House of Commons Hansard Debates for 31 Jan 1992

Mr. Jerry Hayes (Harlow) : It is a pleasant and unusual experience to speak in a health debate in which we are united. Not even the hon. Member for Peckham (Ms. Harman) has said a word against the Bill, which is supported not only by the Government, but by the British Medical Association, the Royal College of Nursing, general practitioners, phamacists and many charities. I join in congratulating my hon. Friends the Members for Chislehurst (Mr. Sims) and for Kensington (Mr. Fishburn), who set the ball rolling, on their collective good judgment and common sense in introducing such legislation.

We should also congratulate Christine Hancock, the general secretary of the Royal College of Nursing. Even my hon. Friend the Minister must accept that Christine

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Hancock has always criticised the Government constructively. She, with her members, has shown much support for reforms such as the NHS trusts and GP fund holding. I also congratulate the chief nursing officer, Dame Anne Poole, who, sadly, will be retiring in a few weeks' time. All involved in health would wish to express thanks for what she has done for the Department of Health and for nursing. We shall all miss her and we send every good wish for the future to her successor.

My hon. Friend the Member for Eastleigh (Sir D. Price), who will, sadly, be leaving the House in a few weeks' time, made a masterly speech in which he summed up the position perfectly. I am not sure how one persuades the Treasury to be relaxed about anything, but the fact that the Government have tabled a money resolution is encouraging.

My hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) made an especially good point about the time that is wasted at present. From briefings that I have seen, it seems that 1.2 million hours of nursing time are lost. As the hon. Member for Eastbourne (Mr. Bellotti) said, there will be benefits for the terminally ill and for the elderly.

Mr. Stern : Although it is unfashionable in this debate, I will say a word on behalf of the Treasury. My hon. Friend the Member for Harlow (Mr. Hayes) will have noticed that, although the Touche Ross report accepts the principle that the Bill would help to save a great deal of time by reducing the hours that nurses, especially district nurses, spend travelling backwards and forwards, the monetary savings would be almost insignificant. Inevitably and rightly, the nurses, who are full-time employees, would use the time in other ways, to the great benefit of patients.

Mr. Hayes : My hon. Friend is right ; he speaks with his usual sagacity. He is an accountant, but I do not hold that against him.

Mr. Arbuthnot : I believe that my hon. Friend the Member for Bristol, North-West (Mr. Stern) is wrong. Health authorities will be able to make choices. As we shall save nurses' time, we can either give the nurses more productive work to do or reduce the number of nurses and spend the money saved on other health care procedures or drugs. The options would be wider and I do not think that the Treasury should be quite so restrictive.

Mr. Hayes : I do not want to sound too much like a Liberal Democrat, especially before a general election, but I must say that I agree with my hon. Friends the Members for Wanstead and Woodford and for Bristol, North- West (Mr. Stern) at the same time. We shall utilise nurses' time and there will be savings, although there is a row over how great the savings will be.

The Government and the whole House accept the crucial role that nurses play in the health care team. It is significant that, since 1979, the three aims of Trevor Clay, the then general secretary of the Royal College of Nursing, have been achieved. First, he wanted an independent review body system for pay, and we have that. Secondly, he wanted the modernisation of the nurses' career structure, and we have that. Thirdly, he wanted a modern training system, which nurses will receive under Project 2000. The hon. member for Peckham mentioned Project 2000, and I will say a few words on it.

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Project 2000 gives more weight to the process of learning and less to sharing the work load in hospital wards. That has been welcomed by nurses. Trainees will have student status and 62 per cent. of colleges in England have now converted to the system. Some £109 million has been spent in the past three financial years, and another £98 million has been allocated for 1992-93.

The trouble with nurse training, as the Government and the Royal College of Nursing accept, is that the training and education programmes have a high degree of rostered service which is not conducive to the learning process. All that will be changed. The education changes should go a long way towards providing a future nursing work force who are better equipped to meet the complex demands of modern health care, and who will have more interesting and satisfying careers.

For the first time, nurses will have a broadly based education which emphasises health promotion as well as the care of the sick. It will enable them to work either in hospitals or in the community without the need for extensive further training. I agree wholeheartedly with my hon. Friend the Member for Eastleigh. When the regulations are introduced, we should look again at the hospital sector. I suspect that nurses are very much like sergeants and sergeant-majors in the Army. They tend to hold the hands--I do not mean that literally--of young doctors in training and they know far more about diagnosis and about prescription than do many of the young men and women who have just entered the medical profession. Nurses should have an even more professional role in prescribing in hospitals, and I hope that my hon. Friend the Minister will consider that point carefully.

There will be a better alignment of the practical and theoretical components of nurse training so that the practical component, which will not diminish significantly, will reflect the theoretical stage reached. There will also be an opportunity to rationalise the confused pattern of post-basic training, thus eliminating duplication and overlap. Provided that we can encourage as many nurses as possible to come in, the end result should be more flexible and adaptable practitioners who can respond to changes in the provision of service. I hope that the whole House recognises that.

I am sure that nurses will take into account the fact that their pay has increased substantially--I know that some would say not substantially enough--by 48 per cent. in real terms since 1978-79. Since that time the number of nurses has increased by 69,000, despite the difficulties in recruitment, which are being overcome. I am sure that my hon. Friend the Minister accepts that this Government are very pro nurses. We have embraced the majority of sensible suggestions proposed by the Royal College of Nursing.

Mr. Stern : My hon. Friend has rightly drawn attention to the Government's record in improving nurses' pay. Would it be introducing an unduly controversial note to point out that, under the Labour Government, from 1974 to 1979 nurses' pay was cut by 3 per cent. in real terms?

Mr. Hayes : I wholeheartedly disagree with my hon. Friend. Nurses' pay was not cut by 3 per cent. in real terms. In the five years to 1979, the Labour Government cut nurses' pay by 21 per cent. in real terms--even if the overall figure was 3 per cent. Nurses should be aware of that. I do not want to introduce a party political note,

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given the unified stance that we have achieved on the Bill, but I had hoped that the hon. Member for Peckham would say that what she said last year and the year before about indicative budgets was totally wrong. I remember all the scare stories--how the elderly, sick and vulnerable would not get their drugs from the doctors. That has not happened at all.

Ms. Harman : Will the hon. Gentleman give way?

Mr. Hayes : I shall give way to the hon. Lady so that she can set the record straight and so that we can have a full televised apology.

Ms. Harman : I came to the House this morning warmly to welcome the Bill introduced by the hon. Member for Chislehurst (Mr. Sims), which has all-party support. I hope that, in addition to securing the Bill's passage through the House today, we shall proceed to debate the Civil Rights (Disabled Persons) Bill--a measure which profoundly affects many of our constituents. I shall not be rising to party political provocation and I am confident that the Minister will not either, so I suggest that the hon. Member for Harlow (Mr. Hayes) addresses himself to the Bill and does not try unsuccessfully to waylay and mislead the House so that we cannot proceed to the next item of important business. Shame on him!

Mr. Hayes : I apologise profusely for giving in to temptations of the flesh. The hon. Lady referred to the next Bill on the list which I wholeheartedly support--as, I suspect, do the majority of hon. Members present. That will be debated at another time.

I ask the Minister to consider the question of head lice--not a pleasant topic for a Friday morning. At the moment, we are in difficulty because parents do not like to think that their children have head lice, but they do have head lice. The presence of head lice does not mean that a child is dirty : they are often to be found on very clean children. Head lice are a taboo subject in many areas. As a result of a change in the regulations, district health authorities cannot supply schools with the prescribed shampoo. My hon. Friend the Minister will no doubt point out that one can still get the shampoo free, but parents will still have to go to the chemist and ask for it, or go to their GP. They will find that extremely embarrassing because everyone knows what the shampoo is for.

I have received a number of letters on the subject. I do not expect my hon. Friend the Minister to comment today, but would ask her to re-examine the regulations and consider carefully allowing district authorities to prescribe to schools the shampoo that is needed to eradicate head lice. There is quite a lot of feeling on the subject. Another matter relating to drugs on which I do not expect an immediate response from my hon. Friend the Minister is generic prescribing.

Mr. Arbuthnot : My hon. Friend has suggested quite an extension of the idea of nurse prescribing for individual patients--nurse prescribing for entire schools. I should have thought that that would be better handled by a doctor, if by anyone.

Mr. Hayes : I honestly do not care who handles it as long as it is handled in such a way as to spare many of my constituents the embarrassment of asking for head lice shampoo publicly--a matter on which they feel very

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strongly. This may not be a subject which ought to be considered on the present Bill, but I ask my hon. Friend to think carefully about it.

I shall refer briefly to the great potential savings from generics on GP prescription. About £50 million could be saved if GPs were given the opportunity to tick a little box on their prescription forms, with the consent of the patient, to indicate that, when the drug was dispensed, its generic equivalent could be given. I understand that the matter has been carefully researched and that £50 million-plus could be saved and ploughed back into the health service.

I warmly welcome the Bill. I wholeheartedly congratulate my hon. Friend the Member for Chislehurst and ask that the Bill be put on the statute book as soon as possible--taking into account the general election. I hope that both Houses will be wholeheartedly committed to rushing it through, because it is needed.

10.35 am

Mr. Hugo Summerson (Walthamstow) : I do not intend to detain the House. I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on his excellent Bill. It is a commonsense measure. There is no reason why nurses, with all their practice and training, should not be permitted to prescribe to some limited extent. As we have heard, the measure is supported by the Royal College of Nursing, and I look forward to the time when nurses can, indeed, prescribe. It will help them ; it will help patients ; and it will help to take a little of the burden from doctors.

I want to make a plea for the continuing expansion of the categories of people who can prescribe and suggest that we draw pharmacists into that widening network. Increasingly, people go to the pharmacist when they have some minor problem and pharmacists are becoming the centre of attention for those who do not want to bother their doctors with petty complaints. At the moment, people have to go to the doctor's surgery to get a prescription. Then they have to take it to the pharmacist to get whatever medicine has been prescribed. There is a bit of a problem, however, and the process can be obstructed if someone living on his own is so ill that he cannot get to his doctor. What can he do? He can ring up the doctor and say, "I am ill." The doctor may know something about his condition and may agree to let him have a prescription. If he is too ill to go to get the prescription, he has to ring friends or relatives to ask them to collect it for him from the doctor, to go to the pharmacist and to bring him the medicine.

I suggest that pharmacists have a valuable role to play. There may be a pharmacist just down the road from where the patient lives and if there were a little more co-operation, perhaps sick people who could not collect medicines themselves could have them delivered to their doorsteps.

The Bill will be of particular value in rural areas where there is rather a waste of petrol as cars rush back and forth. Nurses visiting patients have to return to the doctor's surgery for a prescription, then get the medicine and take it back to the patient. Nurses who visit patients regularly may know their needs better than the doctor does. If the nurses can say what the patient needs and prescribe that item, it will be much better for the patient.

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I was sorry to hear the hon. Member for Peckham (Ms. Harman) bringing in a note of complaint. She said that the Bill could have been tacked on to the Nurses, Midwives and Health Visitors Bill. I have a copy of that Bill and it is clear that there is no way that the present measure could have been tacked onto it.

My hon. Friend the Member for Chislehurst has introduced a welcome measure, which has the wholehearted support of the Government and of hon. Members on both sides of the House. We look forward to its becoming law.

10.38 am

Mr. Dudley Fishburn (Kensington) : It is no coincidence that my hon. Friend the Member for Chislehurst (Mr. Sims) should have introduced the Bill. He is a wise man who has long been interested in all aspects of the medical services, and was a sponsor of the idential Bill which I introduced in the previous Session. I am pleased to be a sponsor of the present Bill and to assist in my hon. Friend's far more successful attempt. I think that I can say that I support every word of the Bill, because it is almost word- for-word the Bill that I introduced last year.

My hon. Friend the Minister for Health, who is present in the Chamber today, is the very same charming Minister who killed the Bill then. Indeed, my hon. Friend the Member for Chipping Barnet (Mr. Chapman) from the Whips Office, although less charming, is from the same Whips Office that used the mechanics necessary to ensure that the Bill did not proceed. I recall being ticked off for writing a letter to The Times which advocated nurse prescribing and which pushed the Government in that direction. All that is now water under the bridge. I am delighted that we are all on the same side and that the Medicinal Products : Prescription by Nurses etc. Bill will make it to the statute book.

If primary legislation is to have distinction and life--and so much does not--it must be rested upon an idea or principle. This short Bill has a principle attached to it--the principle of liberalisation. That principle is the belief that the more responsibility we give to people, the more welcome it will be. Indeed, these new

responsibilities are welcomed by the nurses. The more we can peel back layers of the onion skin of bureaucracy--in this case the bureaucracy of health care--the better society will be. That principle gives the Bill life.

That principle first caught the attention of Mr. Samuel Brittan, the economics writer for the Financial Times. He, perhaps more than anyone, even in this place, has pursued the concept of liberalisation over the past decade. He wrote a column in the Financial Times last year supporting the prescribing Bill and it was no conincidence that he entitled the column :

"A Modest Blow for Freedom."

That, of course, is just what the Bill is. It is modest and it is certainly a blow for freedom. It will free up the system. Sam Brittan got to the core of what is interesting about the Bill when he wrote :

"The main thrust of economic liberalism is to remove unnecessary restrictions and barriers ; and there is no reason for health to be exempt Liberalism is concerned with putting the onus of proof on those who want to restrict.

There are many cases in which there are genuine costs of deregulation to be weighed up against the benefits. Here is a rare case where there seem only benefits."

I wholly agree. That is why the Bill should make progress.

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Although my hon. Friend the Member for Chislehurst has spelt out clearly that the Bill will allow 25,000 community nurses--those with the highest training--to write prescriptions against a limited formula agreed in advance by the British Medical Association and the Government, we should push this a little further. We must consider the ideas put forward by my hon. Friend the Member for Eastleigh (Sir D. Price). In time, some hospitals may seek to have this liberalising measure applied in their wards.

There is an interesting precedent here in that midwives can alter the amount of painkillers, without recourse to a doctor's permission, in hospital, during childbirth. They have done that for years with tremendous skill and without anyone taking any notice or believing that that was a new measure. In time, I hope that we will look to an expansion of the measure to hospital nurses so that they can write their own prescriptions.

Mr. Arbuthnot : With regard to expanding the measure to hospital nurses, will my hon. Friend consider a point made by my hon. Friend the Member for Chislehurst (Mr. Sims) who said that the proposal would not be necessary in hospitals because of the constant presence of doctors in hospitals? The Bill deals with an area where nurse prescribing is necesssary.

Mr. Fishburn : The point is that if it is not necessary, it will not happen. If it is necessary or desired, in a liberal society, it should happen. My hon. Friend the Member for Eastleigh made that point.

The hon. Member for Eastbourne (Mr. Bellotti) referred to the advantages of the Bill in a rural setting where community nurses have to travel great distances. I believe that the Bill will be equally welcomed in an urban setting like my constituency of Kensington. Picking one's way through the urban jungle can be every bit as time-consuming for a community nurse as travelling over the rustic downs of Sussex.

A community nurse in an urban setting experiences an enormous waste of time. She may finally arrive to see a bed-ridden patient in a tower block only to find that a bandage, lotion or painkiller is required, but she must return to base, to her GP's office, to get a prescription. That could easily take an hour or even the better part of an afternoon. That is extremely frustrating for the nurse and worrying for the patient.

I want to question my hon. Friend the Minister on a point which will be important as the legislation makes progress. Will practice nurses be able to prescribe? As I understand it, if a practice nurse has the qualifications of a district or community nurse, she will be able to prescribe. The thrust of this Government, through GP fund holding and the reforms of the past few years, has been to allow family health practitioners to have within their boundaries a range of health provision that brings care as close as possible to the patient.

GPs across the country have increasingly recruited practice nurses and the Government have rightly supported that. It would be a great shame if, as the Bill makes progress, it was not made clear that practice nurses could, particularly if a GP so wished, write prescriptions.

I have four children under the age of 10. When I am not in the House, I spend most of my time in the doctor's surgery. One of my children has mild asthma. Not unnaturally, we visit the practice nurse every two months.

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My child blows into the blower and sucks from the sucker and, once every six months or so, the nurse says, "You're coming on fine. That's great, but you have run out of the lozenge which has to go into the machine." When I say, "Right, I'll take some away now", she says, "Ah, I can't give you more because I cannot write a prescription". The doctor is busy next door--probably seeing one of my other children--so he cannot write the prescription right away. Therefore, I have to go away and come back the next day. That is the kind of inefficiency that the Bill can break through. Does my hon. Friend the Minister envisage that practice nurses will be able to write prescriptions if their GPs so wish? Will the Bill or the subsequent regulations that the Department will bring into effect allow that or will we have to agree amendments in Committee? Everything in this country takes time. As my hon. Friend the Member for Chislehurst is aware, this modest measure has taken a long time. The first report from Baroness Cumberlege appeared in 1986. Considering the most rapid progress that the Bill might make, it is proposed that the regulations will be in place by the autumn of 1993. With a little slippage, we are talking about 10 years between the birth of an idea and its practice.

However, that is the birth of this idea only in Britain. We must not forget that we are not reinventing the wheel. Nurse prescribing is practised widely in other countries that abhor bureaucracy and practise economic liberalism and which believe in having no layers of the onion skin between the patient and the doctor or nurse. Nurses prescribe in Canada and in most of the states in America. I hope that we will not set out on another study in the years ahead, but will act on this Bill with all speed and dispatch.

10.49 am

Mr. Michael Stern (Bristol, North-West) : I am grateful to you, Mr. Deputy Speaker, for calling me to speak on this important measure. I join all hon. Members in congratulating my hon. Friend the Member for Chislehurst (Mr. Sims) on bringing forward this welcome measure. We know that this will be a truncated parliamentary Session. Therefore, the difficulties facing any private Member's Bill are even greater than usual. The Government's support for the measure is welcome. Indeed, the support of the Opposition, despite their somewhat reduced numbers today, is also welcome. We need all that support, and support in another place, to give the measure even the slightest chance of success in a shortened time scale. I am sure that all hon. Members wish it well.

At the outset, I stress that the points that I wish to make in no way detract from my support for what will be a welcome measure not only in rural areas, which are one of the wellsprings for it, but in heavily urbanised areas such as the one that I represent. I wish to draw attention to a couple of aspects of the proposed restricted list of drugs and the formulary which the Bill will set up under regulations. I congratulate my hon. Friend on drafting, or allowing the Bill to be drafted, to permit much of the detail of the Bill to be dealt with by regulation rather than being in the context of the Bill itself. There is a considerable history of successful regulation by the Department of Health. The idea of a limited prescribing list began in the teeth of considerable opposition to the Department of Health, and it has proved

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to be far more successful than the medical profession and Her Majesty's Opposition thought at the time. Because of the rapid change in the work demanded of nurses within the community, there will be a need for equal flexibility within the Department of Health in respect of the powers given to nurses under the Bill.

My hon. Friend is entirely right, albeit that most of us normally deprecate legislation that effectively hands over substantial additional powers to Departments rather than them being within the review of the House. My hon. Friend is entirely right to pass that power to the Department and effectively take it from Parliament. A regulated list of drugs or preparations under the control of the Department finds support in some rather surprising quarters. The Department's work in preparation for the Bill parallels work that has been done in the pharmaceutical world over many years, in particular leading up to the campaign which started a few years ago for pharmacists to be able to sell and advise on certain drugs without a prescription. I hope that the passage of the Bill will not damage that campaign by pharmacists to be able to use their professional knowledge and expertise to a greater extent and that the movement toward non- prescription will not be damaged by the movement towards greater freedom of prescription.

That work has received support from some surprising sources. I remember a pamphlet from the Institute of Economic Affairs some years ago--not a body to which one would normally look in such matters--which argued strongly for greater freedom for pharmacists to be able to sell without prescription. I hope that my hon. Friend the Minister will reassure me that the movement toward greater freedom of non-prescription will not be harmed by the Bills.

The Bill refers to appropriate training for nurses in the use of the restricted list. It is worth dwelling on that for a moment. What may be appropriate training for a district nurse in a rural area may not be appropriate for a health visitor dealing with an area of urban stress. The demands on their time and their abilities to prescribe are likely to be totally different. I hope that, when considering the training schemes that will be set up under the Bill, my hon. Friend will give appropriate weight to the flexibility that will be needed to ensure that nurses are trained for the many tasks that will become necessary under the Bill. I suspect that that suggestion would lead to an unacceptably wide and demanding training course. Alternatively, I hope that my hon. Friend will look at some form of modular training so that a nurse who wishes to take on prescribing rights in, say, an urban area will be able to receive specific training in, for example, dealing with the homeless and areas containing a large number of people with tranquilliser dependency, such as occurs in at least one area of my constituency. Those demands will be totally different from those on a nurse who is training for the right to prescribe in some rural areas or, indeed, urban areas which do not suffer the same social stress.

I now refer to the signature of prescriptions which will be permitted under the Bill. I ask my hon. Friend the Minister how that will relate back to doctors, health authorities or other bodies responsible for a certain aspect of patient care with which the nurse will be dealing when the prescription is generated. In that connection, I draw

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my hon. Friend's attention to an organisation which, so far, has not been mentioned. My hon. Friend will know it well. I refer to the Prescription Pricing Authority, a body which is centered on Newcastle upon Tyne. One's first acquaintance with it would indicate that it is a great contributor to the welfare of the warehousing business in Newcastle upon Tyne, because it stores and sorts, under a system called PACT--prescription analysis and cost--every prescription that is ever written. That body does much unsung technical work to a very high level of professional expertise. Any family health services authority which wishes to inquire into the prescribing habits of a doctor or a practice will be able to go to the Prescription Pricing Authority and obtain from it, with appropriate safeguards, all prescriptions issued by that doctor or practice over a certain period. I do not have to tell the House the extent of the work that is necessary to provide that service.

At the moment, the Prescription Pricing Authority will work to a certain doctor, so the sorting mechanism at the PPA is determined by the need to sort by doctor or, frequently, by type of preparation. I wonder how the PPA will have to adapt its work. A district nurse or a nurse on the official list will sometimes work with a certain doctor or health authority. There may be other circumstances in which the ultimate responsibility for a validity of a prescription will not be relevant to a certain general practitioner. I hope that my hon. Friend the Minister can reassure the House that, under the Bill, the standards of control and the "findability" of prescriptions will be no less than those for prescriptions currently issued by a registered general practitioner.

Recommendation 5 of the Crown report refers to the type of work of nurses for whom prescribing could become useful. The recommendation states :

"In addition to nurses with a district nurse or health visitor qualification, certain community nursing staff who have successfully completed appropriate specialist education, training and assessment should be able within a patient specific protocol".

I emphasise the phrase "patient-specific" as it is underlined in the recommendation--

"to adjust the timing and dosage of medicines which are prescribed by medical practitioners."

That is an important recommendation.

The recommendation continues :

"At present we propose that community psychiatric nurses, community mental handicap nurses, specialist nurses for terminally ill patients and diabetic liaison nurses should be given this authority." I entirely agree with that recommendation. It shows a breadth of understanding of the specialist work of the nursing profession which is highly commendable. However, one aspect of nursing is not covered by the recommendation. I refer to the case of qualified nurses who, under the general training provisions of the Bill, qualify for prescribing, but have chosen a career path that has led them to become matrons in nursing homes, especially for the elderly in the private sector. I have come across cases in my constituency where such matrons who in every way qualify to issue a prescription under the Bill are debarred and may continue to be debarred from issuing a prescription to a patient under their care because those matrons have no direct relationship with the general practitioner who has responsibility for the elderly patient in the nursing home. The case of an elderly person living in my constituency who was urgently admitted to a nursing home on the other

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side of Bristol has recently been drawn to my attention. That patient's GP practised in my constituency and was, therefore, unable to provide an immediate service to the patient. Shortly after the patient was admitted to the nursing home, and before there was time to transfer the patient to the care of a GP close to it, the patient needed a prescription. However, the matron was forced to say to that patient's children that she was sorry but was unable to help other than to arrange for the patient's admission to hospital so that an urgent prescription could be given. It would be helpful if matrons of nursing homes could, as of right under the Bill and subject to proper training, be given the same powers of prescription as will be given to other groups of nurses.

Clause 2 of the Bill rightly extends the duty of family health services authorities in England and Wales to cover the prescription duties. I should declare an indirect interest as my wife chairs such an authority. I assume that, under the Bill, when any nurse is acting for or working with a GP to issue a prescription, any complaint of an offence on the issue or non-issue of a prescription will be related to the nurse and the doctor by the family health service authority. I should like my hon. Friend the Minister to clarify that assumption. One assumes that a disciplinary hearing, which at present can be brought only against a doctor, could in future be brought against a nurse.

However, how will a family health services authority carry out a similar duty if there is a complaint about prescription by a nurse when he or she is acting for a health authority, for a home run by the social services or a privately run home that provides services to the social services authority? How will the family health service authority conduct a disciplinary hearing when the case does not relate to a practitioner who is registered with that authority? That may seem a technical point, but disciplinary hearings cause much anguish both to the practitioner and the patient. It is worth while to reassure all health service users and all nurses that there will be adequate mechanisms for coping with what I am sure will be very few disciplinary or complaints hearings.

There have been a number of comments in the debate on the Treasury's attitude to the proposals. Unlike my hon. Friend the Member for Eastleigh (Sir D. Price), I do not regret that the Treasury has not adopted an open- handed attitude as, by their very nature, Treasuries are debarred from so doing. I congratulate the Treasury on making available, through the money resolution and the Government's support for the Bill, the not insubstantial sum of money that it will cost to implement the legislation. Many apparently equally deserving proposals that would have cost less than the estimated cost of the Bill have been put to the Government and, regretfully, the Treasury has had to refuse. Treasury Ministers deserve praise, not grudging acceptance, for the fact that they are prepared to make available the necessary money.

The notes attached to the Bill make it clear that the sums involved will fall on the budget of the family health service, which generally seems entirely appropriate. But I hope that we may be assured that, when the regulations are drafted under the Bill, the budget of the family health service will not be unnecessarily put upon from either health authority budgets or social service budgets. That could happen as services are provided under the Bill that would otherwise have been paid for by health authority or social service budgets. I speak as an accountant and foresee a difficult accounting problem that should be

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addressed early. Inevitably, even given the greatly expanded funding that the Government have made available to the health service generally, there is still--rightly--considerable pressure of competition on all aspects of budgeting for resources in the health service. So the Minister should account in advance for some of the issues that will occur between budgets as a result of the Bill. I underline some of the points made in the Touche Ross report about the likely costs of the measure. My hon. Friend the Member for Eastleigh pointed out that much of it was guesswork, which means that the report must sometimes, inevitably, put figures to guesswork. Even so, those figures are based on the best analysis available. They take into account all the known factors, so that, although we must accept them with caution, it would be unwise to discount the figures. Although we recognise--I appreciate that my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) takes issue with me on this--that there will be considerable savings in time resulting from nurses not having to travel backwards and forwards to get prescriptions filled out and redeliver them to patients, that degree of time saving, though welcome, will manifest itself not in cost savings but in the more efficient use of nursing time and, one hopes, in less delay in patients receiving the drugs that they need.

Mr. Arbuthnot : My hon. Friend is making the case for the inevitability of the extra time being made available by the Bill to district nurses being taken up by extra work by those nurses. Is that acceptable? We shall have many options to consider when the measure becomes law, including a reduction in the number of district nurses and the channelling of the resources so saved into other areas of health care. It would be unwise to reject those options at this stage of the Bill.

Mr. Stern : I accept that, and my hon. Friend is underlining in many respects the strength of the Bill in that it draws together the support of hon. Members who look at the issue from the standpoint of the greater service that will become available, for example, in some of the most stressful inner-city areas such as that which I represent. That advantage will apply right across the spectrum, through to the services that other hon. Members expect to receive in more rural or less stressful urban areas. I do not anticipate there being any reduction, as a result of the Bill, in the numbers or costs of the services in the area that I represent. But I expect a higher level of service and, I hope, slightly less stress on the providers of that service.

I welcome the Bill because it is about supporting the nursing profession and giving its members more facilities and greater ability to do their job. In that way, we shall not only assist the members of the nursing profession in a difficult and dangerous part of their work, but give them additional responsibilitiess which add to their problems.

I think of one area in my constituency, the walk-up flats in Lawrence Weston. I was recently taken round the area and during my visit, which lasted a day, saw some of the cases and problems that people face on a day- to-day basis. The Bill will not reduce the physical danger in which nurses sometimes find themselves, but it will help them to provide a better service in areas of high stress. It will also

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help them to plan their day better, so enabling them to make more visits and use their time more effectively, for the benefit of their patients.

While we have been in office, there has been an unprecedented increase of about 68,000 in the number of active nurses in the profession. I welcome a measure which, I hope, will not decrease those numbers but will strengthen the hand of the profession in dealing with its problems.

11.15 am

Mr. James Arbuthnot (Wanstead and Woodford) : I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on coming high in the ballot and on choosing a subject that is close to the hearts of us all. We are all subject to the vagaries of health, and he has made it possible, by introducing the Bill, to improve the care that is available to the public at large and to make it more effective and efficient at the point of service.

I echo what was said by my hon. Friend the Member for Harlow (Mr. Hayes) in congratulating Christine Hancock on all the work that she has done in helping to bring the Bill forward. Before moving to her present position, she was the general manager of the Waltham Forest health authority, which covers my constituency. She may have been the first such general manager to occupy her present position, and her work has been extremely valuable.

In May last year my hon. Friend the Member for Kensington (Mr. Fishburn) introduced a Bill under the ten-minute rule which was discussed on the Floor of the House on a Friday morning. It was unusual for such a Bill to come so close to achieving legislative effect. He managed it in a way that is almost unique to him, for he has introduced many ideas that have been taken up only after he thought of them. In that respect he is an admirable successor to his predecessor, our late-lamented colleague, Sir Brandon Rhys Williams. So not for the first time has my hon. Friend the Member for Kensington brought forward fresh ideas that have helped not only his constituents but the country as a whole.

Several reservations were registered to the Bill that my hon. Friend introduced last May, some of which I raise again in the hope that they will be answered. I spoke briefly when that Bill was debated on 3 May 1991, and at that time the Minister did not have an opportunity to deal with some of the issues that I raised. It is crucial that nurses who are given power to prescribe have proper training, and obviously the power to prescribe should be limited to those who have had that training. It is essential for that not simply to involve going through various courses, but for those who go through them to prove that they have an understanding of, and achievement in, what was contained in the courses. Merely to have been sent on a course should not be sufficient proof that a nurse has grasped all the principles involved in this important and delicate matter of prescribing. Training is crucial. I suspect that it should be limited to a relatively small number of nurses, at least at the beginning.

The important question that needs to be addressed is precisely what nurses should be allowed to prescribe. My hon. Friend the Member for Eastleigh (Sir D. Price), in his excellent speech, read out a paragraph from the report of the Social Services Select Committee in which it was said :

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"many witnesses believe that nurses should have freedom to prescribe a limited range of items, such as dressings, ointments and medical sprays, and that they should be able to use their professional judgment on matters such as the timing and dosage of drugs prescribed by doctors for pain relief."

If that report is accepted, the implication is that the Bill should cover only dressings, ointment and medical sprays, and the amount and timings of drugs already prescribed by a doctor.

I am not sure whether the Bill would allow nurses to prescribe new drugs. If it has that effect, we must consider it extremely carefully in the light of the negotiations and discussions since my hon. Friend the Member for Kensington introduced his Bill. That innovation would present dangers and problems. What would happen if a patient were prescribed two drugs that interacted with each other? I raised that problem in my few remarks on 3 May.

Frequently patients do not tell their doctor or nurse what they are taking. Therefore, a nurse could prescribe one drug which would react with another to provide a dangerous effect in the patient. We must guard against that. Doctors are well able to guard against that by reason of their training. If the Bill becomes law, as I sincerely hope it will, nurses, too, should be trained to deal with that. That probably applies even to an increase in dosage, to which the Select Committee report refers.

The next question raised during this morning's debate is precisely where nurses should be able to prescribe. There has been a difference of opinion on that. My hon. Friend the Member for Chislehurst said that health visitors and district nurses who travel a lot in the country should be able to prescribe. They do not want to have to go back to the doctor for a prescription for something about which they may know more than the doctor, then travel to a chemist and back to the patient. All the time that that procedure takes up would be saved.

If the circumstances are expanded to include nurses in hospitals writing prescriptions, altogether different questions arise. My hon. Friend the Member for Chislehurst said that it was not necessary for nurses in hospitals to prescribe because doctors are on hand and, with all their training, should be available to make the necessary prescriptions. He told us that that circumstance was, therefore, not covered by the Bill. I questioned my hon. Friend the Member for Kensington, who suggested that that circumstance should be covered in the Bill on the ground that if it was necessary for nurses in hospital to prescribe, as circumstances might suggest that it would be, the law should allow them to do so.

My hon. Friend is an eloquent proponent of liberalisation of all sorts, but we must be exceptionally careful with the prescription of drugs. Although they can bring great benefits, they can also cause great tragedies. We must be careful about the extent to which we liberalise our drugs regime.

My hon. Friend the Member for Bristol, North-West (Mr. Stern) gave an example to show why it was necessary to consider at least the possibility of some hospital prescribing. He referred to the matron of a nursing home or some similar establishment and related how someone could not obtain a prescription from a doctor as there was no local link with a doctor. That tipped the balance in my mind between the views of my hon. Friend the Member for

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