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NHS Nursing Care

2 pm

Mr. Archie Norman (Tunbridge Wells) (Con): I am very glad to have the opportunity to devote the next hour and half to a discussion of nursing care in the NHS. I want to approach the subject constructively and I hope that the Minister will feel able to do the same and respond to some of the matters that I raise.

I do not intend to claim that there is a crisis in nursing care in the NHS. I shall, however, make a case for dealing with some of the emerging issues and argue that certain other concerns merit clarification, at the very least. It is important that all hon. Members recognise that although NHS nurses in general do fantastic work and are remarkably dedicated, they are comparatively less well paid, despite recent pay increases.

In many respects, nurses reflect the best of the public service ethos, and they undoubtedly provide outstanding care to the vast majority of patients most of the time. They are the bedrock of NHS patient care. Patients' experience and recollection of hospital stays, in particular, is affected as much by the way in which the nurses treat them as by any other factor. It is important to recognise that that patient care and the experience of being treated and looked after by nurses is driven more than anything else by the ethos, motivation and morale of the nursing work force. Highly motivated, well-intentioned, well-trained and disciplined nurses will give outstanding care, but those who work under stress and are demoralised within an unstable work force will find it much more difficult to do so.

When I researched the subject of nursing in the NHS, I found it extremely difficult to obtain many empirical, objective data—the Minister may be able to help with that. Nevertheless, there are quite strong emerging signs of increasing occasional lapses in the quality of personal care; I stress that they are only very occasional. I shall explain later why I think that may be happening.

Other emerging issues, including those of morale, work satisfaction and labour turnover—the number of nurses leaving the profession—are potentially serious and expensive for the NHS. Despite the increase in nurse numbers there are still considerable shortages in many NHS trusts.

I want first to deal with what has happened to the nurse population, why there are still shortages, and what evidence exists for problems of morale and retention and career development in nursing. On the face of it, there has been a significant growth in the number of nurses in the past six years. The Government have made such an increase an objective and have, broadly speaking, achieved it. Depending on exactly which figures one studies, it appears that in the past five or six years numbers of full-time employees have gone up by some 15 to 20 per cent. In 2003, according to the latest statistics that I have, 304,892 nurses were employed in the NHS. That increase compares, however, with an increase of approximately 11 per cent. in the number of consultant episodes and of 17 per cent. in accident and emergency attendance during the period in question.

There has been a marginal increase in nursing intensity in the NHS. The increase in nurse numbers and activity in a very labour-intensive service does not
 
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necessarily mean a significant increase in the available nursing time per patient. That, arguably, is what matters.

There has been a significant increase in the number of nurses in training—from 14,604 to 21,200 in 2001. I do not have more recent figures, but I understand that numbers have risen still further. However, it is important to remember that we are comparing the number of nurses and nurses in training with the relatively low figures of six or seven years ago. We could debate why those numbers reached those levels; it would be possible to argue that there was underinvestment in nurse training and nurse delivery. However, I do not intend to dispute such issues or to go into the history. Although the number of nurses in training has increased, drop-out rates have also risen. As 15 to 20 per cent. of nurses in training drop out before they complete their course, the increase in the numbers delivered is not as great as the increase in the number of nursing places.

Nurse shortages are still reportedly widespread in the NHS. It is hard to establish exactly how great the problem is, but the Royal College of Nursing estimates that there are 25,000 too few nurses, while official figures claim that the figure is nearer to 10,000 or 11,000. By any measure, there is still a significant shortage, despite the substantial increases that have taken place.

Despite the general lack of national statistics, studies have been undertaken on the shortages. They include the British Medical Journal article of September 2002 entitled "Mind the gap", which concluded:

"The serious problems facing acute trusts in England in retaining and recruiting nurses result in high financial costs and low morale and may affect patient care."

It goes on to say that the problem is most acute in inner-city trusts, which will hardly surprise any of us.

The average age of nurses is growing every year. Although there are interesting reasons for that, it is also an indicator of the drop-out rate among younger nurses. The average age of nurses is reported to be 41; that is surprising, given the nature of the profession.

The gap in the supply of nurses, which has been created by nurses leaving the profession and despite the Government's efforts to increase the numbers coming onstream, has been plugged almost entirely by imported nurses. In fact, had we not brought in nurses from abroad over the past five or six years the number of nurses in the NHS would have remained more or less static. Moreover, 30 per cent. of students in nursing colleges are non-EU nationals. I do not mean to imply that recruiting qualified nurses and students from abroad is a bad thing—many of them perform an outstanding job and are extremely well qualified—but it is important to remember that it may leave us open to problems in future if getting nurses from abroad becomes more difficult and our shortages become more dramatic.

The flow of leavers from the profession is large and growing. That says a lot about people's willingness to stay in nursing and about morale in the profession. According to the register of nurses, the number leaving annually has roughly doubled compared with 10 years ago, and there appears to be a gentle upward trend. Of course, the number of nurses on the register is not an accurate measure of the number working in or leaving the NHS, but those are the figures that are available.
 
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The estimated 15 per cent. turnover rate of nurses leaving the NHS is rather high, especially bearing in mind that for the most part they do not leave for non-NHS nursing jobs, but leave the profession altogether.

There is evidence of increasing stress in nurses' work, not least because of hospitals' throughput levels, the need to meet standards and declining morale. I do not want to overstate that point, however, and there is reason to believe that it is part of a wider problem.

The Royal College of Nursing survey for 2003 suggests that 62 per cent. of nurses think that their workload is too heavy. I am not sure whether it has changed much over the years, yet the statistic reflects the concerns felt in today's workplace. The same survey said that 50 per cent. of nurses would not recommend nursing as a career to others. That is an alarmingly high figure—considerably higher, I should have thought, than 10 or 20 years ago. Curiously, 34 per cent. thought that NHS investment in nursing staff was decreasing, not increasing. Although many more resources have been put in and recruitment has increased, nurses feel that they are working harder than ever and that investment in staff is not adequate.

NHS spending on agency nurses has increased by about 80 per cent. in the past six years. The import of that is that agency nurses tend to have less longevity in the work place; that leads to a higher movement of staff through wards, which in turn creates a less stable workplace community that becomes much harder to manage.

I am not suggesting that any one of those factors is critical. Nevertheless, if we look at the total picture we see a profession in which numbers have increased through importing nurses but the number of leavers is rising. That may be a reflection of declining morale, changing workplace patterns and lack of work satisfaction among the nursing community.

The problem might be addressed in several ways; the Minister may want to refer to them. One salient issue is that a high proportion of nurses, especially young nurses, works on shift rotation, which tends to be family-unfriendly. The way in which acute hospitals are run makes it necessary to have nurses on shift rotations, so it is no good my simply stating the problem and telling people to solve it. It is clear, however, that because of today's quality of life issues and the range of options that are available to people it is increasingly hard to get young nurses of family age to work in that way.

Andrew George (St. Ives) (LD): The hon. Gentleman is presenting an important case. Does he agree that given the recent settlement for general practitioners, which means that family GPs are now able to operate on a nine-to-five, five-days-a-week basis while continuing to be well remunerated, we should compare their ability to continue their family life with that of nurses who have to work shifts?

Mr. Norman : The hon. Gentleman makes an interesting point. Not only among GPs, but in the broader health community, we have made progress in making health care work more family-friendly, and nurses working shifts are increasingly conscious of their relative position.
 
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Having established the background in so far as it is possible with the figures available, I want to discuss the changing nature of the role and the diffusion of responsibility for nursing. Lapses in the quality of patient care occur not only because nurses are working very hard and are not always content with their working life, but because of the changing tasks that we are asking them to undertake and the hierarchy in the ward.

Since 1989, there has been a formative change in the nursing profession and in nurse training, with what was then called Project 2000 resulting in a substantial shift in the balance of nurses' training away from practical experience and into the classroom. In addition, the responsibility for the training has been shifted almost wholly from clinical to educational establishments. The arguments for those enormous changes seemed compelling at the time, but they have had important side effects. Nurses' training is now much more academic. Much of a nurse's work is very practical. Nurses enter their profession because they want to do practical work with patients, but spend half or more of their two to three years' training in a classroom environment.

That may have the effect of changing the type of people who enter nursing; it also means that nurses who come on to the wards are less experienced in practical training and the disciplines of nursing. Moreover, as has been widely reported, there is a shortage of mentors to work with training nurses during their clinical practice because a large number of trusts do not take nurses for practical training and there is a shortage of clinical placements. Generally speaking, the stress is on more academic and less practical nursing. I do not want to overstate that case because it is important that nurses should have an academic foundation as we ask them to undertake more complex medical and clinical tasks. However, it is a question of balance. The quality of clinical and practical experience that nurses have when they start working is perhaps not as good as it once was, although they are more qualified in other respects.

The other formative change in the workplace has been the development of health care assistants, or non-qualified nurses. That is significant not only in terms of the makeup of workplace economics and the division of tasks but of the effect that it has on the ward environment and the perception of role. On the whole, the rapid growth in the number of HCAs has happened for sound economic reasons. It is perfectly reasonable to employ people who are less well qualified and earn less to undertake less challenging tasks, but the ratio of qualified to unqualified NHS staff—30 per cent.:70 per cent.—may be approaching the limits of what is manageable.

In theory, health care assistants are supposed to have a national vocational qualification, but the evidence suggests that a large number do not. The King's Fund estimates that only 30 per cent. have a full NVQ, while others may have as little as six weeks training before they start on the wards. Yet in a pressured ward environment HCAs are inevitably asked to undertake important functions, some of which are medically sensitive. Unison conducted a survey—in 1999, so it is out of date—showing that HCAs' tasks can include help with drug administration. Some 18 per cent. carried out invasive procedures, 11 per cent. took blood samples; and 61 per cent. helped with catheter care.
 
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We should not imagine that HCAs undertake only menial or basic tasks, because they are becoming an important part of the patient-health service interface. Anecdotal and survey evidence suggests that some patients have more interaction with assistants than with qualified nurses. It is potentially serious that some HCAs have had very little training and have arrived through what is in effect an unregulated route. The Minister may want to consider whether there is a compelling case for regularising the role of HCAs—I was going to say "regulating", but I do not want to give the wrong impression; I mean that we should standardise their minimum training requirements and what is expected of them—and establishing a smoother career progression that would allow people to start work with the minimum level of training, qualify as HCAs, then qualify as nurses and move on through the management and clinical hierarchy. The elements of progression have been put in place without proper ladders or quality controls.

The other side of the issue is the development of the so-called academic nurse. By way of illustration, although it is not very scientific, The Guardian of 11 October quotes Claire Rayner, the president of the Patients Association, who refers to the lack of practical training of nurses and the development of "academic nurses" and cites the

"yawning gap between academic nurses, who have to spend more time pen-pushing than giving patient care, and the less informed healthcare assistants."

That is backed up by anecdotal evidence from constituents, relatives and other people with recent hospital experience who have told me that nurses on the ward felt that they were too important to undertake patient cleaning and other basic patient care activities. That is unacceptable.

According to the nurse's job description, it is not necessarily part of their official role to deal with the basic tasks of patient care. The qualified nurse is asked

"To provide planned nursing care for patients and their families; To assist in the management and organisation of work as required."

The HCA's role is described in a subtly different way. He or she

"Assists qualified staff by undertaking personal care duties for patients; Reports patient condition to qualified staff."

In a way, the role of the qualified or academic nurse is being institutionalised as having to do with clinical care and that of the HCA as having to do with cleaning patients and ensuring that they are comfortable. I say this with no disrespect, because I know that the vast majority of nurses are absolutely dedicated to total patient care. However, it is important for the NHS to be unambiguous about the fact that all nurses on the ward are responsible for ensuring that patients are clean and comfortable and that their psychological and personal requirements are looked after. We increasingly hear patients complain that they feel neglected because no one comes to clean them, look after them or ensure that they are comfortable. When my mother-in-law was recently in hospital, she was not provided with a proper pillow for 48 hours.

Such problems stem from the emerging hierarchy in the ward environment. They do not only arise in the UK; in Australia and Canada, programmes introduced
 
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to increase the number of lesser qualified nurses or HCAs in the ward environment have had a material impact on the number of mistakes made with patients, as well as on clinical outcomes. I am not saying that the writing is on the wall, but we can learn from the experiences of other countries. We must establish exactly what the roles are to ensure that a situation does not developing whereby some people look after patients and others are primarily clinical in their approach. There is a level beyond which the ratio cannot be pushed.

The last aspect of the problem to which I want to refer is the nature of the workplace and the loss of accountability for the ward environment. There was an entirely different system in the early days of the NHS, although I am not advocating a return to that. For example, ward discipline—control of the ward environment—was much better, which helped nurses to do their jobs and to ensure that patients were properly looked after. Through custom and practice, we have allowed that to slip away. It is a question not just of bringing back matron and putting people in charge, although there is a bit of that involved, but of working and management practice throughout major hospitals. Part of the problem is that many hospitals now have almost uncontrolled visiting hours, which means that nurses no longer have two or three hours in the morning when they can get back control of the ward environment and ensure that it is clean and under control and that patients are properly looked after.

Another problem is that doctors and other members of staff are able to stroll around the ward at will and to appear at unexpected times of day. That may not happen all the time, but it undermines the ward sister's role and her ability to say, "This is my ward. I am in charge of this environment and can be held accountable for it." When my father was a consultant, before there was an NHS, there was no question of his turning up on the ward without permission. He would have to arrive at the right time, then he would be presented with his starched white coat and told when people were ready to receive him. Needless to say, when that happened all the blankets were folded and everything was neat and tidy. I accept that that is a bygone era, but nursing is partly to do with discipline—the ability to control things and having standards that are rigorously enforced. Ward sisters should have enough spare time to check that everything has been done properly and to lead and teach the ward staff—the other nurses and HCAs—to ensure that they are doing their jobs well.

In most major acute trusts, turnover on the wards is probably much higher than the 15 per cent. that I mentioned earlier. If about a third of the ward staff move on every year, as in some trusts, it is much harder to establish a workplace community or any sort of continuity. It is also harder for sisters to manage new staff, who often have to deal with problems that are outwith their experience and need to be shown the ropes.

The Minister is probably planning to refer to modern matrons, and I do not intend to be critical of the initiative to bring them on board. In most trusts, however, the modern matron is not matron as we used to know her, but a new layer of management. The critical role is that of the ward sister, as the person who is in charge of the ward, not that of the modern matron,
 
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who takes broader responsibility for an array of tasks that fall outwith the ward sister's role. The critical question is this: does the ward sister have the capacity and the authority to make decisions about who comes on to the ward and when, the cleaning on the ward, and the management of his or her staff?

We have previously debated MRSA in this Chamber. That is a central issue, as the development of MRSA is all about cleanliness in the ward environment and thus the ability of nurses and HCAs to control what happens there.

I invite the Minister to comment on the emerging trends that I have outlined. Despite the growth in the number of nurses, there is still a problem with nurse shortages that could grow. We are highly dependent on imported nurses, which, if nothing else, would put us somewhat at risk were the flow to dry up.

There are also important issues to do with the balance of qualified and non-qualified staff on wards. The role of HCAs in relation to the standard of the qualifications with which they enter the NHS is becoming a serious issue. It is fundamental that we do not allow a hierarchy of personal care to develop. There is a risk that some nurses may feel that they are a little too important to do the menial tasks involved in caring for patients. That would represent a major erosion of the successful culture of service in the NHS. There must be a case for creating a better continuum of career development through the nursing profession. We need to understand why the number of people leaving the nursing profession seems to be growing and why the average age of nurses seems to be rising.

Is the Minister satisfied that steps have been taken to re-establish a greater sense of discipline and control of the ward environment? That would help to improve the working environment, team working and the people's development, as well as to deal with the more fundamental issue of cleanliness and MRSA.

Mr. Deputy Speaker : I remind the Chamber that this debate is time-limited, and we must conclude by 3.30 pm. I am required to call the first of the three Front-Benchers to make their winding-up speeches 30 minutes before that—in 30 minutes' time. I therefore appeal to hon. Members who seek to contribute to the debate to take that time constraint into consideration both when making speeches and when accepting or responding to interventions.

2.30 pm

Laura Moffatt (Crawley) (Lab): I am delighted that the hon. Member for Tunbridge Wells (Mr. Norman) secured this debate. As a former nurse, I often think that being given the opportunity to talk about nursing is an indulgence, but I am truly grateful that we have the opportunity to talk about many of the issues that face nursing. It is a valuable debate to have.

A couple of weeks before the 1997 general election, I was still nursing on a ward in my constituency. Subsequently, for no remuneration, I have done some night duty, for the experience, and so as to reconnect with many of my colleagues who are still in the
 
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profession. There is little doubt that nursing remains one of the most amazing, challenging and wonderful professions for anyone to go into.

I am guilty of the following offence: I am totally bound by the principle of wards and nurses, when we need to remember that nurses work in all sorts of settings and ways and with all sorts of people. In this debate, it would be wrong not to acknowledge the range of nurses—men and women of all shapes and sizes, working with the elderly, or with young people, and working in ways that may be different from what we shall discuss today. It is important to remember that the nursing profession is incredibly wide, and offers enormous opportunities for many people. The estimate is that more than 80 per cent. of care in the NHS is delivered by nurses, so it is right and proper that we should focus on those care givers.

We need to be clear that nursing in the 21st century is a different deal from what it was even when I started my nursing training in the early 1970s, in that nurses must now work in partnership. The hon. Gentleman created a wonderful picture, and I remember the ward sister's vice-like grip. She was able to create her own environment. At times it was not particularly encouraging of new nurses, or nurses who wanted to progress or develop their skills, but it was a way of making sure that she kept a grip on her ward.

Of course, we cannot operate in that way today. Being an excellent ward manager, and being in charge of a team of people who contribute to nursing care, is a different deal. It is important to give the ward cleaner an equal say about what happens in a particular setting, and it is important to ensure that the consultant is aware that he or she should do a ward round at the appointed time, outside the protected mealtime—an important new development in the NHS, which I welcome. We must remind consultants, as well as nurses, that it is important to wash their hands between patients.

The picture that emerges of nursing and of the care delivered is different from what we might expect, because without that co-operation and that sense of everyone contributing, the workplace cannot function.

The hon. Member for Tunbridge Wells talked about Project 2000. Few of us—certainly few in the profession—would argue that we should return to hospital-based training, because it was so variable. We now use the phrase "nurse education", and nurses are properly educated through the university system. I understand why we moved to the university-based system, and respect that decision. Although that change has created problems, it has without doubt raised the standard of education of nurses and ensured that people have a proper career path into nursing.

I was interested in the hon. Gentleman's comments about the average age of nurses, which has been affected by several factors. I am not sure that it was right for me to go, as I did as a young woman, straight into nursing from a pre-nursing course at college, but I did so because I was so determined to become a nurse. When I go to the nurse education centre at the university of Sussex and talk to people in nurse education, I see a tremendous age range, and I find that heart-warming.

It is encouraging that people who may want a career in the nursing profession, or a profession allied to nursing, who have become health care assistants but
 
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later realise that what they really want to do is to become fully trained and registered nurses, can do so. That is an excellent way to get people into nursing, because it overcomes many of the problems that the hon. Gentleman mentioned, such as the lack of ward-based experience.

There is little doubt that classroom education is desperately needed. I well remember going straight on to the ward after six weeks in a nursing school and being asked to look after 10 intravenous infusions for people who had serious operations. That was unacceptable. The whole flavour of nurse education has changed. If people who have experience on the ward, such as health care assistants, take a measured decision to move into nursing, and trusts encourage that path into nursing and offer support, that is a tremendously efficient way to get nurses into training, not only because such people turn out to be excellent nurses, but because the chances of their falling away from nurse education are much reduced, since they know exactly what they are going into. That area could benefit from further expansion.

Nurses make such a difference today. None of us should run away from the fact that nursing is incredibly pressurised. The way in which the NHS is being reformed and is responding to patients' needs, and the pressure on those who have to deliver care, makes it much more difficult for them: they have to think quickly about how to ensure that patients are treated decently and in time, and that they are not kept waiting. Such considerations add to the problems of those who deliver care, most of whom are nurses.

The hon. Gentleman is right to say that concerns and complaints are often about nursing and associated issues, such as how we care for people on wards. That is understandable, but there are ways to tackle the problem. Many nurse organisations and trade unions are contributing to the way in which nurses develop and gain new skills.

The Royal College of Nursing's "Nursing the Future" campaign is superb, and came from America. It involves a series of nurse ambassadors from all areas of nursing who go out into schools and into the community, promoting nursing in a positive way because they feel positive about what they do and they want to go out and explain what nursing is all about. They all appear in different ways: a mental health nurse turns up in his jeans, while a formal ward nurse wears her uniform.

We can develop nurse education in many ways. The key is giving power to nurses, and we have made enormous strides. The Government have accepted and had to sort out the awful morass of nurse prescribing, which was mouldering in the doldrums and not making any progress. Now we have a comprehensive range of nurses who can prescribe, and do many other good things, themselves. In some settings they can order their own X-rays, and can ensure that everyone is ready to come in and get organised for out-patients' appointments. They have the power to organise their own workplace.

I have visited many areas to see how nurses can operate, and to ensure that they feel valued by their trusts—that is the point. A nurse today, without doubt, is highly respected. However, nurses are also under enormous pressure. They can rise to that challenge if we
 
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ensure that we value them as a profession, and support them. We should not have a silly, rose-coloured-spectacles view of nursing, but we should support nurses properly, either through the Government or by the way in which the community relates to nurses. They do not want wishy-washy support; they want their profession to be properly recognised. I firmly believe that we are moving in that direction. The pressure is on for them, but I am convinced that they are up to the job.

2.43 pm

Dr. Richard Taylor (Wyre Forest) (Ind): I pay tribute to the hon. Member for Tunbridge Wells (Mr. Norman), not only for raising this issue but for tackling it so sympathetically and constructively, and not in a party political way. I also want to pay tribute to the hon. Member for Crawley (Laura Moffatt) for her long experience in nursing—and for warning me before this debate that I had to be a little careful about what I said about nurses, as she is sitting so close to me.

Recently, after a Health Committee meeting, I received an extraordinarily rude letter from a constituent. At that meeting we had been talking about nursing, and I and other Members had repeatedly referred to nurses as being of the feminine gender. That lady got very worked up about that, and it is important to recognise that nurses are of both sexes, of equal efficiency and equal value.

Having got that off my chest, I want to remind the Chamber of what Florence Nightingale said in 1860:

"No man, not even a doctor, ever gives any other definition of what a nurse should be than this—'devoted and obedient.' This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman."

Thank goodness that definition went ages ago, thanks to Florence Nightingale and lots of other people. I agree with the hon. Member for Crawley; I am talking more about hospital nursing, and in hospitals there is a partnership. The nurse is no longer the handmaiden of the doctor. She or he is an equal partner in the ward team running the show in the best interests of the patients.

I want to concentrate on one aspect of nursing that I fear is being lost in some respects—I shall consider the reasons for that after I have given some examples. I am talking about the role of the nurse as the advocate of the patient. All patients are supposed to have named nurses when they go into hospital; that is crucial. With the decrease in the hours that doctors are allowed to work and the lack of continuity of care from the medical profession, continuity is provided by nurses, who have always worked on shifts and are therefore used to handing over when they move on. However, it is in the advocacy role that nurses are needed. That is sad, but it is so.

I echo what the hon. Member for Tunbridge Wells said; it would be easy to be highly critical, because most of the letters that we get are critical rather than supportive. Let me give some examples of cases in which a nurse's advocacy was missing.

An 82-year-old man had an epidural injection that went wrong, resulting in a respiratory arrest, so he was really very ill. He was transferred to another hospital for overnight observation because the first one could not keep him overnight. At 7.30 in the evening, after seven
 
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hours on a trolley, he was seen by a consultant, who said, "If you can walk, you can go home." His elderly wife was there, his son came by car, and they struggled to get his clothes on. He could just walk, so he did go home—and his wife was up all night. In my day, which was after the time of the hon. Gentleman's father, the nurses would not have allowed that. They would have stepped in and said to that consultant, "This chap can't go home now." That is one factor that is missing.

In another case, a 91-year-old suffered from unhygienic conditions on the ward, lack of personal care, two falls, pressure sores, incontinence, loss of dignity and loss of the will to live. The patient died, and there was even a delay in the notification of the death. In a third case, a 19-year-old died of a subarachnoid haemorrhage, which was probably inevitable. The family was up in arms because the information given during the poor girl's final illness was scanty and hopeless. Again, in my day, if I, as a doctor, had been guilty of handling that family as it was handled—this occurred not at my hospital, but a long way away—the nurses would have slaughtered me. They would have gone in and explained to the family exactly what was going on.

The worst example of all is the case of Victoria Climbié. In the inquiries, the social workers were blamed and the doctors were blamed a little bit—I think that the doctors should have been blamed a great deal more—but where were the nurses? One morning, when she was in hospital, a locum senior house officer was on duty, with no consultant cover, for one single shift, and at no stage was that locum instructed by the nurses about what was going on. That loss of advocacy is very severe. Beverly Malone has spoken about people being "too posh to wash", but I will not carry on that theme.

Why have we got into this state? Enough has been said about Project 2000. I agree with the hon. Member for Tunbridge Wells, in that I think that things have gone a little too far. I agree about academic training, but that must be balanced with more practical training.

There are issues of stress, overwork, undue reliance on agency nurses—who inevitably do not take the same responsibility for the patients as permanent staff do—and ward discipline, in which I am a great believer. When I first arrived at the hospital where I was to work as a consultant, I was staggered when I walked into the office and all the nurses and sisters stood up. I had not been used to that at a London hospital, but that was the discipline.

Nurses must cope with the tremendous expectations associated with widening roles. There are nurse practitioners, nurse consultants, managers, modern matrons, and emergency care practitioners, and they are expected to take on the job of the junior doctors who are not there to do it. GPs no longer do the job at night either, so there is a tremendous strain on the nurses.

I recently attended a lecture by an eminent professor of nursing called "The death of nursing". He made the point that every time there was a change, people would say, "Oh, that's the death of nursing." He believed that nurse leaders had to respond to all the changes by ensuring that they had different ways of working. His main point related to leadership of the trained nurses to
 
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get the students, the cleaners, the health care assistants and the junior doctors all working together. I am not altogether in favour of modern matrons; that is simply a name for the unit nursing officers whom we used to have. I would much prefer there to be one senior matron, who makes everyone quail when she goes round the wards.

I appeal to the Minister to remember that the traditional job of a nurse is caring for, as well as organising, other people. A little more practical training would help. As Tacitus said, "Experience teaches," and, from the 16th century:

"Experience is the best teacher."

and

"Experience is the father of wisdom."

2.52 pm

Andrew George (St. Ives) (LD): I congratulate the hon. Member for Tunbridge Wells (Mr. Norman) on securing this very important debate, and echo the praise given by the hon. Member for Wyre Forest (Dr. Taylor) for the way in which the hon. Member for Tunbridge Wells made his case.

It is a pleasure to follow both the hon. Member for Crawley (Laura Moffatt) and the hon. Member for Wyre Forest, because they both speak from a great deal of personal experience of working in the NHS. I declare an interest to an extent, in that my wife is a former nurse. She still occasionally works on a nurse bank in a local hospital.

Like the hon. Member for Wyre Forest, I want to concentrate on acute hospitals. As the hon. Member for Tunbridge Wells rightly pointed out, there may be a disjunction between our debate on the statistics for nurses coming and going, retiring and moving to the country, and what is being delivered in the real world and the stresses and pressures experienced on the wards themselves. I shall concentrate my remarks mainly on wards.

We need to recognise that, as from April this year, the starting salary of a trained nurse will be £17,060 a year. When one compares the antisocial hours, the responsibilities, the life-and-death decisions that nurses have to take or participate in taking, the stresses and strains, and the physical nature of the job, with those of other professions—for example, the police—nurses are undervalued in terms of remuneration.

The hon. Member for Tunbridge Wells rightly emphasised the change in the nature of nurses' training since the introduction of Project 2000. There must be an appropriate balance between the academic and the practical, or the clinical. Those who have been involved in nursing for many years repeat that, in their experience, many new nurses are well trained academically but need more clinical experience before they are let loose on the wards.

In an intervention on the hon. Member for Tunbridge Wells, I attempted, perhaps not particularly well, to contrast nurses, who work antisocial hours and shifts—necessarily, as wards operate 24 hours a day—who make life and death decisions and who accept all their responsibilities, and are paid at a certain level, with GPs, who recently managed to secure for themselves—in
 
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effect, and if they so wish—a nine-to-five job, five days a week. Compared with nurses, they are well remunerated.

I am not saying that GPs do not deserve their pay or that they do not do a good and important job for which they should be properly remunerated, but I question whether the difference in levels of pay for GPs and nurses is appropriate, given the responsibility that nurses have, particularly on acute wards. I would argue from a Back-Bench position that perhaps there is a need for a review, although I would not commit my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) to spending plans, which are for him, not me, to make.

I have only a few minutes left in which to emphasise two points. The first is about the amount of paperwork that nurses are now required to deal with in order to maintain their responsibilities on wards. As I see it, nurses have taken up new roles as patient biographers. They must complete a veritable encyclopaedia of information before patients can be admitted. They need superhuman powers to find the time to engage in nursing care itself, on top of all the paperwork.

Recently, I asked a nurse how much paperwork had to be completed when admitting a patient. I was told that a 28-page form must be completed when a patient is admitted to an acute ward, and that a great deal more paperwork must be completed during their stay.

Laura Moffatt : Does the hon. Gentleman not accept that taking a really good case history and background of the patient contributes to good nursing care throughout that patient's stay?

Andrew George : A balance needs to be struck between the amount of paperwork and the amount of time left for nursing care—that is a question of judgment. I simply make the point that many nurses say that much of the data and information collection is unnecessary, does not help with their job, does not help them come to clinical decisions on the ward and does not necessarily assist with the longer-term care of the patient. They estimate that the amount of paperwork has increased by about 30 per cent. in the past two to three years.

In early September, the Daily Mail—if I dare quote from it—published a letter from Sally Boxall, who stated:

"I'm one of the 40,000 nurses quitting the NHS—in my case, after 25 years. The reasons that have led to my frustration at the whole soul-destroying set-up include the paperwork . . . nurses are expected to make it a priority, before patient care",

and that they have become bed managers rather than carers. We must recognise that there is a difference between what we debate in this Chamber and what actually happens on the ground.

I spoke to nurses recently about a current case in a Cornwall acute trust. Twice during the past two weeks, night duty—from 9 pm to 8.30 am—was covered by one recently qualified D grade nurse on £17,000 a year. She and two health care assistants had care of a ward of 28 seriously ill patients. That nurse had to administer drugs, put in and change drips, discuss medical care with doctors, give information to relatives, talk to nurses from other wards about the transfer of patients, admit emergencies, administer injections, change catheters,
 
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insert nasogastric tubes, and decide whether patients needed oxygen or a remedy for low blood sugar levels. She also had to deal with cardiac arrests, although it needs two nurses to resuscitate patients. I understand that is happening regularly. The local NHS acute trust hospital is short of 80 qualified nurses.

There are serious problems. Nurses are undervalued as well as being underpaid. I hope that the Government recognise that, and that they will take those issues on.

3 pm

Mr. Paul Burstow (Sutton and Cheam) (LD): I add my congratulations to those expressed to the hon. Member for Tunbridge Wells (Mr. Norman) on securing this debate. I also congratulate him on the manner and tone in which he presented his argument and the evidence that he gave in support of it, and I congratulate all who have contributed to the debate. I shall pick up a number of the points that have been raised.

First, I echo what was said at the beginning of the debate about the nature of nursing. Nurses are dedicated, but they are still less well paid than many others in the public sector. As my hon. Friend the Member for St. Ives (Andrew George) said, unfavourable comparisons can be made with other public sector workers, some of whom have done very well—they have received increases in salary and their work is valued.

The hon. Member for Tunbridge Wells was right to say that nurses are the bedrock of patient care in the NHS and that they embody the very best of the public service ethos. We must do everything we can to cherish and protect that, and to build upon it. During the next few minutes, I shall run through some of the issues that have been raised.

The hon. Member for Crawley (Laura Moffatt) rightly said that hon. Members had so far focused on nursing in the hospital setting; she said that nursing was far from being confined within the boundaries of NHS or other hospitals. The profession reaches into many other settings. I think particularly of the key role that nurses play in primary care; increasingly, they lead primary care teams, and many have become practitioners with specialist interests. As we heard, they have taken on a prescribing role, they run clinics, and they are taking a lead in developing and supporting self-management. Those are some of the many aspects that make the profession one that more people should consider as a career. I certainly support the "Nursing the Future" campaign that has been mentioned.

It is worth mentioning the British public's view of nursing—assuming that polls are an accurate reflection of their views. In a poll for Nursing Standard, MORI found that 81 per cent. of people believe that nurses are caring and understanding. In the same poll, eight out of 10 people said that they thought nurses were extremely hard-working. This year, through its in-patient questionnaire, the Healthcare Commission asked patients, "Did you have confidence and trust in nurses treating you?" We should remember that 75 per cent. of respondents in England said, "Yes." We MPs can often be disproportionately influenced by our mailbags. People tend to write to us only when things go wrong, but we must remember the good things when looking at the overall picture.
 
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Reference was made to the ongoing concern about hospital-acquired infections and the need for a management structure that allows nurses to be more clearly in control of the ward environment. For example, concern has been expressed during the past few years about the way in which contracts were let for cleaning and catering in hospitals. Those contracts led to a fragmentation of the chain of control and command in hospitals, which made it more difficult for ward sisters, matrons and others to be confident that what needed to be done could be done immediately, rather than having to go through a lengthy contractual process.

It is interesting to read the reports, also in Nursing Standard, on the National Patient Safety Agency's hand hygiene campaign. The agency found that on average only 40 per cent. of necessary hand hygiene procedures were carried out. I mention that because earlier today I had the pleasure and privilege of visiting the Epsom and St. Helier NHS Trust and joining the infection control team there—Dr. Sharon Chambers, Dr. Louise Neville, Mandy Cehssum and Gill Hickman, who are the infection control nurses—as part of its infection control week.

I visited wards, met a number of modern matrons and the sisters in charge, and took part in a practical exercise to see how good people were at hand hygiene. The powder was put on, and people's hands were washed and run under the scanners. The experience was most interesting—although I came out worst—and it was a good demonstration of how engaged wards are with infection control teams. I applaud what is being done to encourage people to become engaged, in a competitive way, with basic hand hygiene, which is an important aspect of reinforcing good practice.

I want to pick up something that the hon. Member for Wyre Forest (Dr. Taylor) said about pressure sores. My hon. Friend the Member for St. Ives was keen not to commit me to any spending figures in this debate, but we need to consider how to ensure that the resources now available to the NHS are used to best effect. To rehearse some figures, it cannot be to the best effect for more than £2 million a day to be spent on treating bedsores in the NHS. Nearly one in 10 patients are affected by bedsores, more than 90 per cent. of which are preventable.

Good health care assistant practices can materially alter that situation. For example, some research suggests that spending £200 on a pressure mattress can save £1,500 on treating bedsores. There are ways in which the resources can be used more effectively. That would introduce a quantum leap in the quality of care of the individual and save the NHS resources to boot. We should ensure that the existing examples of good practice on bedsore management and reduction become the norm. Perhaps some of the examples of infection control that I have given could be repeated for bedsores.

Feeding is also important. Recent research shows that 40 per cent. of patients going into hospital are already malnourished, and that 70 per cent. of those will become more malnourished within a week of their admission.
 
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Addressing the annual meeting of the Royal College of Nursing in Harrogate about the issue, Caroline Lecko, a matron at King's College hospital, said:

"We saw on the wards that they were extremely busy over the lunchtime period, so busy that the food really wasn't being noticed by nurses, by doctors, by therapists and everybody was too busy to make sure that patients were actually eating.We were seeing patients not really being prepared for meals and not being made comfortable to eat, with food left out of reach."

That is a real concern about practice being overlooked. Ensuring that food is eaten is linked to the other points that have been made about health care assistants.

Reference has been made to age profile of the nurse work force. With between one in five and one in four of the work force over 50, the NHS still faces the huge challenge of ensuring that we do not experience increasing shortages again over the next few years, despite the welcome increase of 67,500 since 1997. Just across the pond, the US estimates a shortfall of 1 million, and nurses are being actively recruited over here. Such pressures will intensify, not go away, and thus further increase our need to import overseas entrants into our work force, as has been said. For instance, last year more than half of those registered with the Nursing and Midwifery Council came from overseas.

One of my concerns about agency nurses relates to the Audit Commission's work a couple of years ago. The commission had serious concerns about the training, supervision and management of agency nurses entering the ward environment and said:

"All these factors increase the chances of patients receiving care of a poorer quality than they would otherwise get."

We spend £1.7 million per day on NHS nurses in agency roles. That is a large sum of money, but I am not certain that it necessarily achieves flexibility for the permanent work force.

That brings me, briefly, to training. A report published in May entitled "Failing Students" echoed mentors' concerns about the academic quality and competence of nursing trainees. Can the Minister explain what is planned for taking forward the work of the Nursing and Midwifery Council on standards for the preparation of teachers of nursing and midwifery to ensure a necessary improvement in the quality of students coming through? I am not talking about those who give up, but those who get through into practice. The NMC report shows that mentors are ringing alarm bells and saying that some people are getting into practice who should not be there.

In conclusion, nurses are the bedrock, and we must do all we can to support them. I look forward to the Minister's response.

3.10 pm

Mr. John Baron (Billericay) (Con): I add my congratulations to my hon. Friend the Member for Tunbridge Wells (Mr. Norman) on securing the debate and on his contribution, as well as the subsequent contributions. We should make it clear that we owe a debt of gratitude to all NHS staff, not just nurses, for their hard work and commitment. The phrase has been used many times, but our nurses are the bedrock of our NHS. In many ways, in people's minds nurses reflect the standard of care that they receive in the NHS. We owe them all a debt of gratitude.
 
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My hon. Friend rightly focused on standards and drew our attention to one or two areas that could be improved. In particular, he mentioned the importance of morale. There is no doubt that morale within the NHS, particularly among the nursing profession, is not what it should be. The Royal College of Nursing survey "Stepping Stones" surveyed around 10,000 nurses at the beginning of this year. One third said that they would quit the profession if they could, and 11 per cent. said that they planned to quit it in the very short term. The internal rotation shift system to which my hon. Friend referred—days, evenings and nights within a short period—was particularly unpopular. It is no surprise that the number of nurses leaving to work in the USA has doubled in the past year alone.

That poor morale has been caused in large part by the Government's micro-management of the NHS through its targets. There is no doubt in my mind that the Government's targets are well intentioned. No one can argue about an increase of more than 40 per cent. in NHS spending, but I believe that the Government are underestimating the extent to which targets are sapping morale within the NHS. Targets, however well intentioned, are preventing money from reaching front-line services, and there is strong evidence to suggest that they are distorting clinical priorities and that is demoralising staff. Targets are clogging up the system, and that is why the NHS is suffering so many retention and recruitment problems. After such a massive increase in spending, there has been only a modest increase in activity. We have seen a 40 per cent. plus increase in spending, but only a 5 per cent. increase in hospital treatment. Patients are suffering because they are having to wait far longer than necessary to be treated. The turnover figures are there for everyone to see.

I believe that the NHS turnover rate runs at around 22 per cent.—well above the national average. In financial terms, that is costing the NHS about £1.5 billion a year—the price of 10 new hospitals. A report by the Audit Commission in 2002 on this issue cited specific factors such as lack of professional autonomy, a sense of being undervalued by the Government and bureaucracy. Those are, without doubt, some of the problems.

I could go on giving evidence suggesting that targets are distorting clinical priorities. One of the most forceful statements recently was that of the outgoing chairman of the British Medical Association, Dr. Ian Bogle, who, as the Government will be well aware, said last year:

"The one memory that will linger long . . . is the creeping, morale sapping erosion of doctors' clinical autonomy brought about by micro-management from Whitehall which has turned the NHS I hold so dear into the most centralised public service in the free world."

He went on to say that doctors, nurses and managers were being forced to collude in widespread cheating to meet waiting time targets designed with an election in mind. Even Unison's head of health, Karen Jennings, has said:

"Hospital staff need to be free to concentrate on clinical needs and priorities instead of chasing crude targets."

Although targets, through their demoralising effect, have frequently been cited as a reason for the failure to retain nurses, the system of star ratings, as the Minister
 
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well knows, has come in for particular criticism. Jim Johnson of the British Medical Association has made the point that the star system

"measures little more than hospitals' ability to meet political targets and take inadequate account of quality of clinical care, or factors such as social deprivation."

The problem with star ratings is that they are a blunt measure. They are fine for measuring hotels, but not complex organisations such as hospitals, because they give patients and the medical professionals working in them, including nurses, no indication of how well their department is doing. The system saps morale, tars all departments with the same brush and means that nurses and other medical professionals are continually trying to raise standards but star ratings are getting in the way.

One could argue that all those things are necessary because otherwise we could not understand how the NHS was performing. However, it would be better to get rid of the targets and introduce a set of clinical standards, decided by the National Institute for Clinical Excellence, whereby the medical professionals themselves, rather than politicians sitting in Whitehall, decided the right level and type of care and treatment that should be provided. There is no doubt about it: Government targets are preventing money from reaching front-line services, and sapping morale. They can also interfere with the implementation of standards, which comes back to a point that my hon. Friend the Member for Tunbridge Wells made.

We know that 5,000 people a year die from MRSA, and although it did not suddenly appear in 1997 but was here before that, figures suggest that it has increased significantly in recent years. Again, Government targets appear to be hindering the fight against MRSA because they are overriding the recommendations of infection control teams to close beds or wards for cleaning. That is clearly wrong, and needs to be put right.

I suggest to the Minister that a useful way of ensuring, measuring or judging the meeting of standards involves patient representation—this too returns us to one of my hon. Friend's central points. Although a tried and tested system of patient representation and monitoring is one way in which standards of nursing care can be gauged, that has been fundamentally undermined by abandoning the tried and tested system of community health councils, which operated for almost 30 years, in favour of myriad bodies.

We know that staff turnover in patients forums is high; in the first four months of this year it was some 11 per cent. Many people have commented that the forums are being starved of resources and facilities. I put it to the Minister that if we lose an efficient system of representation, we take away one of the main props—one of the main ways in which we and the nursing profession, and those outside it, can ensure that standards are being met.

In conclusion, I suggest that standards of nursing care are not necessarily falling. We believe, as do all Members, that nurses are doing a great job. However, the Government are placing obstacles in the way of improvement. For example, recent national service frameworks—the Government's chosen tool to lever up standards—have no targets attached to them. In a world without targets we would welcome that, but in a culture of targets, it spells disaster. Targets equal cash, and medical conditions that do not have targets attached will struggle.
 
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We know that modern matrons have been introduced, but we question their effectiveness on matters such as MRSA when the Government, as I have suggested, get in the way of them raising standards.

The recruitment and retention problems reflect the fact that although improvements have been made in the NHS—there is no disputing that—progress is not what it should have been, bearing in mind the money invested. We can refer to the high turnover rate, but this is not the fault of the nurses and other professionals who work in the NHS. It is the fault of the Government, who cannot see that their approach is fundamentally wrong.

Politicians must stop interfering. The Government must stop bombarding nurses and other medical staff with targets, and micro-managing the NHS. The NHS has been a political football for too long. The time has come to scrap the targets and the star-rating systems, and give all hospitals true freedom, so that they are accountable to patients and not bureaucrats. We believe that that approach will usher in an environment in which doctors and nurses, freed from political targets, will choose to stay because they can enjoy the freedom to give patients a standard of care that they can be proud of.

3.21 pm

The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson) : In the brief time left to me, I shall do my best to sum up the debate. I join other hon. Members in congratulating the hon. Member for Tunbridge Wells (Mr. Norman) on securing the debate. It is becoming a habit for me to respond to Wednesday afternoon debates initiated by the hon. Gentleman. As on previous occasions, I found that much of his speech was sensible and I could agree with it—but not with all of it, by any means.

I join other hon. Members in recognising that NHS nurses are at the heart of the service. They provide 80 per cent. of the care, 24 hours a day and 365 days a year, and much of what we accept as the fabric of the NHS is built on the values of nursing—such as caring, treating people with dignity and respect and combining clinical and technical expertise with the fundamentals of care that matter to patients. For patients and other members of the public, nurses are often the face of the NHS, as has been said. The care that they provide is highly valued, and the Government pay tribute to their hard work and dedication.

I shall first draw attention to some inconsistencies between the remarks of Opposition Members. I am glad that the hon. Member for Tunbridge Wells recognises that we have, broadly speaking, brought about an increase in nursing numbers. That is not the impression that one would get from the remarks of his hon. Friend the Member for Billericay (Mr. Baron), who attacked us on the subject of targets.

Any organisation needs ambition and goals, and a way of telling how well it is doing. We have been instrumental in removing Whitehall controls. That has been the thrust of what we have done. In speaking about targets the hon. Gentleman failed to comment on our very good success rate, whether in the high percentage of patients who now wait only four hours—or much less—
 
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to be attended to in accident and emergency departments, the 12.2 per cent. cut in cancer mortality rates since we have been in government, or the 23.4 per cent. cut in deaths from coronary heart disease in the same period; that percentage is still growing. I could go on, but I do not have the time.

I must tackle one other point made by the hon. Member for Billericay before moving on to the much more sensible resumé of key issues given by the hon. Member for Tunbridge Wells. I refer to the point about hospital treatments and productivity, which was nonsense. In considering productivity, no account is taken of walk-in centres, most primary care work, or NHS Direct. Any successful public health or prevention work does not contribute to those productivity statistics. The more successful we are on prevention and public health generally, the less productive we are by the measures being unthinkingly used by the Opposition. That is completely ridiculous.

Mr. Baron : Will the Minister give way?

Miss Johnson : No, I will not, because I have far too little time.

As we are talking about what the Government have done, I should add that there are now 77,500 more nurses, and there has been a 62 per cent. increase in training places for nursing and midwifery. That means that 21 per cent. more nurses are now caring for patients, according to our figures, which despite slight differences, are broadly in keeping with what the hon. Member for Billericay said.

I want briefly to recognise the new roles being played by nurses, although the issue did not crop up in the debate. My hon. Friend the Member for Crawley (Laura Moffatt) rightly commented on the number of different settings in which nursing takes place. There are now 697 nurse, midwife and health visitor consultant posts, as well as a new top clinical grade that is helping to modernise and improve services, raise standards, retain the most experienced and expert nurses in practice and strengthen clinical leadership. Nurses are also acting as a first point of contact in some of the schemes that I mentioned, such as NHS Direct and walk-in centres. Furthermore, they have a range of new responsibilities and specialist roles. My hon. Friend, with her wonderful expertise and background in nursing, described how nurses can now prescribe medicines at different levels. There is a range of new activities.

More than 18,000 of those 77,500 nurses and midwives have returned to the NHS since 1999. We must not forget nurses in primary care, whose numbers increased by nearly 18 per cent. between 1997 and 2003. In addition, vacancy rates fell to less than 3 per cent. in 2003—I am afraid that I do not have a more recent figure. Finally, the number of nurses entering training has increased dramatically—by 62 per cent. I want to say a little more about nurse training, however, because the issue exercised several hon. Members.

We obviously want to attract as many people as possible into nurse training. We also want to focus on the practical side of nursing and on those who want to take on advanced clinical roles. We need a mix of skills, as I am sure the hon. Member for Billericay will recognise. We have therefore increased the practical element of training
 
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to 50 per cent., to ensure that nurses acquire the skills needed to care for patients in the more traditional way that hon. Members have talked about. It is important to strike the right balance in preparing nurses for the future, and our nursing strategy "Making a Difference", which was published in 1999, led to developments in education that have improved nurses' practical skills. In the formal sense, the provision of practical experience is an essential element of all pre-registration education. UK pre-registration programmes require 50 per cent. theory and 50 per cent. practice, and that seems to me a pretty good balance.

On the question of maintaining people in training, we have no evidence that drop-out rates are increasing. The latest data are still being analysed. The latest complete data that we have go back to 1997–98 when there was a 20 per cent. drop-out rate. Rates vary a great deal across universities and nursing branches, but local work force development confederations are working with local education providers to reduce drop-out rates, so the issue is being considered.

On the future role of health care assistants, hon. Members and others must recognise that such people play a key supportive role, which we need in the skills mix in our hospitals. Most health care professionals are already well regulated. We issued a consultation document called "Regulation of Health Care Staff in England and Wales" on 2 March and closed the consultation period on 2 July. The consultation considered the categories of staff whose work has a direct impact on patients and who have the potential to compromise public safety if their work or behaviour falls short in any way. It set out a range of options, including full statutory regulation for such staff. We are analysing the responses to the consultation and we will decide the way forward in the light of those.

There is huge satisfaction with nursing care. We know from a study by the Royal College of Nursing that the majority of nurses—78 per cent.—are enthusiastic about their work, and 85 per cent. believe that they can provide a good quality of care. The vast majority of patients, too, are happy. The nurses enjoy doing their job, and that is recognised in all the responses that we have; 85 per cent. of the nurses in the RCN "Stepping Stones" survey agreed with the statement, "The quality of care provided where I work is good."

It is important to recognise that a new brand of nurse consultant is out there, as well as all the traditional roles that we have been talking about. Modern matrons have been mentioned, and there are now more than 3,000 of them employed in the NHS, but it is not possible to think that we could go back to the past—

Mr. Deputy Speaker : Order. We must now turn our attention to the next topic of debate. I thought that a Division was about to be called on the Floor of the House, but as that has not happened, we shall start the debate.

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