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Noble Lords: Order!

Lord Morris of Castle Morris: I shall not do that. It is a mass of painless blue bruises caused by two months of daily injections of Tinzaparin. It is an anti-coagulant which almost always bruises because anti-coagulants do. It has to be administered subcutaneously by a trained and skilful nurse unless you want the patient to look like an ancient Briton, ready for battle and covered in woad.

The point is that not all even subcutaneous injections are as simple as they seem. Nurse education requires knowledge plus a high level of manual skills constantly practised. I was delighted to see that recognised by recommendations 10, 14, 16 and 20 of the Peach report, Fitness for Practice, for the UKCC.

We have all heard of consultants and registrars grumbling that newly qualified nurses arrive on the wards full of theory but it takes six months before they are perfectly competent in practical matters. Thanks to the Peach commission that should be heard less often

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in future. But students must be instructed and must be able to practise the acquired skills before they are let loose on hospital wards.

My second point concerns access to nurse education. The cadet scheme, aimed at 16 year-old school-leavers, is a popular success with the trusts. Experience at Sandwell, Rochdale, Lincoln and Warrington has been encouraging so far. A cadet who achieves a level 3 NVQ at Sandwell, for example, is guaranteed a place on a nurse education course at Wolverhampton University and is guaranteed a job with the trust when the course is completed successfully. That is an excellent idea. That is what will bring people in.

Similarly, the Government are to be congratulated on pledging financial support for healthcare assistants to become registered nurses. That fast-track recruitment is a safe and sensible system but it needs careful organisation. In particular, trusts must be sure that universities can provide places for such students and can meet their special needs. Mature HCAs often have families to take into account and financial arrangements which are very different from those of--shall we say?--an 18 year-old school-leaver coming up to university to read English literature. Therefore, universities must be far more flexible in matters like transfer from one university to another if we are not to lose students we desperately need.

Incidentally, a great deal of misunderstanding exists about the drop-out rates in nurse education. We have been talking across the Benches here and figures of 30 per cent, 24 per cent and 18 per cent are often quoted. The point is that the figures for nurse education are based on the number not taking up their bursaries for whatever reason. A student nurse taking maternity leave counts as a drop-out, as do the long-term sick, whether it is meningitis or a broken leg that causes the temporary absence. A student who chooses to take a break is a drop-out. That is not true for comparable university departments and it gives a very false picture of nursing students. Will the Minister please help to remove that depressing anomaly as swiftly as possible?

My third point refers to the weakest in the whole system--clinical placements, which everybody agrees needs a lot of attention. Nursing is still rooted in practical caring skills and those can be achieved only by hands-on experience. But good placements, like good women, are hard to find. The NHS system is estimated to be 17,000 nurses short. I have never quite been able to find out how that number is calculated but nobody seems to disagree with it. So those who are working are having less and less time to instruct learners. The old industrial system of, "Go over there and sit next to Nelly and you do what she does and you'll soon learn", will not work in a busy hospital where nurse Nelly is rushed off her feet and simply does not have the time. I have small faith in the idea that a student can learn much by silent observation.

I suppose that every university department with a nurse education course has its version of the story which I first heard in a South Wales hospital where a

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student "observer" accompanied a ward sister and others handing over from one shift to another. In the midst of that, a patient in bed groaned and turned distinctly green. "Go and see what's the matter, will you, please?" said the sister to the student. "No", said the student, "I am here to observe, not to do things". "Right", said the sister grimly, "well, you just observe Mrs Jones because she has just vomited all over the bed and we'll observe you cleaning it all up, isn't it?"

There just are not enough trained and qualified nurses on the wards to guarantee that form of sophisticated apprenticeship and it is too expensive to do badly. In any case, there are not enough placements to go round. The situation in hospitals is static because bed numbers have been frozen and nurse numbers are at a premium. But student numbers are extremely buoyant. You cannot get a quart into a pint pot.

University nursing departments are having to seek placements for students in hospices, GP practices and mental health units, which are not often places of relevance because they are so specialised. I respectfully ask my noble friend to cause a long and serious inquiry to be undertaken into the problem of placements. It can be even more acute in post-registration education, as Carol Midgley wrote in The Times of 20th January about the problems of any kind of instruction in an ICU or even in an accident and emergency department.

My fourth point is that it was the first century Latin satirist Juvenal, was it not, who wrote "Quis custodiet ipsos custodes?"--"Who is to guard the guards themselves?" Who, where and how qualified are the teachers who will teach that theory part of pre-registration education, the classroom component? I am told that a nurse teacher would require a 3-year diploma, then further part-time work to achieve degree level. This would be followed by a part-time Masters degree taken while working and she would be en route to a doctorate completed, again, part-time before she would be teaching.

That may attract the equivalent of a ward sister's salary within about five years of registration and a settled career thereafter. That may be desirable but it would not be compulsory to have any teaching qualification whatever. That can hardly be satisfactory in a university situation. Can my noble friend assure us that all those who now teach nursing students in universities are tested and qualified and fit to do so? The RCN in its briefing for this debate says:

    "The RCN is looking carefully at this issue and is working on a new model for preparation of those who teach nurses".

Can my noble friend describe the old model and tell us what is wrong with it?

Fifthly, and finally, I am concerned about the status of the new departments which are now up and running in 89 universities in the United Kingdom. Are they an accepted and an integrated part of what we may call the British university system? I am fearful for all this because recently there has been the serious suggestion that nursing students should be returned to employee status. The RCN and many others are seriously

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worried by and opposed to that. I am puzzled that any nursing student should prefer to be an employee with a salary to being a student with a bursary. In my view, it is far more important that they should be given access to student loans and that a fair proportion of Blunkett's bounty of £68 million, announced yesterday, should come their way, as I hope my noble friend will assure me.

I want nursing students to have exactly the same status as all other university students. The dean of nursing at Sheffield shrewdly announced to the university that she would not consider her students fully integrated until they had every Wednesday afternoon free to allow them to play Rugby football. She has a point!

4.32 p.m.

Baroness Masham of Ilton: My Lords, I am pleased to follow the noble Lord, Lord Morris of Castle Morris. I congratulate him on his excellent speech. I am delighted to see him back in your Lordships' House.

With great pleasure I thank my noble friend Lady McFarlane of Llandaff for instigating this debate. We desperately need well trained nurses who do a good job and have job satisfaction, whether in hospitals or in the community. I know that the Minister will not agree with me--although many people do--when I say that doing away with the state enrolled nurse, who trained for two years, was a retrograde step. The state registered nurse and the state enrolled nurse complemented each other.

Often the state enrolled nurse became part of a ward, working there for a long time, or she worked at night when her partner was at home. Now nurse assistants have taken her place. They have little training and are dressed in uniforms so that many patients do not realise that they are looked after by an unqualified person. With high-tech nursing there is a need for highly qualified nurses, but there is also a place for reliable, practical nurses.

Last year, at a reception in the other place, I met a well-respected and well-loved elderly actress. She had just come out of hospital, having had her foot operated on after a fall. As I had met her several times before, I asked her how she was getting on. She told me that one night in hospital a lady in the next-door bed needed a bedpan but could not ring her bell. The actress rang her own bell to call the nurse. When the nurse arrived she was furious, swore at them and told them off. That happened in one of London's teaching hospitals.

What are we teaching the modern-day nurse? Have our standards fallen so low? We appear to have a multitude of agency nurses who are not supervised. Night superintendents used to visit the wards to check on patients and nurses. At night patients are often at risk from uncaring nurses. Often during the day the ward sisters are not on the wards instructing young doctors and nurses but are busy in offices burdened down with administration or attending meetings. Nurses coming from college still have a great deal to learn as they put theory into practice.

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When I was in a serious condition in hospital I found that the nurses who were on a special post graduate course in spinal injuries were by far the best. They were interested in what they were doing and keen to learn. Is it not true that an expert is someone who continues to learn?

I am president of the Spinal Injuries Association, which works closely with the various professional bodies looking after the care of its members. At the moment the most important body happens to be the Royal College of Nursing. Last year at our AGM several members raised the point that when they had been admitted to a district general hospital, usually as an emergency, they had been refused a manual evacuation of their bowels. Many people with spinal cord lesions utilise manual evacuation as their established and routine method of bowel management at home. Therefore, they cannot understand why it is so difficult to continue to receive appropriate bowel management after admission to a district general hospital.

That refusal by nurses has caused some of our members great distress and has put them in danger. The actions and activities of all UK registered nurses are guided by the code of professional conduct published and policed by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. The primary requirement of all nurses is to,

    "act always in such a manner as to promote and safeguard the interests and well-being of patients and clients".

A nurse is expected,

    "to acknowledge any limitations in her knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner".

If a nurse cannot undertake a manual evacuation, she should identify an appropriate source of assistance in order to maintain her patient's established programme of care. She is required to represent her patient's needs and her inability to meet them to her ward manager or senior nurse. Unfortunately, the recent experiences of some Spinal Injuries Association members suggests that some nurse managers are unsure of how to deal with the situation properly. Many are of the mistaken impression that nurses are forbidden to undertake manual evacuation. The Royal College of Nursing is helping to sort out that kind of situation. This is an example of how voluntary organisations, which often know the needs of their members, can be of benefit to individuals when they work closely with professional bodies such as the RCN.

There are many different disabilities and when people become ill many problems arise. Therefore, I am pleased to say that on 2nd March the Royal College of Nursing is holding a conference on disability awareness and nursing.

Section 21 of the Disability Discrimination Act 1995 places new requirements on health service providers. It is vitally important that all nurses are educated about disability in order to influence service provision so that disabled people receive the service that they want rather than the service that they are given.

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Two weeks ago the TV programme "Panorama" showed that paramedics who have to deal with critically ill patients at the roadside, in the home and in the community at large have only six weeks' training. That led to a great many worried and surprised people. What reassurance can the Minister give in that regard?

In conclusion, many clinical nurse posts specialising in HIV are under threat as the cost of providing anti-retroviral drugs is increasing. Basic pre-registration and specialist post-registration training needs to ensure that all nurses have a good basic understanding of medical issues in relation to HIV, including the cultural issues of the communities affected, particularly gay men and African people living in the UK, and the maternity needs to protect the child of an HIV-infected mother.

The training also needs to stay up to date with medical advances. Historically, nurses were trained to see HIV as a terminal condition. Now they will be seeing a much greater number of people with HIV exhibiting a wider range of symptoms. The Royal College of Nursing should be congratulated on producing a sexual health strategy. Sexual issues may be behind a whole range of mental and physical problems. Nurses need to be made aware of those. We seem to live in an increasingly complex society. Without a healthy nation we will face growing problems. Every nurse should learn the importance of health promotion.

4.41 p.m.

Lord MacKenzie of Culkein: My Lords, we must be grateful to the noble Baroness, Lady McFarlane of Llandaff, for initiating this debate this afternoon on such an important subject. Also, I too am pleased to see my noble friend Lord Morris of Castle Morris in his place.

Last year, over several months, the journal, Nursing Times, ran a feature entitled "Nurse heroes of the century", to which I was invited to contribute. I rather indulged myself because I picked two heroes. One was that brave French army nurse who became famous as the "Angel of Dien Bien Phu", Leiutenant Genevieve de Galard. My other hero was someone rather different--an unqualified but brilliant nurse teacher who made it a pleasure for all young student nurses who were eager to learn to return to the class.

So I place great value on nurse education, whether it be degree or diploma courses or in the clinical environment. I have also always supported the need for a level of nurse education to be based in the higher education sector. Indeed, with nurses pushing out towards the frontiers of medicine, how else can it be?

I spent many a long day and evening justifying and supporting what became known as Project 2000. But I also supported the need for a new type of practitioner in addition to the first-level nurse; a new, second-level nurse to be quite different from the enrolled nurse as we knew it. With a number of senior nurses I campaigned strongly for that new type of nurse, since we believed that all levels of practitioners, however

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designated, should have access to education to a required standard and should be regulated by the statutory body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. That battle was lost, with the consequences which ensued. I shall not repeat them this afternoon; they are set out at col. 42 of Hansard of 13th December 1999.

As a result we had healthcare assistants and the appalling mistreatment of enrolled nurses. That was coupled with equally bad workforce planning by the then government. Health departments of the time and the pay review body ignored the warnings of the staff organisations as then articulated by my very good colleague, the late Trevor Clay of the Royal College of Nursing and myself from the Confederation of Health Service Employees representing the nurses of this country. The nursing shortage was as predictable as night follows day.

So it was with some considerable relief that I read Making a Difference where the Government set out their strategic commitment to enhance the role of nurses and--dare I say it?--to enhance the role of nursing. It is clear that the recommendations by the pay review body and the speedy acceptance by the Government had a positive effect on recruitment into nursing. It is reported that there is a 24 per cent increase in degree students and an 18 per cent rise in those taking up diploma courses. That increase is indeed a welcome start to redressing the many years of neglect. But more needs to be done: more in terms of pay and conditions; more in relation to family-friendly policies; and more too in relation to other measures to keep nursing students for the three or four years of their education and clinical placements.

As we heard this afternoon, nursing must compete with the plethora of opportunities offered up in higher education and in later life, often with more attractive salaries and career opportunities. Added to that, nurse students are different from the vast majority of their cohorts. As I understand it, their academic year is 11 months. In clinical placements there is a 37½-hour week commitment. We know that too many nursing students are working as healthcare assistants or in other jobs to make ends meet. So, far from having Wednesday afternoons off to play rugby, they have a great deal of hard work in front of them and a long academic year. It is not quite the higher education experience enjoyed by most other students in higher education and that may contribute to the drop-out rate about which many of us are unhappy.

Despite what has been said this afternoon, given that there are those differences in relation to other students, consideration must be given to reviewing whether bursaries, grants, loans or some form of training allowance should be reintroduced. I note that in this year's pay review body report to the Government it is still recommending student and pupil nurse training allowances. So far as I know, there are no conventional, old-fashioned, apprentice-based nurse training courses left in the United Kingdom, though the review body still recommends payment up

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to £10,155 for a third-year student. Something on those lines may well contribute towards keeping our students at university to complete their courses.

One of the disappointments with Project 2000 is the fact that some newly-qualified nurses are not equipped by the education system with the necessary skills required to provide what the Department of Health describes as "effective" practice. I go further and question whether "effective" in some cases should be substituted by the word "safe".

It is necessary that there be a strengthening of clinical placements, supervision and mentoring. I know that steps are being taken towards that. Again, as we heard this afternoon, the pressures on staff in the healthcare sector today are such that it must be enormously difficult to continue to inculcate the ethos referred to in Making a Difference; that is, that all nurses share the responsibility to support and teach the next generation of nurses. That ethos is not new. It existed when I started nursing more than 40 years ago but it deserves restatement.

Wards today are far too often staffed by healthcare assistants, the residual nursing auxiliaries and many qualified staff from agencies. It is not surprising therefore that monitoring is difficult--so much so that I suspect it may not be too long before someone tries to produce a computer-generated model of a virtual ward, no doubt with virtual patients. Like the noble Baroness, Lady McFarlane of Llandaff, I have no wish to go back to project-based training, but I have little doubt that both she and I experimented with our first injections on an orange, and I think that is much better than on a virtual orange!

Entering into nurse education will be facilitated by that most welcome move, the reintroduction of nursing cadet schemes: indeed events turn full circle. I also think that the initiative that has become known as the stepping on and stepping off is excellent. This will enable a student to leave a degree programme after, say, 15 months with sufficient qualifications to practise as a senior healthcare assistant and will enable young people to take a break for whatever reason--whether the cause is falling pregnant or caring for an elderly parent--and not be lost to nursing or to the health service. I hope that they will return to university to take up and complete their degree course, and so stepping on and stepping off is right and sensible. Can my noble friend the Minister say whether it is true that some higher education establishments are unhappy about this concept and indeed may be lobbying against it? I am not quite sure why they might do that: it might be the notion of "bottoms on seats" and money following, or perhaps they do not particularly like the flexibility of this approach, but I should like to be reassured that this rumour which has reached me is not true.

I want to return for a few moments to care assistants. A recent survey shows that almost one-third of NHS trusts do not give non-registered nursing staff, whether healthcare assistants or nursing assistants, access to national vocational qualifications. The grade of healthcare assistant was introduced some years ago

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on the back of the theory that there would be access to national vocational qualifications with a "links and ladders" approach to pay and promotion or grade.

Much of this has not happened. Whatever good intentions existed were swept away by the other driver to the introduction of healthcare assistants, which is cost-saving.

Healthcare assistants are outside the remit of the pay review body. They are generally paid less than nursing assistants. There is evidence that perhaps the majority who do gain national vocational qualifications do not get better pay or any promotion. I therefore hope that my noble friend will indicate whether it is possible to require, or at least lean fairly heavily on, health trusts to give all healthcare assistants at least access to NVQs and to use the "links and ladders" approach to pay and grading. I am strongly of the view that while good works have been done in increasing the pay of newly-qualified nurses and of experienced staff nurses, we also need to attend to the underpinning: the healthcare assistant, the auxiliary and the enrolled nurse. It would do much for morale, confidence and workforce planning, and not least for a greater resource for fast-track entry into higher education, if more care were given to that end of the nursing workforce.

Healthcare assistants are often mature adults. They are a known quantity to the employer; they are of the community in which they live and work and, when qualified as nurses, they will no doubt return to serve that community. Like the noble Viscount, Lord Bridgeman, I too am concerned that healthcare assistants should be brought within the remit of the United Kingdom central council. I said earlier that I am strongly of that view.

I will leave the matter there. Much good has been done in the past two years for nurses and for nursing. Much more needs to be done, but there is light at the end of the tunnel. That is good for nursing, and what is good for nursing is good for the patient and the client.

4.54 p.m.

Lord Clement-Jones: My Lords, it has been a great pleasure to listen to this debate. I declare an interest in that my two sisters were trained as nurses. One of them works as a health visitor and the other as a theatre sister. I have found it extremely valuable and illuminating listening to the debate and to those who have expressed both their professional and personal experience. I am only sorry that the noble Lord, Lord Morris of Castle Morris, cruelly denied us a practical demonstration half-way through the debate!

I think it is true to say--and certainly this is very much the tenor of what noble Lords have had to say--that the nursing contribution will be a crucial factor in determining the success or failure of the United Kingdom's health services in the 21st century. There are huge problems to grapple with, as has been made clear throughout the debate. We have heard that an additional 17,000 nurses are required, as the noble Baroness, Lady McFarlane of Llandaff, reminded us at the beginning of the debate. Some 140,000 nurses

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have left the profession in the last three years. Clearly we must recognise that recent recruitment initiatives may have had some success but we are faced with an ageing profession. Almost 25 per cent of qualified nurses are over 50, which means that we have a major issue of retirement looming.

As regards district nurses the issue is even greater. In a survey last March it was found that the average age is 45, and most district nurses want to retire at the age of 55; so the issue of retirement is even greater. Set against these shortages, however, the noble Lord, Lord MacKenzie, was quite right to remind us about the use of nurse agencies, which has escalated greatly over the past few years. As a number of your Lordships have recognised, this is a false economy. I wonder whether the Government really are tackling that issue with enough vigour. This process has escalated heavily over the past few years. Some hospital trusts, such as the Royal London and Bart's, have something like 25 per cent of their nursing establishment vacant.

If we are to attract nurses clearly we must create the right climate, as the noble Baroness, Lady Lockwood, reminded us. Indeed the Government's own document Making a Difference said that nurses need a more satisfying and rewarding career. One therefore needs to have the right climate and to set the training and education we have discussed tonight against the backdrop of certain key elements.

The first of these is pay. It is clear that a one-off rise for nurses at any particular time is not sufficient. We need a commitment from the Government to consistent rises over a period. We saw the lower grades receive a higher pay average rise last year and we saw the higher grades receive a higher award this year. There must be consistency and there must be that commitment over a period of years. The pay of the newly qualified nurse is still low compared to other professions. The grade D nurse on registration receives between £14,890 and £16,445. There are still problems as between grades E and F. There is little differential between the grades, which gives little incentive to take on further responsibility by moving up the ladder.

Turning to family-friendly employment policies, there was a Changing Times survey in 1998 which showed that 58 per cent of nurses have caring responsibilities for dependent children and/or dependent adults. Of those responding to the poll, 85 per cent said that family-friendly policies would encourage them to stay in nursing. Above all, they said more flexibility was needed. Quite clearly, the message has not got through to some trusts. What has been the response of the Government to the Melksham Hospital case: the Hale and Clunie judgment? Is the NHSE making sure that this does not happen again? Have health trusts absorbed the lessons of the way in which internal rotation systems were introduced and of their impact on married women?

Thirdly, there is another major issue that we must look at in the context of nurse recruitment and retention plus training and education. Central to those aspects is the whole question of crime and health and safety in hospitals. Major causes of stress were

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identified in a survey of March 1998. Many of these incidents were workload-related; but the element of crime in hospitals is quite frankly unacceptable. A later survey showed that 50 per cent of all nurses said that they had been physically assaulted within the previous year. We know that the Government have been taking certain initiatives to try to prevent crime and to have better security systems in hospitals, but what has been the impact of government campaigns in this respect? What concrete results can the Government show?

I move on to the question of education and training. A number of noble Lords have a vast amount of knowledge and experience in this area, but I think that the noble Baroness, Lady Masham, got it right when she emphasised the need for practical skills. Indeed, the noble Baroness, Lady Emerton, put it very well when she said that the absolutely fundamental issue was the protection of the public.

In that context, like the noble Lord, Lord, MacKenzie, I very much welcomed the Peach Report, Fitness for Practice, and the Government's strategy paper, Making a Difference. There were concerns--and one cannot hide this fact--about the practical skills of the new intake. I thought that the phrase "academic drift" from the noble Baroness, Lady McFarlane, was very telling. One needs to review the status of training and assess how it is fitting in with the modern requirements for nurses. Sir Leonard did acknowledge a lack of practical skills and a "lack of confidence", which I thought was an interesting comment--indeed, the noble Lord, Lord Harrison, also referred to that--on the part of those going on practice placements.

There were also the other steps suggested by Peach, such as the three-month practical placement before qualification and longer practice placements, the emphasis on mentoring and, as the noble Baroness, Lady Cox, pointed out, the emphasis on outcome and a competency-based approach. It was suggested that recruitment should be appropriate and that that should be the joint responsibility of colleges and hospitals. Finally, the actual return to a 50-50 split between practical and academic training was suggested as clearly being of great value.

It is vital that we get the education and training of our nurses right. As I understand it, it costs something like £35,000 to train each nurse. We need to look at the nature of that education and training to ensure that that resource is being properly used. Indeed, is the drop-out rate 30 per cent? Is the noble Lord, Lord Morris of Castle Morris, correct in casting doubt on those figures? Whatever the figure may be it will clearly be high, so there is a major waste of resource. But why is there such a waste? We need to know the answer.

We also need to know over what period of time the suggested reform will be implemented. I understand from the Committee of Vice-Chancellors and Principals that the new courses will be starting on 16 sites in September. Is that an adequate rate of progress? Should we be stepping it up? Does it mean that we have a sheep and goats situation, if you like,

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with a set of nurses being registered who do not have the practical skills that those trained in the new sites will have? It is important for us to ensure that we have that consistency as soon as possible.

Many speakers referred to the way in which one can gain education and training in terms of the flexible routes towards achieving that end. I certainly welcomed the references to the stepping-on and stepping-off approach by the noble Lord, Lord MacKenzie, and to the access programmes mentioned by the noble Baroness, Lady Lockwood. We welcome those schemes to attract ethnic minorities to consider nursing careers, as mentioned by the noble Baronesses, Lady Lockwood and Lady Warwick. I could go on to talk about consultant nurses and the whole management process, which many speakers mentioned. However, time is short. What is quite clear is that generally there will be a much greater role for nurses to play in the future. I felt that the Crown report on prescribing was disappointing in some respects in that a clearer prescribing role was not outlined for nurses. Specialisms are becoming increasingly important. The role of nurses within NHS Direct and telephone helplines generally is of great importance. Clearly their role within primary care trusts and groups must increase as time goes on.

Many speakers referred to healthcare assistants. That is a crucial issue. Our nurses possess precious skills and we must recognise that healthcare assistants will take over some of the non-clinical tasks. However, if they do so they must be properly regulated. Therefore, the Government's current consultations are of crucial importance.

I am always willing to take inspiration from the Government Benches. The noble Lord, Lord Winston, for whom I have the greatest respect, said the following in 1998:

    "Successive governments have failed dismally to grant this profession of highly skilled and dedicated people the recognition and rewards they deserve ... If we lose our respect for the value of nurses then our society and its values are significantly cheapened".

We all expect the Government to take the necessary steps to rise to this challenge. For me, that includes rewarding nurses properly and ensuring that they have the right resources, the right training and standards and the right working environment in which to exercise their skills. I look forward to hearing the Minister's reply to the debate.

5.4 p.m.

Earl Howe: My Lords, this has been an extremely informative and constructive debate. Perhaps I may begin by thanking the noble Baroness, Lady McFarlane, for making it possible. If only to trump the noble Lord, Lord Clement-Jones, I am delighted to say that I, too, have a sister who trained as a nurse at the Middlesex Hospital and who went on to have a fulfilling and varied career, latterly in the specialist field of pain control.

I do not think that one can approach today's debate about nurse training and practice without first recognising the backdrop against which it is set. In

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recent months nursing shortages in many parts of the NHS have reached crisis levels. The number of newly qualified nurses joining the UKCC register has dropped by nearly 18 per cent in four years and, as a number of noble Lords reminded us, according to the most recent RCN figures nurse vacancies are running at around 17,000 compared with 15,000 nine months ago and 13,000 the year before.

The Motion that we are considering is not directly about the issue of nurse recruitment and retention; but it bears importantly upon it, in that unless the education and training of nurses is got right--that is to say, unless it is sufficiently attractive and rewarding to a large enough number of aspiring nurses each year, and continues to remain so--the problem of numbers will get worse, not better.

One of the key questions posed by commentators is this. Does nurse education, structured as it now is, serve to exacerbate or to ameliorate the current nursing shortages? To answer that it is worth reminding ourselves why Project 2000 commended itself to the previous government so strongly in the first place. In the mid-1980s, the NHS was experiencing a very high drop-out rate from nurse training. Demographic trends meant that nursing had to compete much more vigorously for new recruits from a diminishing pool of school-leavers. Greater intensity of care in hospitals and more sophisticated treatments, as well as the shift to a primary care-led service, all pointed to the need to educate nurses to higher levels and to integrate theory and practice in a more structured way than before.

One of the handicaps that the nursing profession had to live with for years was that it was seen as a menial or low-grade occupation. To some extent, I am sorry to say, that is still true. It was essential to try to banish that perception: first, in order to maintain recruitment at adequate levels; and, secondly, to ensure that the NHS could draw upon the skills that it now needed from the nursing workforce--skills which were becoming increasingly complex and varied.

That rationale for Project 2000 remains as valid today as it was at the outset. If anything, the justification for keeping the responsibility for nurse training with the universities is stronger now than ever before. It is difficult, for example, to argue, in the face of a rising number of applications for nurse training places, that the academic element of the programme is off-putting to potential recruits, though there is a good case, I think, for abbreviating and revising the common foundation programme.

It is equally difficult to argue, as some do, that higher education has made nurses too clever for their patients' good, when all the time the clinical and organisational skills that nurses need in the surgery or on the ward are becoming more sophisticated. Nurses need to be "doers"; but, as someone said, they need to be knowledgeable doers. If we look ahead to the advent of genetics in diagnosing and treating illness, we can see that it would be unthinkable to exclude nurses from gaining at least a basic appreciation of the subject. On a less rarefied level, we need only think of

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the demands placed on nurses by the advent of clinical governance, NHS Direct and evidence-based practice to see that nurse education must be pitched at the appropriate level to make these and future developments work as they should. It is worth noting that nurse education in many countries around the world is becoming increasingly degree based.

The noble Baroness and many noble Lords referred to the UKCC report, Fitness for Practice, which was published last September. I agree with the noble Lord, Lord Morris of Castle Morris--whose presence here I warmly welcome--that that report made an exceptionally valuable contribution to the debate about the future direction of nurse education. It occurred to me that the easiest course of action for any Front Bench speaker would be to ask the Government how they were going to respond to the 33 well argued recommendations contained in that report, and then sit down! The House might thank me for it. But that would have the disadvantage of glossing over one of the key criticisms of Project 2000: that it produces nurses who, at the point of registration, find themselves inadequately equipped to perform practical and basic nursing tasks on the ward. This widely held--but for a long time somewhat anecdotal--impression was backed up by the findings of a recent survey in which 59 per cent of recent registrants believed that more practice and less theory was required in the first year of the programme. In the same survey only 29 per cent of experienced staff in contact with Project 2000 nurses regarded them as either very well or quite well prepared in terms of essential practical nursing skills.

It would be helpful to hear from the Minister whether the Government accept that this is an issue, and if so, what action they consider appropriate. In their document Making a Difference the Government undertook to consider EC directives which allow students to have more practical experience. I should be grateful if the Minister would elaborate on that as I was uncertain of the significance of that passage. In theory at least, the ratio of practical to academic teaching in pre-registration nurse training is 50:50. There is powerful evidence, however, that--as many noble Lords have emphasised--much of the practical training is debased by the lack of experienced nurses on the ward to act in a supervisory role, and by the sheer pressure of day-to-day life in a hospital. It is no good if a student nurse has to refer to a healthcare assistant for practical guidance. But that is what the current shortage of trained nurses can sometimes lead to. As I think every speaker has mentioned, the quality of the clinical placement is a vital ingredient in the learning process, and in that context I particularly welcome the recent joint publication by the NHS Executive and the Committee of Vice-Chancellors and Principals mentioned by the noble Baroness, Lady McFarlane, which recognises the importance of establishing close links between universities and NHS trusts. The aim should be to provide better support for students on placements; to give them a sense of belonging--which many of them do not have--and to ensure that those placements count for more, most

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notably by making them of longer duration. Much the same considerations apply to preceptorships for newly qualified nurses.

To say that one is in favour of a diploma or degree based qualification is not, however, to say that entry into nursing should be limited to a narrowly defined group of people. One of the UKCC's main recommendations was that the NHS should try to attract student nurses from every type of background. I should be interested to hear from the Minister what plans the Government have to make nursing more appealing to members of ethnic minority groups who are under-represented on the register at present. I wonder, too, if he can comment on what seems to me an increasingly successful vocational route into the profession; namely, nursing cadet schemes--again these have been mentioned by a number of noble Lords--aimed at 16 year-old school leavers. As the Minister will know, cadet schemes have been championed in a number of hospital trusts and are proving popular. At Sandwell Health NHS Trust, for example, cadets are guaranteed a place at Wolverhampton University when they have achieved their NVQ level 3 and are ready to take a diploma. Another recruiting pool with considerable potential, mentioned by the noble Lord, Lord MacKenzie, and a number of other noble Lords, is that of healthcare assistants. Ways of fast-tracking healthcare assistants, especially those with considerable practical experience, through special nurse education programmes could be explored through the Accreditation of Prior Learning system. Can the Minister say whether the Government are willing to support such initiatives, and if so in what way?

I mention these kinds of example to emphasise a point which many of us, I suspect, feel instinctively; namely, that the entry gate into nursing should be as wide as we can legitimately make it. There must be many young girls and boys who, when they leave school, know that they want to look after people but who may also feel that they are not yet ready to embark on a nursing diploma, still less a degree. Nursing should not shut out those individuals.

I think that all noble Lords have recognised that, if they are to succeed, the style and content of nurse training programmes have to be tailored to appeal to individuals from a wide variety of backgrounds. Within reason the programmes must be flexible so as to deter as few people as possible who would otherwise have wished to enlist.

In the end, the success or failure of nurse education programmes will be measured in three ways: the numbers joining such courses; the percentage of students who continue the programme to the end; and the perceived fitness for purpose of the nurses who qualify. I hope that the Government will recognise, and confirm to us today, that nurse education will remain central to the delivery of high quality healthcare across the country.

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5.15 p.m.

Lord Hunt of Kings Heath: My Lords, I am most grateful to the noble Baroness, Lady McFarlane, for securing this timely debate on such an important subject. She has had a most distinguished career in nursing. She was one of the first professors of nursing to be appointed. She was a true pioneer in the development of nursing education and practice and a towering presence in the nursing profession for many years. It is a particular pleasure for me to respond to her debate.

As other noble Lords have said, it is also a great pleasure to welcome my noble friend Lord Morris of Castle Morris. He has been "cooking up" this debate for many months. I am sure that he will consider that the quality of all the contributions that we have heard this evening have been well worth the effort.

We are discussing nurses, but over the past few weeks when the health service has been under tremendous pressure the contribution of all staff--doctors, nurses, paramedics, ambulance crews, community pharmacists, GPs and many more--has been absolutely outstanding. I take this opportunity to pay tribute to our wonderful staff, of whom nurses are often the most visible presence in all our thoughts.

This debate has been a wholly positive one. It very much reinforces the Government's intent to pick up the point made by the noble Earl, Lord Howe; namely, to put nurses at the centre of all that we do and seek to do to modernise the health service. One has just to think about the potential of nursing in caring, in clinical areas, in leadership at a clinical level, in management and in new developments such as NHS Direct to appreciate that nurses are at the leading edge of the modernisation of our National Health Service. However, they remain true to the principles which the noble Baroness, Lady Cox, mentioned so eloquently today. The comments of the noble Baroness, Lady Emerton, also gave the full picture of what nursing is all about.

As ever, I do not have a long time in which to respond to many of the points which have been made. However, I refer to the particular concern of my noble friends Lord Harrison and Lady Lockwood that nurses should be recognised and rewarded. As my noble friend Lord Harrison pointed out, Making a Difference set out radical plans for a new career framework linked to our proposals to modernise the NHS pay system and to provide satisfying and rewarding careers. The noble Lord, Lord Clement-Jones, mentioned the escalating use of nursing agency staff. I believe that ultimately the best way to attract full-time staff is to ensure that we have a proper career framework; that we address the issue of support for staff in stressful situations; that we are able to develop family friendly policies; and that we ensure that staff are protected from crime.

As regards family friendly policies, I accept the responsibility of making sure that NHS trusts get the message in this respect. We have appointed champions in each region of the English NHS to develop good practice and to send out the kind of messages that the noble Lord has suggested we ought to send out.

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As regards crime, I could not agree more with the points made. It is intolerable that our staff, particularly nurses, are subject very often to abuse, both physical and verbal. We are determined through our zero tolerance campaign to do something about it. I know that the initiatives that we are taking have received a great deal of support from the nursing profession.

When we consider the status of nurses and the wish to assure nurses of the key responsibilities that they have, I commend to your Lordships our appointment of consultants in nursing. That sends all the right messages of what nurses can achieve. It demonstrates the heights, if I can put it that way, that people coming into nursing may attain within a clinical area, and not necessarily by having to move into management posts if they do not wish to do so.

Let me now turn to the issue of recruitment and retention. The noble Earl, Lord Howe, the noble Lord, Lord Clement-Jones, the noble Baroness, Lady Cox, and the noble Baroness, Lady McFarlane, made particular points about the issue of the shortage of nurses.

Of course there is no hope of achieving what we wish to achieve in maintaining and developing services unless we can recruit more nurses to the health service. There is no doubt about that whatever. Our intent is that by 2002 we will make available up to 15,000 more qualified nurses and midwives. As your Lordships know, we have worked very hard to retain the nurses that we have.

Of course pay is a factor in this. I accept the point of the noble Lord, Lord Clement-Jones. Last week in another place my right honourable friend the Secretary of State for Health announced above inflation pay increases for all nurses. Some 60,000 experienced staff nurses are to receive a 7.8 per cent increase. That is a very important signal to the nursing profession, particularly as this is the second year in succession where we have accepted the pay review body's recommendations in full.

Our current nurse recruitment campaign is proving that the NHS is turning the corner in this area. Almost 5,000 nurses have returned to employment in the NHS or are preparing to do so after completing refresher training. Even more encouraging is the fact that recruitment to nurse training at the moment is very buoyant. The Government are committed to achieving 6,000 more nurse training places by 2002. Applications for the diploma programmes have risen by 79 per cent and there has been an increase of 24 per cent in the numbers taking up degree courses.

The issue of degree versus diploma is always interesting. I agree with the noble Earl, Lord Howe, that there is a place for both and that we need to make the entry gate as wide as we possibly can.

I was interested in the comments of my noble friend Lady Lockwood when she raised the issue of attrition rates. My figures show that they are around 15 per cent. We have ironed out some of the anomalies to which my noble friend Lord Morris of Castle Morris referred. Of course 15 per cent is lower

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than some of the figures that we have heard during the debate. None the less, there is no room for complacency. Clearly we must do all that we can to get those figures down.

When we think of diplomas and degrees we come to the issue of how one balances academic qualification against the need for access to nurse training for as many people as possible. I was particularly pleased to hear of the examples of good practice that many noble Lords raised tonight. My noble friend Lady Lockwood, for instance, spoke about Bradford's pioneering achievements--and we have seen a high increase in the number of applications to become nurse trainees from members of the Asian community. A number of noble Lords referred to Wolverhampton and the link with Sandwell Health. My noble friend Lady Warwick referred to new vocational pathways, part-time courses, access and cadet schemes. There were other examples. I was delighted, for instance, that the University of Central England based in Birmingham achieved an honourable mention. I can say to the noble Earl, Lord Howe, that we will spread the message about the successful schemes. There is much to learn there.

I am aware of concerns in relation to student bursaries. Let me make two points: first, in regard to anomalies, to which a number of noble Lords have referred; and, secondly, in regard to the administration of the schemes in the last round, a point raised by the noble Lord, Lord Harrison. As far as concerns the anomalies in relation to student bursaries, I propose to undertake a review of student support which will report within 2001. I am also determined to ensure that we iron out the problems that have occurred over the past few months in relation to the administration of bursaries.

I now turn to issues of nursing practice. The noble Baroness, Lady Masham, made some very interesting points on that. To start with, we need to reflect on the many important new areas in which nurses are leading change--clinical governance, evidence-based practice, skill mix changes and NHS Direct. I never tire of reminding your Lordships of the success that NHS Direct is having. It is, of course, all down to experienced nurses and the advice that they are giving to thousands and thousands of people.

Of course there will always be concerns about the changes that have taken place in nursing practice and nursing management. The noble Baroness, Lady McFarlane, referred to her appearance in the Lord Mayor's Show. I surely did not hear a cry from her of "Bring back matron". We must recognise that we have some very dynamic, expert, professional nurse managers and leaders in the health service, who are well able to handle the awkward questions posed by the noble Baroness, Lady Cox. While I understand the nostalgia for the matron's round and all that that meant, we should pay a great deal of tribute to the quality of nurse leadership that we now find in many of our hospitals and other areas of the health service. It is no coincidence that if one looks at the number of general manager posts occupied in the health service,

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nurses supply a significant number of people to those posts. That is a reflection of the quality that they are bringing to leadership in the health service.

There have been many reports on nurse education over the past 20 or 30 years. The noble Baroness, Lady McFarlane, referred to some of them and to some of the shortcomings, particularly in tackling the new challenges that we all face. She referred to many of the achievements and some of the problems of Project 2000. My noble friend Lord MacKenzie made some very pertinent points and I was particularly interested in the comments of the noble Earl, Lord Howe, which provided information about the background. I agree with him when he stresses the role of the universities and the essential contributions that they now must make to nurse education.

We have listened carefully to the concerns about the current arrangements for nursing education. In Making a Difference the Government set out their priorities to improve nurse education, to tackle concerns that student nurses do not always acquire the necessary practical skills while ensuring that they are fully prepared for their future leadership roles. There will always be a balance between clinical practice experience and the need for academic vigour. It is important that we get the balance right.

With that in mind we have set out a three-point plan: to provide more flexible career pathways into nurse education; to increase the level of practical skills; and to deliver a nurse education system more responsive to the needs of the NHS. Under this new model universities will develop systems which will recognise the existing learning and skills, for example, of NHS healthcare assistants with vocational qualifications, enabling them to fast-track nurse education.

I accept the point made by my noble friend Lord MacKenzie about the need to encourage healthcare assistants, first, to have access to NVQs and, secondly, it is hoped, to fast-track them through to full nursing qualifications. I should like to say to the noble Viscount, Lord Bridgeman, that of course we accept that there is a need to review the status of healthcare assistants and we have recently announced a review to do that.

I believe that the new model that we are developing will provide more opportunities for people from all walks of life to deliver front-line care in the NHS as qualified nurses. There will be a focus on the development of practical skills earlier on in training, and a focus on better clinical placements, with support for students from trained nurses with up-to-date teaching skills and from teachers who are actively practising nurses.

I accept the important point made by my noble friend Lord Morris of Castle Morris on clinical placements. We have already issued guidance on introducing long-term practice placements. Undoubtedly the new model of nurse education will bring in a stronger practice focus through early practice placements and links between education and employment. In response to the comments of the noble

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Viscount, Lord Bridgeman, I support the view that students should also be able to gain experience in the independent and voluntary sectors as a part of their training. More generally, we need to work very hard to ensure that clinical placements are as effective as possible and that those students being so placed receive the support they need in what undoubtedly can be stressful situations.

I shall now turn to the arrangements for dealing with nurse education at the national level. In the wake of Project 2000 there has been some criticism that the NHS effectively handed over responsibility for nurse education to the university sector. Because of that, we have announced the creation of a new education and training unit within the NHS Executive to strengthen delivery and quality assurance of education in England, from lifelong learning for the wider NHS workforce to continuing professional development.

The intention is to achieve a far more consistent approach to education and training. However, that neither ignores nor undermines the fact that it will require a strong partnership between the NHS, the regulatory bodies and the universities. I should like to reinforce the message given by many noble Lords today about the need for that partnership. My noble friend Lady Warwick stressed the need for partnership with the universities. The noble Baroness, Lady Emerton, spoke of the need for partnership with the NHS. I very much look to chairs and chief executives of trusts in the NHS to ensure that that happens.

NHS employers need to know that, wherever nurses are trained, they have acquired the same level of practical skills at the same stages in nurse training. Similarly, the regulatory bodies need to know that nurses meet the standards for entry into the profession and the universities need to know that nurses are fit for the academic award. We want to see a streamlined system of quality assurance to assess fitness for purpose, fitness for practice and fitness for award.

The Department of Health will take the lead on assuring the quality of NHS-funded education through a contract with the new quality assurance agency, working in partnership with the regulatory bodies, the universities and the NHS. I hope that this assures my noble friend Lord Morris of Castle Morris that we will ensure that the most effective teaching by well-qualified people will be undertaken. None of this affects the principle that the regulatory bodies have ultimate ownership of setting and monitoring standards for the purpose of registration, but it does mean a more coherent and collaborative approach to quality assurance.

I should like to turn to regulation. Almost a year ago the Government announced their response to the review of the Nurses, Midwives and Health Visitors Act 1997 and an acceptance of the recommendation to create a new nursing and midwifery council. Since then, we have worked closely with all the health professions. We fully support professional self-regulation, but it must be open, transparent and accountable. Furthermore, we are committed to strengthening the regulatory framework with a new smaller, strategic UK-wide council.

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As regards the order, perhaps I may assure the noble Baroness, Lady Emerton, that we will engage in open consultation. The initial consultation is due to commence shortly with a further three-month period for consultation prior to the order being laid before Parliament.

The clock is against me. I hope that I have assured noble Lords that the contribution of nurses, midwives and health visitors is both recognised and valued. These professions are undoubtedly the backbone of the NHS. They are leading the way towards modernisation. They are an enormously committed workforce for which any other employer would give an arm and a leg. We owe it to them to support them in what they do, to ensure that they are well rewarded, that they have a proper career structure and that, as the regulation and training of the profession is modernised, so we will support them in these new challenges.

5.35 p.m.

Baroness McFarlane of Llandaff: My Lords, time is against us in this time-limited debate. However, I should like to thank everyone who has taken part in what has been a wide-ranging and informative debate. I am sure that we shall all leave the discussion with new vistas on the whole aspect of nursing education and practice.

The experience and expertise of the House shows itself marvellously in a debate of this kind. Where else would we have two university chancellors talking about nursing courses in their universities and a view from an independent provider? Not least, we have heard the four nurses in the House contributing from their personal experience. However, the most eloquent contributions today have come from the consumers, those who have experienced nursing care of various qualities. I should like to thank them for their contribution to our deliberations. That will send us away with a greater determination to ensure that nursing education and practice is improved in the interests of the consumer.

I should like to thank the Minister for the way in which he answered so many of our questions and for the generous personal remarks that many contributors have directed to me. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.

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