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Mr. Denham: Hon. Members have raised wide-ranging issues, which I shall deal with as succinctly as possible. The hon. Member for New Forest, West first asked about the nature of the advisory committee. The power is given under the Medicines Act 1968 either to create a new committee or to ask an existing committee, such as the Committee on Safety of Medicines, to make recommendations to Ministers on which medicines may be prescribed by new groups of prescribers. The Bill allows a committee to be established or an existing committee to be given that responsibility before clause 60 comes into force. We shall not decide until later this year whether to build on the experience of existing committees, such as the Committee on Safety of Medicines, or to establish a new committee. However, the existing body has a great deal of relevant expertise, and I hope that the hon. Gentleman will accept my assurance that a newly established body would be based on the experience of relevant health professionals. The second issue raised by the hon. Gentleman was about prescribing by nurses. The Crown report, which will be implemented under the Bill, drew a distinction between independent prescribers and supplementary prescribers. Under the Medicinal Products: Prescription by Nurses etc Act 1992, nurses are already able, under certain circumstances, to act as independent prescribers, which means that they take on the full clinical responsibility for their prescriptions. The Bill also allows nurses and other professions to act as supplementary prescribers. One reason why nurses are not included as independent prescribers is that they already have that power. Between October 2000 and the beginning of 2001, the Department consulted on proposals to extend nurse prescribing over a wider range of medicines and a wider group of nurses. We received hundreds of comments and are examining them carefully. That consultation, in part, explored the issue raised by the hon. Gentleman. We could work through the entire formulary, saying that some drugs could be prescribed and others not, but about 17,000 different items are listed. We would either have to start again whenever new drugs came into the formulary or issue a more limited list. We may identify other ways of setting out the categories of drugs appropriate for nurse prescribing. The consultation document raised that issue: from memory, it set out five options, but we have not formed a firm view about which one to pursue. Mr. Swayne: Can I edge the Minister towards a view? The royal college put its view forcibly that the whole formulary should be available to nurses, and that it should be up to them to use their professional discretion not to prescribe outside their areas of expertise. Nursing is, of course, a professional organisation and is regulated as a profession. We should expect nurses to take that responsibility. Mr. Denham: I understand that that is the view of the Royal College of Nursing; it will have been reflected in responses to our consultation. However, counter views have been expressed that must also be taken into account; some have argued that only those who have gone through a full medical training should automatically be assumed to have the ability to prescribe freely from the entire national formulary. We consulted on that issue, and Ministers will have to consider it and bring forward recommendations in due course.On the hon. Gentleman's original question, nurses have independent prescriber rights and will be able to have supplementary prescriber rights under the Bill. The hon. Gentleman raised an important point, which we shall need to address through guidance, about communications between people who may be prescribing under different circumstances. We shall obviously have to get that right. The investment that we are making in the development of the electronic patient record should ease that considerably. It should also deal with some of the issues raised by the hon. Member for the Isle of Wight about the transmission of information from NHS Direct, out-of-hours services or walk-in centres to a GP. We will need to ensure that there is an appropriate flow of information between one prescriber and another.
3.30 pmThat is likely to be particularly important for independent prescribers who are exercising full clinical responsibility for the decisions they take about the prescriptions that they write. It is obviously an issue for supplementary prescribers, too, but they will be prescribing under the oversight of independent prescribers. For the supplementary prescriber, it is the independent prescriber who retains overall clinical responsibility. The hon. Member for the Isle of Wight raised a wide range of issues, some of which go to beyond the provisions of clause 60. Currently, two independent prescribers, such as a GP and a hospital doctor, may take decisions about the same patient. Dr. Brand: The Minister is right, but accountability in that case is absolutely clearcut. Responsibility for the overall care of a patient in a hospital is taken by the consultant through clinical governance, and eventually by the chief executive of that hospital. As soon as the patient comes out of hospital, unless on leave as a patient under the mental health legislation, the responsibility becomes totally that of the general practitioner. There may occasionally be a dispute when patients have their pills changed between hospital visits and coming out, and vice versa. That system may not be desirable, but the accountability is clear, whereas in the Bill it is not. Mr. Denham: The principle must surely be the same as it is now, so by extension accountability must lie with the prescriber and the organisation to which they are responsible. The hon. Gentleman has highlighted the need to work closely with the professions when we implement the clause so as to deal with the practical issues arising from the extension of prescribing powers and to ensure safety and clear accountability. The hon. Gentleman said that we should have provided for that in the Bill. I suspect that it is better to try to achieve that outcome through the regulations, rather than attempt to anticipate or predict every possible eventuality in the Bill. I know that the hon. Gentleman supports the broad thrust of Government policy, and I am sure that he will be the first to scrutinise the more detailed proposals as they are introduced. He obviously has great knowledge and expertise in this area. Dr. Brand: In that process, will the Minister also consider the requirements for clinical governance and re-accreditation of prescribers in exactly the same way as doctors are, quite rightly, required statutorily to undergo re-accreditation and to audit their work through clinical governance? Mr. Denham: Re-validation of doctors, re-certification of dentists and the equivalent process in other professions are the responsibility of the professional bodies. Just as for consultants' contract we have tried to ensure that NHS appraisal of consultants directly ties in with, aligns with and is supportive of the General Medical Council's re-validation process, we will want to ensure that we are supportive of reasonable measures by other professional organisations to make sure that their members are fulfilling their proper professional responsibilities. We work with the professional regulatory organisations in the area of professional regulation. Clearly, the narrower area of prescribing in the NHS, to which this provision largely applies, must come within the NHS's own clinical governance arrangements. We should bear in mind the fact that not all the prescribing rights under discussion would be exercised within the NHS as full professional responsibilities. We must co-operate with the professional organisations for all the professionals in that category, and ensure that we have the right clinical governance arrangements in the NHS, where most of those people will be working. Mr. Swayne: Could I bring the Minister back to the problem of the regulations becoming over-prescriptive, so that it would be difficult to revise them to keep abreast of pharmaceutical developments? How will the regulations work? Will they be general, enabling regulations, or will they specify, in detail, who may prescribe what? If the latter is the case, the effect may be to deny patients some of the most up-to-date developments simply because of the limitation of the regulations. Mr. Denham: All that I can say is that I do not have the answer to that today, but we will have to get it right for the extension of nurse prescribing. It is reasonable to assume that nurses will have a wider range of prescribing responsibilities than the other health professionals who will be covered by the legislation. The options that we put forward in our consultation document range from the ability to prescribe absolutely anything to the ability to prescribe from a list of five permitted items. There are various options in between those two extremes, ranging from building up an approved list to ruling out certain types of prescribing. We have not yet completed our response to that consultation. Eventually, we may need to take different approaches to different professional groups. Some of those mentioned in the legislation may have a very limited formulary available to them, certainly in the early days. Having a list of approved items may be the way forward—I do not know. For others, we may need a more flexible approach. I acknowledge the relevance of the hon. Gentleman's point, but we should examine the matter in detail in the context of the current consultation on nurse prescribing rights. We must ensure that we get it right. Dr. Brand: The Minister is right in saying that most of the work will be done by members of NHS-based teams. I support the plea of the hon. Member for New Forest, West that we should not restrict members of those teams by sheer formulae, because that has been so frustrating in nurse prescribing. Everyone should be able to work within their competence to the benefit of patients. There is often a shared approach, and perhaps the question of who should prescribe what should be determined locally. I would be worried if the Minister were suggesting that membership of a professional group would determine what a person could prescribe. The Minister has a real problem. Presumably, once an item is allowed for those belonging to a professional group, from that point on it would be allowable on the basis of only two criteria: the specificity of drugs and membership of that professional group. Such an arrangement would give scope to independent practitioners, some of whom are wonderful and invaluable, and join in with the teamwork, but a number of whom have exiled themselves from teamwork in the NHS, because they have eccentric ideas. It is important to recognise the different pressures on people who are not part of a therapeutic team. Audit and control of those groups is important. This part of the Bill greatly extends not only responsibilities, but opportunities for doing harm. As the Minister acknowledged, I support the widening of prescribing powers. The present powers are demeaning to professionals. That is nothing to do with teams having to be doctor-led or anything like that; it is about protecting the patient, which is best done through teamwork and shared responsibility. However, the Minister must recognise that we are opening the door to people working in isolation, and to people not being prepared to link into the NHS network—or into private networks that work for the benefit of patients rather than practitioners.
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