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Baroness Robson of Kiddington: We on these Benches support the amendment. We have for many years tried to achieve greater recognition of the contribution that nurses make to our health service. It seems to me, as it does to the noble Baronesses, Lady McFarlane and Lady Jay, wrong, when nurses can now be a full partner in a general practice, that they should not be able together to put forward a pilot scheme which might be of the most tremendous use in the community.

One suggestion was that nurses could propose a pilot scheme of 24-hour emergency mental health services. There is nothing we need more in our health service at the moment than an improvement in mental health care in the community. It is difficult to understand why nursing services are not personal medical services--I know why they are not personal dental services--which may be provided under Part I of the NHS Act. It is long overdue for nurses to be given the recognition they deserve. I support the amendment.

Lord Campbell of Croy: It is appropriate that the amendment should be moved by the noble Baroness, Lady McFarlane, who has immense experience in the nursing profession and as a leader of it. I, too, received the text of the amendment, and two others in the group, from the Royal College of Nursing.

As noble Lords will be aware, my main experience of nurses is as a hospital patient over long periods, including a year and two months at the end of World War II. I have tremendous admiration for their dedication and the contributions they make to different parts of the NHS. I am glad that nurses nowadays are authorised to do a good deal more than they were 50 years ago. I shall listen closely to what my noble friend the Minister has to say about the amendments.

Baroness Gardner of Parkes: I, too, am a great supporter of the nursing profession, and, indeed, of all the people involved in the primary care delivered to patients. It will be a pity if they are not all equally entitled to bring forward a pilot scheme. As my noble friend the Minister told us on the previous amendment,

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the pilots will all be sifted by the DHA. So we are not committing anyone to accepting any scheme that is not appropriate and suitable.

It is wrong to stifle the initiation of schemes by excluding a number of different branches of the caring professions. I include pharmacists who are great innovators within their own practices and who are doing more and more all the time towards helping patients and removing the burden from GPs. We have had no mention of opticians. It would be desirable for any people with a health qualification--I am not saying that any member of the public could come forward with a scheme, because that would make the provision too wide--and any member of the caring professions, allied to medicine, or who are part of the primary care team, to be able to bring forward a scheme.

I support the principle behind this group of amendments. However, when it comes to practicalities, I notice that the noble Baroness, Lady McFarlane, referred to Clause 2(7) which sets out the two lists of medical practitioners and dental practitioners. I wonder whether, rather than produce a list of other qualifications--we should need to include them all--there could be an amendment to the effect of "all other approved qualified people" or some more general phrase. Because even within the caring professions, modifications, changes and new terminologies are coming all the time for people doing different jobs. I would rather see the provision sufficiently wide to cover those people who might be branching into a new form of medical care as well as those who are involved at present. I support the principle of the amendment.

Lord Walton of Detchant: I, too, support the principles underlying the amendments. The past 25 years have seen a veritable revolution in the range and quality of services provided by nurses, health visitors, midwives and others. Indeed, within the NHS itself there are many circumstances in our hospital service when nurses have been appointed as managers of various hospital trusts.

The purpose, I think, underlying the amendments is to acknowledge the fact that nurses, working in collaboration with, and in future perhaps in partnership with, doctors are capable of providing a wide range of services and of relieving the GP of certain duties and responsibilities that he or she may, in the past, have carried. It is a very important principle that we should accept. There have been circumstances, particularly in our inner cities, where the most impoverished section of the population and the homeless have found themselves being looked after by nurse practitioners; people who have not registered with general practitioners.

When I heard the Minister reply to the debate on the first amendment I was almost persuaded by her argument that pilot studies must be approved by the health authorities and the Secretary of State on the advice of those authorities. Surely, if we are to give the same responsibilities for the initiation of pilot schemes to members of the nursing and allied professions, only those examples which are regarded by the health authorities and

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the Secretary of State as being suitable will be approved. For that reason I believe that this group of amendments has considerable strength. I support them.

Baroness Eccles of Moulton: There is an aspect of the amendment which we should consider. It follows from the comments of the noble Lord, Lord Walton. In the early stages pilot schemes will require a heavy workload of assessment and monitoring by the health authorities. It would be helpful if in reply the Minister could indicate the effect on the monitoring and pilot process of widening the range of individuals and bodies which can enter into pilot schemes. We must bear in mind that health authorities are continually under pressure to reduce their management activities. Although they will be taking on the extra work of monitoring the pilot schemes, we must be mindful of other tasks which must be performed at the same time.

Baroness Gardner of Parkes: As this is the Committee stage, I am sure that I am allowed to intervene again. I wish to follow the point made by the noble Baroness, Lady Eccles. Of course it might create too great a burden for the district health authorities, but surely through local medical committees and equivalent pharmacy and nursing committees there must be some way of setting up an earlier filtration system in order to avoid that burden. I understand the argument that we would not wish to make the system totally unpracticable.

Baroness Cumberlege: I strongly support the views expressed by many Members today concerning the role of nurses. The noble Baroness, Lady McFarlane, could not be a better champion for the cause, knowing more about the nursing profession than anyone in the Chamber today.

I too have strongly supported the role of community nursing. When I carried out the review, Neighbourhood Nursing: A focus for care, I recognised very strongly in the report that the role of nurses is fast developing and that there is plenty of potential for them to take on more duties and responsibilities and to use their full range of skills. That report recognises the services provided by nurses, midwives and health visitors in their totality of primary healthcare and that primary care was at its best when provided by a range of professional staff working together as members of a primary healthcare team. The Bill before the House and the White Paper, Primary Care: Delivering the Future, which was published today, also significantly support those objectives.

I have given these amendments a great deal of consideration. I am very clear that nothing should stand in the way of nurses, midwives and health visitors playing a full part in using the flexibility provided in this legislation to develop not only their professional skills but to use opportunities. I am convinced that this can be achieved within the Bill.

Amendment No. 2 would allow the services currently provided under Part I of the 1977 Act to be provided through pilot arrangements. These are the services which we usually describe as hospital and community

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health services and are currently provided through health authorities or GP fundholders who may purchase hospital and community health services on behalf of their patients.

The amendment seeks to enable the piloting of community nursing services and others in addition to the pilots for personal medical services and personal dental services. I believe that this Bill already provides a significant opportunity for nurses through the development of their skills as members of the primary care team either in partnership with GPs or through taking on a more significant role in a trust that provides primary care services.

Amendment No. 9 aims to provide an automatic right to have proposals submitted to the Secretary of State to ensure that where, for example, a health authority has reservations about a proposal it may not block its scrutiny and potential approval at national level. Of course, we would not expect this to happen in the normal course of events. We are very confident that health authorities would want the widest range of proposals to be examined. But nevertheless we felt it was important to enshrine the principle of unfettered access to the Secretary of State within the legislation.

The health authority would need to be satisfied that any scheme not proposed by a suitably qualified doctor or dentist, or led by an NHS trust as proposer, could deliver the services proposed and had sufficient merit to warrant submission. Where a proposal was put before the health authority by any other professionals--and a good example might be of a nursing led proposal--it would look at the soundness of the proposal and use its discretion in deciding whether to prepare the proposals and submit them to the Secretary of State.

The proposed amendment does not add to the existing legislation. The health authority can already use its discretion in the way that the amendment provides. A similar line of argument applies to Amendment No. 10 which seeks to add UKCC registered nurses, midwives and health visitors to those persons who would have an automatic right to have their proposal for a pilot scheme passed to the Secretary of State for consideration.

As the Bill stands, nurses, midwives or health visitors putting together a proposal would need to secure health authority support for their proposal to be submitted to the Secretary of State. I believe this is reasonable since a health authority would have to be convinced that a pilot scheme which replaces general medical services with personal medical services would satisfactorily cover those areas of care which explicitly have to be provided by doctors. If doctors are co-initiators of the scheme, which would be the normal model for a pilot with substantial or even majority nursing interest, then the doctor can formally put the proposal to the health authority and automatic submission of the proposal would apply. If doctors are not involved in the proposal then it will need to be clearly set out how the medical practitioner input to the pilot will be made.

It is in everyone's interest that prior to the proposal going to the Secretary of State there is the opportunity for the proposers and the health authority to discuss fully the arrangements. My noble friend Lady Eccles

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spoke of the workload, which is a serious consideration. I am sure that if the health authority believed that a proposal merited support it would want to see it go forward to the Secretary of State.

Amendment No. 28 would seek to take nursing beyond the scope set out during our year long consultation on the future of primary care. What it envisages is that nurses will be able to provide medical services in the place of a doctor; that a nurse, or a midwife or a health professional, would deputise fully for a GP.

Our consultation has made it clear beyond doubt that we need to move to make more of the great potential there is for nursing professionals; but we do not want to turn nurses into doctors. Indeed, this Bill will allow nurses to play a full role as equal partners in the primary care team by allowing more explicit account to be taken of their skills. It is not appropriate that they will do the same job as doctors. I am sure nurses would agree.

The pilots will be replacing general medical services with personal medical services. In doing so, pilots will need satisfactorily to cover those areas of care which need to be covered by doctors. Doctors' vocational training and the particular role that they play in providing services to those on a patient list emphasises the rather different and discrete role that they play. The point is that GPs have spent at least nine years learning about the breadth and depth of the art and science of medicine and diagnosis; which conditions they can treat themselves; and which require the expertise of hospital care or primary health care colleagues, including nurses, midwives and health visitors who themselves possess skills unique to their professions. Doctors do not have all the skills of nurses and neither can nurses stand wholly in the place of doctors.

Amendment No. 48 goes wider than the proposals for pilots or for permanent schemes and is making a separate point about midwives in general. Midwives play a central role in line with Changing Childbirth, as the noble Baroness, Lady Jay, said, and in many cases the midwife is the lead professional providing maternity care across hospital and community settings. Our consultations on primary care reiterated and endorsed many of the points put forward in Changing Childbirth. There was continuing demand for more appropriate use of the skills and experience of midwives and the importance of maternity care professionals working together in a complementary way to give the best care for women.

Midwives of course already have autonomy in the care of women in normal pregnancy and childbirth. I understand that the move towards a primary care-led NHS has led midwives to look at new ways of working. I understand that a very small number have been looking at ways that they might contract through NHS contracts with health authorities and fundholders. The proposed amendment would enable them to contract through NHS contracts.

This Bill would already allow midwives working with GPs or NHS trusts to be innovative. They might, for example, look at new ways of delivering maternity care in the community in partnership with a community trust

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or a GP. This would achieve the aims of midwives who wish to further the aims of Changing Childbirth. Moreover, it would enable them to place NHS contracts with other NHS bodies.

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