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Baroness Jay of Paddington: My Lords, I support the noble Baroness in this group of amendments, to which my name is also attached. As she explained so fully, the Bill as it stands offers unnecessary restrictions which run counter to what we have understood to be the more widespread approach to

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general practice and primary care in which the Bill seeks to engage and which we have generally supported from these Benches. As the noble Baroness said, it unnecessarily limits the potential for innovation.

In her reply in Committee (at col. 1415 of Hansard), the Minister said that some of these amendments seemed to suggest that the intention was to turn nurses into doctors. As the noble Baroness, Lady McFarlane, explained, that is clearly not the intention. She gave the House some vivid examples of the ways in which nurses already take a primary role in primary care. I shall mention just one example that is very well known to me, of a senior nurse running a local minor injuries unit who recently became a very successful chief executive of an acute trust. She would find very odd any suggestion that she was incapable of being the lead proposer or organiser of the type of pilot scheme that is proposed in the Bill.

As the noble Baroness said, the White Paper referred to the equally important role of nurses, although at Committee stage the Minister seemed to feel that that could be well achieved within the meaning of the Bill as it now stands. She seemed to develop the argument to which the noble Baroness, Lady McFarlane, referred that the sifting system of the health authority would enable good schemes by nurses possibly to be included in those forwarded to the Secretary of State.

The point was very well made. If we are to encourage the equal role of the nurse, midwife, health visitor or other professionals mentioned in the noble Baroness's amendments, some positive national lead needs to be given of the type that would be created were the amendments to be accepted. As the noble Baroness, Lady McFarlane, said, the Minister has a very well-deserved reputation for supporting and improving the role of nurses within the profession and within community care. She could do a good deal to enhance that reputation if she were to accept these amendments. I support them.

Baroness Masham of Ilton: My Lords, I wonder what doctors and the Royal College of General Practitioners think about these amendments. Could it mean that the doctors would opt out of some of their responsibilities?

As matters stand, understanding and training in relation to many disabilities and the attitude of many doctors to disabled patients should be improved. Doctors might try to pass that sort of work in relation to disability on to the nurses, as that would save them time. However, the nurse has different responsibilities and training. The doctors have longer training and should be better at dealing with some of the very complex matters. I should be very interested to know the doctors' opinion on these amendments.

Baroness Cumberlege: My Lords, I am grateful to the noble Baroness, Lady McFarlane, first, for giving me notice of a number of the amendments tabled, and

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also for her very generous and fulsome remarks. I am also grateful for the remarks of the noble Baroness, Lady Jay.

Any proposals put forward by the noble Baroness, Lady McFarlane, have to be taken with the deepest seriousness. She is one of the country's most distinguished nurses. I believe that she was the first nurse ever to get a chair in nursing at a university.

I have no doubt whatever that nurses are often the very best people to provide primary care services for particular groups of patients. As the noble Baronesses, Lady McFarlane and Lady Jay, said, there are some excellent examples of innovative primary care services which are not only provided by nurses but were inspired by them. I, too, have seen many of them. I can think of specific schemes to help homeless people where nurse practitioners have been providing the service without a GP being involved; those people particularly did not want to see a doctor, but they would accept a nurse. Many other examples given this afternoon are pertinent and inspiring.

Indeed, many other initiatives are happening now. They all fall within Part I of the National Health Service Act 1977, which is the subject of one of the amendments. So there is nothing now to prevent nurses from putting forward proposals like this to their local health authority. Arrangements for the provision of services under Part I are very flexible. There is no need for this Bill to enable such ideas to be taken forward.

The pilots that we propose relate to services currently delivered under Part II of the Act; namely, general medical and dental services. These are the concerns of the Bill. Up to now, the provision of services has been very tightly regulated. That is why we need primary legislation to allow for new opportunities.

The pilots we propose will cover the delivery of general medical and dental services. Those services will need doctors or dentists. Only suitably experienced doctors can legally provide the medical services received in general practice. That point is reiterated in the Bill.

I continue to think it right that where a proposal is put forward not involving doctors, dentists or NHS trusts, the health authority should be able to consider whether it satisfactorily covers those areas of care that have to be provided by doctors or dentists before it is submitted to the Secretary of State. Where a GP is not involved in the proposal, it will need to be clearly set out how GP input will be provided. That seems to me to be an essential screen at local level.

That does not prevent nurses putting forward proposals. Indeed, I hope they will continue to do so. However, I must also emphasise that I certainly look forward to seeing nurses continue to develop their unique roles through pilots with practices and trusts and to seeing them taking forward the proposals that we set out in Primary Care: Delivering the Future.

I wish to make two further points about the amendment. First, in most cases the proposals will be put forward by nurses employed by a trust. Unless

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those proposing a scheme wish to leave their current employment, it seems right that their proposals should have the support of their employer, who will have to hold the contract with the health authority should the proposal be accepted as a pilot. They are in a very different situation from that of general practitioners and dentists, who are independent contractors.

If a pilot receives such support it will have a direct route to the Secretary of State under the terms of the Bill, because it will be sponsored by the trust that employs the nurses. Secondly, if the nurses are part of an independent organisation then in line with other similar proposals it seems right that the health authority should decide whether or not it should proceed.

I have been through a number of examples given to me by the nursing profession. I have yet to find one that stands up in terms of those other two aspects. I share the aspirations of noble Lords. I wish to see nursing develop and become an even greater profession than it is. However, I really do not think that in the context of the Bill these amendments are pertinent.

To respond to the point made by the noble Baroness, Lady Masham, I cannot tell her what the Royal College of Practitioners thinks about these particular amendments. However, I assure her that the medical profession very strongly supports the Bill and the concepts behind it. I do not believe that there is any intention that doctors should opt out of their current responsibilities.

I hope that the noble Baroness will not press the amendment.

Baroness MacFarlane of Llandaff: My Lords, let me first thank the noble Baroness for her kindness to me personally in what she said. When there is such mutual respect it is all the harder to disagree. I know that her motives are of the highest and that she shows the greatest support for nurses. Nonetheless I believe that the Bill is discriminatory in the way it is drafted and that we should clear that discrimination from the face of the Bill.

At Committee stage there was considerable support from all sides of the House, including from many medical Lords. That encourages me to go forward with these amendments. In the intervening period between Committee and this stage I have sounded out views on the amendments with all the nurses whom I have met. With the exception of one, their view was unanimous that the amendments are necessary if nursing is to play its full role.

Because of the support at Committee stage and the importance of the amendments to the nursing profession, I feel that I should test the opinion of the House.

4.1 p.m.

On Question, Whether the said amendment (No. 1) shall be agreed to?

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Their Lordships divided: Contents, 99; Not-Contents, 130.

Division No. 1

CONTENTS

Acton, L.
Addington, L.
Archer of Sandwell, L.
Ashley of Stoke, L.
Berkeley, L.
Blease, L.
Borrie, L.
Bruce of Donington, L.
Butterfield, L.
Callaghan of Cardiff, L.
Calverley, L.
Carlisle, E.
Carmichael of Kelvingrove, L.
Carter, L.
Chapple, L.
Clancarty, E.
Cledwyn of Penrhos, L.
Clinton-Davis, L.
Cocks of Hartcliffe, L.
Craigavon, V.
Dahrendorf, L.
David, B.
Donoughue, L.
Dormand of Easington, L.
Dubs, L.
Eatwell, L.
Exmouth, V.
Ezra, L.
Falkland, V.
Gallacher, L.
Geraint, L.
Gould of Potternewton, B. [Teller.]
Graham of Edmonton, L. [Teller.]
Grenfell, L.
Halsbury, E.
Hanworth, V.
Harris of Greenwich, L.
Haskel, L.
Hayman, B.
Hayter, L.
Hilton of Eggardon, B.
Hollis of Heigham, B.
Hughes, L.
Hylton-Foster, B.
Ilchester, E.
Jay of Paddington, B.
Jeger, B.
Jenkins of Hillhead, L.
Jenkins of Putney, L.
Judd, L.
Kennet, L.
Kilpatrick of Kincraig, L.
Kirkhill, L.
Lester of Herne Hill, L.
Lockwood, B.
McFarlane of Llandaff, B.
McNair, L.
McNally, L.
Mar and Kellie, E.
Mason of Barnsley, L.
Merlyn-Rees, L.
Methuen, L.
Monkswell, L.
Morris of Castle Morris, L.
Murray of Epping Forest, L.
Nelson, E.
Nicol, B.
Ogmore, L.
Palmer, L.
Paul, L.
Peston, L.
Plant of Highfield, L.
Prys-Davies, L.
Ramsay of Cartvale, B.
Rea, L.
Richard, L.
Robson of Kiddington, B.
Sainsbury, L.
Sandwich, E.
Serota, B.
Stoddart of Swindon, L.
Strabolgi, L.
Symons of Vernham Dean, B.
Tenby, V.
Tope, L.
Tordoff, L.
Turner of Camden, B.
Wallace of Coslany, L.
Walton of Detchant, L.
Warnock, B.
Weatherill, L.
Wharton, B.
White, B.
Wigoder, L.
Williams of Crosby, B.
Williams of Elvel, L.
Williams of Mostyn, L.
Winchilsea and Nottingham, E.
Winston, L.

NOT-CONTENTS

Aberdare, L.
Addison, V.
Ailsa, M.
Alexander of Tunis, E.
Anelay of St. Johns, B.
Astor of Hever, L.
Balfour, E.
Barber of Tewkesbury, L.
Belhaven and Stenton, L.
Beloff, L.
Birdwood, L.
Blake, L.
Blaker, L.
Blatch, B.
Blyth, L.
Brabazon of Tara, L.
Brentford, V.
Bridgeman, V.
Brookes, L.
Byford, B.
Cadman, L.
Campbell of Alloway, L.
Campbell of Croy, L.
Carnarvon, E.
Carnegy of Lour, B.
Carnock, L.
Carr of Hadley, L.
Chesham, L. [Teller.]
Coleraine, L.
Coleridge, L.
Courtown, E.
Cranbourne, V. (Lord Privy Seal)
Cumberlege, B.
Davidson, V.
Dean of Harptree, L.
Denbigh, E.
Denham, L.
Denton of Wakefield, B.
Dixon-Smith, L.
Downshire, M.
Dundee, E.
Eccles, V.
Elibank, L.
Ellenborough, L.
Elles, B.
Elliott of Morpeth, L.
Erne, E.
Ferrers, E.
Flather, B.
Fraser of Carmyllie, L.
Gainford, L.
Goschen, V.
Hacking, L.
Hailsham of Saint Marylebone, L.
Harding of Petherton, L.
Harmsworth, L.
Hayhoe, L.
Hemphill, L.
Henley, L.
Holderness, L.
HolmPatrick, L.
Hooper, B.
Howe, E.
Inglewood, L.
Jenkin of Roding, L.
Johnston of Rockport, L.
Kimball, L.
King of Wartnaby, L.
Knollys, V.
Lauderdale, E.
Lindsay, E.
Long, V.
Lucas, L.
Lucas of Chilworth, L.
Lyell, L.
McColl of Dulwich, L.
McConnell, L.
Mackay of Ardbrecknish, L.
Mackay of Clashfern, L. [Lord Chancellor.] Mackay of Drumadoon, L.
Macleod of Borve, B.
Marlesford, L.
Merrivale, L.
Mersey, V.
Miller of Hendon, B.
Milverton, L.
Montgomery of Alamein, V.
Mottistone, L.
Mountevans, L.
Mowbray and Stourton, L.
Munster, E.
Murton of Lindisfarne, L.
Newall, L.
Norfolk, D.
Northesk, E.
O'Cathain, B.
Oxfuird, V.
Palumbo, L.
Park of Monmouth, B.
Pearson of Rannoch, L.
Pender, L.
Pilkington of Oxenford, L.
Platt of Writtle, B.
Plummer of St. Marylebone, L.
Quinton, L.
Rankeillour, L.
Reay, L.
Renton, L.
Richardson, L.
Romney, E.
Rotherwick, L.
Saatchi, L.
St. Davids, V.
Saint Levan, L.
Seccombe, B.
Shaw of Northstead, L.
Skelmersdale, L.
Strange, B.
Strathclyde, L. [Teller.]
Strathcona and Mount Royal, L.
Sudeley, L.
Swansea, L.
Swinfen, L.
Terrington, L.
Teviot, L.
Thomas of Gwydir, L.
Vivian, L.
Wilcox, B.
Wise, L.
Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

23 Jan 1997 : Column 811

4.10 p.m.

Lord Rea moved Amendment No. 2:


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