all recognise that a fully comprehensive consultative process has taken place and the best possible formula has been found to accommodate all parties. They all say that this has been a long drawn out process that has found an acceptable solution to a very complex situation. The solution has been reached only with the dedication and commitment of the organisation involved, as well as the Departrnent of Health, which has handled this matter in a very efficient manner.

As has already been said, there has been extensive lobbying within Parliament by a small minority of health visitors who want a disproportionate level of representation on the nursing and midwifery council. The whole idea of the council is for the RCM, the RCN and the health visitors to work together in partnership, a word that is often used in this Chamber. Working in partnership is not for their benefit but for the benefit of the public. That will be a very tall order with these rebels creating tension within the three bodies. They oppose the setting up of the council unless they achieve all their demands. That is not democracy at its best and I suggest that noble Lords will recognise it as such.

If we allow this vocal minority of rebel health visitors to succeed, and we halt these orders, we shall see a situation where the public have less protection from practitioners. I am sure that no Member of this House would vote for members of the public to be left unprotected and open to the practices of unqualified medical practitioners.

There is another reason why we should support these orders. Should they fall, the professions will remain under the auspices of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. This body is preparing to be wound up. We know that it wants to wind itself up, because one senior officer has already announced her resignation and I am sure that others will follow. We shall be entrusting the welfare of the public to a body that has accepted that it is now time for a more modern body to come into being.

The organisations concerned with the NMC order are quite clear that they will want a full review of this legislation if there is further opportunity. They estimate that the process may take a further two years and will be an exhaustive affair. Two years of the public—the very public that we want to serve—being left without full protection; two years with the UKCC left in uncertainty; and two years of further wrangling between these august bodies.

We need to think about the welfare of the general public. We also need to take into account the views of the royal colleges of midwives and nursing, as well as the Community Practitioners and Health Visitors Association, which have all found agreement through this legislation. Voting against this order will be a retrograde step for Parliament and the health service and may have detrimental health implications for the general public.

Baroness Cumberlege

My Lords, before I make my contribution, I declare an interest as vice-president of the Royal College of Nursing and of the Royal College of Midwives and I hope a friend of the Health Visitors' Association.

The other day the Minister reminded me that it was I who conceived this difficult debate. When I was a Minister I commissioned JM Consulting Group Inc to review the regulation of nurses, midwives and health visitors. I did so because, prior to becoming a Minister in 1992, I was a lay member of the UKCC. I served under the very inspiring leadership and skilful chairmanship of the noble Baroness, Lady Emerton. I was very conscious when I was serving on the UKCC that the noble Baroness was determined that the issue that was most important was the protection of the public, as well as keeping these professions together in the nursing family.

That was not explicit in the regulations, it was implicit, and the noble Baroness consistently arid continually reminded us of our role. Having served on that body, I understood that the UKCC was cumbersome, rigid, slow, bureaucratic and very demanding of members' time. I should like to pay tribute to all the members of that body, particularly the professional members. But the costs to the National Health Service were high, because those people when they were in committee, on the professional conduct hearings and all the mechanisms involved in that, were not looking alter patients or clients in the community.

Like my noble friend Lady Noakes, I do not subscribe to the conspiracy theory. I understand the health visitors' fear about their professional status being eroded and also that the public is not being fully protected. But their fears are being exaggerated. As I understand the matter, the health visiting profession will be separately identified through the dedicated part of the new register; only a registered health visitor will be entitled to use the title that has been designated from that part of their new register; and under transitional provisions the health visiting profession will have separate representation on the new council and parity with the other professions. That is a huge step forward.

When I reviewed community nursing 15 years ago, I remember the publicity in the press. There were headings such as, "What do Health Visitors do?", "Why are health visitors there?", "What is their role?". There was tremendous ambivalence. There was pressure on my team to try to erode the role of health visitors. Trevor Clay, who was the general secretary of the Royal College of Nursing, asked me, "Are you going to do away with health visiting?" We did not because it has such an important role.

In the intervening 15 years we have seen its role expand enormously. They really are the praetorian guard. They are the people there to promote health. I have seen the cycle of deprivation broken very impressively, not by social workers but by health visitors. So of course I have great feeling for their concerns. But those involved in health visiting see the future. It is interesting that they have even changed the name of their organisation to the Community Practitioners and Health Visitors Association. That is visionary, and I hope that in future they will go on to break new frontiers to improve the health of our nation.

Much consultation has taken place over a long time, which should not be rubbished. The association has been extremely diligent in trying to obtain the views of its members. The view of the minority, and all the rest of it, has already been debated, so I shall not go into that. But the potential of the new council should be realised and the building blocks are there. It is with huge embarrassment that I find myself totally in support of the Government on this occasion.

I shall refer briefly to midwifery. A concern has been expressed about Article 45. I know that the Minister shares my view that women should have a choice about where they give birth. A lot of pressure is being put on women to give birth in hospital rather than at home when they would prefer to be at home. There is concern that where husbands, partners or friends take part in a birth and a midwife is not present, they may be prosecuted under the order.

I should like an assurance from the Minister that that choice will still be open. I hope that he will promote it in any way that he can. I also hope that he will assure us that no prosecutions will take place in such circumstances.

9 p.m.

Lord MacKenzie of Culkein

My Lords, I also rise to support the order and to oppose the amendment in the name of the noble Lord, Lord Clement-Jones. In doing so, I declare an interest as a current registrant in the register held by the United Kingdom Central Council and, latterly, as an associate general-secretary of Unison—although I have not been briefed by Unison for this debate.

There has been every opportunity for the organisations representing the professions to have their say during the long consultation period. Indeed, the outcomes have been very much influenced by the nursing and midwifery organisations. The royal colleges of nursing and midwifery, Unison and the Community Practitioners and Health Visitors Association have all been active in consulting and representing their members.

As someone who gave evidence and made representations to the Labour government in the run-up to the 1979 legislation, which gave effect to the UKCC and the four national boards, I know just how seriously nursing organisations take the issue of registration, professional regulation and discipline. The noble Lord, Lord Hodgson of Astley Abbotts, referred to that legislation and its run-up. It was the last Act carried by that Labour government before it fell in 1979, and I know that many concessions were made. I cannot remember whether the inclusion of health visitors was one of those, but many concessions were certainly made in the wash-up period before the Act was passed.

I also know, unless the world has changed since my day of representing nurses, that none of the organisations will have got everything that it wanted during discussions with the Government. That is the nature of the real world. The order represents an acceptable compromise agreed between the Department of Health and the professions of nursing, midwifery and health visiting. Lest any noble Lord be in any doubt, the unions to which I referred represent the vast majority of nurses and midwives on the register. None of those organisations will regard it as helpful if the amendment is carried.

When I was general-secretary of the Confederation of Health Service Employees—an organisation with about 70 per cent nurse membership, together with some midwives and health visitors—I was familiar with groups of members being unhappy with the outcomes of negotiations, consultations or democratic decision-making. Their cry was, as the noble Baroness, Lady Cumberlege, said, "We've been sold down the river by the leadership". They sought to engage every avenue to pursue their cause—including, of course making representations to Opposition politicians. I know nothing of the current internal business of the CPHVA, but sometimes such causes have as much to do with trying to usurp the leadership or preparing for a round of elections as with the issue.

What we have here is a great deal of compromise to reach middle ground with which everyone can live in the interests of the greater good. A group of health visitors believe that they have been sold down the river. They do not appear to see the wider picture. They do not see what others have given up in the course of reaching that compromise that meets the wider interest.

Let me give one example of such a compromise. If memory serves me correctly, the present statutory body, the UKCC, contains 28 elected nurses, four health visitors and four midwives among its membership. The order tonight provides for four nurses, four health visitors and four midwives. I know many nurses who think that that change in the ratio between the professions from 7:1 to 1:1 with health visitors may be a compromise too far, but the majority of them accept the need for a streamlined, efficient and flexible organisation. Nurses have not become a dissenting voice, notwithstanding what they have given up—some would say, given away.

To carry the amendment would be manifestly unfair to nurses, not least because many nurses—I am among them—accept that health visiting is part of the greater family of nursing. One cannot be a health visitor unless one is a nurse. Nursing is a family with several branches and, within those branches, many specialisms. Of course health visitors do a great job and tribute has rightly been paid to them today. We shall continue to do so. But many others do a great job: practice nurses, palliative nurses, district nurses, community psychiatric nurses and others in community teams who are not nurses, such as physiotherapists and occupational therapists. The boundaries between all of them are becoming increasingly blurred. Which would be in, and which out, in the definitions proposed by the noble Lord, Lord Clement-Jones?

If I can for a moment be critical of my profession, it has a propensity for élitism. All nurses are special, perhaps none more so than nurses registered in the specialty of caring for people with learning difficulties. They are special, but they are not élitist. They have not been lobbying for their own part of the register to be guaranteed. That may well happen—I have no doubt that it will—but they have not been lobbying for it.

Most of my clinical practice was in operating theatres and in trauma intensive care. We were a scarce commodity, but we were not, I hope, an élitist group. How could we be when so many of our colleagues used to suggest that we were really technicians?

In a profession as disparate as nursing, there is no room for élitism. There has to be room for change, development and continuing learning to keep pace with all the changes in society. As the noble Baroness, Lady Cumberlege, properly pointed out, in recent years health visitors have played a tremendous part in that change. I have no doubt that they will continue to do so.

There is no need for the amendment. There is already provision in the order for setting up a part or parts of the register for community and public health specialists. And with one health visitor to every nurse, to every midwife, I have not the slightest doubt that health visitors are well provided for; and I believe that a part of the register will include health visitors. However, the amendment would create uncertainty and would be a distraction from the real business of bringing regulation up to date and, most importantly, of protecting the public.

Baroness Gibson of Market Rasen

My Lords, I rise to support the Nursing and Midwifery Order and to support the CPH VA, whose leadership may have been a little maligned on occasions today. I here declare an interest. Before entering your Lordships' House, I worked for the Manufacturing, Science and Finance Union of which the CPHVA is a valid part. I worked there for 13 years with and for the CPHVA, so I am very familiar with the debate which is taking place in the Chamber today.

I also had the honour—and it was an honour—during that time to attend the annual conferences of the CPHVA. There has perhaps been a suggestion that the CPHVA is not a democratic organisation. Every year it holds a large conference attended by many representatives who represent the 18,000 members. Every year the director of the CPHVA addresses the conference.

I want to read a short extract from a report of the director's address to the 1999 conference because it has been suggested that the CPHVA did not mention to its members what was taking place. The article states: In her opening address she"— Jackie Carnell, director of the CPHVA— said that the CPHVA's developing role in the arena of primary and community health care had meant letting go of some of the things held dear in the past, such as the name 'health visitor' in the title of the new Nursing and Midwifery Council. Ms Carnell is then reported as saying: Some feel that this is a disaster for the future of health visiting. My message to all of you who feel this way is that you are wrong". The article continues: CPHVA members should have the confidence to know that health visitors were still leading the agenda from their place on the new council, so professional differences should be left behind. 'They weaken us and detract from the main agenda—an agenda to secure the right and appropriately regulated workforce for the future". Jackie Carnell was not howled down. There were no shouts of "horror" from the floor. There were no riots at that conference. Instead, she was received with acclaim and a standing ovation at the conference for what she and the executive behind her had done for CPHVA members in relation to this order.

Finally, the CPHVA is not an organisation which is irresponsible. It obviously wanted to look after its members, so it took legal advice. It was firmly advised that the order as it is written fully covers the HVA and what it requests from the order.

9.15 p.m.

Lord Hunt of Kings Heath

My Lords, this has been a high-quality debate. That is not surprising because the issues we are debating are extremely important in relation to the future of these professions. All noble Lords have spoken from a great degree of experience in these areas. The noble Baroness, Lady Emerton, set the context of self-regulation. The enormous strides which have been taken over the past 40 years have been partly as a result of her profound leadership of the profession and her stewardship at the UKCC. While I firmly believe that the current rules surrounding the UKCC are not up to what we need for the modern professions and their regulation, I pay tribute to all UKCC members who have put in an enormous amount of hard work.

My noble friend Lady Howells of St Davids made a telling point about the community interest to black minority ethnic nurses, health visitors and midwives. She pointed out that they, along with most of the professions, which are so dedicated, welcome what is contained in the order.

The most striking point that I should like to make to noble Lords tonight is that the health professions are often accused of tribalism. Sometimes that accusation has been correct, but those professions—I include the 12 professions that we are to debate shortly—within the Health Professions Council have ridden above that tribalism. Surely it is unique that the Government stand before noble Lords with the backing of the 15 professional organisations, together with Unison, in support of the order. It is an order that will enormously enhance the public interest and public involvement in those regulatory councils. I repeat, surely that is unique.

My noble friend Lord MacKenzie spoke of the compromises that enabled this development to take place. Yes, there have been many compromises, but I believe that they have come about through a measured process of consultation. The noble Baroness, Lady Cumberlege, has already referred to her starring role in commissioning JM Consulting. When she welcomed its first report, concerning the professions supplementary to medicine, she said that she welcomed the report and supported its conclusions, but that completely new legislation would be required to streamline the existing arrangements. How right she was. Considerable consultation has taken place since 1996 in relation to the health professions, and since 1997 in relation to nurses, midwives and health visitors.

It is also worth making the point that we published our original proposals for a three-month public consultation on 1st August 2000, and completed those by 1st November 2000. Having considered those responses and having been involved in many discussions between the professions and those organisations which reflect the public interest, as well as the Department of Health, a draft order was then published for consultation. The comments we received as a result of that consultation very much reflected support and a recognition of the fact that the Government had listened.

I come to the issue of health visiting. We have had a long and passionate debate. I am aware of those health visitors who are concerned about the position of the health visiting profession, but I have to say that the professional body for most health visitors has campaigned long and hard for this very change. As my noble friend Lady Gibson pointed out, my experience of the CPHVA confirms that it is an extremely professional organisation that is well able to speak on behalf of its membership. Any government must rely on the basis of discussions held with the recognised professional organisations. That is what we have done.

In the light of all the discussions that have been held over the past few weeks since the order was debated in another place, I have talked to Mr Jonathan Ashbridge, the president of the shadow Nursing and Midwifery Council. I felt that noble Lords would find it helpful if I were able to give the assurances which he has given to me and to place them on the record tonight. In a letter which I received yesterday, Mr Ashbridge states that: I can confirm that the Council is committed to ensuring that there is a part of the register for health visiting. Indeed, at its meeting next Thursday, the Council will be asked to approve its response to the competence framework required for entry onto this part of the register. The NMC's prime function is public protection. The full range of public health and community practice that health visiting embodies is seen by the Council as a vital component of the provision of healthcare in this country. It is therefore essential that the existing high standards of regulation must continue and be enhanced. It is inconceivable that health visitors would not play a significant role in the conduct and work of the Council as the majority of care provided in this country is and remains in the community. Health visitor registrant members are already making a vital contribution to the work of the Shadow NMC. This reflects their comprehensive preparation in terms of education and training, but also their unique ability to articulate the wider health needs of the public. The proactive approach epitomises the modern face of regulation which is encapsulated in the draft order and is a valuable base which will underpin the Council's work". I want to make it clear that we need to be able to protect the public by registering the whole range of health visitors and community and public health specialists. This protection does not come from having a profession named either in the order or in the name of the council itself. The protection comes from being included in the register held by the council. This means having the power to create a part of the NMC register for that whole group of practitioners, with a designated title and appropriate qualifications to match. The order contains a provision to do just that.

As noble Lords have remarked, we have provided for a part of the register for specialists in community and public health and for their four places on the council. In practice, this might change only if they themselves wanted it to happen, by extending their role to cover a wider group of specialists in community and public health. Before any change could occur, the council would have to consult health visitors and must have proper regard to their differing considerations as a group. This would extend their protected title and protected specialist training into a wider group.

The part of the new register will carry with it a protected designated title, which means that only those with the specialist approved training, such as in health visiting, which leads to registration in that part of the register may call themselves by that title. The title and part itself is for the council to propose and the Privy Council to determine. To make a far-fetched suggestion, even if the council tried to overrule the health visitor members by not proposing such a part—which is most unlikely—the Privy Council would still be able to overrule the council.

The title might be "Registered Health Visitor"; it might be "Registered Community Practitioner (Health Visitor), "Registered Community Practitioner (Public Health Practitioner)" or "Registered Community Practitioner (Family Health Practitioner)". The additional identifier in the parenthesis could be whatever health visitors choose, the NMC proposes and the Privy Council decides on to reflect their changing wider role. But, whatever it is, only practitioners with that special training may call themselves by that title. In future, the part of the register may be for "Registered Community Practitioner" with additional identification of the branch of specialist qualification in parenthesis—for example, "(Health Visitor)". There is an exact parallel to this on the Health Professions Council, which we shall come to debate shortly.

As to membership, the election scheme in Schedule 1 Article 2(2)(b) must be devised by the Nursing and Midwifery Council itself. Again, the health visitors on the council will be there to see that the election scheme provides for their part of the register to have members to represent it. Given that there must be health visitors on the council, it is inconceivable that they will not propose to have their own part on the register. From my discussion with Mr Ashbridge yesterday, I can assure the House that there are four very able and assertive health visitors already playing a full part in pursuing their professional interests.

My noble friend Lord MacKenzie made a telling point about membership. At the moment, on the UKCC there are 40 elected professionals. They comprise 28 nurses, eight midwives and four health visitors. The new shadow council, the transitional council, enables there to be four health visitors, four nurses and four midwives. What better protection can there be for health visitors than that change?

Like every noble Lord, I believe that the health visitor profession is a noble one. It has, as the noble Baroness, Lady Cumberlege, said, played an enormous role in developing public health in this country. I believe that the way in which the order has been constructed enables the profession to go forward and to enhance its responsibilities and role. I am convinced that there are sufficient safeguards in the order to enable that to happen.

I turn to the question raised by the noble Baroness, Lady Cumberlege, concerning midwives, and particularly to the proposal to increase the fine applicable to those who commit the offence of attending a woman in childbirth as a provider of care without an appropriate qualification as either a midwife or a medical practitioner. By "attend" we mean "assume responsibility for care".

The proposal is not intended to outlaw husbands, partners and relatives whose presence and general support for women in childbirth is extremely important. The point of the offence is to protect the function of midwifery in the interests of public safety. This has been an offence since the Midwives Act 1902. The fine incurred by the offence was £10 at that time. We received advice from JM Consulting, which thought that the level of the fine should reflect the seriousness of the offence. The Royal College of Midwives and some consumer groups supported that.

I am aware that the Association for Improvement in Maternity Services feels strongly that a fine for this offence should be dropped altogether. I understand why. The association wants this so that, in the case where a woman wants to give birth at home but there are no qualified midwives available to attend her, she may at least have the attendance of a partner or relative on the grounds that having someone unqualified is better than having no one in attendance at all.

The noble Baroness, Lady Cumberlege, knows that I am sympathetic to matters relating to childbirth as two of my own children were born at home. However, I also believe that the safety of both mother and baby is paramount. I accept the challenge that the noble Baroness lays down. But the best way to tackle this is to increase the number of practising qualified midwives to enable the health service to offer the home birth service which I believe it should be offering. I say unequivocally that that is our intention. I point out that there have been hardly any prosecutions for this offence. We have come across only one, which took place nearly 20 years ago.

Again, the quality of the debate has been outstanding. We are all agreed that we want to see enhanced professional self-regulation to enhance the public interest. No one disagrees with the noble Lord, Lord Clement-Jones, as to the importance of health visitors. I hope, however, that I have reassured the noble Lord that the intent in this order is to enhance the profession, to safeguard it, but to create the conditions in which it can expand and develop the services that it offers to the public.

Lord Clement-Jones

My Lords, I agree with the Minister that this has been an extremely useful debate. I very much welcome the support from the noble Baronesses, Lady Noakes and Lady Emerson, and from the noble Lord, Lord Hodgson for the Motion to amend the order.

I admit, however, that I am totally unrepentant in the face of the speeches of the noble Lord, Lord Hoyle, the noble Baronesses, Lady Turner, Lady Gibson of Market Rasen and Lady Howells, and the noble Lord, Lord MacKenzie—whose view seemed to be that I was entering into the trade union politics of the matter rather than debating the merits of the order.

Whether or not they are a "vocal minority" or "rebel" health visitors—and the noble Baroness, Lady Turner, suggested that we do not have to take any notice of tiny minorities, just of the "senior people"—the fact is—

Baroness Turner of Camden

My Lords, will the noble Lord give way? My point was that the people who were consulted were not just senior people; they were elected through the democratic process within the union.

Lord Clement-Jones

My Lords, I and others on these Benches have always taken one of the functions of this House to be the protection of minorities. It is an extremely important function. It is precisely why this Motion was tabled.

That minority has done a great service. It has elicited considerable assurance from the Minister. He elicited the letter from the shadow president of the new body giving the assurances on each of the three areas about which I asked him. That demonstrates that the minority was right in asking for such assurance. It was right to articulate its concerns to Members of this House.

I shall repeat those assurances because I believe that, effectively, the Minister has answered them. The first is that the register will be set up: I believe that the Minister has given us that assurance, and that it will include health visitors. It will not just be on a transitional basis, but it will be permanent. Secondly, there is the assurance about name protection for health visitors. Lastly, I believe that the Minister has also given an assurance about health visitors' qualification standards and that the new order can deal with and enhance those standards as part of the new registration process.

I am pleased that the Minister has given us those cast-iron assurances for which I asked. I believe that all health visitors will be able to unite behind the order. We have had an effective demonstration of how it is possible for Ministers to give such assurances. Although at the first hurdle they did not succeed, at the second hurdle—namely, in this House—we have had a satisfactory debate. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Hunt of Kings Heath

My Lords, I commend the order to the House.

On Question, Motion agreed to.