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Lord Hunt of Kings Heath: My Lords, first, perhaps I may pay tribute to my noble friend and to other noble Lords for their determined campaigns over the years in this area. As I have said before, this issue unites the whole House. I am not sure that the word "undermine" is appropriate in relation to the progress being made by health authorities. However, I am disappointed with the progress that has been made so far. That is why we are redoubling our efforts to monitor the situation and to make clear to the NHS that we are absolutely determined to ensure that the 95 per cent target is adhered to. Furthermore, I assure my noble friend that performance management throughout the next two to three years will ensure that that is done.

Baroness Strange: My Lords, is the Minister aware that, despite appearances, we on these Benches--and on the Bench in front--are not making a statement about the Question, although we should like so to do?

Lord Hunt of Kings Heath: My Lords, I am sure that those are words of wisdom which I shall take away.

Lord Naseby: My Lords, exactly how will the Minister ensure that his aspirations in this field will be successful when they have not been met on matters such as waiting lists and a further host of areas within the health service? Will they be achieved by exhortation or by money? How will he ensure that the 95 per cent target will be met by 2002?

Lord Hunt of Kings Heath: My Lords, I am disappointed that the noble Lord thinks that the Government have been unsuccessful. However, I believe that we are making considerable progress in the modernisation of the National Health Service. Thirty-seven new hospitals are on track. New services

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such as NHS Direct have been set up. In-patient waiting lists are now 87,000 lower than those we inherited and a third of a million more people are being treated as out-patients this year. These are significant steps along the way to modernisation. As regards achieving the 95 per cent target, we have in place strong and effective performance management arrangements. We have made it absolutely clear to regional chairs and directors of the NHS that we want this commitment to be brought to fruition.

Lord McColl of Dulwich: My Lords, have I understood the Minister correctly? The Government will have been in power for five years before they meet their target. However, when the noble Baroness the Lord Privy Seal was Minister of Health, she said on 5th August 1997 that,

    "Any health authority which tells me that it is unable to get rid of mixed sex accommodation within the next two years will have to have a very good reason".

Can the Minister explain the difference in the timetable?

Lord Hunt of Kings Heath: My Lords, the noble Lord's Government had 18 years in which to sort this matter out. The fact is that my noble friend did take a very active interest in ensuring that the health service removed mixed sex accommodation. I have already said that I am disappointed--as, I am sure, is my noble friend--that health authorities have not made the progress that we would have wanted. Because of that, we are redoubling our efforts to ensure that the 95 per cent target at end-2002 is achieved.

Lord Harris of Haringey: My Lords, I am sure that the House is grateful for my noble friend's reaffirmation of the target and assurances that progress is being made. Is it not the case that in many hospitals progress has already been made by the creation of single sex bays rather than single sex wards? While we all wish to see a situation where all wards rather than bays are single sex, can my noble friend confirm that the 95 per cent target has been set for wards rather than bays? That will clearly represent significant progress over what has already been achieved.

Lord Hunt of Kings Heath: My Lords, the target is set for accommodation. It is, of course, perfectly acceptable for segregation to be achieved in wards that accommodate both men and women through the use of single sex bays and individual rooms. I should make it clear that the definition of mixed sex accommodation is exactly the same as that used by the previous government in the Patient's Charter. My noble friend is right. New building techniques can ensure that, within a ward with separate bays, it is possible to provide strong segregation between those bays.

Lord Clement-Jones: My Lords, in view of the Government's performance in this area, and the events

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of the past two weeks, can the Minister confirm that the Government's pledges for the NHS are now being converted from commitments to mere aspirations?

Lord Hunt of Kings Heath: My Lords, this Government made a commitment to modernise the NHS. We are doing so. I repeat my reference to 37 hospitals, NHS Direct and new dental services. These are indications of the kind of health service that we wish to deliver and which we will deliver.

Lord Campbell of Croy: My Lords, can the noble Lord tell the House whether progress is being impeded by the chronic and continuing shortage of nursing staff? Could that be the reason for the problems in this area?

Lord Hunt of Kings Heath: My Lords, I invite all noble Lords to remain in their places for our debate on nursing staff that will begin in a few moments. Of course we are crucially dependent on nurses. However, our recruitment drive is proving to be successful and over 5,000 nurses are about to return to the NHS as a result of it. I believe that the appointment of nurse consultants and the decision of the Government not to stage pay awards but rather to pay nurses the awards recommended by the review body in full will ensure that we shall have the nurses we need to provide the services to which the noble Lord referred.

Electronic Communications Bill

Brought from the Commons; read a first time, and to be printed.

Nursing Education and Practice

3.6 p.m.

Baroness McFarlane of Llandaff rose to call attention to the state of nursing education and practice; and to move for Papers.

The noble Baroness said: My Lords, it is a privilege to be the opening speaker in the first debate of the day, knowing that it will be closely followed by a debate on the teaching profession. Thus in one day we shall deal with two of the professions that contribute so much to our society: nursing and teaching, and which help us to express the values that we hold about health and education.

Perhaps I may begin by saying that the debate in my name owes its inspiration to the noble Lord, Lord Morris of Castle Morris, who, well before the Summer Recess, was urging on some of us the need for a debate on nursing. When he was unable to table the debate in his own name, he delegated the responsibility to others. This debate is the result of our discussions. However, I am sure that we are all delighted to see the noble Lord, Lord Morris, in his place today to contribute to the debate. It is a tribute to the standing in which he places the nursing profession and the affection that he holds for it that he is here today. We

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look forward to his contribution with great expectation, knowing that his analysis will be even more incisive because of his personal experience.

I believe it right that we should congratulate the Government--as the Minister has already done himself--on their moves on recruitment of nurses and attracting nurses back into the profession. Those moves will go a long way to ameliorating some of the shortages. The profession is gratified by the pay award made last week, in particular that made to the clinical nurse specialists. However, as has already been said during Question Time, there are still a number of shortages; namely, an estimated shortage of 17,000 nurses which inevitably has an impact on the practice of nursing and nursing education.

We now look forward to the Government being able to deliver on their strategic aims, expressed in Working Together--Securing a Quality Workforce for the NHS; that is, we want to ensure that we have a quality workforce in the right numbers, with the right skills and diversities, organised in the right way, and to be able to demonstrate that we are improving the quality of working life for staff.

Nursing makes an extremely important contribution to the health service both by virtue of the nature of the care that nurses give and by virtue of the numbers of nurses. There is a growing body of international research that attests to the fact that the therapeutic contribution made by nurses is considerable. Effective nursing care reduces the period of hospital stay. It reduces the incidence of hospital infection. It reduces re-admission rates. So the contribution of nurses is extremely important as regards many aspects. As of July 1999 there were 332,200 whole time equivalent nursing, midwifery and health visiting staff employed in the NHS, three-quarters of whom were qualified.

Nursing practice takes place within the context of a rapidly changing health service. It is not surprising that the content and mode of nursing education needs to be repeatedly reviewed if it is to prepare practitioners for a modern health service. We are used to reports on nursing education emerging at intervals of roughly 10 years. There was Platt in the 1960s, Briggs in the 1970s, Judge in the 1980s, followed by Project 2000. We sometimes tend to forget the criticisms of previous systems of nursing education and wish to return to the past. It was recognised when Project 2000 was put forward that the training previously given tended to be procedure-based and hence rather rigid, though there were hospital schools of nursing with excellent educational programmes. But the nurse of the future needs to be able to practise in the context of rapid changes in medicine, the input of pharmaceutical advances, the changes in advanced technology, the increased use of information technology and a greater concentration of services in primary healthcare. In the modern health service nurses need to have a high degree of technical competence and scientific skills, but those need to be exercised alongside the caring and nurturing role traditionally associated with nursing. There is an

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increasing development of nurse-led services. We have already heard of NHS Direct. There is also a blurring of professional boundaries, with many medical tasks now being taken on by nurses.

Project 2000 courses were designed to offer a common foundation programme and hence provide for greater flexibility between the different branches of nursing and to prepare nurses who would be able to work in a variety of settings. They aimed to give an adequate knowledge base of biological and behavioural sciences for the practice of nursing. They were to be based in the higher education sector alongside other health professionals being educated there, where the knowledge taught would be research-based. The object was to produce a knowledgeable, adaptable practitioner who would work from an evidence base.

Project 2000 courses have now been running for approximately 10 years, so it is timely to review their progress. A number of reports have been issued in the past year, which help us to look at the present state of nursing and nursing education. Nurses are now educated in 89 universities in the UK. There are 47,000 nursing students and 5,000 nursing, midwifery and health visiting lecturers. Therefore, the higher education sector now has a considerable stake in nursing education.

While a great deal has been achieved by Project 2000 programmes, there are concerns about the clinical competence of some of the new graduates and diplomates. While 50 per cent of the course is spent in learning practical skills, the way in which practice placements are organised, their quality and the supervision of clinical practice, gives cause for concern. Because of the quick turnover of patients, there are relatively few acute care situations where students can consolidate practice skills and nurse a patient over any length of time. There is a shortage of trained staff on most hospital wards who can spare the time to supervise student nurses. Ideally, the university lecturer should teach in the clinical situation where she can integrate theory and practice. A number of different approaches to enable university lecturers to do this have been tried. Roles like honorary appointments, joint appointments between the health service and the higher education sector, clinical lectureships and clinical nurse specialists have been tried. There is now a suggestion that there should be clinical deans. A clinical academic career structure is desperately needed if nurses are adequately to integrate theory and practice. There is a need for partnership between the education consortia and the universities in facilitating teaching through a device such as SIFT--Service Increment For Teaching--that is awarded in medical education.

The academic content of the higher education programmes needs to be reviewed from time to time. Some schools of nursing may be more felicitously placed in universities where the necessary sciences are to be found and a nursing course can call on the whole expertise of the university in the true spirit of a university. However, there are signs in some courses of "academic drift". One can find a rationale for

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including almost any piece of theory in a course if one looks for it. But academic drift is not exclusive to nursing courses. I have sat in meetings of my own medical faculty at Manchester University and listened to discussions about academic drift in the medical curriculum. This is something that academic courses, particularly professional academic courses, have to watch carefully. They need to guard the content of their programmes. Universities need to produce a practitioner of nursing suited to work in the present NHS.

Perhaps I may declare my personal interest because until I retired 12 years ago I was professor of nursing at Manchester University. We pioneered a course there which included preparation not only for practice in acute settings but in primary care settings. The graduates came out with qualifications as a registered nurse, a district nurse and a health visitor. Yesterday I learnt that that course is now under question because it is a four-year course instead of a three-year course. Yet that course is producing people who are eminently suited to the modern NHS. At the moment, they come out with qualifications in acute nursing but also specialist qualifications in home nursing, public health nursing and/or community psychiatric nursing. These are people whom employers desperately need and value.

It is essential that the universities and the registering bodies look at the practitioner who is suited to the present work in the NHS. Equally, it is essential that NHS trusts resource the training of the future workforce. I particularly commend the recent report, Good Practice in the Recruitment and Retention of Nurses, published by the NHS Executive and the Committee of Vice-Chancellors and Principals.

I know that other speakers in the debate will refer to the widening of access to higher education which is taking place through university courses. I wish to refer to the fact that the Government have even more radical plans for the future of the professions in general and the nursing profession in particular. In their second report on the future healthcare workforce, the Government point to future multi-professional and inter-professional healthcare delivery. They envisage a healthcare practitioner role, which would embrace much of the current roles of junior doctors, nurses, therapy professions and radiographers. How will that affect the future education of the professions and their self-regulation, about which we have been given so many assurances? My noble friend Lady Emerton will refer to the whole question of regulation.

In the final minute of my speech, perhaps I may indulge in a personal note. This year I had the pleasure of attending the Lord Mayor's Show on the float of the League of St Bartholomew's Hospital Nurses and for the first time rode in an open horse carriage through the City of London. A tremendous cheer went up every time the nurses came into view. Then the president of the league, in stentorian tones as she was dressed as the matron of 100 years ago, proclaimed, "I am the matron of St Bartholomew's Hospital". With that, the crowd erupted. I believe

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that the public and nurses wish to see an identifiable leader of the nursing service. We need that desperately in the face of all that has happened as regards general management. My Lords, I beg to move for Papers.

3.22 p.m.

Baroness Lockwood: My Lords, I am grateful to the noble Baroness, Lady McFarlane, for opening this debate and in so doing drawing on her vast experience in the nursing profession. I should also like to join her in welcoming my noble friend Lord Morris of Castle Morris back to his place. I look forward to his speech, no doubt crafted from his hospital bed.

Today's debate is not about short-term crises. It is about a long-term policy and programme for education and training in the nursing profession. It is about creating the right terms and conditions under which nursing can flourish as a career profession. Most of us at some time in our lives have had experience of nurses, largely associated with hospitals, although today there is a much larger canvas on which nurses can work. I certainly have a perception of nurses as being very professional. Yet so far we have not produced the right framework for this profession to be sufficiently recognised and rewarded.

My interest in the debate stems from my Chancellorship of the University of Bradford. It has a very successful School of Health Studies which works in co-operation with all the local health service trusts. In a recent quality assessment review in teaching, I am delighted to say that the Bradford school received two "excellents", covering seven departments, including nursing and midwifery. We are proud of the contribution that we are making to improving the quality of university education in nursing.

Like most schools of health studies, Bradford provides both pre-registration diploma and degree courses and post-registration courses at diploma, degree and Masters level. Nationally, about 90 per cent of pre-registration courses are at diploma level and about 10 per cent at degree level. Unfortunately, the attrition rate for nursing and midwifery is about 30 per cent, which is much higher than the average drop-out of undergraduates in higher education. For Bradford, I am pleased to say that, at 24 per cent, it is below the national average. Even so, that is still too high.

The dilemma of universities is in balancing recruitment, with good A-level scores to boost their academic profile and provide greater research potential, against widening access. There is also the anomaly that students on diploma programmes get a non-means tested bursary whereas degree level students get a means tested bursary. For universities and students alike, this gives an advantage to the diploma courses.

Universities also complain that a limiting factor in increasing recruitment is the availability of suitable clinical placements, mentors and assessors. On the service side, hospitals and other National Health Service trusts also have a problem of attrition. They

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see one answer to that as local recruitment and the building up of local loyalties. Their need is a stable workforce, with a stream of newly qualified registered nurses being sufficiently experienced clinically to undertake the responsible tasks that nurses have to perform.

It was to deal with this type of problem and the possible conflict of interest that the Peach Commission was set up. Its report, Fitness for Practice, with its 33 recommendations, together with the earlier government publication, Making a Difference, provide the basis for current reform. I want to mention just four of the Peach recommendations which are crucial to future development.

First, it recommended a flexible approach to recruitment. In this, the commission recognised that recruitment will continue to be at different ages and from different backgrounds, with different levels of academic and vocational qualifications. Therefore, it placed an emphasis on access programmes, on prior experiential learning experience and modular studies, with flexible step on and step off courses. Secondly, it recommended that built into the flexible recruitment should be an expansion of graduate courses, because of the nature of clinical decisions that have to be made in complex situations, as the noble Baroness, Lady McFarlane, explained, and to compete with other graduate professions as the participation rate in higher education grows.

Thirdly, the commission recommended pre-registration courses, to be made up of 50 per cent theoretical and 50 per cent practical learning. Most of us would expect that in training, but it will provide a real challenge, especially to the NHS trusts. Fourthly, the commission recommended the provision of career progression in nursing, with appropriate professional training at all levels. The commission recognised that some higher education institutions and National Health Service trusts are already ahead of others in carrying out some of the recommendations. The Government have set up some 15 sites representing a third of the consortia NHS/university partnerships to pilot new models of nurse education on a more flexible modular system.

It is encouraging to see some of the things that are already happening. Here I have to rely on information from the Bradford National Health Service Hospital Trust, with which I have some association, regarding the strategies it is adopting in co-operation with the University of Bradford, Bradford College and other local education bodies, including schools and careers teachers.

The trust is seeking to enrol local school-leavers into healthcare at various levels, and is particularly targeting different ethnic groups who do not see the health professions--apart from that of doctor--as suitable careers. Therefore, close links with schools and the establishment of a cadet scheme for 18 to 20 year-olds form part of the trust's approach. There is also a scheme to support young ethnic unemployed in an attempt to encourage them into clinical support work with the community health trusts while studying

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for a B.Tech. The scheme is a finalist in the National Health Service Equality Awards 2000. Young people on both those courses would qualify for entry to a university diploma course.

Healthcare support workers already employed in the hospital trust who qualify academically are being seconded to nursing and midwifery courses at the university while retaining their basic salary and pension rights--a scheme funded by the West Yorkshire National Health Service/university consortia. I am sure that that is a great boon in retaining and improving the status of support workers.

For those who do not meet the university entry requirements, an access course with the college is available. At postgraduate level there are other initiatives. As part of career development, an advanced diploma and degree modular course has been developed by the university and the trust to comply with the flexible approach in Fitness for Practice.

The trust's framework document, Advancing Nursing Practice in Acute Care, was used by the university to develop new post-registration modules to align with trust strategy. Other new post-registration modules are being developed in cancer care, heart disease and co-rectal care which are commissioned by the regional consortia.

That kind of collaboration does not happen by chance. It has continually to be worked at by all concerned in the education and training of nurses. But it does provide a more optimistic outlook for future patient care, at the same time enriching and providing progression in the nursing profession. Fitness for Practice, combined with the better salary awards in this and last year's nursing pay awards, must surely make a contribution to raising the profile and attractiveness of nursing as a career.

3.34 p.m.

Baroness Cox: My Lords, it gives me great pleasure to take part in this debate introduced by the noble Baroness, Lady McFarlane. Although my own career has developed in strange ways, taking me far afield and away from an orthodox nursing career, I am and always will be a nurse first and foremost. It was my chosen profession until, while practising as a staff nurse, tuberculosis struck. After six months in hospital I had to move from clinical nursing into academic life.

As a nurse, I remember the delight with which the profession received the news that Professor McFarlane had become the Baroness McFarlane of Llandaff--a very well-deserved recognition of personal professional achievements. The comprehensive way in which the noble Baroness introduced the debate reflects the qualities and abilities which made her nursing's first Peer.

I shall focus primarily on nursing education because the quality of professional practice must, to a considerable extent, depend on the quality of professional education which prepares practitioners for their professional responsibilities. As part of an earlier incarnation, I was director of the nursing

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education research unit at London University. One of our major projects was concerned with student nurses' clinical learning; another with post-qualification education, or lack thereof, for the all-important role of ward sister or charge nurse.

We identified many issues and problems. Subsequently, bodies such as the English National Board for Nursing, Midwifery and Health Visiting, the Royal College of Nursing and the UKCC have worked valiantly to try to address some of those problems. Perhaps I may say how good it is that the noble Baroness, Lady Emerton, is present, having done so much for nursing through her work on the UKCC.

I turn first to recruitment. A good health service relies on its staff, especially perhaps its nursing staff, who are needed for round-the-clock care in diverse clinical settings. Despite measures taken in an attempt to improve recruitment, noble Lords will be well aware of the acute problems experienced by the NHS in recent weeks. Hospitals have been inundated with people suffering from 'flu. Some patients have had to lie in corridors; others have had to suffer the tragedy of deferred operations for malignant disease, with possibly life- threatening consequences, because of shortages of nursing staff, especially in areas such as intensive care.

The problems are reflected in the recruitment figures. In England, the number of entries to pre-registration programmes fell from 17,799 in 1987-88 to 15,650 in 1997-98 and in Northern Ireland, from 811 to 459. The number of newly qualified entrants to the UKCC register fell from 32,143 in 1993-94 to a mere 26,465 in 1997-98.

Once student nurses begin their professional education, other problems cause a significant number to leave before qualification. More leave when they encounter the stresses inherent in professional practice, including clinical responsibilities, for which many feel ill-prepared; anti-social shift hours; and relatively poor salary scales compared to other professions.

Nursing's professional organisations have tried to remedy these problems. Nursing education has been transformed in recent decades with the transition to higher education. Emphasis has been placed on academic education, encouraging students to think critically and to adapt to a world where the pace of change in knowledge and practice is perpetually challenging.

Perhaps I may refer to my own experience as a student nurse to illustrate the change in ethos in nurse education. At the end of my first ward placement I went nervously to discuss my ward report with "Sister"--a ward sister for whom I had profound respect. She was a superb clinician; she cared for patients and their families with great compassion and wisdom; and she was an excellent teacher and outstanding ward manager. I was profoundly relieved when she gave me a good report. However, as I was leaving her office, she called me back and gave me these parting warning words, "In your own interests, nurse, as you go through your training in this hospital,

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please do not ask so many awkward questions." I was a shy 18 year-old, unaware that I had asked any questions, let alone awkward ones. But such was the culture of nurse education at that time that students were meant to be passive learners and unthinking practitioners.

Now, with nursing located in higher education, students are encouraged to think. That is essential, as professional education is essentially teleological. It must be judged by its effectiveness in preparing practitioners for their professional responsibilities. And there have never been greater responsibilities and opportunities for nursing. Many exciting initiatives have led to changes in the provision of healthcare which are both care-effective and cost-effective. I give just three instances: nurse-led clinics in primary healthcare which relieve busy GP clinics for consultations on a wide range of problems; clinical nurse specialists who provide highly effective, comprehensive care for patients with chronic diseases, such as asthma and diabetes; and hospital-at-home schemes which provide, for example, care for very sick children to enable them to stay at home and often avoid distressing admission to hospital.

The enhanced role and responsibilities of nurses require appropriate education. Although the transfer to higher education provides the context for a higher level of academic education, which is obviously welcome, there are problems. In too many cases these include a lack of match between academic theory and clinical experience, inadequate supervision and support in the clinical area, inadequate systematic practice and assessment of core clinical competencies, and problems in finding appropriate clinical placements in fields of practice such as community care. The report of the UKCC's Education Commission, Fitness for Practice, published last September, cited evidence of inadequate clinical learning experiences, epitomised in the observation of a theatre sister that,

    "more clinical experience is required ... there appears to be an over-emphasis on the academic at the expense of clinical experience. A good nurse should be able to use her hands as well as her brain".

Part of the problem of inadequate clinical training stems from the shortage of qualified staff on the wards or other clinical areas. There are just not enough experienced nurses available to take time from caring for patients in order to teach, supervise and support students. Thus, students may fail to learn good practice and inadvertently provide inferior or bad patient care. In such situations, not only patients but students suffer stress and anxiety, sometimes to such an extent that they leave.

I shall never forget working on an acute medical ward with a student on her very first day. The staffing shortage was so severe that there were not enough nurses to provide that student with any support. She was given responsibility for some desperately ill patients, one in the terminal stages of a muscular degenerative disease and a cardiac patient who had already suffered four cardiac arrests that morning. While the student was trying to make the terminally ill

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man comfortable, the cardiac patient suffered another arrest. The resuscitation team rushed to the bedside to find that some of the equipment was not in place. The target of their wrath was the student nurse. By mid-morning she was in tears and ready to quit nursing for ever. I hope passionately that the initiatives now being taken to solve these problems, such as the UKCC's new competency approach to the pre-registration of students, will be implemented quickly for the sake of patients, students and the profession.

I turn briefly to the retention of qualified staff. The problems take the form of a vicious circle. Too few new nurses enter the profession and shortages cause stress among practitioners who are unable to provide the quality of care they wish to give patients or provide adequate support to students. That stress leads to plummeting job satisfaction and a tendency to look outside nursing to alternative employment opportunities, often in better paid jobs. Therefore, one has premature retirement, further shortages and heightened stress for those who remain.

While the recent salary increase is welcome, it is not a panacea. A percentage of a relatively low figure is still a small sum. Nursing salaries do not compare favourably with those of other professions. Working hours also compare unfavourably. Given the anti-social hours, disruption of family life, stressful working conditions and having to cope with life-and-death responsibilities, sometimes combined with the risk of physical assault, especially in areas such as accident and emergency or psychiatry, it is not surprising that nurses are tempted to leave for greener, more tranquil pastures. I urge the Minister to encourage the Government to do much more to address the problems of recruitment and retention.

I conclude by emphasising that all is not gloom and doom, thanks largely to the calibre of the people who take up nursing and remain committed to the profession. In spite of all the stresses and strains, nursing brings many privileges and satisfactions, above all, the privilege of caring for people when they are most vulnerable. In his book Moderated Love: A Theology of Professional Care, the philosopher Alastair Campbell describes the essence of nursing as "skilled companionship". As a nurse it is a great privilege to be able to accompany another person on part of his journey through life when he experiences a crisis that necessitates the kind of care which nursing can give--not just "doing to" but "being with" another person in his hour of need. This is the heart of nursing. Nursing is a calling and profession that can give a reward, not financial but personal, that is beyond price. But for this companionship to be rewarding it must, in Campbell's words, be "skilled". That requires good professional education, which was where I began and where I finish.

3.45 p.m.

Baroness Warwick of Undercliffe: My Lords, I join in thanking the noble Baroness, Lady McFarlane of Llandaff, for initiating this debate on nursing education. I also express my delight to see the noble

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Lord, Lord Morris. I wish him well. I declare an interest as Chief Executive of CVCP. Nurses are educated in 89 universities in the UK and it is to that specific aspect that I want to speak.

I am pleased that we have moved on from the debate in early 1999 about whether there was value in better nursing education to the recognition of much of the excellent education that takes place in universities in partnership with the National Health Service. Universities are responsible for the education of all health professionals in the UK; they are essential to the delivery of skilled NHS staff. Much progress has been made since the publication last July of the Government's nursing strategy Making a Difference.

I deal briefly with three points: the relationship between universities and the NHS, which has certainly been strengthened; more flexible career paths into nursing; and meeting the demand for high quality academic and practice-based nursing education. As to the strengthening of the links between the NHS and universities, in November 1999 the CVCP and NHS Executive held a joint conference to focus on improved working between the NHS and higher education. A partnership statement was issued which identified areas of mutual interest and responsibility, such as the recruitment and selection of students and the provision of high quality clinical placements and quality assurance. These shared principles ensure that health professionals are able to meet the country's present and future health and healthcare needs.

I should like to look at some of the ways in which nursing education responds to the problem of recruitment identified by the noble Baroness, Lady Cox. New models of nursing education are being developed which will allow more flexible career paths into nursing and ensure that equality of opportunity and diversity are actively addressed. These include: entrance through new vocational pathways; more part-time education; and more stepping-on and stepping-off points. In November 1999 the CVCP and NHS Executive published a joint report entitled Good Practice in the Recruitment and Retention of Nurses in Higher Education Institutions. Its purpose was to disseminate existing good practice and stimulate discussion on further improvement and innovation. Successful strategies featured in the report involve positive partnerships between NHS trusts and higher education where the partners consult on procedures and develop joint initiatives together.

The report highlights an active approach that balances the expansion of access with the recruitment of a high quality workforce. To give just four examples, Keele University has customised local access courses to prepare mature candidates who wish to enter nursing education. As my noble friend Lady Lockwood said, the University of Bradford is at the forefront in identifying barriers to the recruitment of local ethnic groups. The University of Northumbria also specialises in this area. The University of Central England has a postgraduate diploma in nursing which enables graduates in relevant disciplines to qualify as

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nurses in two years. Middlesex University's Centre for Nursing and Midwifery has arrangements for closer links with clinical practice.

The recruitment drive, from which all this has sprung, is already showing results. There has been a significant rise in the number of student nurses. In England, the vast majority of commissions for nursing education--approximately 90 per cent--are at diploma level and the remainder are for degrees. The rise in the number of both those categories of students has been considerable.

That reflects the key role of universities in attracting more students into the profession and working closely with partner NHS trusts at local level to achieve recruitment targets. Applications for nursing diploma courses rose by 18 per cent from 1998 to 1999 and for nursing degree courses the increase was even higher at 24 per cent. Although that may not address the existing problem, it augers well for the future.

I turn to the third of my areas of progress: the demand for high-quality academic and practice-based education. The government report, Making a Difference, rightly acknowledged that a stronger practical orientation to nurse education is needed and that students should be adequately prepared and supported prior to and during their placements.

Universities cannot achieve these objectives alone; they rely on the NHS to provide practice placements of suitable quality and length. I want to re-emphasise one of the problems raised by the noble Baroness, Lady McFarlane, about the present contracting arrangements between education consortia and HEIs. I refer to the fact that the responsibility for placements has been left largely to HEIs, so the growing recognition in the NHS that this is a shared responsibility is welcome. Every practitioner must share responsibility for the support and training of the next generation of nursing staff, as Making a Difference makes clear.

Universities have systems in place for collaboration with service partners to manage and provide support for students on clinical placements, to achieve a better integration of theory and practice. Perhaps I may give two examples of innovative practice. The first is new educator roles to guide and support students through their clinical placements, as seen at the University of Bournemouth and the University of Central England. The second is clinical practice at Middlesex University Centre for Nursing and Midwifery, which has facilitated closer links with the NHS trust under the motto "moving forward in partnership".

As others have said, nurse education has experienced major organisational changes during the past 10 years. It is now entirely within the higher education sector. As the noble Baroness, Lady McFarlane, said, the challenge for today's nurse educators is to prepare students to work effectively in a highly competitive, highly technical, extremely stressful and demanding environment.

In order to face this workplace, nurses require a far greater level of knowledge and intellectual understanding than ever before. They may even need

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degrees. I say that because for some it is difficult to accept that nursing might require degree-level education. I find such an attitude not only regrettable, but also rather patronising.

Finally, I turn to future developments. A sufficient supply of healthcare professionals who are educated to a high standard and are fit for the purpose is a vital aspect of the modernisation of the health service. The National Audit Office and the Audit Commission are undertaking a joint study on non-medical education and training in order to examine how the NHS addresses this challenge. We in higher education welcome this study because we believe that it will assist in the further development of our partnership with the NHS by offering an independent view on issues of organisation, funding and value for money.

Higher education provides the infrastructure and climate to support the development of those analytical skills and the evidence-based practice required to underpin quality nursing care needed to meet the needs of patients now and in the future. And, as has already been said, quality patient care is the objective that the university/NHS partnership aims to satisfy.

3.54 p.m.

Baroness Emerton: My Lords, I thank my noble friend Lady McFarlane for introducing this important debate. I endorse her remarks on the presence of the noble Lord, Lord Morris of Castle Morris; we are pleased to welcome him back to his seat.

I declare an interest. I cannot claim to aspire to the title of matron but, like the noble Baroness, Lady Cox, I am proud to claim the title of nurse. I have 47 years' experience working in the NHS and currently I am chairman of an NHS trust. I have a background in nursing practice, teaching and management as well as the work of the self-regulatory bodies.

As we debate this important issue of nursing education and practice, I should like to quote a definition of the unique function of the nurse which was written by the late Virginia Henderson in the 1950s. I have yet to receive a more recent definition which describes the functions so ably, but the quotation given by the noble Baroness, Lady Cox, certainly enhances what I am about to quote. It is:

    "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible".

The rapid changes in nursing practice in recent years have been due to the major developments in medical science and technology which have called for changes in nursing education programmes, both pre- and post- registration. However, developing and maintaining the art and science of nursing practice have to be based on the close correlation of theory to practice, whether it be in the delivery of fundamental aspects in nursing care required by patients or the care provided in critical care areas which demand advanced knowledge and skills.

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It is interesting to note that the Health Service Commissioner, in Chapter 2 of his report for 1998-99 published in August last year, made the comment:

    "What sort of nursing and midwifery complaints reach my office? I see many concerns about the traditional areas of nursing care, including prevention and treatment of pressure sores, hygiene and provision of food and fluids. Falls while in hospital and delay in receiving attention also feature regularly. In midwifery complaints, a frequent issue is the 'debriefing' of patients following labour: that is, giving a woman the opportunity to review her labour and birth and offering explanations to her of what happened".

We all hear anecdotal reports of delivery of care, more often than not erring towards the negative rather than the positive, but the Health Service Commissioner's report includes well-researched evidence which gives him cause for concern, as he described, in the "traditional areas of care"; what perhaps I would describe as fundamental nursing care. I am reminded of the inescapable human desire for food, shelter, clothing, love and approval; the fundamental human needs. Whether a patient requires continuing care or is in an intensive care unit requiring critical care of a highly technological nature, he or she still requires basic human needs to be met in the delivery of nursing care. That requires high quality practice.

For that to be achieved, we require high quality preparation through adequate and appropriate education programmes within a standards framework which produces competent practitioners able to provide the care needed, and therefore to deliver a high quality service, and those standards being subject to regular monitoring.

Within the past few weeks there have been many references within the House to the shortage of nurses and midwives both following the Statement on the NHS on 10th January and during the debate on maternity services on 12th January. The Government are leading an enormous effort to increase the number of nurses, midwives and health visitors which has been helped by the Government's acceptance of the recommendations of the pay review body. In addition, an enormous programme of work is under way to bring about changes, including legislative changes, to meet the recommendations of the review of the Nurses, Midwives and Health Visitors Act; the Government's strategy Making a Difference; the UKCC report Fitness for Practice; the Health Act 1999; and the Government's recent announcement to create in England a new education and training unit.

The modernisation of self-regulation as part of the Government's general programme of modernising the NHS is of great importance to the nursing, midwifery and health visiting professions. Effective self-regulation of the nursing profession is paramount to protecting the public who may become patients by virtue of having in place a standards framework for the education, practice and conduct of nurses. That regulatory framework ensures and enables nurses to practise confidently and competently at the point of registration. The users of health services can be reassured by the mechanisms that are in place that an

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individual has achieved the standards required to practise competently and can access mechanisms to verify that fact. In addition, it assures employers that registered nurses possess the knowledge and skills needed to provide the care that patients require.

Professional self-regulation of the nursing, midwifery and health visiting professions has served patients well through the Central Midwives Board (1902), the General Nursing Council (1919) and, since 1983, through the UKCC. The Health Act 1999 will be the vehicle that brings about changes to the current regulatory framework. The Act will facilitate the repeal of the existing Nurses, Midwives and Health Visitors Act 1997 and secure the introduction of an order designed to create a new United Kingdom regulatory body.

During the passage of the Health Bill assurances were given by the noble Baroness, Lady Hayman, to a continuing commitment to the maintenance of self-regulation and that adequate consultation would be undertaken at the drafting stage of the order. I hope that the Minister will be able to reaffirm those assurances.

I also ask the Minister to confirm that the new UK-wide regulatory body will retain the power to set standards and to ensure that their achievement will be retained. That will be essential in ensuring that the future practising professional is competent and capable of working in any countries of the United Kingdom. As I understand it, regulation is a reserve power retained by Westminster. However, it is recognised that implementation issues emerging from creating a UK-wide regulatory body must be considered within the context of devolution. What must be avoided is a fragmented approach to the regulation of nursing, midwifery and health visiting professions resulting in a practitioner having to seek additional verification to practise when moving from England to Wales or Wales to Scotland or from Scotland to England.

The Government's proposals to secure legislative changes by September 2001 present an ambitious timetable. My limited experience from being involved in the passage of the Nurses and Midwives Act 1979 and the 1992 Act remind me of the complexity of introducing legislative change which affects personally such a large number of people currently on the effective register and the future generations, as well as the professions corporately. There will be consequential organisational change and cultural change which will need expertise in the management of change.

I believe that consultation on the proposed order is of paramount importance. I ask the Minister to ensure that not only is there adequate time given to the consultation period, but also that mechanisms are put in place to ensure that 300,000 registered practitioners in the NHS across the United Kingdom and those practising as registered nurse practitioners in the independent and voluntary sectors can be consulted. There remains a certain level of anxiety in the profession. Through the means of an affirmative order

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nurses need to be reassured that the Government will take account of the comments received in consultation as there will not be any debate in either House. It cannot be over-emphasised that regulation is of the greatest importance to the public and employers and of particular importance to registered practitioners. It is important that they understand and agree with the new arrangements which will assure them that they can practise confidently and competently at the point of registration.

Finally, I make reference to the recent consultation document issued by the NHS Executive entitled Consultation on a Partners Council. That will support the Department of Health in strengthening and managing nursing, midwifery and health visiting education. The proposal is to extend the remit to promote multi-professional learning and working. The establishment of the new regulatory frameworks for the professions allied to medicine and the new regulatory framework for nursing, midwifery and health visiting, subject to legislation, together with the current passage of the Care Standards Bill promoting the national care standards commission, all point to the need for closer collaboration between the statutory bodies. The partners council would assist in working together in providing the "seamless service" so often referred to in the provision of healthcare.

However, as well as at national level, I urge the Minister to encourage greater involvement within the NHS of chairmen and chief executives of NHS trusts, primary care groups, primary care trusts and health authorities in the cultural changes necessary to bring about the changes in nursing and midwifery and health visiting education through closer involvement with the universities, as well as ensuring that within the framework of clinical governance programmes for their organisation account is taken of the requirement for lifelong learning to take place within the framework of self-regulation, which in turn will ensure that a high quality of care is delivered to patients in the primary care sector and in the hospitals.

4.5 p.m.

Lord Harrison: My Lords, I congratulate the noble Baroness, Lady McFarlane of Llandaff, on bringing forward this debate today. Like her, I welcome what this Government have done for health in general in the form of additional resources of £21 billion; for nurses in particular who were awarded a generous, above-inflation pay increase, and the recruitment over three years of 15,000 new nurses along with 1,000 doctors and a scheme to encourage 3,000 to 4,000 returnees to the profession. The document launched last July by the Prime Minister entitled Making a Difference is already making a difference by strengthening the nursing, midwifery and health visiting contribution to health and healthcare provision in Britain today.

I also celebrate the Government's readiness to think boldly about the aims and objectives of a modern health service. In particular I welcome the conviction of the Secretary of State, the right honourable Alan Milburn, that a modern NHS must increasingly respond to the patient in the form of consumer needs.

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It is bold because against a tide of rising expectations it would have been easier to take the route of capping such vaulting ambition.

I also rise to speak as a recent consumer of the NHS and of the care of the nursing profession found in community, GP and hospital nursing. I declare immediately my unshakeable faith in, and admiration for, the nursing profession. As with any job, the acid test is whether I would be prepared to do it myself. The answer is decidedly not. Our nurses daily face duties that we mere mortals would run a mile to avoid.

Having said that, my experience in hospital was of some chaos. No amount of tender loving care could quite repair the impression of disorganisation of the nursing care that I received in hospital. The unacceptably high turnover of staff led to contradictory practice and to my annoyance at being repeatedly asked "What is wrong with you?" In my case there also appeared to be a lack of understanding about the care of diabetics injecting insulin. The combination of a diabetic diet with the ubiquitous chips and sugary sweet puddings was nothing short of stomach-turning.

I learnt much else during my period of convalescence regarding the education and training of our nurses. First, there is concern that there is too strong an academic bias at the expense of hands-on experience in current training practice. Giving greater responsibilities to student nurses, even for specific patients, builds confidence as well as competence. The early opportunity for students to effect basic injections or dressings on medical and surgical wards is not encouraged as much as it might be. The emphasis remains on observing more than serving. As one senior nurse put it to me, such students become proficient at bed-making and not much else. That in turn becomes a lose-lose-lose situation, where the student is frustrated, the staff nurse overworked and the patient confused.

Of course, the academic and practical should go hand in hand. The justification for supernurses may be that technology is moving so fast that we urgently need skilled nurses who can absorb and use modern technology to the patient's benefit. But it is true also that many medical technological advances have made therapy easier, not more difficult, and are, therefore, available to a wider range of nursing staff. We should not mystify the mystique of medicine. Indeed, I am informed that some hospital trusts are shy of the highly-trained nurse whose avocation is directed towards the high dependency unit or the theatre but who lacks basic, practical hospital skills or the inclination to exercise them. Surely the trick in all this is the necessity of matching various levels of nursing skill against the needs of a modern health service--indeed, against the needs of the consumer. Diversity is key. In this regard, I am particularly pleased that the Government have set in motion a more flexible approach to nurse education and training.

However, let me redress the balance slightly by reporting on my experience of a nurse at the Countess of Chester Hospital, undertaking original research in

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leg ulcers while holding down a day job in the clinic. It was impressive to see the team spirit adopted by all those concerned in supporting her ground-breaking research, including the unstuffy consultant surgeon who willingly helped the nurse with her information technology needs. We should be proud of the developments that break down authoritarian, hierarchy-ridden prejudice, which stands in the way of creating new models of nursing and co-operative healthcare.

Let me animadvert to some other concerns. Trivial as it may seem, the delay in forwarding bursaries from the Blackpool-based grant authority, sometimes representing eight to 10 weeks' money to student nurses, is having a discouraging effect, especially on those from less-favoured backgrounds where training for nursing may mark a huge personal and financial commitment. I know that students who attend the excellent School of Nursing at University College, Chester have suffered in this way.

I should also like to bring to the attention of the Minister the enormous differential, perhaps of the order of 400 per cent, in the cost of training nurses in different parts of the country. In the north-west the average figure is £4,000; in London and the south-east £15,000 is nearer the mark. Not all of that discrepancy is explicable in terms of cost of living, research obligations or the incorporation of building costs in the comparative statistics. Will the Minister comment on that, and on the desirability of publishing comparative training cost figures?

Will the Minister also speculate on another aspect of the north/south divide? I am given to understand that the recruitment of locally-based, quality student nurses is buoyant in the north. In London and the south-east, recruitment is patchy. What is the Government's strategy in this regard?

I turn to my final comment relating to Britain and the European Union, where the Maastricht Treaty conferred an obligation on member states to share best practice in the field of public health. Should not such co-operation also be extended to sharing best practice in nurse training and practice? During my period of recuperation while still an MEP in Brussels and Strasbourg, I was surprised at the variety of nursing practices exhibited by the French, Belgian, German, Finnish and Italian nurses who looked after me so well. My strong recommendation is to always be ill in English

With the advent of the internal market--Europe's single market, not that of the health service--promoting the free movement of people and, therefore, the free movement of patients and nurses, should we not do more to encourage the sharing of best nursing practice, education and training, aiming for the higher standards of healthcare throughout Europe? For example, I understand that in the EU, as well as in the States, nurses habitually undertake tasks which we still restrict to junior doctors.

I remind your Lordships that the 48-hour working week for junior doctors emanates from Brussels and is to be thoroughly welcomed. The thousand new

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doctors and the conferring of flexibility on our nurses to perform additional and more complex tasks will be needed to make up the shortfall in staff hours resulting from the Government's ambition to eliminate the shame of the overworked junior doctors, who are sometimes too tired to think on their feet.

The Government's welcome and stated goal of matching European Union average funding in the health service also points to the future where there is much to be gained in liaising with our European Union friends and partners, and nowhere more so than in the area of nurse training, education and practice.

4.15 p.m.

Viscount Bridgeman: My Lords, I should like to add my thanks to the noble Baroness, Lady McFarlane, for initiating this debate and say what a particular pleasure it is to see the noble Lord, Lord Morris of Castle Morris, in his place again.

There is an increasing difficulty in the matter of nurse training in the interface between the private and voluntary sector and the National Health Service. Of course, the NHS is where virtually all pre-qualification and training take place. It is difficult to see how that will be changed substantially since the NHS is where the full range of types of nursing currently exists. In the past, many independent sector providers have been content to live with that position. After all, training is expensive.

However, the position is changing. Independent providers are becoming involved increasingly in post-registration training and return to nursing. There are now substantial areas of nursing--care of the elderly, mental health and learning difficulties, to name only three--where the independent sector is a significant majority provider. Indeed, in the case of care of the elderly it may soon be difficult for nurses to gain experience outside the independent sector. Nurse training must recognise the fact that 25 per cent of nurses now work in the independent sector. Training must address the needs of independent providers in terms of strategic workforce planning and specialties. I should like to see educational experience routinely involve independent providers, and that should, of course, become a two-way initiative.

I have the honour to be chairman of an independent charity hospital which embraces both a private acute hospital and a hospice. In the latter, we have contracts with several local health authorities and are uniquely well placed to see the interplay between the two sectors. It is gratifying that mutual dependence and awareness of mutual benefits is becoming progressively greater. Never again should there be occasion for the rather sardonic remark made to me--quite apart, I may say, from my own hospital--that the Department of Health must not be a department of the NHS; it must be a department for health for the whole nation.

I refer to two other small matters. One is the problem of the registry of healthcare assistants. Historically, there has been resistance to include non-professionals in the UKCC. As matters stand, the Care

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Standards Bill provides for the general social care council to embrace only care workers performing personal or social care functions and would appear to exclude healthcare assistants. Many healthcare assistants will routinely do a number of both health and social work jobs. The cross-over is particularly acute in nursing homes, homes for those with profound learning difficulties and mental homes, all of which, as it happens, are predominantly in the independent sector.

I understand from my noble friend Lord Howe that in the course of the Committee stage of the Care Standards Bill the Minister said that he was aware of that problem. We should like healthcare assistants to have the option of being able to register with either the UKCC or the general social care council. At the very least, registration with one body or another would inhibit the practice of healthcare assistants being rejected as unsuitable in one part of the country and being able to apply for a job, unmonitored, in another.

My final point reinforces a matter raised by the noble Baroness, Lady Emerton. Health and social care are devolved matters. There is a danger, particularly in the early stages of the new parliaments and assemblies, that occupational standards, educational syllabuses and so on will be drawn up independently of the other jurisdictions. That would be hugely inefficient, costly and counter-productive and may lead to the reinvention of the healthcare wheel. I hope that the Minister has that problem high on his list of priorities and is in touch with his opposite numbers in the devolved bodies.

4.21 p.m.

Lord Morris of Castle Morris: My Lords, I should like to make just five simple points about this subject. The quickest way for me to make my first point would be for me to undo my coat, lower my trousers, lift up my shirt and show your Lordships my tummy.

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