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Lord Tope: I am grateful to the Minister for her reply. However, I remain far from convinced about why members of health authorities are deemed to be in such a different position from members of local authorities. Local authorities have had a national code of conduct at least since 1974. It is drawn to the attention of all councillors when they are first elected. Most authorities, including my own, include that national code of conduct with their standing orders. I believe that it is along similar lines to the code of conduct to which the Minister referred. It is always required of councillors to declare their pecuniary and non-pecuniary interests.

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It was held not only by local authorities but also by the Government that a national code of conduct which is to an overwhelming extent complied with by all local authorities and councillors is not enough. The Government decreed that a statutory register was necessary, presumably in order to reassure the public and those with an interest, and to ensure openness.

It is right that local authorities can raise a local tax, but health authorities cannot. But surely the real issue is the contract into which local authorities and health authorities enter. A conflict of interest is far more likely to arise in that connection than as regards any level of tax.

I did not intend to suggest that local authorities were not subject to scrutiny by the local press. However, I suggest that in most areas, if not in all, a local newspaper is likely to be full of what the local council is or should be doing than with matters concerning the health authority, except under exceptional circumstances.

I shall withdraw the amendment today. As the Minister said, the noble Lord, Lord Dean of Beswick, feels strongly on this issue. Sadly, he has not had an opportunity to express a view today so I suspect that we shall return to the subject at a later stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 24 not moved.]

Baroness McFarlane of Llandaff moved Amendment No. 25:


Page 20, line 4, at end insert:
("(2) In making regulations under paragraph 2 above the Secretary of State shall have regard to the need to include members with experience in providing nursing care.").

The noble Baroness said: On the first day of Committee and again today we have had lengthy discussions about the pros and cons of professional representation on the health authorities. I am sure that it may seem tedious to move yet another amendment which seeks to plead that point.

In moving the amendment, I have tried to take into account what the Minister said on Second Reading. She said,


    "the Government do not in general support reserved places on authorities for representatives of particular groups".—[Official Report, 6/3/95; col. 70.]

Indeed, she has reaffirmed that position in her answer this afternoon to Amendment No. 20.

I agree with that position, and I am not seeking to plead a representative position on the authority. I am trying to look at the role of the new health authorities, which I believe is managerial and includes an assessment of the health needs of the district, the making of purchasing contracts, specifications of standards of care and auditing of the care given. To carry out those functions, the authorities will need a membership which includes certain managerial skills and, as the schedule provides, access to a wide range of appropriate professional advice.

The Government have given an undertaking that the membership of the new authorities will include a chairman, a chief executive, a director of finance and a

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director of public health. The arguments for a chairman, chief executive and director of finance are self-evident. Indeed, there is an argument for the inclusion of people from outside the health service. Having worked on a health authority, I appreciate the financial and business skills of some of the other members.

The inclusion of a director of public health can be made only on the basis of the expertise which he brings to the authority—the epidemiological knowledge that he has in assessing the healthcare needs of the area and his expertise in medical service planning. It is my conviction that the case for the inclusion of a member on the authority who has expertise in the planning and purchasing of nursing care and the specification of standards of care is equally important if the authority is function with any degree of efficiency.

My conviction stems from the facts which were rehearsed on Second Reading and again on the first day of Committee: namely, that 80 per cent. of patient contact in the health service is given by nurses; and they are the largest professional group in the National Health Service, accounting for 50 per cent. of the workforce and 40 per cent. of current National Health Service spending.

I am not making a case that their work is any more important than any other professional group. However, I am saying that the resource implications of that very large group of the workforce, that very complex service with many specialties, are very great in relation to the health authorities. The ability to make effective and knowledgeable purchasing contracts is crucial.

I am convinced that access to advice on the management of nursing services and criteria for purchasing and standards of care is not sufficient. Expertise on such a large and complex component of the authorities' work needs to be dealt with at the point of decision-making.

I have taken the opportunity to speak to the director of consumer and corporate affairs and nurse adviser on a purchasing authority—the Camden and Islington Health Authority. She described her work in respect of the health needs of the local population, the co-ordination of nursing advice to the authority, which is a very complex task, her role in clinical audit and the establishment of healthcare standards. I have no doubt that the health authority needs to have as a member a director of that calibre.

I have taken the opportunity also to talk to Dame Audrey Emerton, who is the chairman of the Brighton Health Trust—a provider authority. She wrote to me subsequently confirming the points made in our conversation. The letter stated:


    "The inclusion of a nurse as an Executive Director on a Health Authority is of vital importance in the contribution that can be made in relation to the compiling of contracts between purchasers and providers which will include quality specifications. Community Care is expanding and there is a growth of private nursing homes for which there is a legal requirement for inspection to ensure standards are maintained. The contribution of an Executive Director Nurse comes from an in depth knowledge of the care components of a contract which (apart from the clinical intervention of a doctor) are paramount both in terms of quality and cost effectiveness".

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An executive director nurse on the purchasing authority complements the role of the executive director nurse on the provider authority, which is prescribed. It seems illogical not to have such a complementary role.

I trust that in replying to the amendment, the noble Baroness will give it favourable consideration. I ask her to take it that it is not a plea on this occasion for representation; it is a plea for expertise in one of largest and most fundamental components of a health authority's work. I beg to move.

Baroness Robson of Kiddington: I support the amendment moved by the noble Baroness, Lady McFarlane. I have supported her often in the past on the question of nurses. I agree with her 100 per cent. that we want nurse directors because of their expertise and care involvement both in the community and hospitals; and because they are likely to have a much closer and deeper knowledge of what the patients want and need.

Also, patients find it much easier to talk to nurses than they do to talk to doctors. They become rather nervous about addressing that high and mighty consultant or even GP. But they talk quite easily to nurses. Therefore, nurses are likely to have a much more intimate knowledge of what the patients are looking for.

The provider units, the trusts, must have a nurse executive member. It is important to have a nurse on the purchasing authority who is able to negotiate with the trust nurse on matters such as staffing levels and meeting quality standards before placing contracts with a trust. Only a member with experience in providing nursing care can adequately assess the details relating to nursing in any contract.

I know that the Minister said on Second Reading that it would be almost inconceivable that any health authority would not, just by the very nature of things, accidentally—or in whatever way one likes to put it—appoint a nurse as one of the non-executive directors. I am afraid that I do not find that satisfactory: I want an assurance that one of the non-executive directors will be a nurse. As I said, I support the amendment.

5 p.m.

Lord Rea: I should like to express my support for the amendment for all the reasons put forward by the noble Baroness, Lady McFarlane and by the noble Baroness, Lady Robson of Kiddington. Many of the arguments put forward by the noble Baroness, Lady Gardner, as regards Amendment No. 20 also apply. Nurses bring with them an unparalleled, intermittent and practical knowledge of the working of the NHS, learnt at the bedside, in patients' homes, in clinics, in operating theatres and in almost any other location. When nurses are members of a health authority, that knowledge held by experienced members of the nursing profession is enormously helpful to the deliberations of the authority. It helps to prevent, for example, purchasing decisions being taken which may prove to be unworkable or, possibly, against the best interests of patients. I hope that the Minister will rethink her general strictures about

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not having specific professional members named as regards membership of health authorities in this particular case.


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