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Baroness McFarlane of Llandaff moved Amendment No. 2:
The noble Baroness said: I beg to move Amendment No. 2. In doing so I shall speak to Amendments Nos. 9 and 29 in addition. The purpose of the amendment is to clarify that nurses may propose pilot schemes in their own right rather than via a doctor or NHS trust. Amendment No. 9 seeks to ensure that health authorities will prepare proposals for any pilot scheme put forward by nurses; and Amendment No. 29 seeks to allow nurses providing nursing services in pilot schemes to apply to become health service bodies.
At Second Reading the Minister paid tribute to the important contribution of nurses in primary care. She said (at col. 591 of Hansard):
Questions were asked at Second Reading about the nature of the ability of nurses to submit pilot schemes in the terms of the Bill. If nurses are to be full partners in the multi-disciplinary team in primary care and if, as the White Paper Choice and Opportunity states, they have an equally important part to play with other professionals, the Bill needs to give expression to this equality. As it stands, it presents barriers to the nurse acting independently of GPs or trusts in proposing pilot schemes. Subsection (3) of Clause 1 implies that a pilot scheme could include nursing services only as part of a wider pilot but nurses acting alone could not propose a pilot scheme. Amendments Nos. 2 and 3 seek to rewrite this subsection to define pilot schemes as covering all nursing and other services which may be provided.
Clause 2 presents a further barrier. It sets out the duties of health authorities to consider pilot schemes submitted to them by "a qualified person" and to prepare proposals for submission to the Secretary of State. Subsection (7) defines "a qualified person" as either an NHS trust or a medical or dental practitioner.
Amendment No. 9 adds nurses to the list of qualified persons, thus allowing nurse-promoted pilots the same status as other pilots. This would allow nurses to maximise the potential of the Bill.
Amendment No. 29 to Clause 13 allows nurses providing services under a pilot scheme to apply to become a health service body rather than restricting that status to persons providing personal medical or personal dental services. Not all primary healthcare services can
Nurses, midwives and health visitors provide a wide range of specialised services in primary healthcare. They make a major contribution to health promotion through health education and a range of preventive services. The health visitor, for instance, is well trained in epidemiological analysis.
The amendments before the Committee would liberate nurses to develop a range of services for vulnerable client groups who fail to engage with and remain untouched by GP services which exist at the moment on a so-called "come and get it" basis. Pilot schemes in health education, screening programmes and epidemiological services would be eminently suitable as pilot schemes, as well as the child health clinics and monitoring of asthma mentioned by the noble Baroness at Second Reading.
The contribution of community psychiatric nurses has been well acknowledged. It is the view of the Royal College of Nursing that, in partnership with a medical practitioner in mental health, nurses could contract with a health authority to provide a 24-hour emergency mental health service for a locality. Similarly, in partnership a team of nurse practitioners could contract to deliver a wide range of services for homeless people not registered with a GP.
The NHS Executive report published in June of this year, Primary Care: the Future, paid tribute to the role of the nursing services in primary healthcare. It drew attention to their many strengths: the work they do in health needs assessment, health promotion and illness prevention, as well as nursing care of patients with acute long-term illnesses. It said that their services are readily accessible and available in a variety of settings and that nurses are already well qualified and have many postgraduate qualifications and some have degrees.
The nursing contribution to clinical audit and research is increasingly strong. The report drew attention to the fact that nurses play a leading role in the provision of immunisation, clinical cytology and disease management through practice nurses, child health surveillance, nurse-led minor injuries clinics, nurse-led home care schemes and nurse-led specialist services such as parenting skills, dermatology, leg ulcer and palliative care.
In looking for areas of development, the NHS Executive report saw scope for nurses to widen their role but said that there should be a change in the way teams worked and the structures underpinning them. We believe that community nurses are in a prime position to lead and co-ordinate such services with their existing links in the community. For example, an integrated team of community nurses could provide local people with access to acute mental health and community medical services through the nurses themselves and through referral and joint working with GPs and professionals
The amendment before your Lordships' Committee is an essential step in providing the structural arrangements necessary for nurses to be maximised in their contribution to healthcare.
Baroness Jay of Paddington: I would like to support the noble Baroness, Lady McFarlane, in moving Amendment No. 2 and the other amendments in this group. As she has rightly stressed, there are many other professions who contribute greatly to the important overall care that we receive in the primary healthcare setting. The noble Baroness rightly stressed the important role of nurses in this and the need that they have, and professionally feel would be appropriate, to become leading partners and not just supporters in the new experimental pilots which the Bill will allow. It is obvious that nurses are in an advantageous position to put forward ideas and to manage any pilot scheme.
I should like to mention some other professions allied to medicine and working in the primary health care field which equally feel that they could take a lead in forming pilots and delivering services. For example, health visitors are among the other well-qualified people, in the commonsense meaning of the term, who would be able to do that, as are pharmacists, occupational therapists, clinical psychologists and, of course, midwives. As the noble Baroness said, nurses and community nurses are already working independently in organisations such as minor injuries units.
It is clear that the work of those other professionals is often done independently. Indeed, one example has been given of a primary care team where the nurses employ a general practitioner. It seems that it would be legitimate, within the meaning of the Bill and the pilots as they were described by the Minister in introducing the Bill on Second Reading, to give nurses and the other professionals I have mentioned a lead role in the pilots.
The Royal College of Midwives is especially keen that midwives should take a lead in some of the pilots. As it says, maternity care provides an ideal opportunity. It could become a model service. It could move pregnancy and childbirth out of hospital and back into family-centred community services. It feels that that is in line with the spirit of the Government's changing childbirth initiative, with which we know the Minister has had a leading and influential role.
All those people bring their skills and professional backgrounds to the concept of the team approach to primary care which we all welcome and which is clearly an important way of dealing with the needs of the community. My noble friend Lord Rea emphasised at Second Reading the need for the team to be seen as a body of equals rather than as one partner taking the lead over other professionals. In that context it would be interesting to know whether any group of professionals--whether or not the amendment stands--will be able to put forward pilot schemes if they are not formally incorporated into a partnership at the moment.
The Government have today produced a further White Paper on developing partnerships in care entitled Primary Care: Delivering the Future in which they emphasise the notion of the team approach to primary care, specifically include the proposal to extend the existing nurse prescribing pilot scheme and make other proposals which show that they regard nurses, in particular, and other professionals working within the community as equal partners in the delivery of health care in the community. It therefore seems appropriate, as the noble Baroness, Lady McFarlane, said, to include those people specifically on the face of the Bill as people who can lead on the pilot schemes which are proposed. I support the amendment.
Page 1, line 14, at end insert ("or
(c) services are provided which are not personal medical services or personal dental services but which may be provided under Part I of the National Health Service Act 1977 or (as the case may be) Part I of the National Health Service (Scotland) Act 1978.").
"The nursing profession already plays a major and growing part in the delivery of primary care. We want to encourage that trend and also greater integration of the different primary healthcare professions. Our proposals will enable nurses to develop proposals with GPs which include a range of services in which they take a lead, such as child health clinics or monitoring of asthma".
4 p.m.
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