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Baroness Anelay of St Johns: My Lords, I am grateful to the Minister for making clear the Government's plans with regard to media ownership. I am also grateful for his explanation of what the Government mean by Xinform". I am relieved to hear that any such proposals will be part of the draft Bill. I appreciate that that puts an extra onus on the Government to get the drafting of the draft Bill completed in good time. Noble Lords will recall that at the various stages of the Bill we have been concerned about the timing of the draft Bill. The late consultation on media ownership and the Minister's response make it clear that we may wait even longer for the draft Bill than might otherwise have been the case. I give way to the Minister.

Lord McIntosh of Haringey: My Lords, the noble Baroness, Lady Anelay, should not draw that conclusion. As I said, the consultation period will end when the Bill is still in its early stages in the House of Commons. We shall need some time to analyse the results of the consultation, but that will be concurrent with the passage of the Bill through the House of Commons. Therefore, I do not believe that any time will be lost. I have a pocketful of euphemisms on timing ranging from Xvery shortly", to Xshortly", to Xin due course", but I do not think that I need to use them.

Baroness Anelay of St Johns: My Lords, I believe we sometimes feel that the term that should be used is Xeventually", but never mind. I am grateful to the Minister for that explanation. As I made clear, this is a probing amendment. I am grateful that my honourable friends in another place will have the opportunity further to consider Ofcom's structure with regard to media ownership issues. I beg leave to withdraw the amendment.

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Amendment, by leave, withdrawn.

Clause 7 [Short title, commencement and extent]:

[Amendment No. 4 not moved.]

An amendment (privilege) made.

Baroness Blackstone: My Lords, I beg to move that the Bill do now pass.

Moved, That the Bill do now pass.—(Baroness Blackstone.)

On Question, Bill passed, and sent to the Commons.

Nursing and Midwifery Order 2001

8.7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath) rose to move, That the draft order laid before the House on 15th November be approved [10th Report from the Joint Committee].

The noble Lord said: My Lords, this order will implement important reforms to the system of professional self-regulation for nurses, midwives and health visitors. The order will establish a new regulatory body, streamline the present arrangements and deal more effectively with the complex range of issues affecting these vital professions.

The order has been the subject of extensive consultation going back over some years and, I am glad to say, of broad agreement. We have responded positively to many of the points made during the consultation process. A number of significant changes have been made along the way. I confirm today my view that the provisions of the order are compatible with European convention rights.

Under the order, the Nursing and Midwifery Council will replace the UK Central Council for Nursing, Midwifery and Health Visiting and the four national boards. These proposals represent a key component of our wider efforts, working in partnership with the professions themselves, to drive up and sustain quality throughout the health service. The public and patients are entitled to expect that those treating them are properly regulated and that there is consistency across professional boundaries. We signalled our intention to modernise regulation in the NHS Plan in July 2001 and set three tests for the regulatory bodies. They must be smaller, with much greater patient and public representation. They must have faster and more transparent procedures. They must develop meaningful accountability to the public and the health service.

These orders fully reflect those commitments. But this is only a part of the reforms which are now under way. For example, we have strengthened the GMC's powers to deal with allegations against doctors; and we are working with the council on a wide-ranging programme of reform covering governance, revalidation, registration and conduct procedures. We have embarked on reforms to the regulation of dentists. In addition, the NHS Reform and Health

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Care Professions Bill that is being considered in the other place will further strengthen and improve professional self regulation.

The proposals meet the tests set by the NHS Plan. They will provide for a streamlined structure of council, statutory committees and panels, allowing far wider lay participation and expert input from the professions; a flexible, enabling framework with much greater scope for the council to design efficient procedures; a wider definition of unfitness to practise and more powers to deal effectively with it; and a duty to work in partnership with key interests—for example, employers, education providers, the professions and other regulators.

I referred to the need for and the benefits of consensus. The proposals have been endorsed by the professional bodies most closely concerned—the Royal College of Nursing, the Royal College of Midwifery, the Community Practitioners and Health Visitors Association, and Unison. I suppose that I ought to declare an interest in Unison. Those organisations' concern—and surely that of your Lordships—is that the law should be translated into effective action.

The professions concerned are the backbone of the health service—635,000 nurses, midwives and health visitors—and delivering on our aspirations for the NHS depends critically on supporting those key staff and encouraging an active partnership between them and those they serve.

The new council's principal purpose is set out in Article 3. It will, for the first time, be required explicitly to treat the health and well being of patients as its prime objective. The council will have a duty to collaborate with and to consult all those with an interest in its work—the professions, patients and clients, employers, education providers and other regulatory bodies. The council will have to be open and proactive in informing the public and the professions about its work.

The new council's core function, at Article 5, will be to keep a register of qualified professionals. It will establish and monitor compliance with standards of education and training, conduct and performance. The measure will not seek to define those standards—nor should it, since that is properly a matter for the council. In that respect, the order continues the tradition of 150 years of professional regulation. It is designed to modernise that tradition by providing a flexible and enabling framework within which the council can respond rapidly and effectively to changes in the provision of services, education and practice, and in public expectations.

The council will no longer need to seek rule changes through Parliament before it can change its operational procedures, as the UKCC must do now. That will give it the tools to do the job properly. That freedom is rightly balanced by areas that must be subject to approval by the Privy Council that are key to the performance of the core regulatory functions. They are the parts of the register and the protected titles for each part.

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In addition, the Privy Council will approve the fees that the council proposes to charge registrants; its election scheme for registrant members; and its forward business plan. The Privy Council will also appoint lay members and receive the council's annual report and accounts to present to Parliament. Both councils will have wider powers to deal with individuals who present unacceptable risks to patients. They are set out in Articles 22 to 33. The councils will have powers to deal with registrants whose fitness to practise is impaired through ill health, lack of competence or misconduct. At present, the UKCC labours under a wholly opaque definition of misconduct, as

    Xconduct unworthy of a nurse".

The council will also have a wide range of powers and sanctions to apply to registrants who are found unfit to practise. They will include cautions; conditional registration while retraining is undertaken or health is regained; suspensions; and striking off the register in extreme cases where the practitioner needs to be removed from treating the public.

The council will also have a critical role in positively guiding and supporting the vast majority of practitioners whose fitness to practise is never in doubt. The council will be much leaner and more strategic than the current bodies. Its initial composition will be 23 strong, with an elected professional majority of one. There will be guaranteed membership from each of the professions regulated. The Nursing and Midwifery Council will also have statutory committees—including one specifically to advise on midwifery issues, to recognise the unique regulatory function of midwifery supervision. The council's structure allows for an equal number of nurse, midwife and health visitor members.

The council may establish any other committees and panels that it needs, so it will have extensive opportunities to co-opt non-members to advise on professional matters or national policy, or to undertake detailed casework within the strategic framework that it sets. The council will report to Parliament through the Privy Council, which will approve any statutory rules the council makes.

We have taken on board most of the concerns raised by those who responded to an earlier draft but I want to address the issue of health visitors, as there has been great concern about the order among some members of that profession. The Government consider health visiting an extremely important profession, on which the NHS and the public depend. Health visitors have a hugely important public health role. Many people know them best for the help they give to families with new babies and their support through children's early years.

Health visitors also work with the most vulnerable people in our society. Health visitors work with individuals and families, to help them to change their diet; to stop smoking or abusing drink and drugs; and to encourage healthier lifestyles. They work in communities to build support for those with no family

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and friends. That way, health visitors promote physical and mental well being, and help to keep people living in their own homes.

With the developments in primary care that will be introduced over the next few years, health visitors will be at the forefront of joint working with partners in social care. I make it clear that the order will regulate health visitors. The words Xhealth visitors" do not appear in the order because we do not want to tie the new regulatory body to only the health visiting function as it is now. We recognise that health visiting is expanding into other areas of community and public health practice. We want to give the new council the flexibility to reflect that changing role.

The order is the culmination of many years' hard work and discussion. I pay tribute to the representatives of nurses, midwives and health visitors who have made such an important contribution to the preparation of the order. There have been compromises along the way. Not everyone is happy with everything contained in the order's 101 pages but there is broad agreement that the measure represents a sensible outcome that will enhance the professions, provide faster and more transparent procedures, enable greater patient representation and, above all, uphold and strengthen public interest in professional self-regulation. I hope that the House will support the order. I beg to move.

Moved, That the draft order laid before the House on 15th November be approved [10th Report from the Joint Committee].—(Lord Hunt of Kings Heath.)

8.18 p.m.

Lord Clement-Jones rose to move, as an amendment to the above Motion, at end to insert Xbut that Her Majesty's Government should also lay an amended order containing a provision for a compulsory register of specialists in community and public health, including health visitors".

The noble Lord said: My Lords, I thank the Minister for his customary clarity. I declare a family interest in the order, in that my sister is a health visitor—which gives me some insight into the value of the work of health visitors and the deficiencies in the order.

The Health Act 1999 represented agreement that changes to professional regulations would be effected by the affirmative order procedure, not primary legislation—and there were assurances that there would be full consultation. I recognise that there will be a number of competing professional interests and that a government are not always in control of the intra-professional communication that is needed. However, there is an overriding need to ensure adequate consultation and that reforms are not steamrollered over a profession in a minority. That applies both to this order and to the Health Professions Order, which is the subject of our next debate. Examining the Nursing and Midwifery Order convinces me that health visitors are not being treated properly or fairly. No compulsory register will be set

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up specifically for them, as at present, and there is no reference to the words Xhealth visitor" in the title of the order, as there was in the 1979 Act. In fact, there is not a single mention of health visitors in the order.

Let us look at the situation from the point of view of health visitors. They happily believed that their representative organisation was busily negotiating away on a new regulatory structure. Then they heard that in order to fulfil a Xmodernisation agenda" for the creation of a wider group of specialist community practitioners, they would need to give up their right to separate registration. In fact, they were told that they will have to subsume themselves within that wider group and, under Article 6, that there will not even be a compulsory register for the new wider group, only one that may be set up by the Privy Council on the proposal of the new council—the NMC. Their membership may be only temporary to that body and, even then, they will be in a small minority. That is hardly satisfactory.

The only groups with a compulsory register will be the nurses and midwives. How would that make me feel as a health visitor—a member of a profession that has been in existence since 1860 and separately in statute since 1919? I would feel that I had been badly represented and I would be justifiably angry with the Government for creating anxiety and uncertainty among my professional group.

I do not place all of the blame on ministerial shoulders. The representative body concerned, which purports to represent some 16,000 or so public health specialist nurses, district nurses, community nurses, school nurses and health visitors appears to date to have failed to obtain adequate assurances from Ministers and to have caused a great deal of unhappiness among its members by failing adequately to debate these matters.

The Minster and his colleagues have on previous occasions and in correspondence said that everything will turn out all right. They say that whatever the arithmetic of the new council—health visitors will initially represent four out of 23 council members—community nurses, including health visitors, will in due course be granted their own register.

But what evidence is there that that will happen or that health visitors will not simply be treated as specialist nurses without their own register? Both the RCN and RCM are hostile to there being a third register. They say that health visitors are a group within nursing and are not a separate profession. Indeed, the RCN said that separate regulation is Xconfusing" for the public and other specialist interests in nursing. The proposal may never actually come about. It is for that reason that, without wishing to negate the order, we on these Benches want to amend it.

We seek cast-iron assurances from the Minister in various areas. First, we want the register for specialist community and public health practitioners to be definitely set up under the terms of the order, and we want it to include health visitors as a specific registering group or class of registrants. Secondly, we

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want name protection to be given to health visitors as part of that compulsory register. Thirdly, we do not want the order to dilute the pre-registration standards of qualification that are expected of health visitors. Moreover, if review work that is now in progress recommends that longer training is required, we want there to be mechanisms under the order to allow for that.

We on these Benches support much of what the professions and the Government are trying to do in terms of giving greater status and qualification to specialists in community and public health. However, that must not be done at the expense of damaging the morale of health visitors or their professional standing and qualification. That would be highly counter-productive. Research papers have clearly demonstrated that there are difficulties yet to be overcome before the specialist community practitioner role can be properly dealt with. As part of the regulatory reforms, I want a strong and viable public health visiting profession. The Victoria Climbie case has already demonstrated that the role of the health visitor in the community should not be minimised. They assess the factors involved with placing children at risk. I hope that the Minister can give the necessary assurances. I beg to move.

Moved, as an amendment to the above Motion, at end insert, Xbut that Her Majesty's Government should also lay an amended order containing a provision for a compulsory register of specialists in community and public health, including health visitors".—(Lord Clement-Jones.)

8.25 p.m.

Baroness Noakes: My Lords, I thank the Minister for introducing the order so comprehensively and the noble Lord, Lord Clement-Jones, for the clarity with which he moved the amendment. This is a complex area of professional self-regulation. I pay tribute to all those in the professions who have worked hard with the Department of Health to bring forward the proposals.

I am aware that these proposals are supported by the Royal College of Nursing, the Royal College of Midwives, and the Community Practitioners and Health Visitors Association. Those organisations have provided me and, I am sure, other noble Lords with some helpful briefing. Noble Lords should welcome much in the order, which improves the regulatory framework within which those professions work. However, there are aspects of the order that cause concern, as the noble Lord, Lord Clement-Jones, made clear.

The Nursing and Midwifery Council, which will be created by the order, is the successor body to the UKCC. We should remember that the UKCC, while usually known by the initials of the first four words of its name, was in fact the UK Central Council for Nursing, Midwifery and Health Visiting. The new body, however, takes within its title only the professions of nursing and midwifery, not that of health visiting.

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Noble Lords may well ask: what is in a name? Names matter because they send powerful signals to the outside world. As the noble Lord, Lord Clement-Jones, said, health visiting has existed as a profession in statute for more than 80 years. The disappearance of the name from the title of the regulatory body could mislead the public as to the status of health visitors. More importantly, it could lead health visitors to believe that they are not a profession. That is important because the belief in, and practice of, specific professional standards is crucial to the delivery of high-quality care, the maintenance of standards and recruitment.

As the noble Lord said, just as serious as the omission of the name from the title is the omission of any mention of health visiting anywhere in the order or the Explanatory Notes. Conspiracy theorists would have had a field day. Health visitors have been amazed at the Government's fierce determination to refuse to mention health visitors. I was glad that the Minister took the opportunity today to place on record the Government's support for the profession of health visitors and their value in society.

The noble Lord, Lord Clement-Jones, explained that while the Community Practitioners and Health Visitors Association has supported the order, that is only part of the story. As he said, there is a strong body of opinion among health visitors that they have been sold down the river by the CPHVA. While the CPHVA claims that it has around 80 per cent support from its membership, it has never asked its members whether they are content with the terms of the order. The question that gets 80 per cent support is whether health visitors should remain part of the family of nursing. Health visitors have not been asked about the order, which contains no entrenched protections for the profession of health visiting.

A small group of health visitors, including a recent former chairman of the CPHVA, became disturbed at the development of the draft order and the absence of specific reference to the health visiting profession. They enlisted the support of a number of branches of the CPHVA and called for a special meeting of the association to discuss the matter. The council of the CPHVA refused that elementary democratic process. This group of health visitors, who have styled themselves the Grassroots Network, have contacted a number of individuals who are involved in the affairs of the association's branches. It does not claim that those people form a statistical sample. However, the overwhelming view of those to whom they spoke wanted to see Xhealth visiting" in the title of the NMC. That is perhaps not surprising. But 80 per cent of the members expressed concern about inadequate regulatory safeguards in the order which they believed would adversely affect health visitor training and education.

The amendment put forward by the noble Lord, Lord Clement-Jones, refers to the compulsory establishment of a separate register for community and public health nurses. That is not the desire of the Grassroots Network, whose primary aim is to protect

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and enhance the role of health visiting. At present there is no recognisable profession of community and public health nursing, and it is not self-evident that such a register will provide the necessary protection for the health-visiting profession. But, on the basis that half a loaf is better than none, I am confident that if there were a requirement for a separate register for community and public health nurses the democratic processes of the CPHVA could be harnessed for the benefit of the health-visiting profession in that context.

Health visitors form a small part of the professions of nursing. As the noble Lord, Lord Clement-Jones, said, they fear that their larger cousins in the Royal College of Nursing and the Royal College of Midwives do not regard health visiting as an identifiable profession. While health visitors will initially have four out of the 23 council places, there is a fear that, once the NMC arrangements are in place, the other bodies will gang up on the health visitors, remove the separate register, resist the creation of a separate community and public health register, and thereby remove specific representation of health visiting on the council.

I do not believe that that is a flight of fancy. The general secretary of the Royal College of Nursing said in a letter to me that the name of the NMC—that is, excluding reference to health visitors—

    Xreflects the view of the majority of RCN members that it is appropriate that the regulatory body refer only to the professions, rather than groups within the professions, that are regulated".

The RCN thus believes that health visiting is a group within nursing and not a profession.

Of course, if this were to come to pass, a majority of the council would have to be persuaded to remove the recognition of health visitors, and the Privy Council would also need to be involved. But I have been involved in professional bodies for a good part of my working life and I know how easy it can be to marginalise minorities. These are very real fears.

I want to raise a number of important questions relating to health visitors in addition to those put by the noble Lord, Lord Clement-Jones, to which I believe answers should be given. Is it the Government's intention that a part of the register will be maintained for health visitors, both transitionally and for the future? Do the Government believe that the health visitors' part of the register should not be closed without the consent of the council members who are health visitors? Do the Government believe that the health visitors' part of the register should not be closed unless a majority of health visitors themselves agree to closure? Do the Government believe that council representation for health visitors should not be removed; for example, if a majority of the council voted to close that part of the register but did not set up a separate community and public health register? And do the Government agree that the NMC must facilitate the protection and development of the professional knowledge of health visiting; for example, by updating its training rules?

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If the answer to any of those questions is anything other than an unequivocal Xyes", health visitors everywhere will fear for their profession. And noble Lords would rightly conclude that the amendment proposed by the noble Lord, Lord Clement-Jones, is an essential adjunct to the order before us today.

8.34 p.m.

Lord Hoyle: My Lords, in rising to speak on this matter, I declare an interest. I am an ex-president of MSF, which is the permanent body to which the CPHVA is affiliated. I also want to say that I speak for the vast majority in the profession. I speak for many thousands of people. I must also put into context the health visitors' Grassroots Network, which I believe has written to all of us about this matter. Having said that I speak for the vast majority of its members, I should add that they number 150.

There has been talk about consultation, and several figures have been quoted this evening. It was said that 81 or 94 per cent of health visitors wanted Xhealth visiting" in the title. But only 88 per cent of the people were consulted, which means that the survey was based on only 81 people. Against that, the CPHVA consulted all its members. It held a ballot and 81 per cent of those who replied were in favour of the order as it stands. Since then, independent surveys have shown that 5,000 people have been balloted—

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