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Health: Specialist Nurses

Volume 691: debated on Tuesday 1 May 2007

asked Her Majesty’s Government what they can and will do to prevent primary care trusts and hospital trusts reducing spending on specialist nursing services in the treatment and support of patients with long-term conditions.

The noble Baroness said: My Lords, I declare an interest, as I founded the Spinal Injuries Association and am a life president. I also had immense help from specialist nurses over the years when my late husband had to endure diabetes, the results of strokes, Parkinson’s disease and cancer, which resulted in his having to have a stoma. The advice that I personally had for my husband was from the specialist diabetes nurse, who was the link with the hospital unit and the community. She would visit our home and check the records. When the blood sugar went too low or too high, she would advise on the insulin, and she was a link with the consultant. For our carers to have such support was invaluable.

The other specialist nurse who gave advice was the Parkinson’s disease nurse from Leeds. Drugs for Parkinson’s are very important, and the monitoring and timing are essential. That nurse was without doubt a valuable support. The other help that we appreciated was from the specialist advisers from the firm that supplied the stoma appliances. Each stoma has to be cut to the special size of the individual patient’s incision. If faecal matter escapes, it can cause very sore rashes and burns on the surrounding skin. Special lotions for this are available, but it is specialised knowledge that counts, and having that advice available is vital. Many district nurses are not trained in such expertise. The Minister knows too well what it will mean to rural areas should that home service be discontinued.

I thank all noble Lords and Baronesses and the Minister for taking part in this short but extremely important debate, and I look forward to their contributions. Specialist nurses are a lifeline to many people with long-term complicated conditions. They are also a support to junior doctors and nurses in hospitals, GPs and district nurses in the community.

Your Lordships may have noticed that my colleague, the noble Baroness, Lady Wilkins, has not been in this House for the past few months. That is because she has had a problem to do with her paraplegia. She has given me her permission to say that she was wrongly diagnosed by her GP and is now in the spinal unit at Stoke Mandeville Hospital. She has had an operation and is on the mend, but says, “Thank goodness for being at a place where they know what they are doing”. Expert medics and trained spinal nurses understand complicated problems that can arise due to paralysis with no feeling. If correct treatment is not received, disasters occur and unnecessary expensive periods are spent in hospitals repairing the damage.

I have been told by the Spinal Injuries Association that five specially trained spinal nurses have been moved from the spinal unit at Wakefield to general wards and have been replaced by care assistants. That is frustrating for the nurses, but very worrying for those who depend on their expertise.

On Saturday evening, I met a young married woman with young children. She has lupus, a condition that affects the immune system. She has good and bad times. She told me that the specialist nurse dealing with her condition was her lifeline and was always available at the end of the telephone. The nurse had been told that her job was under threat. How can these vulnerable patients from so many specialties be put at so much risk and with so much insecurity? What is happening to our NHS?

The situation of specialist nurses in stroke care was getting better. They were able to take more responsibility with advanced training, having independent clinics and prescribing necessary drugs with the back-up of consultants. They help to prevent secondary infection and, when strokes occur, they can book much-needed urgent scans, which are vital before patients are given thrombolysis, the clot-busting treatment that has to be given within three hours of the onset of a stroke. They help to link everyone together and advise junior doctors in A&E departments, who spend only two months there.

With a stroke, there can be swallowing problems. The specialist nurse can do the necessary screening, which must be done by a trained nurse who knows what she is doing, as so often speech therapists are not available. They keep data and guidelines, and provide specialist continuity of care. The specialist nurses can give a much higher quality of care. If they are removed because of shortage of funds, it will be an economic disaster in the long run.

The Department of Health has emphasised that the onus is on local trusts to deploy specialist nurses in accordance with their needs. The Healthcare Commission demands compliance with NICE guidelines as well as with the national service framework, which both say that those with MS should be put in touch with a skilled nurse with knowledge of MS and counselling experience. These guidelines are often overlooked by local trusts that are struggling to prioritise funding and looking for an easy pot to raid.

One in four specialist nurses fear that they have no future in the NHS. A recent survey conducted by Bowel Cancer UK and the Royal College of Nursing has identified that NHS specialist nursing posts are under threat. A total of 460 specialist nurses working in gastroenterology and stoma care across the UK took part in the survey. Seventy-two per cent of nurses who had been made redundant or now work on wards said that patient care would suffer.

The Progressive Supranuclear Palsy Association feels strongly about the current lack of specialist nurses within the NHS and is horrified by the plans to reduce their numbers still further. The NHS support system works increasingly on a 9 am to 5 pm service. The PSP Association has 24-hour telephone counselling services that enable carers to contact the nurses in the evenings and at weekends, when NHS services—other than for real emergencies—are increasingly unavailable.

Epilepsy is a serious condition, which needs careful monitoring of drugs, and there is a campaign for more specialist nurses. NICE clinical guideline 20, Diagnosis and Management of the Epilepsies in Adults and Children in Primary and Secondary Care, states:

“Epilepsy specialist nurses should be an integral part of the network of care of individuals with epilepsy”.

SIGN guideline No. 70, Diagnosis and Management of Epilepsy in Adults, states that,

“all epilepsy care teams should include an epilepsy specialist nurse”.

I am sure that this conclusion could be echoed by many other voluntary organisations dealing with long-term conditions. There are so many that I could mention if time allowed but, as a vice-president of the Haemophilia Society, I will relay a few of the clinical nurse specialist duties in caring for people living with haemophilia and related inherited bleeding disorders.

The haemophilia nurse is usually the first point of contact for patients and families, and plays a pivotal role in the specialist multi-disciplinary team. Haemophilia treatment is expensive, but the lives of patients and their families can be transformed by high-quality expert care. The role of the nurse encompasses accountability for the clinical efficiency and cost-effectiveness of the home treatment programme, maintaining an ongoing process of record-keeping, audit and review.

Haemophilia comprehensive care centres have a wide catchment area, which creates the opportunity for the haemophilia nurse to demonstrate clinical nursing leadership and influence care. This includes administering treatments, including intravenous clotting factor concentrate; contributing to genetic counselling; providing support for patients and families in the community, including home and school visits; educating and supporting families post-diagnosis and at different life stages; and meeting the complex needs of those affected by HIV and hepatitis C as a consequence of past treatment. Haemophilia nurses also act as a source of specialist advice and information for hospital staff, primary healthcare staff, dentists, schools, employers, social services and other community agencies.

I stress the importance of specially trained infection control nurses, who strive to keep infections such as Clostridium difficile from wards. So many patients with long-term conditions have compromised immune systems and cannot fight infections. More must be done.

With the European directive on doctors’ working hours, specialised nurses are more important than ever. So many organisations and people throughout the country feel strongly that the NHS should be providing the crucial support of specialised nurses in many long-term conditions. The Royal College of Nursing and nurses working within the Department of Health are also strong supporters but, above all, the patients’ needs are paramount. I urge the noble Lord, Lord Hunt of Kings Heath, to plead with the Government not to leave all decisions to PCTs and trusts but to take the lead and request them to provide specialist nurses who do so much to keep vulnerable people in our society healthy.

My Lords, it is very opportune that the noble Baroness, Lady Masham, has obtained this debate today, for which I thank her, as three of the charities that look after patients with long-term conditions have today been in discussions with the Minister Ivan Lewis on this topic. We await the outcome of those deliberations with interest.

I will concentrate my remarks on the importance of specialist nurses for the treatment of people with epilepsy, the most common serious neurological disease. I declare an interest as president of Epilepsy Action and chair of the All-Party Group on Epilepsy.

The first epilepsy specialist nurse—ESN—was appointed in 1988; since then, they have proved a crucial source of support and advice to patients with epilepsy. There are three types of ESN: those who specialise in caring for adults with epilepsy, those who specialise in caring for children with epilepsy and those who specialise in people with epilepsy and learning disabilities. As the noble Baroness, Lady Masham, said, their specialist knowledge is crucial to those people. They enable many patients to manage their epilepsy effectively and to remain independent in the community.

Epilepsy Action calculates that in England at least 60 per cent of people with epilepsy—230,000 people—should have regular or, at the very least, occasional access to an ESN. Further, the ESNs should have a caseload of no more than 250 patients with active epilepsy. That means that there is a need for 920 epilepsy specialist nurses in England. Currently, however, the figure stands at 152.

ESNs fulfil many differing roles. They give guidance to people with epilepsy and their families as well as helping to improve communication and co-ordination between primary and secondary care, social services, education and employment services and the voluntary sector. Patients and carers want and need the face-to-face opportunities that ESNs provide. This is especially true for women, who need special support, particularly during pregnancy.

The noble Baroness outlined the evidence from SIGN and NICE. In 2004, the NICE clinical guidelines stated:

“Epilepsy specialist nurses should be an integral part of the network of care of individuals with epilepsy”.

On 21 November 2006, Ivan Lewis said in a Written Answer:

“Specialist epilepsy nurses provide an additional clinical resource and have spearheaded the development of nurse led and fast access clinics, monitoring treatment regimes and seizure control, support and information on aspects of medication and side effects and lifestyle precautions”.—[Official Report, Commons, 21/11/06; col. 77W.]

In spite of that statement, recent figures show that around 8 per cent of ESNs across the UK are threatened with redundancy, reduced hours, assignment to non-specialist duties or not being replaced. There is no dispute about the contribution they make and how they save the NHS money by releasing consultants’ time and reducing waiting times to see a neurologist; reducing accident and emergency admissions; enhancing patients’ adherence to anti-epileptic treatment; and reducing the use of hospital beds.

However, despite the already chronic shortage of ESNs across Britain, we are now forced to defend the status quo rather than focus on expanding the excellent service they provide. Local NHS organisations facing financial pressures are making short-term cuts, which will seriously impact on the quality of life of those with epilepsy. It is not necessary. In its manifesto for epilepsy in 2004, the Joint Epilepsy Council showed how improvements in epilepsy care could realise savings estimated at £160 million per year— the annual cost of epilepsy misdiagnosis, based on the figures from NICE—and £66 million per year through reduced costs of disability living allowance for people with epilepsy. Together, that is more than enough to fund the improvements called for.

Furthermore, 72 of the current ESN posts were created because of pump-priming funding through Epilepsy Action, with agreements with the NHS trust concerned that the post would continue once the pump-priming funding expired. Through the scheme, Epilepsy Action provided £30,000 to £50,000 of financial support to NHS trusts for them to set up an epilepsy specialist nurse service. Since the scheme was set up in 1995, more than £2.5 million has been invested, creating 83 nurse posts within the NHS. But, disgracefully, seven NHS trusts have not honoured their agreement to continue funding the posts once the pump-priming funding ceases. These breaches of agreement of the written commitments made, not only in the field of epilepsy but to other charities that work with patients with long-term conditions, are likely to affect their provision of valuable seed funding to the NHS.

I appreciate that the Minister will no doubt indicate that it is for local NHS areas to determine their own priorities, but they are going against the government strategy of providing more care in the community, which enables and facilitates self-management of patients’ conditions and is vital to delivering the quality requirements of the National Service Framework for Long-Term (Neurological) Conditions.

While local NHS bodies have a degree of autonomy, I urge the Government to issue further guidance to ensure the implementation of the 11 quality requirements in that national service framework is not compromised, that the commitment in the NICE clinical guidance on specialist epilepsy nurses is fully implemented across all NHS trusts, and that the aim to transform how health and social care services support people who live with long-term conditions is achieved. Maintaining specialist epilepsy nursing teams is essential if we are not to see postcode lotteries for the care of the 456,000 people in the UK with epilepsy.

My Lords, there is no doubt that all chronic conditions greatly improve with the help of a specialist nurse. We have just heard about epilepsy, and the noble Baroness, Lady Masham, told us about strokes, Parkinson's disease, diabetes and haemophilia. Whatever condition you mention, having a specialist nurse is extremely advantageous for the patients concerned. I thank the noble Baroness, Lady Masham, for initiating this debate and covering the subject thoroughly.

I declare an interest: my daughter has multiple sclerosis and is a patron of the MS Trust. In a moment, I will tell you a little more about the MS Trust, because it is a leader in this field.

The noble Baroness, Lady Masham, made a good point about the confidence it gives patients, quite apart from the home service, to have nurses available on the end of a telephone line. That is a marvellous thing for someone who needs it. It gives reassurance and deals with the need for someone to be available to tell you what should be done and decide whether you need full and urgent treatment or just reassurance. That reassurance, given by specialist nurses, saves the National Health Service a huge amount of money. Research has been done showing the savings. The Royal College of Nursing has explained that one acute hospital showed a net cost of its MS nursing service of £118,000 but an income generation of £733,000.

The Question asks how we prevent people reducing spending on services, but that is asking for something very difficult. The PCTs guard their right to decide these things, and for any Minister to say, “No, you must choose this or that”, is not the principle on which they run. They need to be convinced that it is good economically for them, that it is not only a good service but in their financial interests to use it instead of being landed with higher costs because people have to become inpatients. In all ways, it is better to have the benefit of specialist nurses.

The MS Trust was the first charity to develop education for MS specialist nurses and it is still considered a leader in that field. The courses are regularly oversubscribed and also offer full ongoing support. Patients with an MS specialist nurse value self-referral and swift advice by phone or e-mail. An MS nurse can refer onwards to a wide range of services—physio, occupational therapy or counselling, or, to return to the point I made earlier, back to the consultant if appropriate. It saves people being referred to the consultant when it is not appropriate. Time to access the nurse is minimised; in relapse situations, which are of course a feature of multiple sclerosis, this is essential.

Being a specialist nurse is almost generic because any chronic condition that you care to name has its own specialist nurse. Whatever they specialise in, they are the key to successful management of long-term conditions. As I said, the findings also prove that they are cost-effective.

I know that the time for this debate is short, and I noticed that the noble Baroness, Lady Masham, ran a couple of minutes over time, so I shall try to make up for that by stopping now. I have made my point, and plenty of others wish to speak.

My Lords, I, too, thank the noble Baroness, Lady Masham of Ilton, for instigating this important and timely debate. It is timely for several reasons. At present, specialist nursing posts are being reviewed in many trusts across the UK and are subject to downward cost pressures, and the Department of Health is reviewing nursing and embarking on modernising nursing careers.

One must have some sympathy with trusts that took in pump-primed posts three or so years ago and now find that the salary bill in the trust has changed and the budget for the post is eroded. Charity funding and some NOF funding were used to set these posts up, and although the charity’s name remains attached it no longer funds the post. Some other charities have established other partnership models of funding, which would seem to protect all parties better. Some have really had their fingers burnt with the pump-priming of such posts, and in the end patients have suffered when the post is removed.

I shall focus on what a specialist nurse is and is not, for there is much confusion around the label. The training and specialist skills and competencies are not always clearly defined. Specialist nurses are employed at different levels in different trusts, despite Agenda for Change—some at level 5, some at 6 or 7 and a few at level 8. Why? Because the money is not there for the posts to be unified by grading even when the post-holder has appealed against the grading and when differences are evident between trusts.

The difficulty for trusts is that the job is there and the work needs to be done, but there is no clear definition in the different subject areas of what a specialist nurse is versus a specialised nurse. Throughout the country specialist nurses now find they are under threat and fear for their posts as trusts try to get the books to balance. To clarify specialist versus specialised nursing, I shall take the example of Marie Curie Cancer Care—I declare an interest as a vice-president of Marie Curie.

Marie Curie Cancer Care has 2,500 nurses. Almost 1,500 are community Marie Curie nurses providing care for patients in their own homes. These nurses have training and experience in care of those who are terminally ill; they are highly specialised, but they do not have specialist-level training and competencies. The NHS contributes 40 per cent of the salary costs for these nurses. Then there are just over 400 Marie Curie hospice nurses, almost 200 care assistants and 25 specialist nurses. So one in 100 of the Marie Curie nurses are working as specialists but the others are certainly specialised—though that is not to denigrate the care that they give.

Specialist nurses in the community have a vital role to play in helping patients to stay at home, organising care and providing social support and equipment as needed. The specialist nurse also has unique skills to support patients' psychosocial needs and the needs of the family, especially when relatives are vulnerable by dint of age, being either very young or very old, or through infirmity. So often the specialist nurse is the named nurse, working across hospital and community boundaries and guiding care. They can and should now form pooled out-of-hours rotas to ensure that care does not dip at nights and weekends.

In palliative care, the input of a specialist nurse as part of a multi-professional team can even double the chance of a patient staying at home, and with that go cost savings. In paediatric palliative care in west London, where a specialist paediatric palliative care nurse post has been removed, the number of bed nights has gone up as, out-of-hours, parents panic, out-of-hours services panic and the child is admitted. That is sad, because so many of those admissions could have been avoided. In Northwick Park hospital, the diabetes specialist nurse in paediatrics has resulted in the hospital stays of newly diagnosed diabetic children falling from an average of five to six nights down to only three nights, and the long-term control of the children's diabetes has improved as the quality of care has been driven up. That must be a long-term cost saving to the NHS overall because we know that good diabetic care results in lower morbidity.

These specialist nurses in the community cannot be replaced by community matrons, who have high-level generic skills and a different set of competencies. The term “specialist nurse” does not mean that the nurse is pluripotent. A specialist nurse in diabetes cannot just become a specialist nurse in multiple sclerosis overnight. That nurse will have to retrain in the disease-specific aspects of the patients to be cared for. However, some skills, particularly managerial skills, are eminently transferable. In medicine nobody would accept a neurosurgeon suddenly being appointed as a specialist in cardiology. Their specific training is assessed and a certificate of completion of specialist medical training in one discipline is then registrable.

In some areas of nursing such as paediatric community care there are excellent university courses which teach reflective practice based on the nurse’s clinical caseload. These have been proven to improve the nurse’s practice, and hence the experience of her or his patients. Such validated courses ensure training and education to specialist level but are not in place for all areas of practice. Now that specialist nursing has truly come of age it is time for a similar register to be set up as in medicine and for a parallel system to be established for nursing. Such a register would protect the patient, the employer and the nurse.

In many clinical areas the specialist nurse is now an essential core member of the multi-professional team, working with specialist doctors, physiotherapists and others. Losing the specialist nurse from a team is a disaster. They complement the care of the generalist and the specialised nurse, leading by example, driving up standards, evaluating care and participating in research and education.

This is a very important debate. I hope that we shall see nursing move forward into a new age with clearly defined specialist nursing.

My Lords, I am grateful to the noble Baroness, Lady Masham, for giving us the opportunity to debate the important topic of specialist nurses. Inevitably, we shall each discuss the specialism about which we know the most or of which we have the most experience. I want to talk specifically about MS nurses, as did the noble Baroness, Lady Gardner. I declare an interest as my son has had MS for a number of years.

I understand that this country has one of the highest rates of MS in the world with an estimated 85,000 persons with the disease and approximately 2,500 new cases diagnosed annually. Recently my right honourable friend the Secretary of State for Health suggested to the Royal College of Nursing that she did not believe that there was any evidence to support the concept of specialist nurses. While I have the highest regard for the Secretary of State, in this case I do not agree with her.

In 2001, the MS Trust funded research which showed that MS specialist nurses keep people out of hospital and save money. I want to say a little more about that. Evidence shows that they free up neurologists’ time and reduce hospital admissions, especially emergency admissions. It is estimated that they achieve up to a 50 per cent reduction in the length of hospital stay. Those are very impressive savings. Money is not everything as regards treating people; patients are the most important. However, money is important. If the NHS is looking to its money and these savings are of the order I have suggested, that alone justifies having more MS nurses on economic grounds, to say nothing of patient care grounds.

MS specialist nurses make a world of difference to people suffering with MS. They provide time, specialist support and, above all, understanding of the lives of people affected by the disease. Part of the argument for specialist MS nurses is the very nature of the illness. It is different from other illnesses and a specialist nurse can make a more effective contribution to the care of patients. It is estimated that there are 200 MS nurses in the country and that we need a minimum of some 300. In a Written Answer of 19 February my noble friend Lord Hunt said:

“The annual National Health Service workforce census does not separately identify multiple sclerosis nurses from the rest of the nursing workforce. It is for NHS employers and strategic health authorities to determine how many multiple sclerosis nurses are required to meet local service needs”.—[Official Report, 19/2/07; col. WA 182.]

I am not sure whether that is not a complicated way of saying, “We don’t know”, but at any rate it suggests that the estimates I have received do not have the imprint of the department. It shows that services for people with MS have a relatively low priority in the NHS and that the implementation of NICE guidelines for the management of MS in primary and secondary care and the National Service Framework for Long Term Conditions is being undermined.

MS nurses are funded from three separate sources: partly by the NHS; sometimes by the voluntary sector—the MS Society funds 76 specialist nurses; and also by the pharmaceutical industry. A survey of services for people with MS presented in January 2007 suggested that there were areas of particular excellence and that there was a significant commitment to MS by health professionals, not just nurses but across the health service. I am very impressed by the commitment that health professionals show to sufferers of MS. However, there is not a universally good service. Among the conclusions is that there is no evidence of a co-ordinated response by the NHS and that there are serious financial constraints. At the moment, at least some MS nurses funded by the NHS are in danger of losing their jobs.

I will say a little bit about what MS nurses do. They help with patient concerns, with the inevitable depression and with relapses in the condition. They are an essential point of contact, providing reassurance and care. They help MS sufferers broadly to deal with their condition. They provide advice and information. Above all, they have a holistic approach. Each MS sufferer is different, but an MS nurse is able to look at an individual patient’s total circumstances to provide the help that is important. They are a valuable addition to GPs, few of whom acknowledge that they have confidence in identifying potential MS patients. GPs as a whole are grateful that there are specialist MS nurses who can provide the input that GPs normally acknowledge that they cannot provide.

MS nurses provide a tremendously important service for MS sufferers. They can be justified not only in the overall savings to the National Health Service but, above all, by their providing better and more sensitive care for MS sufferers and giving them a better quality of life. Surely that is essential to people suffering from a difficult and dreadful illness.

My Lords, I, too, thank the noble Baroness, Lady Masham, for initiating this debate. As always, her contribution is timely, and grounded in compelling personal testimony.

I have been a long-time admirer of the nursing profession, and my report, Neighbourhood Nursing, published 20 years ago, first mooted the idea of nurse prescribing, a concept which, to their credit, successive Governments have cautiously taken forward. In that report we also promoted a new role, that of the nurse practitioner. It was then that I really got to know what nursing was about. There are not many of us, except perhaps my noble friend Lord McColl, who can tell anyone—anyone at all—to take off all their clothes, and they will; or stick a needle into them, and they will not complain; or insert a tube into any orifice, and then be thanked for doing so.

In the past two decades nursing has developed in knowledge, skills and confidence, not least through new roles such as nurse consultants and specialist nurses. I tried to find out how many specialist nurses are employed, and despite considerable efforts by the ever helpful RCN—I declare that I am a vice-president of the RCN—I have been unable to do so. I understand that the Department of Health no longer collates information centrally on nurse numbers, broken down by bands or title, and I wonder why that is. I therefore ask the Minister: who is in charge of nurse workforce planning? Is it left to individual strategic health authorities, NHS trusts, PCTs and universities? If so, with the private and independent sector becoming such a major employer, who is to ensure nationally that the right number of qualified staff are available? We need clarity about where that responsibility lies. It is critical to know because, without a doubt, as we have heard tonight, specialist nurses have improved the quality of care for patients and their families and they are now an integral part of healthcare. For instance, over the past 22 years, the Parkinson’s Disease Society has developed a network of more than 230 posts. Together with PCTs, NHS trusts, and SHAs, it has invested £7 million over the past 15 years and, in the past three years, half a million pounds in nurse training. There is no doubt that specialist nurses increase capacity and, as we have heard tonight, save the NHS money.

I now want to address the issue of another group of specialists—midwives. I declare an interest as a vice-president of the Royal College of Midwives. In particular I want to talk about independent midwives. They are a remarkable professional group who pioneer truly women-centred care. When I produced my report Changing Childbirth, I was so impressed by their philosophy and practice that I used them as a model for the NHS maternity services. They did not disappoint. Independent midwives provide an alternative to what is offered locally by the NHS. In addition, many are opinion leaders who interpret research, write articles on good practice and help to change unhelpful attitudes within the NHS. They also teach and have student midwives on their electives. They are the gold standard for midwifery services.

Independent midwives have helped to keep the option of a home birth alive as a real choice for women. Collectively, they achieve a home birth rate of 75 per cent, compared with the national rate of between 2 and 3 per cent. Their caesarean rate is only 15 per cent, compared with the national average of 23 per cent. That is not surprising, as independent midwives have been the pioneers of caseload midwifery and provide continuity for women throughout pregnancy, the birth and postnatal care. These remarkable professional women are being written out of the script at a time when there is a serious shortage of midwives. We can ill afford to lose them. They have been caught in the trap of professional indemnity insurance. It is not a new problem. Since March 2002, independent midwives have had to practise without insurance. That is not a situation that they want or with which they feel comfortable, but pregnant women have indicated their confidence in independent midwives by continuing to employ them, knowing that that is the case.

In the autumn of last year, the Chief Nursing Officer told the Independent Midwives Association that Ministers had decided to introduce legislation to ensure that all practising healthcare professionals should have compulsory indemnity cover. He followed that up with a letter suggesting that independent midwives should try to obtain funding through a social enterprise route. They have tried to do so, but without success. They were turned down by the Pathfinder scheme. They are the only professional group that cannot get cover.

The department has not been very clever. It held meetings with the Association of British Insurers without even telling the Independent Midwives Association, let alone involving it in meetings. I understand that one such meeting took place only yesterday. It is extraordinary. Whose career is this? Whose professional practice is being discussed? Whose livelihood? Who has the passion for this remarkable life event, helping women give birth and the starting of a new life, except midwives themselves?

I know of the Minister’s commitment to maternity services. I know that he is responsible for indemnity and insurance. I know of his ability to persuade, to negotiate and to be savvy. This problem needs to be resolved, especially as the Government have brought the issue to a head in their proposal to legislate. I am asking the Minister to take action personally, to work with the litigation authority, to involve the Independent Midwives Association in negotiations with the insurers and to resolve the problem. If all else fails, will the Government consider underwriting the insurance for this, the only professional group that cannot get cover? We need more independent midwives. We need more midwives per se. We cannot afford to lose a single one, let alone 150 of the best, at the stroke of a ministerial pen.

My Lords, I, too, thank the noble Baroness, Lady Masham of Ilton, for initiating this debate. She has much experience and personal knowledge of the role of specialist nurses and eloquently expressed her concern about patients and specific specialty nurses faced with the threat of possible reductions in service.

The NHS Plan clearly set out the Government’s intent to devolve from central Government to strategic health authorities and primary healthcare trusts the planning and commissioning of local services. In theory, that sounds excellent, with the Government being in a position to monitor against service agreements. We are all aware of the 2006-07 deficits and their various effects on services so that the books might balance at the year end, but we cannot hide behind last year’s deficits for ever and we need to move forward. Is there not a problem in the lack of joined-up thinking on workforce planning between strategic health authorities, primary care trusts, NHS trusts and educational establishments, as mentioned by the noble Baroness, Lady Cumberlege?

We are constantly reminded by Ministers that there has been an increase in resources, resulting in an increase in the total number of doctors, nurses and healthcare professionals, but are they of the right qualification and in the right place at the right time? We also hear from professional organisations that there is a shortage of midwives, health visitors and nurses.

In recent years, there has been a tremendous growth in advanced specialist nursing roles, as evidenced by the presence of nurse practitioners, clinical nurse specialists and nurse consultants, who have all gained advanced practice skills following studies for advanced qualifications. Evidence shows that these nurses, midwives and health visitors have contributed to an improvement in patient care and service capacity, including caring for patients at home, thus avoiding hospital admissions. This is especially valuable in supporting patients with long-term conditions, such as multiple sclerosis, diabetes, Parkinson’s disease, epilepsy, mental health conditions and terminal illness, to name but a few specialties.

Just as medical specialties have expanded rapidly, so, too, have those in nursing, with nurses taking on roles in, for example, prescription and endoscopy, thus relieving medical practitioners of some areas of work usually undertaken by doctors alone. These specialist nurses are frequently described by patients and families as a lifeline with whom they could not exist, as my noble friend Lady Masham has already said.

Here, I declare an interest as a retired regional director of nursing for the South East Thames Regional Health Authority, where I was responsible for the workforce planning of in excess of 33,000 nurses and midwives over a period of 17 years covering four major government reorganisations. During that time, many changes took place in the delivery of patient care, with a move to more specialisation. In many cases, in order to meet the need, agreements had to be made with charitable organisations to sponsor specialist nurses, as has already been mentioned. This was particularly so for cancer nurse specialists and Parkinson’s disease nurses in the early days. This still happens today but it is very distressing for the charity, the patients and the practitioner when the agreed time comes to an end and the PCTs fail to meet their agreement.

My experience in workforce planning showed me that there was a need to identify how the specific needs of patients could best be met by delivering high-quality care within the resources available. To do that, I needed a small team of nurses with a range of knowledge and skills who could advise on the workforce plan necessary to deliver safe, high quality care.

I have yet to be convinced that the current SHAs, PCTs and NHS trusts have the necessary knowledge and skills available to enable sound decision-making to be made on the workforce plan. There is a need to understand care pathways that are suitable for each condition and to carry out individual care that is both effective and cost-effective, as has already been emphasised this evening. Can the Minister say how many nurses employed at strategic health authority and PCT levels are involved in workforce planning? Having explored a few trusts where there have been no redundancies of advanced practitioners, I have discovered that those trusts have carried out a thorough review and have decided not to cut because of the recognised detriment that that would have on service delivery. One director of nursing, having carried out a detailed review of all specialist nurses in the trust reported to me:

“To date the findings can confirm they are value for money as well as improving patient care. Making them redundant would be a false economy".

Again, that was emphasised by the noble Baroness, Lady Gardner of Parkes.

Would it therefore be a worthwhile exercise to examine where redundancies have occurred, early retirement advised or downgrading has taken place, and the posts at risk identified, giving the basis on which the decision was made and the background expert knowledge and skills of the specific speciality, including the detrimental effect to patients and families and the resultant lowering of morale on nurses and the healthcare team? Could the Minister please comment on this situation?

The Government’s policy to move more care into the community will obviously have an effect on the numbers available in the workforce to meet the increased demands. How many strategic health authorities have decided to cut the admission of students to undertake health visiting training for this coming year as the South West SHA has already announced no places for health visitor training?

The nursing profession is pro-patient care, not anti-reform, and has been in the forefront of leading and delivering reform. For example, nurses have taken on a range of new prescribing responsibilities, carried out extensive reviews of repeat prescriptions and saved millions of pounds by stopping irrelevant medicines for the current conditions. They have adopted flexible ways of working that have reduced waiting times and waiting lists. They have taken on new leadership roles, such as consultant nurses and modern matrons.

Nurses are working as lead clinicians in primary care, in home care support services and in the management of chronic diseases. Nurse-led clinics are revolutionising patient access to quality service—endoscopic and diabetic nurses, to name but two specialisms.

The Commons Committee for Public Accounts has criticised the Department of Health for its failure to properly cost, and thereby fully fund, certain policies and reforms. In the light of these criticisms, and the question posed by my noble friend Lady Masham, will the Minister consider holding a review of workforce planning currently in place in strategic health authorities, PCTs and NHS trusts to ensure that there are adequate knowledge and skills to balance the forecast demand with supply? This is vital when the forecast shows 180,000 nurses are due to retire over the next 10 years, and that in 2011, there is a predicted shortage of 19,000 nurses. That poses very real problems for workforce planning and resourcing adequate training places in the next three years to meet the demand for pre-registration and post-registration students, and to meet the projected shortfalls and enable safe, high quality care to be given to patients.

I join the noble Baroness, Lady Finlay, in emphasising the importance of this debate in seeing that there are adequate nurses to meet the requirements of patients.

My Lords, I join other noble Lords in thanking the noble Baroness, Lady Masham, for her excellent speech, and for giving the House this opportunity to discuss the current financial deficits in the NHS.

It has always been argued that the whole GDP could be spent on the health service. Indeed, I remember Keith Joseph making exactly that point when he was first appointed Secretary of State. With the many very welcome medical breakthroughs since then, the challenge for the Minister has become even greater. The need, above all, is to spend on the right priorities.

Clearly that has not always happened. Spending on the NHS was £36.7 billion in 1997; it has more than doubled since then; and it is growing. Sadly, there are all too many examples of waste and poor value for that money. The recent example of the misjudged doctors’ pay settlement more than illustrates the point. So too, there are far too many examples of key staff being made redundant as a result of yet another round of “reform”, and then being re-engaged as management consultants at a much higher price.

It is, of course, the effect of all this on the nursing profession—in particular, on specialist nursing posts—that we are concerned with this evening, and the detrimental effects that such cuts in staff are having on the services that are particularly important to those patients with long-term conditions.

The nursing profession has indeed made real progress in recent years, with increases in its pay, responsibilities and qualifications. I pay tribute to the previous Government, when the noble Baroness, Lady Bottomley, made raising the status of the nursing profession one of her priorities as Secretary of State; so, too, to this Government, who have more than continued that investment. As a result, a recent joint Department of Health and Royal College of Nursing survey showed just how far advanced nursing practice had significantly contributed to improved patient care and service capacity, including caring for more patients at home, thus avoiding hospital admissions. That is why it is such a sad commentary on those achievements that these new specialist nurses, originally seen as a major part of the Government’s reform plans for a more patient-centred service, have now become an all-too-easy target for those cuts which the Government require to be made by trusts in financial deficit.

When I think back to when I served on the Briggs committee on the future of the nursing profession—when all nurse training took place on the wards and practically no specialist nurse training existed at all—and realise all the progress made since then, it is an even greater sadness to see the nursing profession targeted in this way. It is also worrying that the huge extra resources allocated to the NHS have clearly not yet been adequately managed so as to match the changing special needs and expectations of citizens and patients. Today, we see longer life expectancies and an increasing percentage of older people in the population, a similarly growing number of handicapped patients, and that those with long-term conditions are living longer and likewise growing in number. Those suffering from dementia, for example, now numbering 700,000, are expected to number 1.7 million in 10 years. We also know that there are nothing like enough mental health facilities for adults; indeed, many end up in prison. There is such limited provision for children that deeply worrying stories circulate of their being housed with severely disturbed adults. That is why we must start with the need to give priority to those specialist nursing services that are certainly needed by some young people but, increasingly, are even more necessary for the older population over a longer period.

One more illustration of the need for specialist nursing is stroke, the UK’s third biggest killer. It is also one of the most expensive diseases in the country, costing the nation around £7 billion a year. The Stroke Association believes specialist stroke nurses are a fundamental part of this service. Consultant nurse posts in that field are still low in number, and over a quarter of hospitals have no form of senior stroke nurse specialist. Yet the national clinical guidelines for stroke say that:

“Specialist stroke services should be available in the community as part of an integrated system of care to facilitate early supported discharge”.

Against this background, my final worry is that the case for the patient and the carers involved seems increasingly unrepresented, despite government protests to the contrary. As recently as 2003, the Government set up over 400 PPIs—patient and public involvement forums—specifically as a voice for local NHS consumer concerns. They also set up the Commission for Patient and Public Involvement in Health, which was to be the national voice representing patient and public issues and concerns. Yet only three years later—and in a pattern disturbingly similar to that proposed for the Probation Service in the NOMS Bill—this whole structure is to be disbanded and replaced by LINks: local involvement networks. Notwithstanding the fact that there will no longer be any central body to present the national picture, the Government claim that this will,

“strengthen the system of user involvement”.

The House of Commons Health Select Committee’s latest report calls the LINks network model “vague and woolly”, and says,

“The lack of clarity about LINks role and structure is likely to create confusion and inactivity”.

Unsurprisingly, the Royal College of Nursing is also concerned. It points out,

“that the means by which it has been developed indicates one of the deficiencies of existing systems of consultation”.

For, as they say, the existing systems of PPI have not been given sufficient time or resource to bed in effectively, nor has the model been fully evaluated.

I hope that the Minister will be able to reassure your Lordships on these points, but this is one more reason why we should be grateful to the noble Baroness, Lady Masham, for having brought these matters to the attention of the House.

My Lords, I, too, thank the noble Baroness, Lady Masham, for introducing this subject with her characteristic feistiness and passion. I convey the best wishes of, I suspect, the whole House to the noble Baroness, Lady Wilkins, for a speedy and complete recovery.

Nurses have a unique role within the health service. I hope that the noble Lord, Lord McColl, will back me in the assertion that they are one of the few groups of people who can strike terror into the hearts of consultants. They are therefore of immense value.

I, too, want to talk about two issues in particular. The first is workforce planning, mentioned by the noble Baroness, Lady Emerton—ensuring that we have nurses in the right place at the right time. Following in the steps of the noble Baroness, Lady Finlay, I believe that it would be useful to identify exactly what we are talking about. The RCN, in its report Maxi Nurses: Advanced and Specialist Nursing Roles, identified five main types of jobs: nurse practitioners; clinical nurse specialists; nurse consultants; specialist nurses; and advanced nurse practitioners. In those roles, nurses spent 60 per cent of their time in clinical activity; 17 per cent in education; 14 per cent in management; and 4 per cent in research. Some 90 per cent of A&S nurses carry out patient assessments and referrals and offer specialist advice. Overall, clinical nurse specialists and specialist nurses tend to focus on case management, while nurse consultants and advanced nurse practitioners do more diagnostic activities.

I found that information rather interesting and it helped to explain a key problem. The development of specialist and advanced nursing roles has come about with a lack of clarity. Alarmingly, that lack of clarity extends to other people within the medical profession, which in turn leads to a misuse, or an underuse, of this very important resource. Nurses are an important resource. The average age of specialist nurses is 46 and typically they have between 16 and 20 years’ experience, of which 10 years is in the speciality of which they are deployed. That is a very valuable resource within the NHS, where reorganisation and turmoil have led to a great deal of turnover.

Half those specialist nurses are based in hospitals, mostly in specialist units, while 10 per cent are in GP practices and 20 per cent are in the community. That raises the question of the extent to which they are involved in preventive work and in the maintenance of long-term conditions. Is the balance in that correct? According to the RCN research, 72 per cent of the work of advanced and specialist nurses is primarily on their own, with a high level of autonomy. They express a high degree of satisfaction with that, particularly the degree of patient contact and their ability to see cases through to the end. Patients welcome that continuity and the chance to build up confidence.

It is clear that specialist nurses play a vital role in drawing together different parts of the NHS. What is less clear is the extent to which they are a pivotal force in ensuring continuity of health and social care. That is important, given the Government’s recent announcement that practice-based commissioning will extend to social care. I declare my interest as someone involved in social care.

The noble Baroness, Lady Cumberlege, touched on one of the most important questions in the debate: what will happen to the role of specialist nurses as their commissioning and employment become ever more fragmented? Speakers in today’s debate have talked about the role of PCTs. Noble Lords may know that, three or four weeks ago, Kingston PCT announced that it would no longer be a provider of services and would only commission them from the independent sector.

That leads to the key question of workforce planning. How will those responsible for commissioning services determine the optimum configuration of specialist nursing staff? Throughout this debate, we have heard about the vital role that specialist nurses play as the bridge between consultants, clinical staff and patients in the community. They can help with medicines management, which is now an important and increasingly complex aspect of nursing. How are we going to get the correct configuration, even in a place such as London where we have teaching hospitals, a large number of PCTs and a strategic health authority?

The Minister will be aware of the economic advantage that specialist nurses bring to the NHS. It is a paradox that, while specialist nurses say that they like to be autonomous and to work on their own because of the development of their skills that that brings, in relative terms they are perhaps more valuable when they work in multi-professional teams, because they take demand away from more expensive acute services and enable patients to manage themselves. Nurses will have a huge role in the development of self-care.

Perhaps the best and most hopeful answer that the Minister could give to the question posed by the noble Baroness, Lady Masham, is that, within the dreaded phrase “modernising nursing”, his department will provide comparative studies of different models of deployment of specialist nurses. They could be of different models in acute trusts, primary care trusts and GP practices jointly employing nurses, or they could be population studies. We know that the populations of people with different conditions vary dramatically. Some neurological conditions affect only a small number of people in a given area. What is the best specialist nursing arrangement for such conditions? The value of the specialist nursing role is not in doubt, as evidenced by tonight’s debate, but the question of the value of different patterns of commissioning and deployment has yet to be answered. That is the information that the department could most usefully provide.

My Lords, I, too, thank the noble Baroness, Lady Masham, for initiating this valuable debate. Most of what I was going to say has already been said, so I shall not repeat it. However, I shall draw the attention of the House to Thomas Guy, who was a governor of a famous London teaching hospital 300 years ago. He became dissatisfied with the way that the chronic sick were being looked after. He made a fortune printing bibles in Holland, and he used his money to build a hospital called Guy’s Hospital for Incurables. Unfortunately, he died before the hospital was opened, and it soon put aside the business of the chronic sick and got on with acute medicine and surgery. Nothing changes: the chronic sick were soon forgotten, as they always seem to be.

We ought to remind ourselves that half of us will be disabled to a greater or lesser extent before we die. Perhaps if altruism is not enough to motivate the Government, a touch of realism might be a greater stimulus. In England, there are 17.5 million disabled people with long-term conditions, who account for 80 per cent of GP consultations and a majority of elective and emergency admissions to hospital. They are the people who most need the support of specialist nurses.

I draw your attention to stomatherapists, who have been mentioned. They are worth their weight in gold. They transform the life of those who have to have a colostomy or ileostomy—especially an ileostomy, which is so much more difficult to control, as the effluent is fluid. They make an enormous difference. They try to rehabilitate patients so that they can live a pretty normal life.

One lady who had to have an ileostomy for her urine was very active and did not like emptying the bags, which are rather inconvenient. The stomatherapist and the lady concerned agreed on a quite amusing way to deal with the problem. She had a long, thin bag which went down her trouser leg inside her trousers with a tap on the bottom. When she needed to empty it, she used to go up to a parked car, kneel down in front of it and pretend to be doing up her shoe lace while she was really emptying the bag. Of course, it is quite usual to have fluid around the front of the car and on the road, so no one commented. The only problem was that garage owners could not understand why all the motorists were so neurotic, bringing their cars in to say that they had a leaking radiator. Anyway, stomatherapists are tremendous people and make a great difference to those who have to suffer an ileostomy or a colostomy.

The Royal College of Nursing found in its survey that 86 per cent of specialist nurses were worried about financial pressures. The figure that has already been cited—that one in five think that they will be made redundant—is quite shocking. June James, a specialist diabetic nurse, was reported on the BBC as saying:

“Posts are being downgraded and services cut and I think it shows a lack of respect for the work that we do”.

Another key part of the NHS workforce who should be caring for people with long-standing conditions is district nurses. Yet, again, among that group of health professionals, we witness the effect of the financial problems. In the past 10 years, we have witnessed a one-fifth reduction in the number of district nurses, from 14,000 to 11,000. In the past year alone, 800 district nurses have been lost. It is clear that the Department of Health strategy for moving care out of hospitals into the community is in serious danger.

The worry is that the demand for more specialist nurses will not be met in future, not only because the NHS is cutting back on those posts but because it is cutting back on the education and training budget for the third year in a row. That is worrying, especially as the Government have allowed at least six of England's 10 strategic health authorities to cut their training budgets, despite the NHS chief executive promising, as recently as February, that that would not happen. Specialist nurse training will undoubtedly suffer.

Much has been said about ESNs, who are also essential. As the noble Baroness, Lady Gould of Potternewton, said, we do not have enough of them. The NICE guidelines are absolutely clear but are not being kept to. The business of pump-priming is very important. Epilepsy specialist nurses, known as Sapphire nurses, were set up with the pump-priming. As has been mentioned, £2.5 million was spent on that. The agreements made between NHS trusts and charities have been flouted. That is disgraceful and it would be very helpful if the Minister could tell us what the Government's view is on those written agreements. That is a great shame.

Will the Government take urgent steps to ensure that the NICE clinical guidance 20 will be fully implemented across NHS trusts? To repeat it, it states:

“Epilepsy specialist nurses should be an integral part of the network of care of individuals with epilepsy”.

My Lords, I very much welcome tonight’s debate and congratulate the noble Baroness, Lady Masham, on allowing us to debate the critical role of specialist nurses, who, as she so eloquently pointed out, work with some of our most vulnerable patients. Every noble Lord who has spoken has paid tribute to the role of specialist nurses, whether in the area of multiple sclerosis, epilepsy, Parkinson’s disease, strokes, spinal care—on which it was very good to hear of the progress made by my noble friend Lady Wilkins—diabetes, palliative care or other fields. The noble Lord, Lord McColl, mentioned Thomas Guy. He pointed out that, given the demographics ahead and the number of disabled people likely to be in our community over the next 10, 20 and 30 years, the role of specialist nurses in caring, supporting and encouraging those people is very important.

Much of this well informed debate essentially revolved around the roles of the Government and local health services in making decisions. My noble friend Lady Gould and the noble Baroness, Lady Masham, in particular, focused on the role of Government. As I see it, the Government’s role is to fund the health service appropriately and to ensure that proper guidance is available to local decision-makers through national service frameworks and organisations such as NICE. We depend on effective commissioning by primary care trusts and practice-based commissions, with financial payment by results to incentivise local trusts to provide cost-effective services.

The role of the regulator, the Healthcare Commission, is to ensure that that adds up to effective performance and that the services provided are high quality and safe. I know that the noble Baroness, Lady Howe, criticised poor management in the NHS, but I am convinced that this is the best approach to getting good management as opposed to central, top-down, micromanagement. I accept that the Government have a strong role in encouraging local NHS bodies to consider and understand the role of specialist nurses, but it cannot be their role to dictate to the NHS and individual primary care trusts what they do.

My noble friend Lady Gould and the noble Baroness, Lady Masham, in particular, referred to the NICE guidance. It is powerful, and I very much hope that local NHS bodies take it to heart. There are very important points to make about the availability of central information on the number of nurses. I well understand the point made by the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Dubs. My understanding is that we have never collected nursing numbers broken down by band or grade. As we have heard from other noble Lords, because there is no standard definition of specialist nurses, even if we were to count, it would be difficult given our present understanding.

None the less, we have seen an increase of 80,000 nurses in the health service since 1997. Overall there has been a huge increase in training commissions. In the early 1990s nurse commissions went down to as few as around 13,000. There are now more than 20,000. As has been described, we have also seen huge areas of development in the skills of nurses, specialist practitioners, nurse consultants and community matrons. Nurses work independently and autonomously. They are leading services with medical colleagues and they are equal and respected members of the healthcare team. The noble Baroness, Lady Cumberlege, referred to nurse prescribing. She and I have shared a real passion for ensuring that that is developed. I also thought that the comment made by the noble Baroness, Lady Barker, about medicine’s management was very well made.

That leads us to the question of workforce planning in the health service, which the noble Baronesses, Lady Cumberlege and Lady Emerton, asked me to describe. I have seven minutes left. Very basically, the key responsibility is at the strategic health authority level. The job of the strategic health authorities is to pull together service needs on the one hand and training commissions on the other. They then have a service level agreement with the department so that the effect of their work comes together and we have an overall national strategy and understanding of the workforce requirements. This has, of course, always been a problematic area for the health service. There has usually been a huge pendulum swing. There have been too many training places and then not enough work places for those people, followed by a swingeing cut in training places and a shortage of staff. Clearly, we want to avoid that. I do believe that what I have described is the best approach. I understand the point made by the noble Baroness, Lady Emerton, about the need to ensure that nurses are involved in workforce planning at the SHA level. I do not know the numbers—I doubt that anyone does—but the point that she makes is very important.

The noble Baronesses, Lady Gould and Lady Masham, and other noble Lords referred to the MS specialist nurse post. I understand the concern about the failure of PCTs and trusts to pick up the cost. All I can say is that I very much regret that this problem has arisen. The Government’s intention is absolutely clear; we want to continue to improve the care of people with long-term conditions, including those with MS. Clearly, these posts were seen as a very important component of that general strategy.

A number of noble Lords talked about funding. All I will say about funding is that it was absolutely right to require trusts overall to get into financial balance. That has led to very difficult decisions having to be taken. However, the Chief Nursing Officer has asked all nurse directors who are redesigning services to ensure that an impact assessment is carried out to maintain the quality of service to patients. That very much relates to the role of specialist nurses. I very much take the point made by my noble friend Lord Dubs and the noble Baroness, Lady Howe, about the cost-effectiveness of the employment of specialist nurses. That is absolutely right. The point has been made clear to those helping trusts in particular financial difficulty to understand that when taking decisions on achieving financial balance, possibly by cutting specialist services.

Some very interesting points have been made about the actual definition of specialist nurse roles. I understand that the Nursing and Midwifery Council is considering the variations very seriously. The title of specialist is not protected through registration. Some nurses may be called specialist but do not actually have the higher level of skill needed, which leads to a concern about the quality and safety of patient care. I therefore support what the Nursing and Midwifery Council is doing in this area, and I take note of the comments made by the noble Baroness, Lady Masham, about registration. This must also be seen in the context of modernising nursing careers. This is another opportunity in the work to be led by the Chief Nursing Officer to ensure that we embrace the points that noble Lords have made here.

On the question of stoma care, I shall move on quickly from the interesting comments of and example cited by the noble Lord, Lord McColl. I want to make it absolutely clear that there is no reason at all why, under this review, home services should be discontinued. Indeed, I take this opportunity to deplore the conduct of certain commercial undertakings. They have caused unnecessary concern to patients by distributing wholly inaccurate information. I utterly deplore that and I can assure noble Lords that the last thing that I want, in taking forward this review, is for patients to be affected in the way described by the noble Baroness.

I turn to the question of independent midwives. The noble Baroness, Lady Cumberlege, knows that I am concerned about this situation. She is a little unfair to the Chief Nursing Officer. There is no reason why the CNO, who is as exercised as I am about this and is involved in a lot of discussions, needs to be accompanied by representatives of the independent midwives to every meeting. I would be happy to meet the noble Baroness and the association to discuss the issues further. I am concerned about the situation, but there is no easy answer. However, I would be happy to take it forward. The noble Baroness knows my views in this area. I do not want to see the practice of independent midwives inhibited in any way, but it is a difficult issue.

I conclude by saying that my honourable friend Mr Ivan Lewis held a summit today of the MS Society, Epilepsy Action, the Parkinson’s Disease Society and the RCN to discuss the issues that noble Lords have raised tonight. There was agreement to produce best-practice guidance and to encourage PCTs to advocate the role of specialist nurses across the country. My honourable friend is very supportive of that work. Further, let me say at once that I think that there is a general acceptance that our main role is in encouraging NHS bodies locally to do the right thing. However, I have taken note of the comment made by the noble Baroness, Lady Barker, about models of deployment and population studies. It is an excellent idea and I will take it back with me. I do not know whether it can be embraced in this joint piece of work, but I shall certainly suggest it. It could be a very useful way forward.

The Government have no disagreement whatsoever with the proposition put forward in this debate of the importance of specialist nurses, particularly when we are clear about the role that they have to play and agree that they have the right professional qualifications to do so. We do not believe that this is something to be dealt with through government diktat; it must be achieved through encouragement and information. I can assure noble Lords that my honourable friend Mr Lewis and I are very concerned to work with the key organisations to ensure that that happens.

House adjourned at 9.28 pm.