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Lord Carter: My Lords, on these Benches, we are pleased to support this amendment. In moving the amendment, the noble Baroness, Lady McFarlane, set out the arguments extremely clearly. Perhaps I may repeat the crucial statistic which she mentioned. Nurses are the largest professional group in the health service, providing

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80 per cent. of direct patient care. The noble Baroness explained why the profession should be involved in the way which the amendment proposes.

Like the noble Baroness, I noticed the remark which the Minister made on Second Reading to the effect that she would be very surprised if the majority of health authorities did not appoint executive members with nursing experience. We need something rather stronger than ministerial surprise in this instance.

On a previous amendment I quoted from an excellent article in Health Director, which is produced by the National Association of Health Authorities and Trusts, by Mr. Ian Wylie who is head of communications at the King's Fund. He gives a very good summary of the operation of the health service. He says:


    "The present operation of health services involves a constant and complex interaction of six elements: professionals, purchasers, providers, patients, public and politicians".

I notice that it is also rather alliterative. He goes on to say:


    "Each of these six parts must work with and influence each of the others to reach a balance which is the best solution for healthcare. As health services cannot function without an effective interplay of the six partners so the communication processes for health services must also involve all partners".

It would seem to me that if it is to involve all those partners, the paragraph sums up the situation extremely well. If there is to be an effective interaction and interplay between all parties, there should be a means of ensuring that nurses are represented.

I do not believe that other professionals would be offended if the nurses were represented because of the very vital role which they play in terms of their skill and expertise and the sheer weight of their involvement—80 per cent. of direct patient care. I hope that the Minister will feel able to accept the amendment.

Baroness Cumberlege: My Lords, first, I thank the noble Baroness for giving me notice of this amendment. I should like to take this opportunity to apologise to her for stating at an earlier stage in the passage of the Bill that she was a vice-president of the Royal College of Nursing. In fact, she is a fellow of the Royal College which, in my view, is a much more exalted position because it must be earned professionally.

Perhaps I may also thank the noble Lord, Lord Addington, for filling in for the noble Baroness, Lady Robson, at very short notice.

We have debated the question of nurse membership at each stage of the Bill's passage. I recognise that the continuing debate is not just special pleading for a particular group. It reflects the very real conviction that the involvement of nurses in purchasing will lead to better services for patients.

It is easy for me to talk about the essential contribution which nurses make to the work of health authorities—and I strongly believe that nurses have distinctive experience to bring to bear on purchasing. But words need to be backed up with actions. The Government have demonstrated in many material ways that they value nurses, and trust their professional skills; for example: our nurse prescribing initiative extends the role and influence of nurses. We believe it will be shown to bring genuine benefits both to patients and staff.

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Over £400 million has been made available to support the introduction of Project 2000, which is achieving higher standards of education and training for nurses. Project 2000 students are educated to become flexible, innovative and accountable practitioners in both hospital and community settings. Better trained nurses means better care for patients, and, as the Royal College of Nursing reminds us, as did the noble Baroness today, nurses have 80 per cent. of direct patient care. Practice nurse numbers have grown significantly over the past 12 years. They have significantly enhanced the skills of primary care teams.

The Changing Childbirth initiative is helping midwives to strengthen their position in the routine care of women during labour. The Government have provided significant funding for the initiative, including support for a full-time implementation team; for 14 development projects last year; and £1 million for further investment this year. NHS trusts have created new opportunities for nurse leaders with the establishment of executive director posts.

Those initiatives, more than anything I can say today, speak of our commitment to the nursing contribution. I believe that they should reassure nurses that we mean what we say in the draft guidelines on professional involvement which we issued earlier in the year. The guidelines call for nurses to be involved in planning and purchasing of health services, in clinical effectiveness strategies, in the inspection of nursing homes, child protection, midwifery supervision, Mental Health Act responsibilities and many other areas. They point out that nurses are playing a key role as health authority employees. The new statutory duty to involve professionals, introduced in another place, will enhance that role. Perhaps I may quote briefly from the draft guidelines:


    "The skills and knowledge which nurses bring include an appreciation and clear understanding of health care drawn from practical experience across all clinical areas, an ability to challenge clininal practice and an understanding of ... how staffing and skill mix can be fine-tuned to achieve optimum use of resources."

The guidelines make clear that the regional offices will be monitoring the arrangements made by health authorities to ensure that they command the confidence of the professions locally. If the new arrangements do not command the confidence of the nursing profession, I can assure your Lordships that the regional offices will take action.

The noble Baroness, Lady McFarlane, mentioned the IHSM survey. We are not complacent about the findings of that report, but I should like to point out that the figures are moving in the right direction. The 58 per cent. of purchasers with a nurse at director level compares with only 40 per cent. in the 1992 survey.

We recognise that the noble Baroness is proposing an amendment which she feels will guarantee a full nursing contribution to the work of the new health authorities. Although I fear that we shall not reach full agreement on this issue, I hope that I have been able to convince her that our disagreement is about the appropriate means, not about the desirable end. I have emphasised in previous debates that membership is not the only or, we believe, the most important way to achieve a nursing input. I have

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spoken before about the role of nurses as health authority employees, as expert advisers, as members of review teams, and so on.

We agree with the noble Lord, Lord Carter, that a broad and integrated involvement is what we will be looking for and we believe that it is more effective than relying on a single nurse member. Three of the five executive posts are already filled—by the chief executive, director of finance and director of public health. We believe that we must leave it to the judgment of the chairman and the non-executives to fill the remaining two executive posts with the officers whose skills best match local needs. I regret, therefore, that I cannot support the amendment.

Baroness McFarlane of Llandaff: My Lords, I thank the noble Baroness for her personal generosity and also for the many things which she has done personally for the profession and the contribution which she continues to make in that direction.

However, I do not believe that the catalogue of measures to which she has referred, such as Project 2000, dear as that is to my heart and, I know, to hers, really answers the question about having a nurse with expertise on every health authority. But I take the point that she has made and am reassured to a certain extent.

I shall watch developments with interest because, at present, I do not think that I can put a vote of confidence in the membership of the health authorities. But, at this stage of the proceedings, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendment No. 5:


Page 30, leave out line 13 and insert:
103.—(1) The Employment Protection (Consolidation) Act 1978 shall be amended as follows.
(2) In section 29").

The noble Baroness said: My Lords, in moving the above amendment I shall speak also to Amendments Nos. 6 and 7. We discussed at Report stage the future arrangements for the contracts of registrars and senior registrars. As I explained then, the employment contracts of these staff are currently held by regional health authorities and need to be held elsewhere when RHAs are abolished.

There are in fact a number of staff whose contracts of employment are at present held by regional health authorities and who are undertaking rotational training programmes which require them to move regularly between different NHS employers. Clearly, when RHAs go, new arrangements need to be made for these staff.

Junior doctors and dentists in the registrar and senior registrar grades are the largest group affected. Others affected include clinical psychology trainees, finance and general management trainees and some pharmacy and scientist training grades.

While the contracts of these staff are held by regional health authorities, they can move between different NHS bodies as part of their training without losing the employment rights which depend upon serving a period of continuous employment. The most obvious place for contracts to be held in future is with the NHS trust or other NHS employer. The provisions in Schedule 2 to the Bill

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ensure that there is protection of continuity for staff who move from RHAs to other NHS bodies on 1st April 1996. However, without the amendment, the continuity of employment of those trainees would be broken on any subsequent moves between NHS employers.

It is an important matter. The Government recognise that the way the contracts are handled in future could affect those employment rights which depend upon serving a minimum period of continuous employment. For example, both protection against unfair dismissal and the right to return to work after maternity leave depend upon having served two years with one employer.

Staff in these training grades must move regularly between employers in order to gain a high standard of professional training. We need to ensure that there are no obstacles to discourage them from moving. That is what the government amendments are designed to achieve.

The Government have made clear that their preferred option for these staff is for their employment contracts to be held by their employer—usually an NHS trust. That is consistent with the treatment of other staff. It is consistent with the principle that personnel issues are generally best managed at local employer level; and with trust freedoms to determine the quantity and type of resources that they employ.

Devolving contracts to employers is still a matter for discussion with the various professional bodies representing such staff. I hope that the amendment will offer them a significant reassurance. It enables the Secretary of State, by order, to specify particular groups of staff undergoing professional training which involves moving between NHS employers. For these staff, employment with successive employers as part of their training programme will be treated as continuous employment for employment protection purposes. In other words, the employment rights of these staff will be exactly the same as if their contracts had continued to be held by the RHA.

I am aware that particular concern has been expressed that transferring junior doctors' contracts to NHS trusts might cause problems for maintaining the required level or standards of training. We have just completed consultation on a discussion document which sets out the various options and possibilities for the employment arrangements of junior doctors, including their contracts. That is set in the context of an overall strategy for the organisation and management of postgraduate medical education. The document was issued widely to representatives of the medical and dental professions, to the education bodies and to employers' representatives. We will take careful account of the comments received before final decisions are taken. The amendments do not in any way pre-empt that consultation, or the various discussions going on with professional bodies. They simply ensure that, where trainees are employed by more than one NHS body during their training, continuity of employment can be safeguarded.

Your Lordships may wish to know why we thought it appropriate to specify in subordinate legislation the categories of staff to whom the new paragraph is to apply. It is to enable us to ensure that the necessary protection is provided not only to the grades currently employed by RHAs but to any equivalent successor grades which may

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in future replace them. I should, however, make clear that the intention is not to extend further the employment rights of these staff but to preserve their existing rights. We have no plans to use the power to provide for categories of staff not currently employed by RHAs.

I will now turn to the amendment tabled in the name of the noble Baroness, Lady Jay. That amendment seeks to provide for postgraduate deans to be health service employers for the purposes of the government amendments. I can assure your Lordships that NHS authorities listed as employers in the government amendment encompass the full range of potential employers for the staff concerned after 1st April 1996.

I would be entirely inappropriate for deans to be added to the list of employers. They are not health service bodies. No other individuals are statutorily designated as employers within the NHS; nor are any other NHS staff employed by individuals in the way that the amendment would suggest. The postgraduate deans will themselves be employees of one or more other bodies. Decisions are yet to be made about the various options in our discussion document, but there is even a possibility that the deans might in future be employed outside the NHS.

I hope that I have made clear that the amendment would not be workable and that, therefore, the noble Baroness will consider withdrawing it. I invite your Lordships to agree to the government amendments which, we believe, provide a helpful and necessary safeguard. I beg to move.

4.45 p.m.

Lord Rea: My Lords, I should like to take the opportunity to speak to Amendment No. 7 which is included in the current group of amendments. We tabled the amendment in order to allow us to continue the discussion on postgraduate and continuing medical education. In fact, at each stage of the Bill in this House the matter has been discussed. We need to continue to discuss the matter because, despite what the Minister said, we are still not quite certain about how the Government intend to safeguard the training component of the contracts of junior hospital doctors, notwithstanding the issue of a document during the Committee stage giving options for postgraduate, medical and dental education.

As the Minister said, even while the Bill has been going through the House, consultations and discussions are still taking place with universities, the British Medical Association, postgraduate deans and Royal Colleges. We do not yet know the Government's intentions. It would be useful to us if the Minister could, perhaps, expand a little on how far those deliberations have gone and tell us about the Government's current thinking on the matter.

To allow the contracts of junior hospital doctors in training posts—that is, registrars and senior registrars, as they will be in a unified grade in future—to be held by a regional "post-graduate Dean", as suggested in the amendment, would ensure that contracts were drawn up so as to allow adequate time and facilities for post-graduate studies to be made available, as is the case at present. I understand that it is the Government's intention that regional postgraduate deans will remain in post, possibly partly university funded and partly NHS

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funded, and that they will work in conjunction with the regional offices of the National Health Service Executive, which will be the successors to the regions.

I also understand that postgraduate deans will continue to have a supervisory role in the educational part of junior doctors' contracts. However, a drawback to that arrangement is that the postgraduate deans will, at least in part, become civil servants if they are employed through those offices and that they will, therefore, lose some of their independent status.

However, we feel that by relinquishing overall administration of the junior doctors' contracts to a trust —as the noble Baroness has said—or possibly a group of trusts, as the Government amendments would allow, the postgraduate deans will lose their bargaining power on behalf of junior doctors. For example, if a trust is hard pressed financially or it has an increased workload, it will be tempted to cut down on the time allowed for training activities and to increase pressure on junior doctors to carry out purely service activities. That is likely to occur partly because of the move—it was a welcome move—to reduce the hours of junior doctors, especially for house officer and senior house officer grade. This will increase the pressure on registrars to perform faster and to see more patients. That tendency is already occurring because of the increasing use of technology and more rapid turnover through hospitals.

There is a real need for a powerful independent voice from postgraduate deans to ensure that these pressures do not squeeze postgraduate medical education out of junior doctors' timetables. It would be some comfort if the noble Baroness could state that the contracts for junior doctors in training could be uniform nationally so that individual trusts could not modify them to suit their own needs, with adverse consequences for training. The British Medical Association is keen that contracts should be established on a national basis. It states:


    "The reason that national terms and conditions of service for junior doctors was agreed at the time of the NHS and Community Care Act was because it was feared that juniors would be particularly vulnerable to exploitation by trusts. It is essential that all junior doctors continue to be employed on national pay and terms of service, and there must be no question of any local deviation".

That, unfortunately, would appear to be possible under the arrangements that are being developed. The amendment allows contracts to be held by a postgraduate dean. I agree with the criticism that the noble Baroness has put forward about employment by a single person. That was suggested simply in order to stimulate discussion at this stage of the Bill. But in order for that to function a supportive administrative apparatus would have to be in place. That should not be difficult because the structure is there in the regional health authority set-up. That structure could be transferred to a special health authority. In fact a special health authority is one of the bodies mentioned in the noble Baroness's amendments. That is the British Medical Association's preferred approach.

The BMA proposes,


    "a special health authority arrangement for holding contracts of postgraduate deans which could assume responsibility for all doctors in training within the region. It would have the benefit of establishing

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    a clearly identifiable purchaser of medical education and training within the existing NHS system of management, with clear lines of accountability".

This would preserve the strategic planning function of the present regional structure with regard to manpower planning and training needs for future numbers of consultants, as well as preserving the degree of independence for postgraduate deans which they need in order to protect the interests of junior hospital doctors.


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