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Baroness Emerton: In the absence of my noble friend Lady Finlay, I rise to speak on her and my own behalf on Amendment No. 46, which relates to the inclusion on the board of a clinician, a nurse and professions allied to medicine.

I am very aware of the comments made during the first day of Committee and, indeed, this morning about minimum requirements and maximum flexibility. That raises considerable concerns in certain directions. Flexibility is good in many instances, but I believe that there are many examples where flexibility can be detrimental and have a negative effect. I want to give an illustration of that which concerns nursing but it also has a medical aspect as well.

In January 2002, the Department of Health published a report entitled, Shifting the Balance of Power: The Next Steps. It sought to put patients and staff at the centre of the NHS by giving greater authority and decision-making powers to patients and front-line staff. The report recognised that the commitment and engagement of nurses were essential to the delivery of the NHS Plan in improving health and healthcare.

A visible senior nurse with the credible strategic experience and skills required of a modern leader would provide that experience at every level of the NHS to ensure that the contribution of front-line nurses was optimised and a high quality of service delivered. It was envisaged that the strategic health authority would have a senior lead nurse in the team linking to the chief nursing officer at the Department of Health. That was in line with the statement of the World Health Organisation's ministerial conference of 2000, which endorsed nursing and midwifery contributions to decision-making at all levels of policy development and implementation. Therefore, it followed that nurses would be essential in ensuring that strategic health authorities performed their functions successfully.

However, where it has been left to the discretion of individual strategic health authorities to determine whether or not to establish an executive nurse director, my noble friend Lady Finlay has met with a mixed response. To begin with, very few nurses have been appointed to strategic health authorities. I believe that that illustrates the difficulty of flexibility when it is left, in this case, to the foundation hospital to decide whether it is necessary to include a nurse. The same applies to clinicians.

I remind the Committee that 80 per cent of patient care is delivered by nurses. They play a very important part within the healthcare team, both in facilitating patient recovery and, in so doing, in improving the efficiency of the service by reducing the length of stay and subsequent bed-blocking.

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The professional development of nursing has led rapidly to an increase in specialist nurses in departments which carry out various procedures. However, alongside the delivery of specialist treatments, the basic care of patients still needs to be met. That includes nutrition, fluid balance, hygiene and comfort. When one considers that the average length of stay in hospital is increased by 11 days due to hospital-acquired infections, it can be seen that nurses play an important part in the policies and procedures that cover the control of infections. Because of their close inter-reaction with patients and families, as well as with the local community, nurses are highly skilled in interpreting people's needs and expectations of care.

For many years, the United Kingdom has been the envy of many other countries in that an executive nurse has been included in the management team at government level—the chief nursing officer—and every level of management. It seems incredible that an executive nurse could not be included in the list of directors, as well as a doctor and a representative of the professions allied to medicine. As the noble Lord, Lord Clement-Jones, said, clinical governance plays a very important role, and we are talking about a health service.

I hope that the Minister will be able to take on board the amendment. The Royal College of Nursing, which has 360,000 members, is committed to the NHS and its founding principles, and is a major contributor to the development of nursing practice and standards, thoroughly supports the amendment. I ask the Minister to give it his consideration.

Baroness Cumberlege: I too support the amendment. As the noble Baroness, Lady Emerton, has said, the phrase that has echoed through this Committee stage is "minimum requirements and maximum flexibility". I understand why the Minister and the Department of Health want to keep it that way.

In some ways I feel that the Bill is being presented to us like an impressionist painting: we are being invited to admire it at a distance and, without peering too closely, agree its power and beauty. That is not good enough. In Committee we have to examine the techniques; we have to look at the brush strokes; we have to see the composition; and we need to know the detail. The NHS is not an art form; it is very practical. It employs practical people who do practical things. They give injections; they administer drugs; they peer inside people; they cut them open and sew them up again, hopefully successfully. The care that they take in doing those things is enormous and they always seek to do things better. As the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Emerton, have said, they embrace clinical governance in a way that would surprise some of us. The leaders in clinical governance at all levels are doctors, nurses and practitioners in the health service.

Recently my brother was a medical director of a first wave trust. I visited him and we talked a lot. I admired the way in which he worked with his colleagues. Not only was he a consultant radiologist, but he was also a manager. The way in which he called his colleagues to

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account was courageous and very necessary. My point is that he could say things that managers could not say because he knew the business inside out as well as knowing his patients inside out.

As the noble Baroness, Lady Emerton, has said, 80 per cent of the care is given by nurses. They are in an equally good, or perhaps strong, position. Increasingly nurses are on the ascendancy, which is terrific. Their knowledge of the organisation is often wider than that of surgeons and physicians because they tend to move around the hospital and do not always stick to the same specialties. As the noble Baroness has said, they take on matters such as infection control which embrace the whole organisation. They have a different view of how a hospital is working, and allied health professionals are equally important.

The Government were very prescriptive in the arrangements that they drew up for primary care trusts, saying that there had to be a GP and a community nurse on primary care trust boards—that was very clearly defined—and on professional executive committees. So the Government went down to the detail of saying who was to sit on a committee of the board of a primary care trust.

I hope that the Minister will consider some of the arguments that have been made by Members of the Committee today and not be shy in acceding to what I believe is a very reasonable request. This may hurt, but we know that the public believe professionals more than they believe politicians. With the proposals that are put forward for governance in the Bill, we are likely to have party-political appointees serving on boards of directors in a way that will be disruptive. One way to try to mitigate that would be to put on the boards the health professionals who understand the business.

Baroness Noakes: It is a pleasure to welcome the noble Baroness, Lady Emerton, to the Committee. She has considerable experience of the NHS and of nursing and was a chairman of an NHS trust for a considerable period of time. If the Minister will not listen to these Benches perhaps he will listen to her words of wisdom.

Our Amendment No. 47 is in this group. It is similar to the other two amendments, but less prescriptive. It does not require a director of nursing, as Amendment No. 45 does, nor does it require representatives of the three clinical groups, as does Amendment No. 46. It requires that one of the executive directors should be,

    "a person practising as a clinician in the corporation".

That person could be a doctor, a nurse or a member of one of the allied health professions.

I believe that it is right not to be over-prescriptive about the composition of the executive component of the boards. The boards should comprise a blend of skills and experience and they will want to ensure that the best executive talent within the organisation is able to sit on the boards without having too many restrictive titles. That is certainly the experience of the private sector and I believe that it has also been the experience of NHS trusts since they were first set up.

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Like the Minister, I value flexibility, but I cannot comprehend a circumstance in which a foundation trust would have no practising clinician on the board, which is why our amendment talks about one such member. Often a board will have two, but we have plumped for a minimum of one. Perhaps I can explain this to the Minister. In days gone by I had to argue the case, quite forcefully, for the finance director to be an essential NHS trust board member. I am exceptionally glad to see that that has survived today. The reason was that 13 years ago not all chief executives valued the role of finance. I would not accuse any current chief executive of not valuing the role of clinicians, but I do not believe that that should be left to chance. It should be clear in the legislation that there are roles for clinicians at the top table, which is why we have tabled our amendment.

4.15 p.m.

Lord Turnberg: I too support these amendments. I express an interest as a clinician who worked in the NHS for many years. We have heard much about morale in the health service. "Morale has never been lower" is a constant refrain. I suspect that the major reason why morale is often low is that clinicians feel that they are not heard; they are not part of the system; they are ignored; and they are not involved in the way in which the service is provided. They are at the end, at the cutting edge, and deliver the care, but they have the sense that they have no control or influence.

It is important to try to improve the morale of clinicians. We need to improve the morale of our staff, but that alone will not be enough because there is an enormous amount of expertise, knowledge and ability among the clinical staff—the nurses, doctors and other healthcare workers. They are in day-to-day contact with the patients so they must have some idea of what the patients want and need. Of course, they should not be in the majority; they should not have the final say—many people should have a say—but they cannot be excluded. However, nurses, doctors and other healthcare workers should be there, so I strongly support the amendment.

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