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Nurses' Pay And Conditions

Volume 113: debated on Tuesday 26 May 1987

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Motion made, and Question proposed, That this House do now adjourn.— [Mr. Portillo.]

8.32 pm

I intend to speak at a little length about nurses' pay and conditions of work. The House will know that I am sponsored by COHSE — the Confederation of Health Service Employees. It has supplied me with writtten evidence that it and others have put before the pay review board that was set up by the Government in 1984. I hope that the Minister has read and digested that document. It is a powerful indictment of what the Government have or have not done for nurses in the past six or seven years. That written evidence is agreed not only by COHSE but, for the first time in a long while, by virtually all other professional organisations associated with the nursing profession. I refer to midwives, health visitors, and all organisations normally associated with moderation within the Health Service.

Before I refer to nurses' pay and conditions, I shall make a brief comment about Project 2000. At a later stage in this Session of Parliament, a separate debate might be initiated by me or by another hon. Member specifically on the proposals made by the United Kingdom Central Council for Nursing and Midwifery on nursing training and education, which is the basis of Project 2000. Clearly, at this stage I shall not go into the merits of the 25 recommendations that it made. It is common knowledge that the population is aging. The number of people over the age of 75, and even over 85, is increasing. At the other end of the scale, there is a decreasing number of young qualified people whom one would expect to look after the aging population. Within that context, the principle is generally agreed that aging people are better looked after in the community rather than in institutions, whether they be hospitals, nursing homes, or whatever.

One cannot save money on the implementation of community care. If we are properly to conduct community care, carers—whether they be in institutions or in the community — must be adequately qualified and paid. Community care is not a cheap option. Until now, the Government appear to have considered it to be a cheap option. There must surely be a comprehensive rethink of the ways in which we recruit, train, reward and retain the personnel needed to perform such services. It is my view — I think it is widely shared—that we shall never get such personnel in sufficient numbers and with the necessary human and academic qualifications unless we are ready to offer them much greater incentives, whether they be pay, promotion, accommodation holidays, or sick pay incentives.

As the Prime Minister said in another context when the Falklands war was being fought, "Whatever the cost, we had to win." There was no question of cash limits or anything like that. I use those words in this context. Whatever the cost, we have to meet the challenge. We cannot afford not to meet it.

There is broad agreement that the present pay and working conditions of our hospital and working staff—whether they be ancillary, health visitors or district nurses —are patently inadequate and are creating problems in recruitment and retention on a worrying scale. I hope that the Minister will give us figures to contradict that fact or will tell the House what the Government propose to do to solve the problems.

The pay review machinery that was established in 1984 has done nothing to alleviate the problems The level of pay during training, after qualification and at maximum levels of basic pay are unattractive compared with the pay and conditions of other public servants. Startling evidence on this point was given by the staff side. The staff side document refers to police pay. No Opposition Member begrudges the police their increase in pay. They do a very good and dangerous job; but so do nurses.

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

indicated assent.

The Minister is nodding assent; she knows what I am talking about.

When he enters the police force, a man does not have similar qualifications to those of a student nurse, but he starts on £7,752 a year, while a student nurse starts on £4,325 a year. Assuming that a policeman is not promoted, after 16 years in the profession he is paid £12,936, an increase of more than £5,000. When a student nurse becomes a staff nurse, she receives £7,750. After eight years she is still on £7,750, assuming that she, too, has not been promoted. A policeman receives roughly £100 a week more than the fully qualified, highly trained and experienced staff nurse.

Nobody in the country could pretend that after 16 years' service a policeman is a more valuable citizen than a staff nurse. The only difference is that the one is almost invariably a man whereas the other is almost invariably a woman. I appeal to a woman Minister to defend that, if she can.

A case came before the High Court yesterday about equal pay for work of equal value. If the nurses' professional organisations challenged the facts I have just given in the courts and said, "We assert that the work nurses are doing is equal in value to the work that is done by policemen; therefore, their pay ought to be the same as that of policemen", I am certain that they would win their case.

Does my hon. Friend think that members of this highly skilled profession will be attracted by the offer of work outside this country and that there will be a nurses' drain? I draw his attention to an advertisement two weeks ago in the Nursing Times and Nursing Mirror in which British nurses were offered $35,000 a year in California and absolutely exemplary conditions of service. That is over £23,000 a year. I am not suggesting for one second that nurses should be paid as much as that, but I ask my hon. Friend to remember that there could be a nursing drain if something is not done to improve the pay and conditions of employment of nurses.

My hon. Friend is a doctor and speaks with a good deal of experience. I shall deal with that point in due course. He knows as well as I do that Americans have recently been recruiting Scottish nurses for hospitals in Texas.

As for the exchanges on this matter during the Budget debate, the Chief Secretary to the Treasury referred—as the Prime Minister has done on many occasions at the Dispatch Box in the last few months—to the £155 a week nurse. There are not many of those about in the National Health Service. However, the Chief Secretary took that as a typical case and said that as a result of the Government's very generous Budget the £155 a week nurse would get back £2·64 a week as a result of the reduction of 2p in the standard rate of tax. That is broadly true, but I remind the House that when the pay hoard recommended last year an 8 per cent. increase for nurses the Government gave them 6 per cent., because they froze it for three months. Therefore, the staff nurse who has been given back £2·64 had £3 a week taken off her last year because of the Government's reaction to the pay board's recommendations. Therefore, she is worse off now than she was a year ago.

Last Wednesday, the Chief Secretary to the Treasury also claimed that
"in real terms the income of nurses"—
not a nurse—
"is up by 33 per cent. since 1979."—[Official Report, 18 March 1987; Vol. 112, c. 960.]
The Opposition and many people outside Parliament now treat the Chief Secretary's figures on any subject with extreme caution and suspicion. I asked the House of Commons Library to produce some figures for me. They differ substantially from those that were implied in the Chief Secretary's statement. My figures relate to gross pay on maximum scales. In real terms, taking account of inflation, a first year student nurse is 1·8 per cent. worse off now than she was in 1979. In real terms, a staff nurse on the maximum of her scale is 13·2 per cent. better off. We all welcome that. Nevertheless, although the Government boast about the marvellous success of the economy since 1979, they can only say that a staff nurse has had an increase in real terms of less than 2 per cent. each year since 1979. A ward sister has had an increase, in real terms, of 21·5 per cent. during that period, or of 3 per cent., in real terms, each year. Only yesterday. The Independent said that last year company directors had an average salary increase of 10 per cent.

One looks at figures of real wages and inflation with very different eyes, depending on the side of the Chamber upon which one sits. I appreciate the hon. Gentleman's point about directors' pay, and I do not doubt that one could find even more bizarre examples. For a Government not only to match inflation but to increase pay in real terms by 2 and 3 per cent. per annum for each of the years between 1979 and 1983 is a substantial achievement. In view of that, the hon. Gentleman should not overplay his broad case.

This Government are about the meanest that we have had since the end of the war, and that is reflected in the way that they have dealt with nurses' pay and conditions. I shall shortly give the nurses' reaction to the Budget. They do not accept for one minute that they have been treated other than meanly by the Government. With all their trumpets blaring, the Government established a pay review board to give an independent assessment for nurses and take them out of the heat of political controversy. It has done nothing of the kind, because on every occasion that the board has made recommendations the Government have overturned or reduced them.

The hon. Member for Oxford, East (Mr. Norris) is right when he says that the real earnings of nurses have gone up. But so have the real earnings of other people, and, compared to them, nurses have fared badly. Let not the Government take any credit, because they sought to resist all kinds of wage increases. Even now the Government and the Confederation of British Industry are saying that these "unfair and unjustified" wage increases must be stopped. Now the Government claim credit for them.

Let us be under no illusion about what has happened. Whatever increases nurses or any other workers are getting, they are getting them in the face of ruthless opposition by the Government. There is no question about that. Because of the poor conditions of female nurses, they are voting with their feet by either getting out of the profession or refusing to come into it. I shall give one or two examples of what is happening. The Minister will have read in The Guardian of 20 March about the state of the West Middlesex hospital. The Guardian said:
"The West Middlesex hospital in Hounslow, which provides accident cover for Heathrow Airport, is to divert all ambulance and GP emergency cases to neighbouring hospitals while two wards are emptied and closed. 'We have reached such a crisis point in nursing levels that we just can't keep them open,' Mr. John Branczik, the unit general manager, said last night."
The unit general manager went on to say:
"The hospital has 180 nursing vacancies out of a complement of 640, and is regularly relying on more than 100 agency nurses to keep going. We are in a real crisis. We have an excellent nursing school with high standards, but we have simply got to ease the strain and make the job more fulfilling."
I was in touch this morning with the unions at that hospital and they tell me that the figures are not quite as bad as the figures that the unit manager was reported in The Guardian as quoting. The unions told me that currently there are 107 nursing vacancies and that the hospital authorities have been trying to recruit in Scotland and Ireland but have failed because there is a lack of accommodation in and around Hounslow. I was told that no emergency cases have been admitted to the hospital in the last four to five months and that it has been on red alert since March 1986. I was told that last week two medical wards were closed because of shortage of staff.

Despite that, the health authority has decided to sell nurses' accommodation in order to raise £750,000. It has also decided that it would like to take on youngsters from the youth training scheme to work in the wards. Quite rightly, that has been violently opposed by the trade unions. I was told that two months ago the health authority tried to force nurses to work 12-hour shifts. Again, there was fierce opposition by the trade unions, and they were absolutely right to react in that way.

I am told that the health authority took a decision to pay the private Royal Masonic hospital in Hammersmith £150,000 to carry out hip operations for which the Health Service could not cater. That £150,000 was provided by the Department to reduce the waiting lists in the National Health Service. The Government's boast is that they have reduced waiting lists. To do that, they have handed £150,000 to the profit-making private sector. The Prime Minister repeatedly says that the National Health Service is safe in her hands. It is about as safe in her hands as a lamb among a pack of wolves. She does not even use the Health Service herself.

I shall quote from The Independent another example of what is happening. On 16 March that newspaper had a headline which said:
"NHS losing 1,000 nurses a year to private sector".
Those nurses are trained at great public expense. The private sector does not train them. Taxpayers pay for that and then the nurses are taken into the predominantly American-financed private sector.

My hon. Friend says that that is poaching. That is a polite way of describing it. Nurses are going into the private sector hospitals or nursing homes after being trained at our expense. As the article in The Independent makes clear, the demand from the private sector is rising as the Government encourage the growth of private profit-making hospitals and homes. I have given one or two examples and I shall give one or two others. I quote from the March 1987 issue of the journal of the Confederation of Health Service Employees, my own union. The journal says that staffing cuts kill the patient. I shall quote directly from the article. It says:

"Savage cuts in staffing levels led directly to the death of a 62-year-old woman in a Glasgow hospital.
June Thomson bled to death on the renal unit of the Western Infirmary because a shortage of nurses meant that none could be spared to sit with her and check her condition constantly.
As a result, an arterial shunt stitched into her ankle came loose and she died within 10 minutes. Nurses had been able to carry out checks only every 15 minutes that night."
It continues:
"A sheriff's court inquiry into the death cleared nursing staff of all blame and found that staff to patient ratios were inadequate and had been for many years."
Figures compiled by COHSE, Scottish region, show that between 18 April and I September last year Greater Glasgow health board slashed 326 nursing posts on top of a loss of 750 nursing posts between 1982 and April 1986. That is one more example of what is going on in the Health Service today.

My hon. Friend the Member for East Kilbride (Dr. Miller) referred in an intervention to the brain drain of nurses going abroad. An example of this was reported in the Scottish newspapers a few days ago. A leading Dallas hospital is recruiting Scottish nurses and offering many young nurses more than twice their present salaries. The unions and others in authority are reported as saying:
"It's appalling that we're spending about £25,000 to train student nurses and losing them to the private sector, Saudi Arabia or the United States".
The newspaper article continues:
"The Parkland Memorial Hospital in Dallas, which faces a severe shortage of nurses, is recruiting in Edinburgh and Glasgow. It offers starting salaries of between £14,000 and £15,400 with extra payments, and benefits adding 18 per cent. to the package.
Ms. Elizabeth McLaren, secretary of the Royal College of Nursing's Scottish Board, said she was very sad, but not surprised, at the prospect of losing young people to this golden opportunity."
Ms. McLaren is quoted as saying:
"The Dallas team have picked the right pychological moment to come, with so much unrest, the tremendous stresses, the salary problem and in many places the quite atrocious conditions."
She felt that it was especially serious to lose nurses when the birth rate was falling and that a chronic shortage could be expected by 1990 unless conditions were made far more attractive.

In the light of those comments, I come to the Chief Secretary's remarks in the Budget debate and to my exchanges with the Chancellor at Question Time today. When I asked the Chancellor about the nurses' response to his Budget proposals, he said that it must be good because he was taking 2p off the standard rate of income tax. The 25–31 March edition of Nursing Times—not a Labour party magazine, but one for decent, moderate, gentle nursing folk—commented that
"in overall terms, the Budget gives the 'average' nurse just about enough money to buy a weekly bottle of cheap wine … but with nothing left to celebrate."
The same edition states:
"Staff nurse Judith Gosmore, who works at London's Westminster Hospital, will get an extra £1·89 in her weekly pay packet thanks to last week's budget."
There is a photograph of her. She seems a very nice girl, but not too prosperous. She looks as though she could do with a good meal, but she will not get one for £1·89. The article continues:
"But she is less than impressed. 'I want a decent salary instead of a paltry tax reduction,' said Ms. Gosmore. Ms. Gosmore is paid the minimum staff nurse salary of £6475 and will, as a result of the budget, now have a take-home pay packet of £88·80 per week."
That is a disgrace to a society that presumes to be prosperous and civilised.
"'After five more years as a staff nurse, I will be paid a maximum of £7750 (at current rates),' she says. 'This is £2 per year less than a raw recruit into the police force receives after only 20 weeks training.'"
The extract gives many more examples. It is like a Labour party propaganda sheet. It states:
"Last week, West Middlesex Hospital announced its accident and emergency department—one of the busiest in west London — would take only life and death cases to allow it to close wards."
It quotes the unit's general manager, whom I have already quoted, as saying:
"We are 180 nurses short in an establishment of 640".
It continues:
"Many hospitals in London and the home counties are embarking on employment drives in areas of high unemployment."
Ealing health authority has been looking around in Dundee, Newcastle and Belfast.

In its report on the control of nursing manpower, published in February 1986, the all-party Public Accounts Committee said:
"The prospect of a future shortage of nurses is a most serious matter of direct importance to patients, and we expect the DHSS to consider urgently what needs to be done, calling upon whatever expert advice is available."
I should like to know what has happened since that report was published. One year on, the staffing problems seem to be worse than ever. According to evidence that we are receiving from all over the country, recruitment and wastage problems show no sign of solution; on the contrary, they are probably getting worse.

Page 12 of the staff side document states:
"The last few years have seen significant falls in the number of recruits to the schools of nursing. In the past year alone there has been a decline of 7·7 per cent. in the numbers applying to enter student training and a decline of 20·3 per cent. in the number applying to enter pupil training."
It also refers to an
"unacceptably high level of national vacancies especially in the staff midwife and tutorial grades".
The recruitment difficulties are exacerbated by the high wastage rates. People leave nursing for many reasons, either during their training or after it, but research studies show that wastage rates from training were as high as 35 per cent. for RGN courses and 30 per cent. for EN courses. Fewer qualified nurses left, but I believe that a wastage figure of up to 15 per cent. after qualification is no exaggeration.

The survey conducted by COHSE found that the problem may be even worse than the figures show. Nurses were asked a variety of questions, and it was found that 59 per cent. of nurses and nursing auxiliaries had left the NHS or were seriously considering leaving. The figures can be nothing but disturbing to anybody who has the welfare of the Health Service at heart.

In June 1986 Mr. Peach, then the chairman of the National Health Service management board, acknowledged the "stark" recruitment problems. He did not refer to inadequate pay as the prime cause.

On page 16 of the report it is stated:
"The results of the RCN and COHSE surveys demonstrate the extent of discontent in nursing and midwifery discontent associated primarily with staffing levels and pay levels. The surveys also revealed that the majority of those still. working in the NHS adjudged increased pay levels to be a major factor likely to influence retention rates. The RCN surveys of midwifery vacancies over three years indicate that there has been no improvement in recruitment and retention."

Does my hon. Friend agree that other factors involved are greater overwork, overstrain and responsibility because of technological advances in recent years?

I could go on about that for three hours. I suspect that the Minister has not read the document. hope that she will make it compulsory reading before the Government respond to the review body's recommendations. Those recommendations should be in the Minister's possession within days.

Nursing is a grossly overworked profession. The overwork, the strain and the stress are having serious effects, in both the short and the long term, on the quality of work.

On page 20 of the document, paragraph 5.11 refers to the health visitor grade, and states:
"The alteration in internal relativities created by the Review Body's downgrading of the health visitor grade in 1985 remains unacceptable to the Staff Side. The basis on which the clinical grading review is being undertaken is to examine the extent to which clinical expertise, professional responsibility and relevant additional qualifications and experience can assist in the determination of equitable pay levels. In this context, the downgrading of the health visitor grade because it does not carry a significant level of managerial responsibility is a retrograde step. Like other groups of qualified nursing and midwifery staff, health visitors undertake additional training, and possess a range of skills which cannot be adequately reflected in the current grading system. The degree of independence with which health visitors conduct their duties and the requirement for a range of clinical and communication skills are factors which cannot be ignored, and should not be undervalued in the establishment of a responsive pay grading system."
Anybody who knows anything about health visitors must accept that they take important decisions as they move round the community day after day. As we move towards a wider acceptance of community care, so the health visitor will become more and more important. It is time that we thought seriously about upgrading that worthy profession.

Another pay review body report is imminent. I think that the Government expect that report by I April. The evidence of the Government to that body has been leaked. The Minister knows what I am talking about. The Government have said more or less precisely what the Chief Secretary said about nurses — they have been doing rather too well in the last six or seven years and it is time that it stopped. The Government have said to the review body, "Make sure that you do not give them more than a minimal increase."

It is already written in the cash allocations to health authorities that the increase shall not be more than 3·75 per cent. The Chancellor of the Exchequer has already admitted that by mid-summer of this year the rate of inflation will be 4·5 per cent. If the Government's recommendation to the pay review body is accepted, the nurses will be faced with a real cut in salaries in the next 12 months. I say to the Minister that that is completely unacceptable not only to Labour Members but to the British people. Whatever pay increase is given, even if it is just;3·5 per cent., if the Government run true to form they will say to the health boards: "You already have 3·75 per cent. written into your cash allocations. Anything above that will have to be paid for by cuts in other parts of your services."

I want some assurances from the Minister. First, that the Government will immediately respond to whatever recommendations are made and that they will not be held over until after the general election, whenever that might come. Secondly, we want the Prime Minister's response to be as sharp, quick and unequivocal as it was when the Top Salaries Review Body made its recommendations some two years ago when, without the flicker of an eyelid, the Prime Minister said that every top civil servant, judge, admiral and general in the Army shall receive increases of £40, £50, and £60 a week. Nurses are in a different category. I hope that the Prime Minister and the Government will respond as generously to the nurses as they did to the Army, Navy and Air Force — the generals, air commodores, and so on.

The Government have gone further in their evidence to the pay review body. They have said not only that they want minimal increases, but that they want pay determined locally, not nationally. They want payments to be given for specific skills and target payments for unpopular types of work. I do not know how those matters would be worked out, but the health authorities would have a miserable job if those recommendations were to come into effect. The Government want job sharing, part-time work, and so on.

The Minister has a case to make, and no doubt she will plead poverty; but in the last several weeks—and we shall see this increasingly over the next few weeks as we move towards a general election—the Government have been trying as hard as they can to sell to the public their wonderful success story to the effect that the economy has never been stronger and is getting stronger by the day. We are getting sunshine all the way. Santa Claus is coming every week. We shall drink, laugh and be merry. Our future is set fair. But that is not true for nurses. Even if half the Government's claims were true, the nurses would be in for a substantial increase. The Government might even have said that, although the pay review body recommended only 10 per cent., they thought that the nurses deserved 20 per cent. There is not a hope in hell of the Government doing that.

It is too late for the debate to influence the review body's recommendation. I understand that. But I want to ask the Minister some questions and I hope that she will give us frank answers, although I fear that she is not in any position to do that. I know that she will not reply to them, but I want to put them on the record.

Will the Minister give an assurance that for the first time since the inception of the pay review body machinery the Government will accept its recommendations in full without qualification? Will she say categorically that those increases will be financed with additional money, without insisting that the cash for the increases must come from cuts in other parts of the service? Those are not extravagant requests. I hope that there will be a statement from the Government on those matters before the Easter recess.

The British taxpayers, with their sense of fair play—all public opinion polls show that that is the case—are more than ready to foot whatever bills need to be met to make our NHS once again the envy of the world. I hope that the Minister accepts that. I hope that she understands the strength of feeling in the country as the British people see the Health Service decaying all the time. It is not safe in the Government's hands. The sooner we get rid of the Government, the better for the sake of the Health Service, the nurses and all who serve in it.

9.22 pm

I always had a rather grudging respect for the hon. Member for Fife, Central (Mr. Hamilton). I always saw him, even if I did not agree with him, as a doughty fighter and a man of some considerable integrity. I am sure that his standards are as high as ever as he contemplates his journey southwards, but I was disappointed at the way in which he introduced this important subject this evening. Nurses' pay is an important subject and it is certainly taken seriously by my hon. Friend the Minister and others of my colleagues.

It is ever so slightly sanctimonious of the hon. Gentleman to bewail the plight of nurses as if it were a plight that suddenly arrived under this Government, ignoring the fact that it was this Government who introduced the independent pay review body and recruited an additional 55,000 nurses into the profession—26,000 full-time equivalents — after taking account of the reduced number of working hours per week that the Government gave to the nurses. The hon. Gentleman also ignored the fact that since 1979 nurses' pay, after taking account of inflation, has risen on average by more than 10 per cent.

On that latter point we heard the most extraordinary nonsense from the hon. Gentleman. He seriously suggested that it was somehow an indictment of the Government that not only had nurses' pay kept pace with inflation, but their pay had increased by only 3 per cent. in real terms for every year that the Government have been in office. That was not enough. He described this Government — I think these were his words — as the meanest Government in history. All I can say is that if we are a mean Government, it beggars description of the previous Labour Government who supervised the only real terms reduction in nurses' pay, when compared with inflation, since the inception of the Health Service. It is frankly appalling to hear the hon. Member for Fife, Central describe the present position in such terms.

I was extremely sorry that the hon. Gentleman, by overplaying his hand, masked the real problem—a problem that any responsible Member should be prepared to examine. I have been interested in nurses' pay for many years. I was involved in a health authority for many years before coming to this House, and indeed for some years after I was elected. I have probably more Health Service workers than car workers in my constituency. Some of the largest and most complex hospital installations are in my constituency—the John Radcliffe, the Churchill, the Nuffield, the Warneford, the Littlemore and the Park hospital. Nurses' pay is an important issue and I am one of the few hon. Members, drawn from both sides of the House, who is a member of the Royal College of Nursing parliamentary panel.

I hope that we shall have some serious discussion about nurses' pay as a result of tonight's debate. I believe that nurses still do not get paid anything like enough. That in no way detracts from the achievements of the Government, which have been substantial and in stark contrast to the Labour party's record. It is in no sense a betrayal of the Conservative party's record. The Government have done what they can at a time when the economy has been going through a difficult period. Indeed, it is not often that a Chancellor can produce a Budget similar to that presented last week. Indeed, my right hon. Friend made plain—and any common sense observer would agree—that he was only able to produce such a Budget because we had dragged the economy round from an especially difficult period. Nevertheless, during that time we have made progress on nurses' pay, but I believe that substantially more needs to be done.

I believe that the urgency of the problem is accentuated by a reduction in potential recruits for nursing. In 1982, among school-leaving age girls, there were about I million potential recruits for nursing. By 1992, on demographic grounds alone, that number will be reduced to 600,000. That represents a 40 per cent. reduction in available intake and does not take into account the fact that recruits must have five O-levels and two A-levels. No one wishes the technical and educational standards to drop, but such standards further reduce the catchment of potential recruits.

The necessity for recruitment will place further pressure on nursing conditions. As well as pay, we must consider most carefully the question of training. The hon. Gentleman, during his lengthy speech, mentioned the considerable drop-out rate from training. I shall also mention the drop-out rate among qualified nurses. It is reported that a third of those training, taking account of both courses, do not complete their course. It is important to try to ensure that that figure is reduced. The hon. Gentleman and I are ad idem on that.

I do not believe that that fall-out can be marked down to students not knowing what they want to do. The problem represents a vicious circle. Inadequate numbers of staff mean that trainees are used as ballast to do jobs for which they have not yet received proper training. They are concerned about the level of responsibilities that they must accept, and as a result they feel they are placed under considerable extra pressure—arguably more than we should place upon them.

An interesting exercise recently carried out by the Royal College of Nursing—I am sure my hon. Friend the Minister is aware of that exercise—suggested that more technically advanced training for nurses resulted in a higher retention rate. In other words, nurses felt that they were receiving the right academic input. That is a pointer for deferring nurses' training to polytechnics and other institutions rather than specifically and wholly within hospitals. Nurses felt better about their job and their commitment to the service. If more than 60 per cent. of those who enter the service do not complete their training, we have little chance of matching the need on the wards by fully qualified staff.

There is a problem with the private rented sector in Oxford because of the pressure of student numbers. It is an undeniable fact that in Oxford a nurse cannot afford to rent accommodation in the private sector. Demand ensures that rents are extremely high, but there are solutions to the problem which lie within the private rented sector. I am pleased that my hon. Friend the Minister for Housing, Urban Affairs and Construction has creative proposals to deal with the problem.

It is ironic that with such a heavy demand on the private rented sector there should be 600,000 to 700,000 units of accommodation standing empty. The relevance of the high pressure on the private rented sector in a place such as Oxford is that it impinges on the Griffiths review of nurses' accommodation, and there is a danger of health authorities reacting rather over-zealously to the Griffiths recommendations. The report made it clear that health authorities own a great deal of accommodation that they should not have, and that is right. Health boards were found to have houses dotted around towns in which were found engineers, superintendent cleaners and technicians, but not nurses. The houses were occupied by those who happened to know the man who had the key to the letting register. There appeared to be no logic attached to the authorities' policy of letting houses, and that was clearly not in the interests of the service.

We must be careful to distinguish that problem from the other real problems which arise from the high cost of renting in certain areas. We must think seriously about the provision of more upgraded nursing accommodation. Unless we do that, it will be extremely difficult to retain nursing staff, especially in an area such as Oxford.

An even more worrying symptom is that there is a wastage rate of about 10 per cent. within the 300,000 nurses employed in the NHS, which means a loss of about 30,000 nurses per annum. The hon. Member for Fife, Central has alleged that many nurses decide to go to Saudi Arabia or America to earn more money. I am glad that he shakes his head, but I am sure that there are some nurses who do that, and it is understandable. One of the great attractions of working in the United States was that the top rate of tax—until my right hon. Friend the Chancellor of the Exchequer introduced his most recent Budget—was one percentage point lower than the basic rate of tax that a nurse would pay in Britain. I pass over that consideration because the implications will not be lost on the hon. Gentleman.

By far the greater reason for nurses leaving the profession is that of marriage. As they settle into their lives they find that their hours are antisocial, that the work is difficult and that they have difficulty in coming to terms with shift work. When they have had their families they have no contact with the Health Service because there are inadequate contact link schemes to encourage them back.

As nurses are essential to the Health Service, should they not be made a special case?

I hope that the hon. Gentleman will accept that the Government's actions prove that they believe that the nurses should be treated as a special case. I shall not reiterate the reasons for that because I advanced them at the beginning of my speech. I hope that the hon. Member for East Kilbride (Dr. Miller) will follow what I am saying. I suggest to my hon. Friend the Under-Secretary of State for Health and Social Security and to other Ministers in the Department that there should be an urgent scrutiny of some of the measures that could be employed to ensure a higher retention rate among trained nurses and a better response rate from those who leave the profession and who could eventually, as trained recruits, be persuaded back into it.

Ninety per cent. of nurses are women. If that is likely to remain the proportion as between male and female nurses, I suggest to my hon. Friend the Under-Secretary of State that we need to develop more positive policies to manage the career break that is caused by the family. We must provide better child care facilities for those nurses with the problem of a young family but who would enjoy the extra income and the opportunity to make the commitment that nursing involves. We must provide them with flexible shift work and perhaps more part-time work within the Health Service. We should organise better backto-nursing courses for those who have been out of the profession and want to retrain to ensure that they are au fait with current techniques and can go back on the wards with confidence.

If only we could cut the wastage rate from 10 per cent. to 9 per cent., we could keep 3,000 more trained nurses in the system who would not have to be replaced by staff who must be trained at a cost running into tens of thousands of pounds per head. I urge that action on my hon. Friend because, as she will readily acknowledge, it is cost effective. At present, there is an appalling waste of economic and human resources. The human resources are the more important. It is terrible that we should spend so much on them, only to see them slip away so easily and apparently irrecoverably.

The Government's record is one of which they and my hon. Friend can justly be proud. It is wholly consistent with that to say that nurses remain among the highest priority groups for further special attention from the Government. The Government have increased their spending from £7,750 million in 1978–79 to nearly £19,000 million this year. Their whole approach has been one of strong, firm commitment to the Health Service. I am sure that the Government will take note of what has been said in this important debate. I look forward to hearing from my hon. Friend what she thinks she can do in the short term and, with her colleagues, in the long term about the urgent matter of nurses' pay.

9.37 pm

I thank my hon. Friend the Member for Fife, Central (Mr. Hamilton) and the Minister for allowing me to participate in the debate. My hon. Friend made a first-class, detailed contribution to the debate, to which he brings his experience as a member of an organisation that represents nurses throughout the Health Service.

The speech of the hon. Member for Oxford, East (Mr. Norris) was exactly as I would have expected it to be. He backed up, supported and protected the Government and took away the Minister's job. No doubt the Minister will make exactly the same remarks when she speaks.

My hon. Friend will probably remember—Conservative Members will not—that not many days ago nurses and student nurses lobbied this place. I met nurses who work in one of the hospitals in my constituency. Indeed, I took it upon myself to meet other nurses from hospitals in Conservative constituencies simply because Conservative Members did not respond to the green cards that came in with regard to the people who were lobbying. It may be, judging by the speech of the hon. Member for Oxford, East, that he does not understand the problem. He would do so if he met the nurses who provide the services which we so desperately need within the National Health Service. We have a total responsibility to the nursing service and to the marvellous people who provide it.

Is the hon. Gentleman alleging, as he skates rapidly over his allegations, that I would not be interested in meeting nurses from my constituency or have not done so on the occasion either of the last lobby or of any other lobby? In the absence of any confirmation of that, would the hon. Gentleman like to list those hon. Members, whether from Conservative or Labour constituencies, whose nurses came to visit them and who were not available to see them?

I should be here until midnight if I reeled off all the constituencies and the names of the people who came from the nursing service to lobby the House of Commons. What I am saying is fact; it is the truth. Conservative Members did not carry out their responsibilities as far as that lobby was concerned. I have made the point and that is the end of it. They all ought to be here listening to what is being said.

I have had experience of the nursing service in a different way. Last year, on 30 September, I was unlucky enough to land in a hospital bed, so I have experience of the situation right at the work point of nurses.

As the Minister knows, I am a member of the Parliamentary Commissioner for Administration Select Committee. We get all sorts of information about the National Health Service in that Committee because so many things go wrong. When we discuss the problems of the nursing service, the difficulties in providing the service because of shortage of numbers emerge loud and clear. That was what I experienced when I was in hospital for nearly a month in September and October last year.

I had a fairly serious operation and I was pretty poorly for the first couple of days after it. What really acted as a pick-me-up was the note I received from you, Mr. Speaker. I realise that there are many hon. Members, 649 plus yourself, Sir, and you cannot keep tabs on everybody but are dependent on information filtering through. I was hoping that you would not come back to the Chair tonight so that I could say this in your absence, but I feel that it must be said. If any hon. Member has a problem of that kind and Mr. Speaker gets to know about it, he acts immediately. I know that I have said this privately, Mr. Speaker, but I want to do so publicly and I feel that I should do so. The little note that you wrote to me was a real pick-me-up. I thought, "Mr. Speaker is bothered about me being in this bed and he is looking forward to me being back in the House again". That I shall never forget, and I thank you very sincerely for it.

The nurses in Harvey ward No. 2 in Nottingham hospital were marvellous. A person who goes into hospital always says when he comes out that the nurses who provided the service were first class. But often there are too few nurses. The Parliamentary Commissioner for Administration Select Committee has received far too many reports of things having gone wrong in the Health Service. For example, it is wrong that unqualified nurses should be responsible for a ward. That reflects the shortage of nurses in the NHS and the many other problems to which my hon. Friend the Member for Fife, Central referred. We should all be worried about what is happening and collectively do something about it.

The hon. Member for Oxford, East and my hon. Friend the Member for Fife, Central mentioned training. It is disturbing and a tragedy that the number of students in the nurse training school in my area has been reduced. The more nurses there are in the school, the more nurses will qualify, and the more nurses will fill the shortages. If there are more students, surely that must help youngsters leaving school and reduce the massive unemployment list. I do not know whether such training reductions are occurring nationwide. In my area there were disastrous effects on the number of nurses who could qualify at the end of their full training and on the number who could be allocated to ward work.

I compliment the nurses who looked after me in Harvey ward No. 2, the consultant, Mr. Patrick Bates, and his junior staff. They provide a first-class service in the difficult conditions created by the fact that sufficient financial resources are not available for them to carry out their job properly.

It will always be argued that we must look more seriously at the Health Service. The hon. Member for Oxford, East spoke as though everything in the garden was lovely, but the garden is not lovely. There are some awful things in it which reflect on patient lists. If patients cannot get the service which they require, they are shoved on to the waiting lists. The hon. Member for Oxford, East and the Under-Secretary of State know that hon. Members have expressed their views on waiting lists. I felt that I had to speak in the debate on my feelings about the NHS, the nursing service, the massive team of consultants and the junior doctors who, incidentally, from time to time get a raw deal.

But tonight we are talking about nurses' pay and conditions. We all believe that they do a first-class job. No matter which party is in government, it has a responsibility to give those nurses the right pay for the job. As my hon. Friend the Member for Fife, Central said, many people get more than their fair share. There is no doubt about that in respect of those in the top income bracket. I was a little surprised that the hon. Member for Oxford, East spoke about that because he left himself out. Members of Parliament have had much larger pay increases than nurses in the NHS. He omitted to mention that. We are not on our own. Many other people in different jobs and work places are getting a lot more in increased earnings than the nurses. The Government should accept and live with their responsibilities and pay the nurses the right pay for the job. When they receive their just earnings, all of us will be a lot happier, including the nurses and the patients. After all, the reason for the National Health Service coming into being was to provide the service that patients require.

9.56 pm

I wish to intervene only briefly because I have a long journey to make to my home. Some of us live many hours from London and it takes a long time to return to our constituencies.

I would like to raise two matters. One is the attitude of witnesses before the Public Accounts Committee when evidence is being given on matters relating to nursing manpower. I have now sat through three sessions of questions to the National Health Service management board and also to DHSS officials. I sense that they do not quite know what is going on on the ground.

Following those hearings, I have been approached by nursing organsations outside the House. On one occasion I was approached by a group of journalists who were reporting on the effects of cuts in three regions. Following a series of questions that I asked during the course of one Committee sitting, they provided me with information that was totally at variance with the evidence that was being given to the Select Committee. I do not blame civil servants for that. I understand that they are under instructions from Ministers, and Ministers accept responsibility for what civil servants may say before Select Committees of this House.

There is a major difference between those who run the service and those who work for it about what is going on at ground level. The survey by the Confederation of Health Service Employees reflects that difference. That survey, published on 8 March, was on the staffing crisis for nurses in the NHS. It referred to a massive 90 per cent. of nurses saying that staffing levels in their own wards were low or dangerously low. They said that low staffing levels were responsible for falling morale and rising stress.

My hon. Friend mentioned the article that was published in the COHSE paper about staffing cuts killing a patient. I would genuinely like to know what happened there. I hope that the Minister will carry out an inquiry to find out what happened. We want to know. Cut the politics out of it. I want to know why and how this incident happened in a hospital in Scotland. If the Department is at fault, or if the budgets were too low to cover the demand and requirements for health care in that area, then the Minister should be honest and straightforward with the House.

The survey in Scotland compared the conditions or nurses now with two years ago. Eighty-five per cent. of nurses said the quality of care had been adversely affected, and 94 per cent. of those blamed staff shortages. Ninety. one per cent. said that stress levels were higher or much higher, and 88 per cent. of those blamed staff shortages Eighty-two per cent. said their work load was more or much more. Eighty-four per cent. reported falling morale. and 87 per cent. of those blamed low morale on staff shortages.

The COHSE Scottish regional officer, Jim Devine, said of one hospital:
"Lennox Castle has notoriously low staffing levels and this survey shows just how badly nurses are affected by that."
When I go round different parts of the country, I make a point of asking nurses—particularly following the Public Accounts Committee proceedings and questions that I have asked of civil servants—what is going on in their hospitals. They repeatedly tell me what has been denied to the PAC—that untrained, unqualified nurses are running wards in the NHS hospitals. It is happening, yet it is being denied. It is unimaginable to me that people who are simply not qualified are required to take on that great responsibility. Furthermore, the nurses tell me that they feel under pressure and stress when they are held responsible for those wards.

The hon. Member for Oxford, East (Mr. Norris) referred correctly to the fact that a large number of nurses in training were lost to the Health Service. It may well be that, while they are untrained, they are unwilling and feel incapable of managing wards and accepting the responsibilities that are placed upon them by the administrations of certain hospitals. I should have thought that that was a legitimate reason for leaving the NHS. People who are untrained cannot be expected to carry that responsibility.

I should have thought that Ministers would wish to carry out a national survey to find out to what extent that is going on and to ensure that it never happens. I will tell the House what happens in hospitals when a mistake is made. There are cover-ups. There have to be because doctors or administrators, finding that the manning arrangements on particular wards at particular times were deficient, automatically try to cover up what has happened when mistakes are made so that there is no reflection on the administrative arrangements governing the management of hospitals. That is not good enough. Cutting out the politics, there must be unanimity across the country that in every ward in every hospital there should be a level of expertise below which no one is asked to administer and to manage.

Perhaps one of the major reasons why we have problems is that many people simply do not accept health care to be the priority that many of us in the House think it is. Part of the reason is the existence of the private sector. Wherever one finds the private sector in what otherwise would be social provision, one finds that the more articulate elements in society—not all, but certainly many—are inclined to route themselves around the social provision. In doing so, they remove themselves from the argument about the quality of service that is provided in the social and, if one might call it such, the free provision paid for by the taxpayer. It is the same in education. The very existence of public schools undermines secondary education because it prevents a real debate developing and it prevents people from addressing the real problems and ensuring that the resources are given to education.

Health care is exactly the same. If one wants to raise standards of health care and ensure that the moneys are made available, one bites into private health. The reverse is happening today. As the provision for private health care is liberalised, key individuals who should play an important part in the debate are being removed from the argument about social provision and medicine.

I only wish that we had a Government who would bite into private health and ensure that a real debate took place about priorities. My view is that if that debate were to take place we would see a massive transfer of resources into education and health. The problems in the nursing profession and in the wider National Health Service will evaporate with the rapid passage of time as people see what is best for the public interest.

It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.

Motion made, and Question proposed, That this House do now adjourn.— [Mr. Ryder.]

I shall quote from a document entitled, "Project 2000: Nurses-Midwives: How it Affects You" which is produced by the Confederation of Health Service Employees. It refers to aides. It states that the proposal must go. I have raised this matter in the Public Accounts Committee. I reflect only the anger of people who refer such matters to me. The document states:

"Project 2000's proposals to replace existing nursing auxiliaries and assistants with aides is motivated by elitism. The use of the word 'nursing' in existing job titles is a perfectly proper use of the English language."
It goes on to condemn the introduction of the new term "aides". Many people in the National Health Service object to the use of that term. Hon. Members may laugh, but they feel strongly about it. They believe that it is a slight on their profession. The Minister might give us an undertaking that that term will be dropped and that a more respectable term will be introduced to cover the job description of such people who, according to the document, are covered by the proposal.

10.1 pm

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I am grateful to the hon. Member for Fife, Central (Mr. Hamilton) for giving us the opportunity to have what has turned out to be quite an extended debate on nurses' pay and some aspects of their work. I hope that hon. Members will excuse me if I do not comment on Project 2000, although it has been mentioned many times, because the consultation process on it is under way and decisions by us are certainly some way off, although we recognise the importance of the proposals. I understand that the final United Kingdom Central Council proposals on it drop the use of the word "aide". In fact, it is replaced by the word "helper", which seems in many ways to be a more respectable word.

The total spend on nurses in Great Britain in 1986–87 is nearly £4 billion. The total cost, among other things, of the 1986–87 pay rise was £201 million. We should add to that another £81 million for other health and community health services staff who are covered by review bodies. In Great Britain, nursing and midwifery staff, including agency nurses, now account for more than 400,000 whole-time equivalent posts. That is about 50 per cent. of all the staff in whole-time equivalent terms—the largest single group who work in the Health Service.

Our nurses are important people. Everyone in the Health Service is important. I was a little disappointed to hear the hon. Member for Ashfield (Mr. Haynes) praise only the doctors and nurses who cared for him recently. We would also regard as important laboratory staff, technicians, kitchen staff, ancillaries and indeed everybody who works in the Health Service. Possibly, our nurses are important not only because they are the largest single group but because most nurses have repeatedly refused to strike or to take any action that would damage their patients. That has certainly been true of members of the Royal College of Nursing. I have a feeling that some members of COHSE have taken a rather different view.

I recall, back in 1982, when I was chairman of the central Birmingham health authority, hearing that a charge nurse had walked out of Birmingham children's hospital in the middle of a dispute and left children on his ward in need of care simply because he was a member of COHSE and took the view that industrial action, which might just damage the interests of his patients, was acceptable. As a result of the action of unions such as COHSE, waiting lists climbed in 1982, as they had done under the previous Government. I look forward to the day when COHSE, like the Royal College of Nursing, decides that it is in the interests of patients and staff that strike action of that kind should be repudiated for good.

I take very much the points that were made by my hon. Friend the Member for Oxford, East (Mr. Norris) and other hon. Members about what has happened recently to nurses' pay. I see in his place my shrewd and capable colleague the Member for Nuneaton (Mr. Stevens). Recently he asked how much nurses' pay has increased in recent years, in real terms. Today we are able to answer this question. The information is as follows.

Between 1974 and 1979, nurses' pay fell by 21 per cent., in real terms. Since 1979, nurses' pay has increased by 23 per cent., in real terms; and since 1983 nurses' pay has increased by 10 per cent., in real terms. The real increase in percentage terms reflects the percentage cash increase in the pay round year that runs from 1 August, deflated by the RPI increase in the pay round year, in the 12 months to July. If a percentage cash increase, compared with the RPI, of 23 per cent., in real terms, since 1979 is mean, words fail me as to what one might call the cut of 21 per cent., in real terms, under the last Labour Government. A word like "pathetic" might just about do it.

In 1976–77, nurses' pay was cut by 10£7 per cent., in real terms. In one year there was a 10 per cent. cut, in real terms, in nurses' pay. That was 10 years ago, just as we are now celebrating the Lib-Lab pact of those years that helped to keep that despicable Government in office.

I could say even more about that Government's acceptance of review body reports. I recommend hon. Members to read again the diaries of the right hon. Richard Crossman who was Secretary of State in my Department in the late 1960s. On the eve of the 1970 election the entire review body resigned en masse, since he had completely failed to accept the recommendations of the review body for doctors—the main review body in those days.

My hon. Friend the member for Oxford, East was right when he said that we have been pushing the staff much harder. We have been pushing everybody in the National Health Service much harder. We have therefore increased the number of in-patients from 5 million, under the Labour Government, to about 6 million in-patients now, and 37 million out-patient visits are made each year. I noted with interest my hon. Friend's point that the more qualified staff cope better. He may be aware that the proportion of qualified nursing staff has increased from about 54 per cent. to nearly 60 per cent.

As for basic pay rates, on 1 July 1986 there was an 8 per cent. increase in the basic rates for most nurses. Students, pupils and auxiliaries had increases of between 5·5 and 6·5 per cent. The allocation was deliberately skewed in favour of the more highly experienced and highly qualified staff. That was exactly what the review body had suggested. Inflation was then running at 2·4 per cent. It is now running at 3·9 per cent. but the real increase is still very substantial.

On top of the basic pay, many nurses take home far more than the basic rate. There are premium rates for night and weekend work and for overtime, and there are other allowances. The estimated percentage addition to the basic pay for the main grades that form nearly 90 per cent. of NHS nursing and midwifery staff is between 12 per cent. extra for a student and 24 per cent. extra for a nursing auxiliary. That means an enrolled nurse on her maximum basic pay of just over £7,000 can expect, on average, to get another £1,200 as a result of the uplift that I have mentioned. The figures for a nursing auxiliary or a staff nurse are similar. A ward sister whose maximum is £10,800 can expect, on average, 14 per cent. extra for the uplift, and that comes to about an extra £1,500.

At the moment we cannot pay the same sort of rates as the Americans, but merely to quote basic rates of pay is unreliable and unrepresentative. The hon. Gentleman asked a series of questions because, he said, he knew we would not be able at this time to reply to them. He knows that, because he put down a parliamentary question and that is the answer that he received on 5 March. He also knows that some of his questions are for my right hon. Friend the Prime Minister who, no doubt, will respond to him in no uncertain terms when the time comes.

The hon. Member for Fife, Central asked whether we would accept in full and without qualification the recommendations by the review body, give the additional money and make a statement before the recess. The first report of the review body in 1984 recommended a 7·5 per cent. increase and it was implemented in full. We accepted the recommendations in the second report and staged them slightly to give the Health Service a chance to absorb their impact.

We accepted the amount in the third report in 1986 and deferred the operative date from 1 April to 1 July and gave the health authorities in England, exceptionally, an extra £50 million to maintain the levels of service. Therefore, at different times we have done all the things that the hon. Gentleman demands.

I remind the hon. Gentleman that that is set against the record of a Labour Government that 10 years ago saw fit to cut real pay by 10·7 per cent. The fourth report is awaited and will be submitted not to me, but to my right hon. Friend the Prime Minister. I cannot anticipate the outcome. I hope that when the hon. Gentleman hears the outcome he will be pleased with it and will say so.

Some points were made about the difference between gross pay and net pay, take-home pay. We have worked it out. It is certainly possible for a staff nurse on average gross pay of, perhaps £160 a week to end up taking home only £90 a week after deductions of tax, national insurance and contributions to the superannuation fund and so on. If the Opposition think that that is so dreadful, why on earth do they not support all our campaigns for tax cuts? Why on earth do they not recognise that tax cuts matter just as much to a woman nurse as they do to a male miner or to anybody else? Those tax cuts matter more to lower paid people, many of whom work in the Health Service, than to the better off. The Opposition should be campaigning for tax cuts and urging us to make even more. They should be urging us to do what has been done in the United States and say that our maximum tax rates are a disgrace and that we ought to get the minimum rate down even further.

Let me remind the House about what Opposition Members said repeatedly in last week's Budget debates.

They said that they would put income tax up again. Therefore, they would take even more of a poor nurse's pay than is being taken now. Of course, that is exactly what the last Labour Government did.

I shall now deal with wastage, manpower and nurse staffing levels. I congratulate my hon. Friend the Member for Oxford, East on his sensible speech which was backed with his experience as a member of a health authority and its vice-chairman for many years. He knows what he is talking about. It is a pity that the hon. Member for Fife, Central does not.

Of course there is wastage. Nursing is substantially a female profession. People marry or have a career break; people go. Year by year we recruit more to fill the gap, and the service given then increases. Not all vacancies are filled by newly qualified nurses. We estimate that about one third are filled by qualified staff returning to the NHS. It follows that a lot of nurses come straight back.

Between September 1979 and September 1985 nursing and midwifery staff in England increased by about 42,700 whole-time equivalents to 401,200—an increase of 12 per cent. As I have said, the proportion of qualified staff also rose. At 31 December 1986, the most recent figures that I was able to obtain, the number of nursing and midwifery staff, excluding agency nurses, was still slightly higher than the previous year, and the trend of recruitment still appears to be slightly upwards. In other words, the disasters described by the hon. Gentleman are not apparent in the figures.

The number entering training in England in the year ending 31 March 1986 was 23,705. There was a decrease of about 7 per cent. over the previous year because the number entering enrolled nurse training dropped by 19 per cent., which seems to have been largely the result of the comments made in Project 2000. Indeed, I was at a press conference at which Dr. Eve Bendall, adviser to the UKCC, said that we seemed to have shot ourselves in the foot on that. The number entering registered nurse training in the same period decreased by only 3 per cent., which roughly paralleled the demographic change in the age cohort from which those women are recruited, so the Opposition's description of our training and recruitment is quite wrong.

The hon. Member for East Kilbride (Dr. Miller) talked about the brain drain. In the year ended 31 March 1986, the UKCC reports that just over 5,000 requests for verification of qualifications were received from the EEC or elsewhere. That is 1 per cent. of the work force. Moreover, we recruit from other countries. Last year, 600 nurses came here from Australia, so they clearly thought that this was a good place to be. I suspect that the girls who go to the United States will find that the only thing that is cheaper there is petrol and that a major factor is the lack of a national health service. Having lived and worked there 20 years ago, I came home convinced that the best thing about our country was our National Health Service. My commitment to it stems from those days and can be traced unbroken through my career. I believe that we are extremely fortunate to have the Health Service run as it is by the Government, and the girls who go to America may return with the same view.

As for the problems of London and the 1,000 nurses per year going into the private sector, I understand that private hospitals in London are also having difficulty recruiting staff. Inner London has lost 2½ million people in recent years, including many of the groups from which we used to recruit staff. That problem affects many employers in London, not just the Health Service. As for nurses leaving the Health Service, we have always trained nurses to go into old people's homes, to work for local authorities or to work in private care facilities. That is a very good thing, because if those facilities were not available the patients would be in the National Health Service, perhaps not always in the comfort and privacy that the private sector can offer, especially in residential care.

In the light of all the anecdotal evidence, the NHS management board commissioned a survey of recruitment and retention problems in a number of different health authorities—not just in London, although London was included. We found that, although in the country as a whole the picture was less gloomy than the anecdotes suggested, there was evidence of shortages in certain key specialties in London and the south-east—in areas such as intensive therapy units, theatres and neo-natal care. One reason may be the lack of any incentive to gain the additional qualifications required for that very stressful work. Recognition of extra qualifications through the pay structure is therefore under review in the negotiating council.

There are, however, a number of areas in which local management can and does take action. One thinks of more flexible employment opportunities—part-time working, employment on a sessional basis, job-sharing, and so on — and much better management of career breaks, a point on which I agree with much that has been said. There are also possibilities for improved training facilities, better recruitment drives, the recruitment of men and of various other groups from which we have not tended to recruit in the past. All those matters are now under active discussion with authorities which have been experiencing difficulties. In all those ways, I believe that we have taken on board many of the problems that have been described.

Our nurses are very special people. We owe them a great deal and we more than any previous Government have recognised that fact. It behoves the House to back what we have tried to do and to recognise the service that nurses try to give and the effort and interest that we have taken in their pay structure, their work, their training and their welfare.

Question put and agreed to.

Adjourned accordingly at nineteen minutes past Ten o'clock.