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As a result, if the employee approaches a trade union representative who is not also a colleague, any disclosures made in the context of that conversation will be protected. The right to disclose your pay is of limited use, however, if you do not also have the right to ask colleagues about theirs, so the amendments also make clear that a secrecy clause which purports to prevent an employee simply asking a colleague about their own pay also cannot have effect. In particular, if a trade union representative who was in the same employment could not ask colleagues if they were willing to tell him or her what they were paid, in order to look into the question, the task would likely be fruitless. This amendment makes it clear that he or she can do so.

The amendments also make clear that making or seeking to disclose information about pay, receiving such information and seeking the disclosure of such information from a colleague are all protected acts for the purposes of the prohibition on victimisation in Clause 27, so that if action is taken against the employee for doing any of those things, they have a remedy through that clause. The protection extended by these amendments is not all-encompassing. It is not intended, for example, to protect disclosures to competitors aimed at obtaining a better offer. The important effect of the clause is to focus the protection on disclosure of information about pay aimed at uncovering any pay discrimination to help expose pay inequality affecting individuals.

We have taken seriously the concerns that have been expressed about this clause, and I hope that the Committee will agree that the wording of the clause, as amended, better expresses our intent, so I ask the noble Lord to not move his amendment, and agree to ours. I beg to move.

The Deputy Speaker (Viscount Ullswater): I advise the Committee that if this amendment is agreed to I will not be able to call Amendment 81 because of pre-emption.

Lord Lester of Herne Hill: I am grateful to the Minister, who has given me a lot to think about. My amendments are probably too broad in that they would have allowed disclosure about pay to anyone, including hated journalists. I can see why that might be objectionable.

Can the Minister clarify whether a trade union representative would include a trade union official officer representative of another union? Let us take the speech therapists' case-speech therapists are in one union, hospital pharmacists are in another and clinical psychologists are in another, and there are big arguments about the absence of equal pay. Would the government amendments allow the information on the discussion of the pay of each of the three groups to be fully disclosed to the trade union representatives of each of those three unions, all within the National Health Service and all dealing with the same cluster of pay issues? Or is it contemplated to be confined only to your own trade union representative, in which case Pam Enderby could talk only to the MSF trade union representative and not to the representative of the other unions?

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7.30 pm

Baroness Thornton: Yes, it would include representatives of the other unions as the noble Lord has described. The aim is to uncover pay discrimination in order to expose pay inequality affecting individuals, so the trades unions of those related occupations would be covered as well. That is my understanding.

Lord Lester of Herne Hill: This is my fault; I have not focused on this. Are there words that say that in the amendment?

Baroness Thornton: We think the amendment covers those, but I will check.

Baroness Turner of Camden: I thank the noble Baroness for this amendment and for what has been said in support of it by my noble friend, because, of course, disclosure is a very important point if you are dealing with differences in pay. We all know that there is a lot of concern about the differences in male and female pay, and we cannot move forward on that unless we have complete disclosure and the protection of people who participate in such a disclosure. The amendments proposed by my noble friend cover that, and I am very grateful for them.

Baroness Morris of Bolton: When this clause about discussion with colleagues was discussed in another place, we put on record our absolute support for it and I reaffirm that support from these Benches. We believe it to be absolutely right that employees should be protected from employers who would seek to impose any sort of pay secrecy clause; this should not be condoned in any way as it could be a method of trying to cover up pay inequalities in the workplace. The Bill allows discussion to take place between an employee and a colleague, or a person who used to be a colleague.

The amendments tabled by the noble Lord, Lord Lester of Herne Hill, would widen this still further to include any person at all. This would certainly increase transparency, particularly in circumstances in which, for example, an employee was too nervous to talk to someone at their place of work. Nevertheless, there could also be concern that it perhaps widens provisions too far, as the noble Lord, Lord Lester, graciously acknowledged. For instance, would that mean that an employee could discuss pay information with a competitor of their company or an outside group with a vested interest in using this information improperly? We want to ensure that companies are called to account for any gender inequality in their pay programmes. Nevertheless, it would not be desirable for companies to be damaged as an unintended consequence of legislation that is designed to ensure so much good.

Baroness Butler-Sloss: I am having slight difficulty in understanding Clause 77, because the word "colleague", to me, would assume somebody working alongside, or at least in the same employment. I do not understand how that could include a trade union official who is not, or has not been, a colleague. Can the Minister explain that? She said a while ago that this would perhaps include somebody who was a trade union official working in an allied industry, but not necessarily

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as a colleague working in the same industry. I am not sure that "colleague" would take you as far as the Minister seemed to say the Government were expecting to go.

Baroness Howe of Idlicote: I support these amendments. It may be that the noble Lord, Lord Lester, has not yet quite clarified whether he can go as far as he originally thought, but reading the Bill as it was and the amendments as they have been tabled, there is certainly a need to expand the number of colleagues and non-colleagues-relevant people that you can have discussions with. I very much support that side of it, although I must say that it would be nice to know, perhaps on Report, when the noble Lord, Lord Lester, has had a further look at his original thoughts, whether he can come back with an even wider choice.

Lord Lester of Herne Hill: I thank both noble Lords for what they have just said. My proposal goes too wide, there is no doubt about that, but I am worried about the point raised by the noble and learned Baroness, Lady Butler-Sloss. The word "colleague" does not seem to me apt to include a trade union official from another union, albeit a union concerned with bargaining for the terms and conditions of that area. Since I think it is common ground that the Government intend to cover that, I wonder whether it would be appropriate to bring this back on Report, thinking about the word "colleague" and what might go in its place to deal with trade union officials and other interested persons.

Baroness Thornton: Our amendment removes "colleague" except in relation to a request to another colleague to discuss pay. I refer noble Lords to Amendment 81B:

"Page 49, line 34, leave out from 'A' to 'whether' in line 36 and insert 'disclosure is a relevant pay disclosure if made for the purpose of enabling the person who makes it, or the person to whom it is made, to find out'".

We think this covers the issue of "colleague" and also the issue of different trade unions and trade union representatives.

Lord Lester of Herne Hill: What is the limit on that? If that is right, what is not covered by that?

Lord Mackay of Clashfern: I think the only restriction is that it has to be a relevant pay disclosure. In other words, it is with a view to applying the equal pay provisions. I think that there is a lot to be said, at first sight, anyway, for the Government's interpretation of this, that it is not restrictive except in so far as it is directed towards trying to deal with an issue of equal pay.

Baroness Thornton: The noble and learned Lord is absolutely correct.

Lord Lester of Herne Hill: I am satisfied with that.

Amendment 80B agreed.

House resumed. Committee to begin again not before 8.37 pm.

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NHS: Staff Qualifications

Question for Short Debate

7.37 pm

Tabled By Baroness Gardner of Parkes

Lord Faulkner of Worcester: My Lords, due to an oversight, time limits for speeches in tonight's debate were not publicised as part of the speakers list. If Members' contributions, including that of the noble Baroness, Lady Gardner of Parkes, are kept to 10 minutes, and that of the Minister to 12 minutes, the debate will conclude within its one-hour time limit. I apologise to the noble Baroness.

Baroness Gardner of Parkes: My Lords, it is opportune that we are able to debate this topic today, as the nursing registration body-the Nursing and Midwifery Council since 2002-goes out to public consultation on 29 January to determine the new draft standards for pre-registration nursing education. For this reason, I intend to speak mainly about nursing, as I think it is those changes that presently propose the greatest risk to the NHS. This consultation will be on the NMC website and the link is I hope that many people will respond as I believe it would be against the interests of patients and the NHS if nursing became a degree-only qualification and was therefore closed as an option for many ordinary men and women from 2013. Nursing is one of the oldest professions in the world and nurses are held in very high regard by both patients and public. This confidence must be maintained and justified.

The Council of Deans of Health, with 86 member universities throughout the UK, has as its number one aim,

It is not surprising that its policy statement on key areas of interest includes:

"The future shape of the healthcare practice workforce, engaging with and influencing healthcare workforce planning issues and processes, engaging with and influencing the Modernising Careers agendas, seeking to generate agreed postgraduate career frameworks and secure funding for post-registration education pathways to support the career frameworks and influencing discussion on the development of the assistant practitioner workforce".

The famous expression, "They would say that, wouldn't they?", seems appropriate.

Many of the best nurses are not academic. They have other qualities and skills and have had good training and great experience in hospitals. The report issued in June 2009 by the noble Lord, Lord Darzi, states that 180,000 nurses will retire in the next 10 years, 100,000 are over 50 and 80,000 are over 55. I am concerned that this country is becoming obsessed with the idea that everyone must have a degree. When the state enrolled nurse-SEN-was abolished in 1989, I thought that it was bad for patients. I still do, and my view is shared by many. I feel it particularly when I

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meet young people who would have made excellent, caring nurses, but could not obtain the required entry qualifications.

There were other practical problems too. At that time I was chairman of a large NHS trust in London, a teaching hospital. We had a nice and certainly convenient nurses' home where trainees lived during their student years. Under the student system introduced in the 1990s, we had to provide accommodation for each student for only one year. The trust, under financial pressures and demands for change from the local council, decided that the nurses' home would be sold off. Nurses found it difficult to obtain suitable accommodation within reach of the hospital, and that is still the case today.

It is understandable that deans of health want everyone to have a degree-that is their job. It is a great ambition but it lacks realism. Not everyone is up to getting a degree, and many of the excellent nurses who prove daily that they do not need a degree might never have been able to get a diploma, much less a degree. Caring about people and caring for people are the things that really matter.

I am a great supporter of higher and better training and opportunities for those who have the ability to achieve a degree and get postgraduate training. Nurse practitioners have been a success and led services in primary and acute care all over the country since 2000. Specialist nurses have made a huge difference to patients and they save much time for consultants by dealing with all the day-to-day problems that patients have. I think that we need more specialist nurses in ever more fields.

My concern is the black hole in healthcare that will be left when the needed number of degree nurses is not realised. The drop-out rates in degree courses are high. Fifty-one per cent of students fail to complete the degree programme in adult nursing in one university in the north-west. In the south-west, West Midlands, Yorkshire and Humber, one-third of students are dropping out. Nursing Standard magazine shows that 78 per cent of students on a children's nursing degree course and more than 54 per cent on a mental health nursing course failed to graduate. Such high drop-out rates are very worrying and costly. Universities are facing financial cuts and drop-outs on these scales surely cannot be acceptable. There is a need to look into the causes and find out how to prevent these losses to a profession that will sorely need these graduates.

Who will fill the black hole that I expect in NHS staffing? At present, those who cannot qualify as diploma nurses can become healthcare assistants who deal with many of the patient's day-to-day needs. The noble Lord, Lord Crisp, who has great experience in the health service, told me last week that all the HCAs he has encountered would like to have the title "nurse". He is currently abroad, so I got his permission to quote him. I have some sympathy with that wish, as anyone referred to as nurse has a standing in the community and a reason to be proud. That means a lot to someone who is looking after patients and caring for them, as HCAs do.

Could nurses not move up a stage in their terminology to become specialist nurses or nurse practitioners? There must be a new title-perhaps graduate nurse-that

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we can give to all degree nurses. I qualified long ago as a dentist. With just my original degree study, I became a dental surgeon. Later the term doctor-dentist was introduced, and now all dentists seem to use the honorary title doctor. Are dentists any better?

On a different note, today I received a letter from the father of a young man who wants to become a clinical psychologist. He has a hearing disability caused by an operation that went wrong when he was an undergraduate. He went back to university and obtained a masters degree, but to pursue a career in psychology he needs work experience, and he considers that the NHS has failed to honour its disability equality duties by not giving him the opportunity to get that work experience. He is of the opinion that his access to joining the NHS is an example of failure in entry level requirements. I want to place that on record for him.

According to the Royal College of Nursing, the trade union for nurses, 1.4 million people work in the NHS in England: about 700,000 are clinical staff, including 133,000 doctors; 408,000 are qualified nurses, midwives and health visiting staff; 22,000 are practice nurses; and 355,000 are clinical support workers, including healthcare assistants. The Nursing and Midwifery Council keeps no record of how many SENs-as opposed to SRNs who qualified before the days of diplomas-continue to work as NHS nurses. The last non-diploma registration was in 1991, and everyone has to be an SRN now. I am not concerned about the catchphrases about degree nurses "too posh to wash" or "too clever to care". My interest is in ensuring that the NHS has the number of well trained and caring nurses that it needs to continue to provide a proper service to patients. Nurses are the backbone of the health service.

The NHS has a different problem in the working time directive, and doctors, nurses, staff and patients will be affected. I hope that something can be done about this. That is not my remit today, and my speaking time is nearly over. The many of us who care about the NHS want to see it improve and continue to serve our people well. I have raised this Question today because I am convinced that the time to think about the impact of a degree-only nurse requirement is now, before 2013. The full implications may not yet be appreciated but they must at the very least be considered carefully.

It would be most unfortunate if the NHS found itself without enough nurses in the next few years. There are many points to think about. First, it is estimated that the applicants who are offered nursing training opt three to one for degree rather than diploma courses. That is understandable, as everyone would prefer the higher status. Secondly, why is there the high drop-out rate? Have students taken on more than they can manage? Thirdly, where do they go if they want to continue nursing but have dropped out for whatever reason? They could possibly become healthcare assistants, but surely they would still prefer to become nurses, even if not graduate nurses. Fourthly, how easy will it be for nurses to move up within the profession after they graduate? How will they be encouraged to become nurse practitioners or specialist nurses? Fifthly, how will the need for more nursing staff be met after 2013? Sixthly, is there a need to develop a registration process

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for HCAs, or do we risk over-regulating all health professions, as we have already done in some other professions?

I end as I began, by reminding everyone to respond, whatever their views, to the consultation on the NMC website from 29 January.

7.47 pm

Baroness Finlay of Llandaff: My Lords, I am grateful to the noble Baroness for having raised this important topic in such a timely way. I declare an interest as a practising clinician and as president of the Chartered Society of Physiotherapy, which is a graduate profession. I remind the House that to enter physiotherapy the A-level requirements are as high as for medicine.

In Wales, we already have an all-graduate nursing profession, but I saw the transition, and there are lessons to be learnt. I am fortunate enough to work now with some of the best nurses I have ever worked with. One in particular, Viv Cooper, started as an auxiliary, trained, did a degree and a higher degree. She is now one of the most senior nurses in Wales. When she left school, she was not ready to enter at degree level. It is important to remember that people mature at different rates and need to be able to move up later on.

The briefing of the Council of Deans of Health stated that the key message is that to provide high-quality care, we need a high-quality workforce. Of course we do. Nobody could dispute that statement, but I was alarmed when I read the briefing because it states:

"Nurses who are required to meet future healthcare challenges must be analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, change agents and the critical consumers of research"

It does not say compassionate or risk-intelligent.

There is a problem in a lot of education. Students are being educated to be risk-averse, not to be risk-intelligent. They are now not taking risks on behalf of patients-risks which should be taken-and in the process, the patients are being denied the opportunity, the care, and the decision-making that they ought to have. So I found this briefing somewhat alarming. I was glad to see that it stresses the importance of continuing professional education. Whether it is to diploma level or to graduate level, education is no good unless there is ongoing reflective practice, and ongoing education and training in the workplace.

There is an enormous range of things to be done under the name of nursing; certainly there are some very high-tech, complex procedures that need very highly-trained staff. To be an ITU nurse or a cardiac nurse, for example, you need a very high level of competencies. I worry that the nurses coming out through the graduate entry route may not be adequately trained to do some of the other tasks in nursing; they feel quite intellectually dissatisfied with some of what you might call the more mundane, but emotionally much more challenging situations, such as in psychogeriatric care, where you need an infinite amount of patience, an infinite amount of compassion, and an infinite amount of risk-intelligence. It was for that reason that I was particularly concerned that the briefing did not contain those words. When you listen to complaints from patients, lack of compassion comes high on the list. Sadly, complaints against nurses

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have gone up by 44 per cent in the past 10 years, and the NMC figures show that allegations have increased dramatically.

There are so many complaints that it is now taking nearly two years to get them resolved. Recent examples, which are on the website and are freely available, included the instance of a midwife handing a newborn to its mother, not realising that the baby was stillborn. It seems unbelievable that somebody could be practising as a professional, and have that lack of basic common sense, let alone competence.

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