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Baroness Cumberlege: My Lords, the amendment seeks to place a formal requirement on regional offices to set up liaison arrangements with universities. It would not be workable in its present form, and, more importantly, it is entirely unnecessary. I fully understand the reasons why the noble Baroness has tabled the amendment. I know it reflects the more widespread concern that the relevant interests of universities and their medical and dental schools might somehow be overlooked after RHAs have been abolished.

I can reassure the noble Baroness that there is no need for a new statutory provision to ensure that that does not happen. Effective liaison arrangements, both formal and informal, are currently in place, even though most of them are not required by legislation. Indeed, the recent report from the Joint Medical Advisory Committee of the Higher Education Funding Councils presents a very favourable picture of the effectiveness of liaison between NHS trusts and medical schools. There is no reason why that should be undermined once RHAs are abolished, nor will we allow it to be.

I have previously referred to the 10 key principles in your Lordships' House, during debates on the Bill. They provide a very clear and firm statement of the need for effective liaison. The Joint Medical Advisory Committee's report says that they are working well. The amendment proposes a statutory provision which is so vague that I believe it might well undermine the effectiveness of the 10 key principles. People might say, "We meet our statutory requirement, why should we comply with the 10 key principles as well?" We would not want that to happen.

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My right honourable friend the Secretary of State has also made it clear to the regional chairmen, who are all members of the NHS Policy Board, that she expects them to take a particular interest in ensuring that there is good liaison between the NHS in their region and universities. Any problems will then come swiftly to our attention and can be dealt with quickly and effectively.

Finally, I should also report that a meeting has been arranged between senior people in the Committee of Vice-Chancellors and Principals and senior officials of the NHS Executive (including the chief executive) on 9th May. They will discuss the question of appropriate arrangements for effective liaison between regional offices and universities. I am sure that that meeting will be constructive and productive.

I hope that I have made it clear that the amendment would not be workable and is in any case entirely unnecessary. I invite the noble Baroness to withdraw it.

Baroness Jay of Paddington: My Lords, I thank the Minister for that reply, in particular for the information about the further meeting between the CVCP and the Department of Health on 9th May. We have had lengthy discussions about the subject during the various stages of the Bill. It is unfortunate that the final meeting to resolve the matter will take place after the Bill has passed all its stages in another place and in this House.

The arrangements are of great concern to the academic medical community and, as I have stressed several times in this House, to those of us who are anxious about the excellence of patient care. It is unfortunate that such important matters have been left until the last minute before being resolved and that they will be resolved when we will be unable to discuss them in the course of dealing with this legislation.

However, on the understanding that progress is being made towards an agreement with the Committee of Vice-Chancellors and Principals, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness McFarlane of Llandaff moved Amendment No. 4:

Page 19, line 32, at end insert ("including at least one officer who is a registered nurse and who has had, in the twelve months immediately preceding his or her appointment, experience of managing services to patients.").

The noble Baroness said: My Lords, I rise to move the amendment standing in my name on the Marshalled List. To do so may appear to be tedious in the light of the lengthy consideration given to the principle of professional representation and related amendments at each stage of the Bill. However, I have looked at the Minister's replies to the amendments, pleading not for professional representation but for a representation of the expertise that nurses bring to health authorities. In every case, the replies were in terms of professional representation.

I am the first to agree—as we did after the Second Reading and the Committee stage—that to plead for professional representation of every profession in the health service would be impossible. But it is the expertise which nurses bring to a health authority for which I plead.

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If no obligation is laid on the authorities to include within their membership a registered nurse who has experience of managing services to patients that would create a notable departure from historical precedents. Your Lordships' House will know that since the days of Miss Nightingale the history of the health services of this country has been punctuated by a succession of redoubtable ladies—and in some cases gentlemen—who have managed those services with great expertise. They achieved national eminence as a result.

Since the first National Health Service reorganisation in 1974 each district health authority has had an executive nurse director. To manage the service without a lead nurse at each level would be departing from historical precedent. The chief nurse has not been in lead positions on health authorities as a professional representative. She has been there as an indispensable contributor to the work of the health authorities at every level. The reasons for that were well rehearsed during previous stages of the Bill. They include the size of the nursing service; its sophistication and complexity; its specialist roles; its intimate impact on patient care and on all other services; and the intricacies of skill mix.

Nurses provide 80 per cent. of the direct patient care and the cost of the nursing service is 40 per cent. of current National Health Service expenditure. It is unthinkable to leave the policy decisions of that great resource to the vagaries of personnel or lay managers, or even to the directors of public health who have no special knowledge of the manpower and legal requirements of the service. At district health authority level I have witnessed attempts at that and I have been appalled at the outcomes and failures in patient care that have resulted.

The Minister herself has endorsed the crucial contribution of nursing to the purchasing function. On Second Reading she expressed the view that she would be very surprised if the majority of health authorities did not appoint executive members with nursing experience. I refer your Lordships to col. 70 of the Official Report of 6th March.

Current evidence appears to be to the contrary. At the beginning of the year the Royal College of Nursing conducted a survey which revealed that only half of the district health authorities and the family health service authorities currently have nurses in executive positions on their boards. More significant is the Government's own research, Creative Career Paths in the NHS. A study by consultants for the NHS women's unit reported in March this year and showed that only 58 per cent. of the purchasing organisations surveyed had a nurse at director level.

For the purposes of our argument today, these trends can only impoverish the health service further as it diminishes the number of those who are available to take executive roles on purchasing authorities. I believe that the real argument for an executive member with experience of managing services to patients lies in the necessary expertise that they bring to the work of the authority. That was amply illustrated by the study commissioned by the nursing directorate of the NHS Executive. It took the form of structured interviews with chief executives and nurses working in purchaser organisations. It listed the contribution that nurses can

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make to purchasing. To summarise: they can challenge clinical practice because they are clinically credible; they can challenge the basis of prices because they have a breadth of practical experience across clinical areas, understand how nursing costs are calculated and have experience of managing budgets; they can evaluate alternatives because they have worked at the sharp end of "care"; they can interpret users' needs; and they can contribute to quality because they have working experience of setting up quality standards in processes and procedures and see quality from the users' point of view.

I spoke to an executive nurse on a health authority and I asked her what contribution she makes to the work of her authority in purchasing. She stated that she is able to give advice on nursing skill mix changes being proposed by a provider unit. She is able to provide a nursing focus on complaints and untoward incidents. She leads the quality standards programme for the health authority. She facilitates the involvement of users in commissioning and contributes to health needs assessment work. She advises on value for money in contracts. She contributes specialist knowledge and expertise in contracting for different care groups, and so forth. It is difficult to conceive how a health authority can function adequately without such expertise at its immediate disposal and not just at an advisory level.

I conclude by quoting the secretary to the Welsh Board of the Royal College of Nursing. She states:

    "There is no doubt that the proper exercise of those statutory functions of the Authority which relate to nursing or midwifery practice or to the protection of the public will continue to require the expertise and vigilance of the most senior of nurses and for which that nurse will be accountable to the United Kingdom Central Council which endorses, strongly, the claim now being made".

I beg to move.

4.30 p.m.

Lord Addington: My Lords, this is a reasonable amendment which provides that representatives of the nursing profession shall be included on all health authority boards. As the noble Baroness has just told us, nurses provide over three-quarters of the actual contact with patients and are involved at virtually every level of treatment. However, a survey conducted at the beginning of the year showed that half of the boards currently do not have a member of the nursing profession in an executive position.

It just does not seem to make sense that there is no representative of the nursing profession, which has most of the direct contact with patients. I suggest that the Government should look again at this matter because it is not sufficient to say that they would expect there to be some form of representation for the profession which provides the majority of contact with patients.

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