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There have been cases of abuse by both graduate nurses and non-graduate nurses against patients. We have to be very careful not to assume that just having a degree will necessarily improve everything. Claire Rayner, president of the Patients Association, commented that she felt that for each complaint there were another hundred where people did not actually dare to complain because they were too frightened or they did not know how to. In response to this announcement, the Patients Association press release stated:

"The basics of nursing care are dignity, compassion, and above all, safety ... Since the introduction of Project 2000, which shifted training from the bedside to the classroom, nurses look to the personal prizes of nurse specialisms, and have been allowed to ignore the needs of their sick, vulnerable and often elderly patients. These new proposals risk making the situation worse."

It is to do with the way that the degree-level education and Nursing 2000 have gone, not the degree per se. If you educate people out of the classroom, rather than integrating bedside experience and good examples, then you will not train people to high levels of practice. People need a role model when they are learning. We have discovered when training medical students that the most powerful factor of all is a good role model. That is the person on whom they model their clinical practice for the future. They are all graduates, obviously, but they copy, we hope, good behaviours, although sadly sometimes of course they also copy bad behaviours. If they are being taught by people who are in the classroom, and are not up to date, then they really do not have that role model to build upon.

I wonder whether we should be thinking about a pre-registration year, such as the one we have in medicine. Nurses will be out there and working, but will have to prove their competence and their skills in the workplace just as junior doctors do, and then become registered. It would go with an additional pre-registration year, which entails practical experience. In her recent report Patients not Numbers, People not Statistics, Katherine Murphy, director of the Patients Association said:

"It showed what happens when nurses focus on the wrong things and neglect fundamentals, such as helping patients with feeding, bathing and toileting, or assisting those recovering from an operation to get back, quite literally, on their feet ... Patients and their families contacted us in their hundreds. They were angry that their final memories were of a loved one enduring appalling neglect-they were right to be."

I have had an e-mail from a Member of this House whose cousin was last weekend in hospital, and is still in hospital. He contacted me in desperation, worried about his cousin's situation, whom I will call P, for Patient, to anonymise this, and whose daughter I will refer to as D. The e-mail said:

"D was there today when the Ward Manager decided to move P to another bay".

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All sick patients were to be together, because this poor lady had contracted diarrhoea and vomiting. He went on:

"P's relatives were gloved and aproned. The staff were not. P is not allowed a bedpan, but has to wear a nappy and pass water and defecate into the nappy. A so-called matron and an auxiliary came to clean her up, and threw all the dirty linen on the floor. They took her hearing aid out, and put it on the left locker, where she cannot reach it. She is not good today, and rather tearful. I am not surprised, being subjected to this indignity ... Last Wednesday, Granddaughter asked a nurse if she could help move Granny as she had slipped down in the bed and was lying awkwardly. Nurse refused because she said of Health and Safety rules she could not. Granddaughter lifted her grandmother up in the bed quite easily. P is petite and slim ... Today, D cleaned her mother's right hand thoroughly, as it looked unpleasantly soiled under the fingernails."

Those are the things in care that matter to people. I have had a patient ask me to cut his fingernails, because he did not want to die with dirty fingernails, and I took in my own nail clippers to do it. That is not a menial task; as a professor, I believe that it is my duty. But we need to make sure that however we change training, we have a workforce that meets the needs of the patients that they are there to look after.

Some groups, such as physiotherapy, have done really pretty well. They are doing very well in terms of getting their physios really trained up to look after the cohort for whom they are there. Nursing needs to look at itself quite carefully, and the way it is training people, because otherwise we are going to have a huge gap.

A consultation is being launched about the regulation of healthcare support workers. At the moment, healthcare support workers do a huge amount of work. They do a lot with patients, and are now, at Band 3, often working unsupervised; they are not a regulated group and often exhibit overwhelming compassion and care. I have found that in clinical practice, they are really the mainstay, particularly in the care of patients at home.

This is an important question. I fear that health economics might rebound quite badly. It costs about £26,000 per year to employ a healthcare assistant who can work on her own; it costs about £44,000 per year to employ a registered nurse. There are going to be increasing cost pressures on the NHS; I would not like to see nursing squeezed out by pushing up the banding and the cost, with all nurses being graduate nurses, and then finding out that all we have done is squeeze them out. We would have to reinvent the SEN grade, which had its problems at the time.

7.58 pm

Baroness Masham of Ilton: My Lords, the noble Baroness, Lady Gardner of Parkes, has asked a most important question which needs to be addressed. I was not certain that I could be here today, but when I found that I could I arranged to speak in the gap. When severely disabled people are ill or have an operation in hospital they need the best nursing care from people who will listen and understand their special needs. They are very vulnerable for many reasons.

Years ago, when I was a new patient at the spinal unit at Stoke Mandeville Hospital and in considerable pain, I found that the high-quality nurses on the post-graduate courses were the best. The senior sister always seemed to get the pillows in the correct position,

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which made all the difference. With the matron and the night superintendent coming around the wards, nursing care was kept up to a high standard. In latter years, the experiences of many vulnerable, ill patients has not always been as good. Will a university degree make a great deal of difference? To some who want an academic profession, it will. Many university graduates may be attracted to work overseas as university life will encourage them to widen their horizons. Will we have enough nurses to cover the ever-increasing needs?

We need highly educated nurses for highly technical procedures, but we also need the dedicated practical nurse who will care for the skin, watch the pressure areas, control infections and not always be moving on to higher positions. Many people felt that it was not a good idea to replace state enrolled nurses with lesser trained care assistants. Even in the private sector, care assistants are dressed as nurses and patients do not know the difference.

Last week, I took evidence about care at the end of life for patients with motor neurone disease. A senior neurologist told us that we have the same percentage of neurologists in the UK as in Albania. We need far more highly skilled specialists in many specialities, be they doctors, nurses or other health professionals. But we also need good, practical nurses who, as has been said, are not too posh to wash but will also take responsibility.

8.01 pm

Baroness Barker: My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for raising this issue in a timely fashion. More than 20 years ago, my mum was in Raigmore Hospital, Inverness, for several months-a hospital about which I have spoken previously in your Lordships' House. She was there for so long that when she left the staff threw a party for her and I am pleased to say that the consultant contributed by making a cake.

Because my mum was in hospital for a long time we went to see her every few days. One day when I went to visit she was very down. I asked what was wrong and she said, "You know, there are nurses and there are nurses, and some nurses are different". That little observation about the way in which someone had been treated predates Nursing 2000 and the change in education about which the noble Baroness, Lady Gardner of Parkes, talked. There have always been nurses who are overwhelmingly compassionate individuals. There are others with different styles of doing their job. In reflecting on this matter, I think that we will fall into a terrible trap if we assume that professionalism is somehow the enemy of compassion. I do not believe that that is true.

The noble Baroness made an interesting comment about dentists. Tempting as it is, I will not go down the route of talking about dentists. But I will say that there was a time when dentists were barbers. Nowadays, my dentist has to know about anaesthetics, radiology, some fairly complex chemistry, and so on. My point is that medicine is becoming much more complicated. What I find worrying about this debate is that time and again we seem to come back to saying, "We recognise that medicine is becoming more complicated.

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We recognise that standards in all other areas of the healthcare profession are important". However, we somehow feel that nurses have to stay in the same place and that if they do not something will be jeopardised.

That is dangerous because, as noble Lords have already identified, nurses spend by far the most amount of time with patients. In terms of improving patient care, it is important that the people who spend the most time with patients should have their status elevated so that they can bring about change and argue for change with people who often do not spend very much time with patients-for example, consultants. In some disciplines, consultants do not spend a lot of time looking at what happens to their patients. I want to make the case forcefully that upgrading the nursing profession in an objective and demonstrable way is a very important part of increasing patient care.

I turn now to degrees and training. The noble Baroness helpfully talked about the way in which nurse training has developed over the years. Since the early 1990s, nurse training has been based in universities. I understand from the briefings I have received that 50 per cent of university-based education programmes at degree and sub-degree levels continue to be delivered in hospitals, health centres, surgeries and people's homes. When people listen to a broadcast of this debate, we are in danger of them getting the impression that all nurse education is solely academic. I do not believe that that is the case. Will the Minister confirm that, in future, degree courses will contain a great deal of practical application and that people will learn not only about anatomy and physiology, but also about patient interactions and the importance of bedside manner and communication? If that is the case, I would be happier to support some of the move towards degree-based entry.

Another important point is that nurses in this country have frequently made the observation that nurse education here lags behind the best international practice. Nursing is becoming a profession in which people are much more mobile. Fortunately, in this country we are blessed with nurses from all around the world. Nurses, just like their counterparts at practitioner level, have the right to move around and to have a common set of international standards. I understand that under European directives, degree and diploma students have to complete 2,300 hours of theory and 2,300 hours of practice over three years. I should like confirmation from the Minister that that is the case.

The noble Baroness raised a very important point about the dropout rate of students from degree courses, which is worrying. Today, I telephoned the Nursing & Midwifery Council about that. Its research found that 62 per cent of students leave their course because of financial worries. That is a serious matter and it is at the bottom of all this. Currently, as I understand it, there is funding of about £6,500 for a person undertaking a diploma, but they do not have access to student loans. Funding for degrees is £2,500, but those students have recourse to student loans, which is my key concern. Will that funding regime carry on? Will the Department of Health continue to fund the fees for the courses? As part of the monitoring following the implementation of this policy, will the department closely monitor the effect of student financing on nurses? If that does not

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work the terrible predictions about gaps in nursing staff made by the noble Baroness, Lady Gardner of Parkes, will come to pass.

That is the most important issue that lies behind this. We are possibly more in danger of deterring competent, caring nurses in the future if we do not get the funding base right than we are by changing the status of the education which they have to go through in order to qualify. I agree too that healthcare assistants are an important part of the workforce. There is a strong case for looking at regulation and career progression for healthcare assistants. They can make a huge difference to the experience of patients in hospital and they are vital. As noble Baronesses have already said, the hospital that treats you but does not care about you is not a very good hospital at all.

8.11 pm

Earl Howe: My Lords, my noble friend Lady Gardner has raised a subject of far-reaching importance-as so often she does-and for that she deserves our collective and very warm thanks. The question of whether nursing should be a degree-based qualification has been the subject of debate for a number of years. It is a debate which recently entered a new phase with the Government's announcement last year that from 2013, new entrants to the nursing register will be confined to those who have attained a nursing degree. Those with nursing diplomas who are already on the register will be allowed to stay there, but as a route to entry, a diploma will no longer count.

My noble friend got to the heart of the question that this presents. What good will flow from this change? The justification for it, as we have heard, is the increasing complexity of the nurse's role and the raised levels of responsibility which accompany this. It is certainly true that the job of a nurse is very different today from the way it was even 20 years ago. We have nurse specialists in many different disciplines. The noble Lord, Lord Darzi, stated in his final report that the skills of specialist nurses can help to keep patients out of hospital. Nurses can prescribe medicines; they are in charge of walk-in centres; they can carry out procedures previously reserved for doctors, such as endoscopies; and increasingly, they will be working in a diverse range of community settings. The argument runs that more and more nurses will find themselves assuming leadership roles and having to think critically as well as with a high level of technical knowledge.

All this is surely valid. We need nurses with degrees and we need more of them, not least because of the considerable number of nurses who are due to retire in the next few years. The question is whether it is wise to insist that all new nurses should have degrees. Those like my noble friend who are sceptical of the change believe that its effect will be to deter applications from people who would make good nurses but who are not suited to academic study. The RCN's answer is that this is about encouraging more people to take a nursing degree and not about restricting entry to the profession. That is a good aspiration, but frankly, I cannot see how it can fail to restrict entry to the profession, and I therefore think that the potential shortage of recruits is a worry we need to take seriously.

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What research have the Government done to convince themselves that this possibility can be discounted? We should also be worried by some of the reasons being given for the decision. The Royal College of Midwives said:

"We welcome this development, as it will improve nursing care and improve the status of nursing".

I am afraid that I see "status" as having rather too much to do with all of this. Status is quite the wrong place to be starting. The proper starting point is to ask what it is that makes a good nurse in the 21st century and how best can we deliver it.

Talk to any senior nurse, and they will say that there are certain qualities in a good nurse which are indispensible: compassion, kindness and a caring approach. Technical proficiency is essential, but no nurse can ever be a mere technician. Good nurses know their patients; they are team spirited; they are practical people. These are qualities which either you have or you have not, they cannot be taught. Those who oppose degree-only entry say that an absence of such qualities is not the focus of a degree course and is therefore not a determinant of whether you pass or fail, whereas under the old-fashioned apprenticeship system, it would be picked up straight away.

If that is so, then there is an obvious answer. A consultation is under way, as my noble friend mentioned, on the content and structure of the new degree course. There is a big opportunity here to ensure that the character and attitude of a trainee nurse is treated with every bit as much emphasis in awarding a degree as their academic and technical proficiency. I should be glad if the Minister could say whether this is being considered-I hope it is. The suggestion of the noble Baroness, Lady Finlay, of a pre-registration year is a constructive one.

The stories that we hear about bad nursing, not least the appalling accounts published recently by the Patients Association, centre often on nurses who are thoughtless, lazy and uncaring in their approach. There is a lack of basic aptitude and competence. A large part of the argument for raising the bar as regards entry qualifications, rests upon patient safety. For me, this is where the argument for making the change is at its strongest. There is some quite compelling evidence from the United States showing that in hospitals with higher proportions of nurses educated to the baccalaureate level or higher, surgical patients experience significantly lower mortality rates.

There is another compelling reason for the change which we need to appreciate, and that is the effect of the European working time directive on junior doctors' hours. To the extent that doctors are no longer present on a hospital ward to take responsibility for clinical decisions, nurses are now being called upon to do so in their place. There was an interesting article in last week's Nursing Times which lays bare this whole topic. Many nurses report that since 1 August last year, which was when the 48-hour week came in, they have been under greater pressure to make clinical decisions that have major implications for the care and treatment of patients. Their complaint is not that this extra responsibility is wrong in itself: it is that very often they do not feel adequately trained for it, added to

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which they have less time to carry out their basic nursing duties. The net result for as many as half of those responding to the survey is that patients are being put in danger. That is clearly a worrying finding. It is also extremely ironic that an EU directive, which was intended to have health and safety at its core-albeit the health and safety of workers-should be the cause of putting patients at risk. Whether or not we like it, we are stuck with the working time directive. It follows that the mix of staff and the mix of skills on a ward are, in many environments, likely to experience permanent change, and that change has to be catered for in nurse training.

If more nurses are to assume more responsibility for more complex roles, it follows that many basic aspects of patient care, such as washing and bed pans, will fall to healthcare assistants. That implies that it does not really matter if those tasks are not carried out by qualified nurses. That worries me on two counts. First, healthcare assistants are not regulated and require only an NVQ or similar to start work, which does not guarantee much in the way of good patient care. The second worry is about why it is important for nurses to practise basic nursing. I recently received an e-mail from a retired senior nurse, who said:

"Current staff don't seem to realise that ordinary tasks like washes, bedpans and temperature rounds were golden opportunities to develop a much better understanding of each patient and the nature of their illness; and it allowed for a build-up of trust between staff and patient. While seemingly mundane activities are being carried out, patients no longer feel isolated. They feel they can ask their questions and share their concerns without being a bother. In this way the nurse becomes the patient's advocate".

In other words, once you start treating basic nursing tasks as mere routine to be delegated to those less qualified, you risk preventing nurses from delivering nursing care in the fullest sense.

I hope that the work now being pursued by the Nursing & Midwifery Council to introduce a proper system of regulation for healthcare assistants can proceed apace because we need to guarantee standards at that level. I also hope that, with more graduate nurses on hospital wards, we will hear less and less of the phrases "too posh to wash" or "too clever to care". Hospital nurses who will not give basic care to a patient or who will not ever clean up a dirty floor are simply not doing their job.

Graduate-only entry to the nursing register is a decision that has been taken. For it to work as intended, much will depend on how readily we can recreate the apprenticeship model of training on hospital wards, with proper supervision and the right disciplines being instilled in trainees from the outset by experienced nurses. Much, too, will depend on trainees who lack the right attitude being weeded out rapidly. The word "vocational" is no accident in the context of nurse training, for surely every nurse should feel that the work they do is something close to their heart and more than just a job.

Over the next few months or so, during which the new training curriculum will be designed, we will be presented with an opportunity to get the balance and content of the nursing degree absolutely right so that the aspiration which we all share of a nursing workforce fit for modern healthcare can truly be attained.

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8.22 pm

Lord Tunnicliffe: My Lords, I, too, thank the noble Baroness, Lady Gardner, for tabling the Question for this interesting debate. I shall start my response on the issue of assessment, which is central to her Question.

Assessments are made case by case where significant changes to national level education programmes or qualifications are proposed. These programmes and qualifications are regularly reviewed by those responsible to ensure that they are up to date and fit for purpose. Such reviews will take account of a range of issues: higher expectations of patients and staff; changes in demographics; changes in the nature of disease; and technological advances. Often these changes are incremental.

However, in recent times these reviews have focused on nursing and midwifery, which have needed more significant changes. In 2008, the minimum qualification to become a midwife was raised to a degree. It was only after a long period, during which increasing numbers of new midwives qualified with degrees, this non-contentious change was required by the Nursing & Midwifery Council in response to the complex and rapidly changing healthcare environment. Midwifery continues to attract more than sufficient applicants to courses.

Similarly, nursing is becoming more diverse and demanding: some types of hospital-based care will be provided in the home or within communities; technology is getting more advanced; people are living longer; and health needs are often more complex.

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