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Chislehurst and the views of my hon. Friend the Member for Kensington. We should consider whether an amendment should perhaps be made in Committee.This century matrons have acquired a respect. They were noticed only when they began to disappear as a result of some health reforms some time ago. I am delighted to say that matrons are now coming back, partly because of our health reforms. They are increasing our respect for the health service. Those who would prefer a doctor to a matron to give a prescription would often be considered to be rather odd.
Mr. Stern : I entirely agree with my hon. Friend about matrons. He called for an amendment to the Bill, but he may well find on reading the Bill that the extension to which he referred could be dealt with by regulations under the Bill as it stands.
Mr. Arbuthnot : I have read the Bill, and it deals with amendments to other legislation which one then must follow through and follow through and follow through. It is complicated to work out precisely the effects of
"after the words exemption conferred' there shall be inserted the words or modification made' ".
I am grateful to hear from my hon. Friend that that could be done by regulation. If that is so, I hope that my hon Friend the Member for Kensington will consider it.
The Bill will create for the first time--I am open to correction on this-- two different forms of prescription : those produced by nurses, district nurses or health visitors, and those produced by doctors. An essential aspect of the Bill is that chemists must be able to tell at a glance which prescriptions are being presented to them. They must be able to ensure that nurses' prescriptions are limited to the drugs or appliances that are permitted by the regulations introduced under this legislation.
I am not sure how it is proposed that those prescriptions should be differentiated. Perhaps they should be on two different coloured prescription pads so that chemists may know that a white prescription comes from a doctor and a green prescription from a nurse. In that case a green prescripton would not permit a chemist to give over the counter to a nurse drugs that only a doctor can prescribe. That, of itself, would mean that not only nurses but chemists would need training as a result of the Bill. That is to be welcomed. Contrary to the belief of my hon. Friend the Member for Bristol, North-West, I believe that the Bill may well produce financial savings as well as savings in time and effort. The training of chemists in that respect could easily be absorbed within the money resolution.
The Bill will save district nurses and health visitors time and journeys now wasted on going to the doctor, writing out the prescription for the doctor, persuading the doctor to sign it, going to the chemist, and taking the appliance, or whatever, to the patient. But doctors, who are very highly paid, will also experience a saving : they will no longer have to spend time dealing with prescriptions for patients about whom they propbably do not know very much.
My hon. Friend the Member for Bristol, North-West feels confident that the savings in time would be absorbed immediately by the extra work done by district nurses and, probably, by doctors. I disagree. One of the benefits of the health reforms that we have introduced is the fact that health authorities are being literally forced to be sensible about priorities, and to allocate resources accordingly. If
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they find that district nurses or health visitors have more time available as a result of the Bill, health authorities will have not only the ability but a positive duty to consider whether to reallocate the resources that have been saved--to hip replacement operations, for instance. In the constituency of my hon. Friend the Member for Bristol, North-West, those resources might be used to increase the amount of productive work done by district nurses.Mr. Stern : An artificial disagreement is being created. I agree that the Bill would allow resources to be reallocated, but I was trying not to give the impression that it would result in a net cost saving ; it would merely result in an increased provision of service.
Mr. Arbuthnot : On that note of harmony, I shall move on to another point. The hon. Member for Peckham (Ms. Harman) said that trained nurses were leaving the national health service at a rate of 80,000 a year. I am not sure whether that statistic is correct, but I understand that there are now 69,000 more nurses and midwives than there were when the present Government took office. That may be a result of a pay increase of nearly 50 per cent. in real terms. Nevertheless, the retention of nurses is essential. One advantage of the Bill is the increase in job satisfaction that it would give nurses. At present, a district nurse is forced to say to a patient, "I am sorry, but I cannot provide you with this ointment. It is silly, but I will have to go to a doctor who knows nothing about your case and get him to sign something that he probably will not read. I will then have to take the prescription to a chemist--who probably will not be able to read it--and bring the ointment back to you."
Not only is that process a waste of time ; it humiliates the nurse or health visitor, and makes her feel that her job is menial--which it certainly is not, and which it should never be considered to be. The Bill would give that nurse or health visitor the responsibility that--in practice--she already exercises : she would be seen to have that responsibility. I believe that such an increase in job satisfaction would contribute greatly to the retention of district nurses and health visitors. Their job is already rewarding, but the Bill would make it more rewarding.
That valuable increase in the responsibility of district nurses and health visitors would also involve a valuable decrease in the burdens borne by doctors. I do not know whether the retention of doctors has been a problem, but, if so, the Bill might help to solve it. Still more can be done to improve job security for nurses. We can increase the provision of training, not just in regard to prescriptions but in regard to other matters.
Mr. Deputy Speaker (Mr. Harold Walker) : Order. I very much hope that the hon. Gentleman is not using a Second Reading debate to make a general speech about the nursing profession, and that he will adhere more closely to the terms of the Bill.
Mr. Arbuthnot : I was going to say that I hoped that the Bill could be used to increase nurses' job satisfaction. Training is an essential aspect, and one reason for it is that increase in job satisfaction. I hope that the Bill will be used almost as a platform to give nurses the status of highly qualified medical
practitioners--not quite on the same level as doctors, but more respected than they are now.
Mr. Gordon McMaster (Paisley, South) : I do not wish to detract from the importance of what the hon.
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Gentleman is saying, or from the value of the Bill, but I was interested by his remarks about giving people a better quality of life and more job satisfaction. The next Bill on the Order Paper --the Civil Rights (Disabled Persons) Bill is also very important, and many of us hope that we shall reach it today.Mr. Arbuthnot : I am aware of that, and I shall end my speech shortly.
It is pointless to restrict the prescribing of medicines, ointments and appliances to doctors, given that the number of prescriptions with which they must deal makes it inevitable that they will sign forms without giving them proper attention, and without exercising the required clinical judgment. The same applies to Ministers : if they have to sign about 100 letters each day, they will inevitably sign some without reading them.
In many cases, nurses might well be better at prescribing than doctors. A district nurse with 25 years' experience would have much more knowledge of individual patients' needs and circumstances than a newly qualified doctor who did not have the same opportunity to get out and about.
I welcome the Bill. I am glad that both the Government and the Opposition support it, and I wish it every success.
11.37 am
Mr. Roger Moate (Faversham) : Although I am sure that we all appreciate the importance of reaching the Civil Rights (Disabled Persons) Bill, I have no doubt that every hon. Member also appreciates the importance of this Bill, small though it is. It gives us the opportunity to comment both on the use of nursing resources generally and on the implications of the Bill for our constituents. I apologise to my hon. Friend the Member for Chislehurst (Mr. Sims) for entering the Chamber towards the end of his speech ; I was inadvertently delayed. As I came in he was saying, in effect, that the Bill need not be extended to cover hospital nurses, because doctors were normally in attendance. Would that that were the case. I welcome the Bill. Like many others, I have long believed that the medical skills of our experienced nurses are an underused resource. The more that we can utilise their skills, the better it will be for patient care. The Bill is a small step in the right direction. It inches forward when perhaps we could have taken a giant step for mankind, but I hope that it will be used to go further, perhaps within the regulations that might follow.
I hope that we shall not lose the momentum to develop further the use of skilled and experienced nurses for services where the patient is not getting that speedy and rapid service that he or she desires, There is a long way to go. I do not go as far as my hon. Friend the Member for Kensington (Mr. Fishburn), who wished to apply Mr. Samuel Brittan's rules of economic liberalism to prescribing. I accept some of his economic prescriptions, but not his medical prescriptions. I accept, too, that we must be careful of simplistic solutions. As my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) said clearly and concisely, not only benefits but risks will be conferred by easier prescribing.
One understands why the medical profession moves carefully and slowly, but it can go too slowly and I suggest
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that it has done so. Although the Bill is welcome, the Cumberlege report was published in 1986 and it will be a long time before the benefits of the Bill are conferred on midwives, community nurses and patients. I hope that the medical profession will try to speed up the process whereby we extend the use of nursing skills into other areas.I am sorry if I missed the more detailed explanation that my hon. Friend the Member for Chislehurst gave of why it is not necessary to extend prescribing rights to hospital nurses. Perhaps we shall hear more from my hon. Friend the Minister about that.
I feel strongly about the Bill because in my constituency--I am sure that this experience is shared in other constituencies--the services of smaller hospitals have been progressively cut. Services have been concentrated on general district hospitals. The acute services and other facilities of smaller hospitals and, indeed, of medium-sized hospitals have been cut. Those cuts have been made under every Government in the past 25 years. To a large extent, it has been a question not of resources but of changing medical practice. In areas such as the Isle of Sheppey--this is echoed elsewhere in the United Kingdom--acute local hospital services are now denied to local people, who must travel further afield for urgent medical attention. A welcome new trend is the greater emphasis on primary care hospitals, community hospitals or GP hospitals, whichever is the preferred term. Some of the primary care hospitals will be substantial. None the less, we cannot expect them to be manned constantly by consultants, trainee doctors or GPs, who might be on call. Many emergencies and minor matters will have to be treated at a district general hospital many miles away.
It is extraordinary that a highly trained but relatively inexperienced paramedic ambulance driver may take a patient to hospital, but a senior nurse at that hospital with 20 or 30 years' experience cannnot use the same equipment to the same degree as the paramedic. That does not make sense.
There is a new senior grade of nurses--nurse practitioners. I am unaware of the extent to which they are being encouraged to practise. My impression is that their use is not widespread, but it would be a tremendous step forward if nurse practitioners, with the ability to prescribe and use the emergency equipment, were encouraged to practise in smaller primary care hospitals. All nurse practitioners should certainly also practise in the larger new health centres operated by general practitioners.
That seems such common sense that I suspect that it would receive widespread support, as long as it was done within the proper disciplines and standards that we expect of the health service. But it all seems to be taking so long--and time that we do not have--when the speed of change in the hospital service is so great and when facilities are being closed rapidly to meet the increasing demands of modern technology and science. We should be moving quickly to release the tremendous resources and skills of those nurses.
Are there any impediments to developing the nurse practitioner facility in the hospitals that I am talking about? Close to my heart is Sheppey general hospital, which has lost many acute services. It will soon be redeveloped as a fully fledged substantial community hospital. The same applies to Sittingbourne hospital. It would mean much to my constituents if nurse practitioners were able to use their skills and resources in a 24-hour minor casualty service. If the problem is extending
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prescribing powers--I think that it might be--would the Bill allow the extension of prescribing powers to nurse practitioners? Or is the problem money? If many nurses are promoted to higher grades to carry out those services, is there a problem of relativity within the nursing profession and, if so, could it be resolved by extra resources? If that is so, it is an issue which we must tackle. I return to what I said at the beginning. The real problem is that in many hospitals doctors are not on hand at all times and must be called in, which takes time. For that reason, casualties are often directed to other hospitals many miles away. That is an unsatisfactory situation which could be solved by the philosophy contained in the Bill.I have said how far I should like the Bill to go and why it is important, but I regret that it has taken us so long to get this far. However, I welcome the Bill for what it says explicitly and I congratulate my hon. Friend the Member for Chislehurst on introducing a measure which will help the elderly and chronically disabled people in my constituency and elsewhere. It will help people in rural areas--such areas are a large part of my constituency--and it will encourage nurses and give them greater job satisfaction. Many of them undoubtedly have great skills which should be better used. The Bill will save their time because they will no longer have to go to the surgery to get a prescription signed. It is in general a good measure which should be warmly welcomed. I wish it a speedy passage, but I hope that we shall use it as a foundation stone on which to build more extensive involvement for senior and experienced nurses in the delivery of good patient care.
11.51 am
Mr. Harry Greenway (Ealing, North) : Like my hon. Friend the Member for Faversham (Mr. Moate), I shall be brief because I appreciate the importance of moving on to the next Bill. I join him in congratulating my hon. Friend the Member for Chislehurst (Mr. Sims) on the introduction of this important measure. It is right that it should be properly debated, especially when one bears in mind the fact that the three categories of health service workers mentioned in the Bill perform a very important task.
I pay tribute to the work of nurses, midwives and health visitors. I have had a great deal of contact with them during my 23 years as a teacher, during one or two spells in hospital and during my constant hospital visits to my sick constituents which I and all my hon. Friends and all hon. Gentleman make.
It must be said that nurses, midwives and health visitors already undertake virtually the duties set out in this valuable Bill. They cannot do so by law, but they have a good knowledge of the drugs that patients need. They are in constant contact with patients--at least in hospitals--and are well aware of any changes in a person's health. Like most doctors, they know what medicines are needed in a particular situation. In my experience of hospitals, I found that nurse would tell patients that they needed this, that or the other and that they would write the prescription. They could not sign it but they could produce it.
It seems absurd that such health workers do not have the written and delegated legal authority to sign prescriptions when they have the knowledge to suggest a prescription. They also have the detailed knowledge that
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only a nurse can have--in many cases, more so than the doctor--of the way in which a patient reacts in the short and in the long term to a particular medicine. Such workers are in an almost unique position to suggest sudden changes in medication and it would be right and proper if they had the authority to authorise such changes.Hospitals are well geared to handle nurses' prescriptions just as they are geared to handle doctors' prescriptions. After all, there is a pharmacy in most hospitals and nurses' prescriptions could be used or cashing in--so to speak--in such pharmacies as well as anyone else's. Therefore, the health service is well geared to responding to the measures set out in the Bill should it be enacted.
What about midwives? Surely they, more than almost any other category of health service official, operate on their own. When my three children were born I was present on each occasion. We did not see much of any doctors ; the midwife was the figure--the health service representative--with whom my wife and I continued to deal afterwards. She must have had a unique knowledge of the health or otherwise of our children and must have been in a position to suggest and authorise any medication required. Happily, none was required in our case, but we all know that, sadly, in many instances midwives have to suggest to doctors particular medication for mothers and babies if doctors are unable to get to them. It is ridiculous that midwives do not have the final authority.
Sir David Price : My hon. Friend will be aware of the fact that under separate legislation midwives today have limited powers of prescribing.
Mr. Greenway : I am aware that they have limited powers of prescribing. They always have had such powers, but why should they be limited? My grandmother was a midwife and as children we used to walk around with her and she would point to some enormous man or woman and say that he or she was one of her babies. She would then give a detailed explanation of the parent of that child and the medication needed. She could do a great deal even all those years ago, but midwives still do not have the full powers for which we are arguing. Health visitors also have limited powers. I should not want anyone in this country or anyone else in the world to have unlimited powers, because that is unhealthy. However, health visitors should have fuller powers than they have at present. I have had much contact with health visitors in schools and the work that they do with mothers and children. There are not many parents who do not have more than one child and a child's school attendance is often affected by the health or otherwise of a younger child, especially when the parents have to go out to work. In those circumstances, the younger child is often visited by the health visitor who will advise parents on how to handle the particular case. It does not make sense for health visitors not to have the full authority to dispense prescriptions. From every point of view, the Bill has a great deal to offer. It will resolve a problem that should have been dealt with long ago, perhaps even when the health service first came into being but certainly shortly afterwards. For nurses, midwives and health visitors not to have the authority and powers set out in the Bill is, in a sense, a slap in the face for them. It is a denial of their professionalism and their contribution and of the fact that their
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contribution could save the valuable time of doctors and sometimes of consultants and others. I strongly support the Bill.12 noon
Mr. John Browne (Winchester) : I shall be very brief because I am conscious that hon. Members are waiting to debate the Civil Rights (Disabled Persons) Bill. I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims), first, on winning his place in the ballot, and, secondly, on what I think will be viewed as an excellent choice of subject for health care, especially by the patients. I declare an interest in the medical field, as listed in the Register of Members' Interests.
This is an excellent Bill, which is long overdue. The fact that nurses cannot prescribe does not keep up with today's world and the level of education that nurses have reached. That fact militates against patients because doctors and others who prescribe are overloaded. It also decreases the efficiency of nurses.
I agree with my hon. Friend the Member for Faversham (Mr. Moate) that the Bill should be seen as the thin end of the wedge for future legislation.
My constituency is a rural area. In addition to the City of Winchester, we have the towns of Alton, Bishop's Waltham and Arlesford, but there are also some 74 villages. The Bill will be given a special welcome in rural areas because it will greatly increase the efficiency of nurses and midwives. It will also increase the efficiency of doctors, because a load will be taken off them. The Bill will also increase the morale of doctors, midwives and nurses. It will greatly benefit patients in the NHS, especially those in rural areas where the inefficiency and inconvenience of travelling backwards and forwards to surgeries are so manifest.
I wish the Bill all success on its passage through the House. 12.1 pm
The Minister for Health (Mrs. Virginia Bottomley) : Many hon. Members have made clear in the debate their strong commitment to the introduction of nurse prescribing. I warmly congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) as well as my hon. Friend the Member for Kensington (Mr. Fishburn), who has played such an important part in these matters. It is perhaps fitting that my hon. Friend the Member for Wanstead and Woodford (Mr. Arbuthnot) paid a tribute to the predecessor of my hon. Friend the Member for Kensington, Sir Brandon Rhys Williams, whose wife is chairman of the family health services authority in that area, and she does a magnificent job.
My hon. Friend the Member for Chislehurst paid tribute to the work of our noble Friend Baroness Cumberlege. He hopes that she will steer the Bill through another place. Her work for community nurses is second to none. That work, which she is now able to carry forward as chairman of a regional health authority, ensures that right at the heart, in the leadership of the NHS, there is someone with special knowledge and authority in this area.
I wish to remind the House of the context of the debate, both the development of the service and the status of
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nurses, into which nurse prescribing fits. It is a step of great significance, which I believe will mean that the status of nurses, which is so fundamental to the health service, is reinforced and enhanced.Our commitment to the health service is based on our determination to improve services for patients--nothing more, nothing less. That is why in the health reforms outlined in the patients charter we have spelt out our commitment to patients, especially the commitment to have a named nurse so that patients know to whom they should turn in times of difficulty, whether that be a midwife, a nurse or a health visitor. We are already seeing remarkable results. The maximum use of those who work in the service is fundamental to our being able to deliver further and improved patient care.
I am grateful to those hon. Members who have seen the Bill in the context of our introduction of care in the community. It is essential that those community nurses make a maximum contribution to enhancing the care of patients once they have left hospital. We know about the improvements in hospital care for the elderly--the 43 per cent. rise in geriatric consultants and the 84 per cent. rise in the number of elderly patients treated. However, patients are increasingly treated in the community and the support of community nurses is important. I appreciate the comments of my hon. Friend the Member for Harlow (Mr. Hayes), who spelt out the three long-standing aims of the Royal College of Nursing, all of which have been achieved. He referred to the work of Trevor Clay, and then paid tribute to his successor, Christine Hancock. I thank my hon. Friend for his warm remarks about Dame Anne Poole, who, as chief nursing officer, has made an important contribution and has ensured that the interersts of nurses, midwives and health visitors are kept in the forefront of our considerations. One of the first decisions of my right hon. Friend the Secretary of State was to appoint the chief nursing officer to the policy board so that, as we considered reforms and changes, we had her advice at the centre of our considerations.
Nurses have achieved an independent pay review body. As hon. Members have made clear, their pay has risen by 48 per cent. in real terms, ahead of inflation, since 1979. Pay is important, but so is training. Again, I thank hon. Members for their reference to Project 2000. Some £207 million has been put into that new form of nurses' training, to provide the qualified nurses that we need for the next century. We need those dedicated professionals, and we must get a better balance between classroom skills and hands-on care. We have provided a better career structure under the new clinical grading structure introduced in 1988. Nurses now have better opportunities than ever before if they remain in clinical practice. Last year, we introduced a new senior nurse structure, which provides greater flexiblity and access to performance-related pay. Just this week the Nurses, Midwives and Health Visitors Bill completed its Committee stage. It will strengthen the professional self-regulation of nursing. Again, we worked closely with the professions to ensure that we have the mechanisms in place that can best enable self-regulation and the control of training. Those are very important steps. The hon. Member for Peckham (Ms. Harman) was wrong to suggest that nurse prescribing could have been appended to that important and significant Bill.
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I must mention the work of the nursing development units and nursing audit. In a number of areas there is a practical commitment to recognising and enhancing the role of nurses. Nurse prescribing fits well into that background. It will be a significant and worthwhile improvement in the services for patients. They will be able to get their medicines and dressings more quickly, and so have speedier treatments. Nurses will have greater responsibilities as professionals in their own right. The Bill builds on our determination to ensure that nurses achieve their rightful status in the health service.Mr. John Marshall (Hendon, South) : One of the important issues in nurse prescribing is the number of nurses who work for general practitioners. I congratulate my hon. Friend the Minister on the fact that in 1979 there were only 990 nurses in general practice, whereas in October 1990 there were 7,700 full-time equivalents--making 13,520 nurses in general practice. Is not that a remarkable achievement, which underlines the case for the Bill ?
Mrs. Bottomley : My hon. Friend is right in his figures. I am grateful for his comment. The role of the practice nurse is important. Primary health care has been transformed beyond recognition. More general practitioners are using computers. The whole area of general practice is developing. The practice nurse plays a vital role in that. If my hon. Friend will bear with me, I shall explain how we envisage the increasing involvement of practice nurses.
It is important to go into the details, even if only briefly, because it is a significant and important step. A number of comments during the debate show that there is some misunderstanding about precisely how the new arrangements will work.
We have long supported the principle of nurse prescribing. In 1986, the Cumberlege report on community nursing recommended :
"The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well-defined circumstances."
The Government accepted that recommendation in principle and, through our standing medical nursing and midwifery and pharmaceutical advisory committees, set up the advisory group on nurse prescribing to advise us
"how arrangements for the supply of drugs, dressings, appliances and chemical reagents to patients as part of their nursing care in the community might be improved by enabling such items to be prescribed by a nurse, taking into account where necessary current practice and likely developments in other areas of nursing practice."
The recommendations of the advisory group included a considerable number that required further work. One of the key aspects was the economic implications. Now that we have completed that further work, we are in a position to support nurse prescribing in practice as well as in principle.
I share the feelings of many hon. Members who wish that we had been able to make speedier progress. However, it is important to ensure that we have examined all the aspects--costings, cost-effectiveness, the mechanisms of how the prescriptions will be organised and referred back, and how the other professional groups have responded. One of the reasons why we have received such warm and wide support for the measure is that we have been able
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to take the time to consult effectively and to take people with us. The advisory group report recommended that certain groups of nurses working in the community should be authorised to prescribe from a limited list of products and to supply medicines or vary their timing and dosage, within agreed protocols.My hon. Friend's Bill provides the primary legislation to enable prescribing aspects of the recommendations to be implemented. Those are the aspects of most interest to community nurses, GPs, pharmacists and--most important--patients and their carers. I should also mention--this has been raised in the debate--that at the same time we are taking forward the recommendations concerning supply and changing timing and dosage. That aspect does not require primary legislation ; it is a question of agreed protocols.
In its recommendations about prescribing, the report considered that nurses working in the community who had a district nurse or health visitor qualification should be permitted to prescribe the items that they needed for the nursing care of their patients. That is the basis on which we have worked in preparing the secondary legislation needed to turn my hon. Friend's Bill into a reality. My hon. Friends the Members for Eastleigh (Sir D. Price) and for Faversham (Mr. Moate) and others have said that they support the idea with regard to community nurses and asked, "What about hospital nurses?" The advisory group reported in the context of community nurses, but the Bill would establish a framework whereby the concept could be extended to hospital nurses.
I was interested in what my hon. Friend the Member for Eastleigh said about people working in ophthalmic casualty. Before we took that further step, however, careful consideration and consultation would be required.
Mr. Moate : I am interested to hear my hon. Friend say that. Is she suggesting that such a consultation process might be put in hand or that she would view favourably the beginnings of such
consultation--the start of a process of extending the provisions to cover hospital nurses?
Mrs. Bottomley : At this stage our view is that we welcome the Bill and would like to see it translated into practice, but we do not envisage community nurses being able to prescribe until October 1993. Then there is further work to be done in considering what other items may be made available and how other groups may be incorporated. Special consideration should always be given to the role of groups such as community psychiatric nurses and others, and to the items that they may be able to prescribe.
A move such as that envisaged by my hon. Friend the Member for Faversham is therefore a considerable way off. We must be sure that we have established the right framework for the first group before opening our minds to the question whether others might have an important part to play.
My hon. Friend made a point--perhaps I should deal with it now rather than later--about the changing role of the health service and the development of community hospitals. He spoke of the combination of acute high-tech medicine in district general hospitals, alongside more effective and sophisticated comprehensive care in the community. The point was well made and we certainly wish the role of the nurse, whether in the hospital or in the community, to be developed and maximised.
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As I have said, we want appropriate nurses to be able to prescribe the items that they need for the nursing care of their patients. There will be a formulary of items that they may prescribe which represents the items that nurses in the community with district nurse and health visitor qualifications might need for the care of their patients, and which it would be appropriate for them to prescribe. Some hon. Members may have envisaged that nurses will be able to prescribe a far wider range of items than is proposed.The Joint Formulary Committee, which produces the British national formulary and the dental practitioners' formulary has set up a sub- committee to produce a nurse prescribers' formulary. Medical, nursing and pharmaceutical interests are represented on the sub-committee, which has already met twice, and plans to complete its work in the summer. We are very grateful for its urgent help. Hon. Members who are interested in the types of product that nurses will be allowed to prescribe should refer to the illustrative formulary in the advisory group report. Items include laxatives, stoma care products, pain killers such as aspirin and paracetamol, skin preparations, and a wide range of appliances and dressings. Most items can be bought over the counter by patients. The illustrative formulary lists a number of prescription-only medicines : Nystatin, for oral fungal infection ; Clotrimazole, an antifungal preparation ; Iodosorb, a medicated dressing ; and Varidase, a desloughing agent. We anticipate that the final nurse prescribers' formulary will cover the same range of items, or similar items.
Other aspects have been raised by hon. Members--about the full implications of the Bill, about the nurses who will be able to prescribe and about their qualifications.
The advisory group gave very careful consideration to which groups of community nurses it would be appropriate to allow to prescribe and recommended that, at least initially, prescribing should be limited to those holding a district nurse or health visitor qualification. Secondary legislation under the proposed Act will, therefore, limit prescribing to appropriately qualified district nurses and health visitors working in the community. Before such nurses may prescribe, they will, of course, need training in nurse prescribing. In future, nurse prescribing will be integrated in district nurse and health visitor training courses, but at present we are working urgently and closely with the UKCC and the national boards to produce a nurse prescribing training module for those currently employed. Many hon. Members will know a great deal about the work of the UKCC and the national boards, as we have spent some hours in Committee discussing their work. Hon. Members will be pleased to know that extra money has been made available for the training module. We have provided funds in 1992-93 for setting up the courses and providing training materials. We have also provided funds for 1993-94 and 1994-95 for running the training modules at the various centres around the country that run district nurse and health visitor courses. In England, taking account of practice nurses with district nurse or health visitor qualifications there are about 25,000 potential nurse prescribers. Some of those will leave or retire before implementation, and they will usually be replaced by
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nurses who have received nurse prescribing training as part of their initial training, so we anticipate that about 23,000 would-be nurse prescribers will attend the special course between April 1993 and April 1995.The UKCC has advised us about standards, kind, content and length of courses. The national boards are now organising further discussions with course tutors. I know that my hon. Friends will want to be satisfied about the courses, because we are taking a new step and it is important to consider all the aspects.
The courses will cover, of course, the items on the nurse prescribers' formulary--drug interactions, reporting adverse reactions, communication with other professionals, good practice in prescribing, budgetary accountability and monitoring and all the other relevant issues. The courses will need to meet the criteria set by the UKCC and to be approved by the national boards.
At the end of the courses, potential nurse prescribers will be assessed and only if they reach the required standard of knowledge will they be allowed to prescribe. Nurses who have satisfactorily completed the training module will have their details submitted by the national boards to the UKCC which will be able to identify them as nurse prescribers on the UKCC register. Eligibility to prescribe can then be checked by bona fide inquirers with the UKCC at any time. It has been important to ensure that we consider all those angles to ensure also that, as we start the new move, it is carefully monitored and properly prepared for.
Budgetary accountability and monitoring were mentioned, scarcely surprisingly, fairly thoroughly by my hon. Friend the Member for Bristol, North-West (Mr. Stern), as well as by a number of other hon. Members. My hon. Friend has expert knowledge in these questions and a close awareness of the working of the family health services authorities. I made it clear that one of the areas that would-be nurse prescribers would need to address was budget accountability. We plan that the cost of nurses' prescribing, specifically the net ingredient cost of the items that they prescribe and the pharmacist fees, will be met in the family health services budget.
It is not appropriate to meet the costs from the hospital and community health services budget because, on the whole, nurse prescribers will be prescribing for general practitioners' patients and if the community nurses were not prescribing for them, the general practitioners would be doing so.
If nurse prescribers are practice nurses--that is, employed by GPs--we envisage their prescribing costs being linked to their GPs' indicative or actual prescribing budgets. If nurse prescribers are health authority employed, we envisage each provider unit being responsible for prescribing costs. More work is needed in that area before final decisions can be made. Through the Prescription Pricing Authority, GPs and community nurse managers will be able to monitor the patterns of their nurses' prescribing.
My hon. Friend the Member for Wanstead and Woodford raised the question whether there would be a differentiation between GP and nurse prescriptions. We intend that nurse prescriptions will be a different colour from GP prescriptions. I am sure that my hon. Friend is aware that pharmacists already manage to distinguish between GPs' and dentists' prescriptions, so there will be
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no difficulty in identifying a nurses' prescription. Apart from the different colour, the prescription will have the nurse prescriber's name on it.My hon. Friend the Member for Bristol, North-West also raised the question of the Prescription Pricing Authority and its work. The PPA, which does not always get the tribute it deserves, is a remarkably efficient and effective body. It will be able to identify the nurse prescribing undertaken by a particular group of nurses attached to GPs or by nurses prescribing in the community. It intends to identify the amount spent on nurse prescribing, not by individual nurses, but only according to a nurse's unit of employment.
Mention has been made of the Touche Ross report. I am the first to acknowledge that these questions are complex.
Mr. Arbuthnot : Would not it be beneficial to have the prescribing practices of individual nurses identifiable, if purely from a budgetary standpoint?
Mrs. Bottomley : That is a matter to which we have given careful consideration. My hon. Friend's point would introduce an extra layer of complexity. We are talking to health authorities and especially to those in the family health services about the further steps that we need to take in monitoring the prescribing practices of, particularly, community nurses. Our judgment is that the most helpful way to take the matter forward is to be able to identify the nurse prescribing undertaken according to the GP practice in which the nurse is employed or according to her employment in the community. We can, no doubt, consider that aspect further as we finalise details. According to the Touche Ross report, apart from the one- off cost of implementation, nurse prescribing, as my hon. Friend the Member for Chislehurst said, will cost the Exchequer £15 million a year in England. Most of the extra costs--£11.65 million--are estimated to come from the cost of additional items prescribed. In addition, there are the cost of pharmacists' dispensing fees, costs at the PPA for pricing nurses' prescriptions and monitoring them, the cost of providing copies of the nurses' formulary, the drug tariff and prescription pads, and various other administrative costs. Against those costs, we must consider the considerable benefits available from introducing nurse prescribing. There will be concrete benefits in terms of community nurses and GPs being able to save time. Nurses will no longer have to make trips to the surgery to get prescriptions signed, as several hon. Members eloquently described. GPs will no longer have to sign those prescriptions. Those time savings are considerable in total, although none of us believes that those time savings have the significance that the benefit of the measure would have in improved service for patients and for the convenience of those who are in the community.
There will be improvement in terms of the satisfaction of community nurses who will know that they can take full responsibility for the nursing care that they provide. It is ludicrous that district nurses with years of experience must bother GPs to get them to sign prescriptions for the nursing care of patients. I am very pleased that, through the Bill, we can recognise the skills and competence of community nurses.
The safety of patients will not be compromised. I have already outlined the special training that will take place. I
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mentioned the nurse prescribers' formulary which will mostly contain medicines and appliances that patients can buy over the counter. We also fully recognise the importance of good communications between nurse and doctor to ensure good-quality care for patients and to maintain patient safety. We shall issue further guidance before implementing nurse prescribing on the handling of adverse reactions and on the maintenance of patient records. My hon. Friend the Member for Chislehurst rightly asked about implementation. Having reached this stage, he, like my hon. Friend the Member for Kensington and many others who have championed the cause so excellently, wants to ensure that we achieve our implementation date of October 1993. We are working to a good timetable. We shall begin work on the regulations as soon as the Bill becomes an Act. There should be no problem in preparing the regulations in accordance with that time scale.There is more to be done. There is the secondary legislation under the Medicines Act 1968 and under the National Health Service Act 1977 to specify the types of nurses, the training and the circumstances. We are already consulting all interested parties before we can make the statutory instrument under the Medicines Act.
Clearly, the question of legal liability is important. Nurses are professionally personally accountable for their actions. In terms of legal liability for actions carried out in the course of their duties, their employers take vicarious responsibility, so that health authorities will be responsible for the prescribing activities of health-authority employed nurses and general practitioners will be responsible for their practice nurses' prescribing. My hon. Friend the Member for Bristol, North-West referred in particular to the family health services authorities and their service committee hearing proceedings. It will be the GP who is subject to such proceedings because it is the GP who is answerable, but all nurses are subject to the control of the UKCC, so in cases of professional misconduct, whether involving a practice nurse or a nurse in the community, should there be difficulties, proceedings could be taken by the UKCC.
Hon. Members have made it clear that they take a close interest in the role of pharmacists. My hon. Friends the Members for Wanstead and Woodford and for Walthamstow (Mr. Summerson) will know that we are already working on the wider role of community pharmacists. I can advise my hon. Friend the Member for Harlow (Mr. Hayes)--without whose contributions a debate on health matters would be almost empty--that recent information was sent to community pharmacists on the vital question of head lice, which he brought to the attention of the House. I hope that that reassures him on that front.
We are also working to consider those items that could more appropriately be provided over the counter. Obviously safety is the key criterion in deciding whether an item should be prescription-only or whether it should be available over the counter. The Secretary of State acts on the advice of the independent Committee on the Safety of Medicines and the Medicines Commission in reaching such a decision. I am grateful to my hon. Friends for their comments. I want to comment briefly on the importance of retention and recruitment and the role of nurses in the service generally, to which the hon. Member for Peckham
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