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24 May 2006 : Column 468WH—continued

10.27 am

Dr. John Pugh (Southport) (LD): I congratulate the hon. Member for Crawley (Laura Moffatt) on her opening speech in this important debate, to which she contributed a good deal of expertise. I marvel at her commitment—there is hardly a health meeting that I go to in this building to which she does not show up and make a valuable contribution.

I am not an expert, like the hon. Lady, but I have something in my CV that is vaguely relevant. In a gap year, when I was a student, I worked as a nursing assistant in an old-fashioned mental hospital in Maidstone, Kent called Oakwood hospital. I started
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there with not a day’s training and no secondment. I was simply given a white coat and set off, and I ended up on refractory and block wards. There must be few other MPs who have shown people into padded cells, administered electroconvulsive therapy and seen a straitjacket used.

In those days, I was familiar with the division between state-enrolled nurses and state registered nurses—one could tell them apart by their varying epaulettes and colour-coding—and the further division between them and the lower grade of nursing assistant, which I was. As such, I was completely unqualified and untrained, and I muddled through as best I could. We were aware that SRNs were the crème de la crème, who were going somewhere. They would become the charge nurses and, for those who were very fortunate, the matrons. However, my impression was that the training then was not anything like as intensive as it now is and that monitoring of performance was somewhat weak. I was aware at only one stage in my work of being inspected, and that was when the boards of hospital visitors, or whoever they were, trooped through from time to time and took more interest in the state of the floors than in the condition and happiness of the patients. That seemed to be their major and fundamental preoccupation.

In those days, one was aware of the clear demarcation between the nurses, who saw the patients very often, knew a great deal about them and could do much for them, and the doctors, who were of course the experts without whom nobody could move, who none the less saw patients relatively infrequently.

My brief experience of nursing before going off to study philosophy at university was intensely interesting and enjoyable. It was also a good preparation for other career moves. I say that because someone recently described this place as the last Victorian asylum. That may be a little unfair, but this place is full of people talking out loud to no one in particular.

Things have changed radically in nursing. I start on a good note by saying that the Government and the profession are to be congratulated. We have an increased supply of nurses—more than ever before—and we depend less on foreign staff, who ought to be working and providing health services in their own countries. We have increased salaries and improved career paths for nurses and others in the nursing profession. We also have improvements in the quality and variety of nursing education, and the link with higher education is an important boost in status, which the hon. Lady said was much needed and which is firmly to be welcomed. Nursing training also encourages career development and builds on nurses’ skills.

I warm to the concepts of nurse practitioners and of nurses being able to prescribe. Those long overdue and necessary reforms will break down the strict divisions that hitherto existed between nurses and doctors and their relevant areas of expertise. If we are to have decent medical care in the community, we need greater qualifications among the nursing profession. If we are to take pressure off the accident and emergency departments by having more minor injury units, we shall need nurses who can deal with a variety of
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unexpected conditions. If we are to advance the healthy living agenda and have flexible and effective care we will need expert and skilled nurses, and we are getting them stage by stage.

The Government’s strategy is essentially correct. I doubt whether anyone would speak against it. The strategy is correct and the profession is to be congratulated on endorsing it. However, it is a long-term strategy, as evidenced by the comments that we remember hearing when we remember our own experiences, and my concern is that it will be blown off course by short-term financial needs, or that it will be cross-grained with other initiatives. I think specifically of payment by results, and the drive to turn every NHS unit, whatever it be, into a financially autonomous, solvent, trading and entrepreneurial unit almost overnight.

The system cannot bear that sort of stress, because it effectively asks organisations to wipe out in one year deficits that have been built up over many years. That is what led to the right hon. Member for Oxford, East (Mr. Smith) talking about feast and famine in nursing training in relation to recent resource cuts. It was also referred to as stop-go in a briefing that we all received. They are all phrases that will be familiar to the Minister after his Treasury experience. Boom and bust is another. I assume that he is agin it.

It is clear that SHA training budgets are often raided, that they are sometimes underspent, and that they are only notionally ring-fenced. They can therefore become a source of brokerage, top-slicing or centre-saving. Whatever one calls it, the money just goes—especially in those areas that have the biggest problems. It is in those areas with larger deficits that existing staff are most fearful, job security is declining and additional training prospects are worsening. To cite a personal example, the acute trust in my constituency has a substantial deficit. It has announced 200 redundancies, but it has said that nurses will not be made redundant, which is welcome. I should declare an interest. My son’s partner, who has trained as a children’s nurse, cannot gain employment and is looking for a job outside nursing that will use her considerable talents.

Setting that against the general complaint of the royal colleges and the strategic liaison group about the lack of clinical academic pathways, one can begin to see a problem emerging. They complain about the difficulty of combining the service and the education roles. That can only bring about a reduction in effective mentoring. People’s experiences cannot easily be traded in both areas as effectively as they might. They also complained—this point, too, was made by the right hon. Gentleman—about a lack of work force planning and the fact that we have not linked training places to needs, as has happened for the medical profession.

What is happening is not something that could be dressed up in tabloid headlines as a meltdown, collapse or crisis in nursing; however, it is a genuine and serious problem, which can and should be tackled, and which calls into question the coherence of what the Government are doing and the haste with which they are acting. Hon. Members have spoken warmly about the Government’s support of the nursing profession
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and nurse training, but they are in danger, on this issue in particular, of snatching defeat from the jaws of victory.

What is required is a broad view, consistency and sensible pragmatism—all of which I associate with the Minister and elements of the ministerial team. The strategy can be right, and we agree that it is, but if the tactics are wrong we end up with a bit of a mess.

10.36 am

Mr. John Baron (Billericay) (Con): I, too, congratulate the hon. Member for Crawley (Laura Moffatt) on securing this important debate, and I welcome the Minister to his new post.

As we all know—we have all mentioned it—nurses perform an invaluable role. The NHS could not run without the hard work and dedication of its work force. Nurses more than anyone else are on the front line of patient care. However, I suggest to the Minister that there is growing frustration in the nursing profession. That was particularly brought home at the recent rally and lobby of Parliament. Many nurses are questioning what is happening. We all accept that extra money has been put into the NHS and welcome it, but not enough has reached front-line services and nurses increasingly point to the administrative burdens that they must undertake and the fact that the number of managers in trusts has grown faster than nurses’ numbers.

One cannot dispute that the number of nurses has increased, and we welcome it, but nurses make the point that not enough of the new money reaches front-line services. They feel they labour under an increasing burden of bureaucracy and political interference from a Government who insist on micro-managing the NHS through targets and red tape. I suggest that a fair number of the current frustrations and concerns are inevitably linked to NHS deficits. I ask the Minister not just to dismiss that point as party political, but to take on board those concerns expressed by nurses, and deal with them in the debate.

Nursing training has been mentioned a few times in the debate so far. The concern is that places on courses are being cut and that clinical placements are being cancelled.

Ann Keen: Does the hon. Gentleman agree that in the 1990s nurse training was dramatically reduced, which caused the shortage that we inherited in the late 1990s? Will he at least acknowledge that that is what happened?

Mr. Baron: Yes, there were cutbacks at times. There is no doubt about it. Yet what seems not to be accepted is that over the entirety of that period there were real-terms inflation-beating increases in the budget of the NHS.

By way of illustration of that, and to deal with one of the points that the hon. Member for Crawley made about improvements in cancer provision, the improvements that have been made since 1997 have not, despite all the extra money that has been put into the NHS, broken the trend of decreasing mortality rates that goes back to the early 1980s. Yes, improvement has continued, but despite all the money, there has been no marked improvement on decreasing
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cancer mortality rates. That is one example of how the money has indeed been provided, but not enough has reached front-line services, because much has been soaked up by the bureaucracy that has been created in the NHS.

Ann Keen rose—

Mr. Baron: May I make some progress? The hon. Lady may want to intervene again later, although I want to leave the Minister some time to respond.

Let me give an example. According to Nursing Standard magazine, half of all the SHAs in England that responded to the survey admitted to cutting training posts, and the average reduction in England as a whole was 10 per cent. That must cause concern, because it means that fewer student nurses will get the practical experience that they need to qualify and the NHS will be poorer for not having fresh talent to replenish an increasingly ageing work force. That is a particular concern given that the RCN’s own study has shown that about 100,000 nurses are due to retire in the next five to 10 years. Meanwhile, the Council of Deans and Heads has suggested that the reduction in the number of students who are being commissioned is greater in areas where SHAs report larger deficits, so there can be no dispute that deficits are having an impact on training places.

In addition to the cuts imposed by SHAs, there is already a high drop-out rate among trainee nurses, and about one in four students are thought not to be completing their courses. Perhaps the Minister will be kind enough to outline what studies, if any, have been done of nurses’ reasons for walking away from training opportunities. I expect that inadequate access to bursaries has something to do with it, but the flexibility and family-friendliness of training hours are also important, because the average age of nursing students is about 29, and many of them have young children. Those problems must be addressed, although difficulties at the NHS student grants unit last year did not help matters.

However, the problems in nursing are not confined to students. Even when nurses do qualify, many find it difficult to get jobs, because NHS trusts are riddled with deficits, as we have heard. The Royal College of Nursing regional director recently claimed that, in the west midlands alone, about 4,000 student nurses who were due to graduate in the next two months will not have jobs to go to. That is symptomatic of the growing problem of graduate unemployment in the NHS as a whole, of which physiotherapists are another example. Indeed, the problem of vacancy freezes seems to be getting much worse. Given that it costs about £100,000 to train a nurse, it is a great waste of public money and a missed opportunity to enhance patient care if nurses do not find work in the NHS soon after graduating.

Vacancy freezes and graduate skills going to waste are one concern, but to return to a point made by the hon. Member for Crawley, it cannot be denied that the nurses who heckled the Secretary of State last month were also worried by the prospect of redundancies.The RCN has estimated that at least 13,000 posts are due to be lost as a result of the financial pressures on the NHS.

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Mr. Devine: Does the hon. Gentleman agree that the language used is important? If someone is given compulsory redundancy, they know that they have been told that they are going, but I have looked at the figures and I do not see 13,000 redundancies—I see a freeze on vacancies, a reduction in the number of agency nurses and management of the financial problems.

Mr. Baron: The hon. Gentleman makes a valid point. The problem is that we do not know for sure what the number is. Locally, we are seeing job cuts and people being made redundant, but I agree with him about the validity of the 13,000 figure. I have not checked that figure, but have the Government come up with figures that reflect the true state of affairs? At the moment, nobody knows, and all we hear are headline figures for job cuts. Broadly speaking, therefore, I agree with the hon. Gentleman and I ask the Minister to give us a better estimate, rather than just relying on the RCN figure.

When the scale of the deficits crisis did become known—this is where I will take the Government to task—the Government argued that job losses in NHS trusts and acute hospital settings were broadly justified by the shift in emphasis towards care in the community. However, perhaps the Minister would care to explain how—taking the RCN figure—13,000 job losses can be made up when there 4,000 fewer full-time equivalent district nurses in the NHS than there were in 1997, with a 3 per cent. fall last year alone? Those weaknesses in primary care must be addressed before acute nursing posts are cut.

The Government White Paper “Our health, our care, our say” argues for transferring NHS activity from acute to primary care. There is much in the White Paper to be commended, but the Government will not be able to make good their pledge unless they develop capacity in the community, and at the moment that is not happening. Instead, the number of district nurses is decreasing; there is a shortage of school nurses; and birth centres and community hospitals are closing. Capacity is being shut down without any proper assessment of whether it is required. I suggest to the Minister that that could be storing up problems for the future and I would appreciate his response on that point.

Those problems illustrate nurses’ concerns about the security and status of their profession within the NHS. The bottom line seems to be that many nurses are still leaving the profession because their expertise and hard work are not being respected. An RCN survey published last year showed that more than a quarter of nurses’ time was spent on clerical or administrative duties. Half of all nurses who left the NHS in the previous year cited stress and the work load as reasons for changing job, and those problems are likely to become more acute as the work force contracts. Is it any wonder that 30 per cent. of all respondents to a recent RCN survey—up from 27 per cent. in 2003—said that they would leave their employer within the next two years? That is the RCN’s own survey.

Conservative Members have long called for a different approach—one that would reverse the recent rapid growth in the number of managers and administrators and force politicians to withdraw from
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the day-to-day running of the health service. We would reduce the need for central control and leave hard-working nurses to get on with the job. In short, we would seek the re-emergence of nursing as a respected and largely autonomous health care profession.

Nurses deserve our support, but the crisis in NHS finances has placed burdens on staff. We can do a great deal to promote nursing in the medium and long term, but the immediate task is to assess the damage caused by the consequences of deficits and to address the concerns of nurses themselves.

10.47 am

The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis): It is always a pleasure to serve under your chairmanship, Mr. Cook. I congratulate my hon. Friend the Member for Crawley (Laura Moffatt) on securing this Adjournment debate and on the passionate and knowledgeable way in which she described the development of nursing over a relatively short period. She described experiences that she had when she was a front-line nurse in the national health service and some of the challenges and difficulties that nurses faced. She also described the sense of reward that she got from being a nurse and recognised how significantly things have changed in recent times.

It was good to hear it highlighted that it is the Labour party that, since 1997, has welcomed the election of not only my hon. Friend the Member for Crawley, but my hon. Friends the Members for Brentford and Isleworth (Ann Keen), for East Lothian (Anne Moffat) and for Livingston (Mr. Devine)—all serving nurses who have been elected to the House of Commons. That is a step forward for democracy. When my hon. Friends the Members for Crawley and for Brentford and Isleworth were elected, it was the first time in history that nurses had been elected to Parliament. I am very proud that all of them are Labour Members of Parliament. They are some of the best colleagues in the parliamentary Labour party, as I am sure everyone agrees.

My hon. Friend the Member for North-West Leicestershire (David Taylor) always turns up to make a contribution. However much he goes on about my talents as a Minister, I am not in a position to make announcements today on additional resources for midwifery bursaries, but I take on board the general concern that he expressed about retention of midwives, particularly on some courses. What are the obstacles getting in people’s way and what issues do I need to address in my new role to deal with that?

My right hon. Friend the Member for Oxford, East (Mr. Smith) made a very important contribution to the debate. I think that the last time we both participated in a debate in Westminster Hall, we were discussing cash machines and access to cash. This is a slightly different subject—such is the nature of government. He referred to health care assistants and secondment programmes. As I understand it, that is very much left to local discretion, depending on the market and on supply and demand. However, I am willing to look into secondment programmes for health care assistants—that specific opportunity to get into nursing—and into what is happening and what we want to happen.

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