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NHS: Staff Qualifications

Volume 716: debated on Tuesday 19 January 2010

Question for Short Debate

Tabled By

To ask Her Majesty’s Government what assessment they have made of the effect on the National Health Service and patient care of the increasing level of qualifications expected of staff and the entry requirements for qualifications.

My Lords, due to an oversight, time limits for speeches in tonight’s debate were not publicised as part of the speakers list. If Members’ contributions, including that of the noble Baroness, Lady Gardner of Parkes, are kept to 10 minutes, and that of the Minister to 12 minutes, the debate will conclude within its one-hour time limit. I apologise to the noble Baroness.

My Lords, it is opportune that we are able to debate this topic today, as the nursing registration body—the Nursing and Midwifery Council since 2002—goes out to public consultation on 29 January to determine the new draft standards for pre-registration nursing education. For this reason, I intend to speak mainly about nursing, as I think it is those changes that presently propose the greatest risk to the NHS. This consultation will be on the NMC website and the link is I hope that many people will respond as I believe it would be against the interests of patients and the NHS if nursing became a degree-only qualification and was therefore closed as an option for many ordinary men and women from 2013. Nursing is one of the oldest professions in the world and nurses are held in very high regard by both patients and public. This confidence must be maintained and justified.

The Council of Deans of Health, with 86 member universities throughout the UK, has as its number one aim,

“to be the principal source in the UK of higher education”.

It is not surprising that its policy statement on key areas of interest includes:

“The future shape of the healthcare practice workforce, engaging with and influencing healthcare workforce planning issues and processes, engaging with and influencing the Modernising Careers agendas, seeking to generate agreed postgraduate career frameworks and secure funding for post-registration education pathways to support the career frameworks and influencing discussion on the development of the assistant practitioner workforce”.

The famous expression, “They would say that, wouldn't they?”, seems appropriate.

Many of the best nurses are not academic. They have other qualities and skills and have had good training and great experience in hospitals. The report issued in June 2009 by the noble Lord, Lord Darzi, states that 180,000 nurses will retire in the next 10 years, 100,000 are over 50 and 80,000 are over 55. I am concerned that this country is becoming obsessed with the idea that everyone must have a degree. When the state enrolled nurse—SEN—was abolished in 1989, I thought that it was bad for patients. I still do, and my view is shared by many. I feel it particularly when I meet young people who would have made excellent, caring nurses, but could not obtain the required entry qualifications.

There were other practical problems too. At that time I was chairman of a large NHS trust in London, a teaching hospital. We had a nice and certainly convenient nurses’ home where trainees lived during their student years. Under the student system introduced in the 1990s, we had to provide accommodation for each student for only one year. The trust, under financial pressures and demands for change from the local council, decided that the nurses’ home would be sold off. Nurses found it difficult to obtain suitable accommodation within reach of the hospital, and that is still the case today.

It is understandable that deans of health want everyone to have a degree—that is their job. It is a great ambition but it lacks realism. Not everyone is up to getting a degree, and many of the excellent nurses who prove daily that they do not need a degree might never have been able to get a diploma, much less a degree. Caring about people and caring for people are the things that really matter.

I am a great supporter of higher and better training and opportunities for those who have the ability to achieve a degree and get postgraduate training. Nurse practitioners have been a success and led services in primary and acute care all over the country since 2000. Specialist nurses have made a huge difference to patients and they save much time for consultants by dealing with all the day-to-day problems that patients have. I think that we need more specialist nurses in ever more fields.

My concern is the black hole in healthcare that will be left when the needed number of degree nurses is not realised. The drop-out rates in degree courses are high. Fifty-one per cent of students fail to complete the degree programme in adult nursing in one university in the north-west. In the south-west, West Midlands, Yorkshire and Humber, one-third of students are dropping out. Nursing Standard magazine shows that 78 per cent of students on a children's nursing degree course and more than 54 per cent on a mental health nursing course failed to graduate. Such high drop-out rates are very worrying and costly. Universities are facing financial cuts and drop-outs on these scales surely cannot be acceptable. There is a need to look into the causes and find out how to prevent these losses to a profession that will sorely need these graduates.

Who will fill the black hole that I expect in NHS staffing? At present, those who cannot qualify as diploma nurses can become healthcare assistants who deal with many of the patient’s day-to-day needs. The noble Lord, Lord Crisp, who has great experience in the health service, told me last week that all the HCAs he has encountered would like to have the title “nurse”. He is currently abroad, so I got his permission to quote him. I have some sympathy with that wish, as anyone referred to as nurse has a standing in the community and a reason to be proud. That means a lot to someone who is looking after patients and caring for them, as HCAs do.

Could nurses not move up a stage in their terminology to become specialist nurses or nurse practitioners? There must be a new title—perhaps graduate nurse—that we can give to all degree nurses. I qualified long ago as a dentist. With just my original degree study, I became a dental surgeon. Later the term doctor-dentist was introduced, and now all dentists seem to use the honorary title doctor. Are dentists any better?

On a different note, today I received a letter from the father of a young man who wants to become a clinical psychologist. He has a hearing disability caused by an operation that went wrong when he was an undergraduate. He went back to university and obtained a masters degree, but to pursue a career in psychology he needs work experience, and he considers that the NHS has failed to honour its disability equality duties by not giving him the opportunity to get that work experience. He is of the opinion that his access to joining the NHS is an example of failure in entry level requirements. I want to place that on record for him.

According to the Royal College of Nursing, the trade union for nurses, 1.4 million people work in the NHS in England: about 700,000 are clinical staff, including 133,000 doctors; 408,000 are qualified nurses, midwives and health visiting staff; 22,000 are practice nurses; and 355,000 are clinical support workers, including healthcare assistants. The Nursing and Midwifery Council keeps no record of how many SENs—as opposed to SRNs who qualified before the days of diplomas—continue to work as NHS nurses. The last non-diploma registration was in 1991, and everyone has to be an SRN now. I am not concerned about the catchphrases about degree nurses “too posh to wash” or “too clever to care”. My interest is in ensuring that the NHS has the number of well trained and caring nurses that it needs to continue to provide a proper service to patients. Nurses are the backbone of the health service.

The NHS has a different problem in the working time directive, and doctors, nurses, staff and patients will be affected. I hope that something can be done about this. That is not my remit today, and my speaking time is nearly over. The many of us who care about the NHS want to see it improve and continue to serve our people well. I have raised this Question today because I am convinced that the time to think about the impact of a degree-only nurse requirement is now, before 2013. The full implications may not yet be appreciated but they must at the very least be considered carefully.

It would be most unfortunate if the NHS found itself without enough nurses in the next few years. There are many points to think about. First, it is estimated that the applicants who are offered nursing training opt three to one for degree rather than diploma courses. That is understandable, as everyone would prefer the higher status. Secondly, why is there the high drop-out rate? Have students taken on more than they can manage? Thirdly, where do they go if they want to continue nursing but have dropped out for whatever reason? They could possibly become healthcare assistants, but surely they would still prefer to become nurses, even if not graduate nurses. Fourthly, how easy will it be for nurses to move up within the profession after they graduate? How will they be encouraged to become nurse practitioners or specialist nurses? Fifthly, how will the need for more nursing staff be met after 2013? Sixthly, is there a need to develop a registration process for HCAs, or do we risk over-regulating all health professions, as we have already done in some other professions?

I end as I began, by reminding everyone to respond, whatever their views, to the consultation on the NMC website from 29 January.

My Lords, I am grateful to the noble Baroness for having raised this important topic in such a timely way. I declare an interest as a practising clinician and as president of the Chartered Society of Physiotherapy, which is a graduate profession. I remind the House that to enter physiotherapy the A-level requirements are as high as for medicine.

In Wales, we already have an all-graduate nursing profession, but I saw the transition, and there are lessons to be learnt. I am fortunate enough to work now with some of the best nurses I have ever worked with. One in particular, Viv Cooper, started as an auxiliary, trained, did a degree and a higher degree. She is now one of the most senior nurses in Wales. When she left school, she was not ready to enter at degree level. It is important to remember that people mature at different rates and need to be able to move up later on.

The briefing of the Council of Deans of Health stated that the key message is that to provide high-quality care, we need a high-quality workforce. Of course we do. Nobody could dispute that statement, but I was alarmed when I read the briefing because it states:

“Nurses who are required to meet future healthcare challenges must be analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, change agents and the critical consumers of research”

It does not say compassionate or risk-intelligent.

There is a problem in a lot of education. Students are being educated to be risk-averse, not to be risk-intelligent. They are now not taking risks on behalf of patients—risks which should be taken—and in the process, the patients are being denied the opportunity, the care, and the decision-making that they ought to have. So I found this briefing somewhat alarming. I was glad to see that it stresses the importance of continuing professional education. Whether it is to diploma level or to graduate level, education is no good unless there is ongoing reflective practice, and ongoing education and training in the workplace.

There is an enormous range of things to be done under the name of nursing; certainly there are some very high-tech, complex procedures that need very highly-trained staff. To be an ITU nurse or a cardiac nurse, for example, you need a very high level of competencies. I worry that the nurses coming out through the graduate entry route may not be adequately trained to do some of the other tasks in nursing; they feel quite intellectually dissatisfied with some of what you might call the more mundane, but emotionally much more challenging situations, such as in psychogeriatric care, where you need an infinite amount of patience, an infinite amount of compassion, and an infinite amount of risk-intelligence. It was for that reason that I was particularly concerned that the briefing did not contain those words. When you listen to complaints from patients, lack of compassion comes high on the list. Sadly, complaints against nurses have gone up by 44 per cent in the past 10 years, and the NMC figures show that allegations have increased dramatically.

There are so many complaints that it is now taking nearly two years to get them resolved. Recent examples, which are on the website and are freely available, included the instance of a midwife handing a newborn to its mother, not realising that the baby was stillborn. It seems unbelievable that somebody could be practising as a professional, and have that lack of basic common sense, let alone competence.

There have been cases of abuse by both graduate nurses and non-graduate nurses against patients. We have to be very careful not to assume that just having a degree will necessarily improve everything. Claire Rayner, president of the Patients Association, commented that she felt that for each complaint there were another hundred where people did not actually dare to complain because they were too frightened or they did not know how to. In response to this announcement, the Patients Association press release stated:

“The basics of nursing care are dignity, compassion, and above all, safety … Since the introduction of Project 2000, which shifted training from the bedside to the classroom, nurses look to the personal prizes of nurse specialisms, and have been allowed to ignore the needs of their sick, vulnerable and often elderly patients. These new proposals risk making the situation worse.”

It is to do with the way that the degree-level education and Nursing 2000 have gone, not the degree per se. If you educate people out of the classroom, rather than integrating bedside experience and good examples, then you will not train people to high levels of practice. People need a role model when they are learning. We have discovered when training medical students that the most powerful factor of all is a good role model. That is the person on whom they model their clinical practice for the future. They are all graduates, obviously, but they copy, we hope, good behaviours, although sadly sometimes of course they also copy bad behaviours. If they are being taught by people who are in the classroom, and are not up to date, then they really do not have that role model to build upon.

I wonder whether we should be thinking about a pre-registration year, such as the one we have in medicine. Nurses will be out there and working, but will have to prove their competence and their skills in the workplace just as junior doctors do, and then become registered. It would go with an additional pre-registration year, which entails practical experience. In her recent report Patients not Numbers, People not Statistics, Katherine Murphy, director of the Patients Association said:

“It showed what happens when nurses focus on the wrong things and neglect fundamentals, such as helping patients with feeding, bathing and toileting, or assisting those recovering from an operation to get back, quite literally, on their feet … Patients and their families contacted us in their hundreds. They were angry that their final memories were of a loved one enduring appalling neglect—they were right to be.”

I have had an e-mail from a Member of this House whose cousin was last weekend in hospital, and is still in hospital. He contacted me in desperation, worried about his cousin’s situation, whom I will call P, for Patient, to anonymise this, and whose daughter I will refer to as D. The e-mail said:

“D was there today when the Ward Manager decided to move P to another bay”.

All sick patients were to be together, because this poor lady had contracted diarrhoea and vomiting. He went on:

“P’s relatives were gloved and aproned. The staff were not. P is not allowed a bedpan, but has to wear a nappy and pass water and defecate into the nappy. A so-called matron and an auxiliary came to clean her up, and threw all the dirty linen on the floor. They took her hearing aid out, and put it on the left locker, where she cannot reach it. She is not good today, and rather tearful. I am not surprised, being subjected to this indignity … Last Wednesday, Granddaughter asked a nurse if she could help move Granny as she had slipped down in the bed and was lying awkwardly. Nurse refused because she said of Health and Safety rules she could not. Granddaughter lifted her grandmother up in the bed quite easily. P is petite and slim … Today, D cleaned her mother’s right hand thoroughly, as it looked unpleasantly soiled under the fingernails.”

Those are the things in care that matter to people. I have had a patient ask me to cut his fingernails, because he did not want to die with dirty fingernails, and I took in my own nail clippers to do it. That is not a menial task; as a professor, I believe that it is my duty. But we need to make sure that however we change training, we have a workforce that meets the needs of the patients that they are there to look after.

Some groups, such as physiotherapy, have done really pretty well. They are doing very well in terms of getting their physios really trained up to look after the cohort for whom they are there. Nursing needs to look at itself quite carefully, and the way it is training people, because otherwise we are going to have a huge gap.

A consultation is being launched about the regulation of healthcare support workers. At the moment, healthcare support workers do a huge amount of work. They do a lot with patients, and are now, at Band 3, often working unsupervised; they are not a regulated group and often exhibit overwhelming compassion and care. I have found that in clinical practice, they are really the mainstay, particularly in the care of patients at home.

This is an important question. I fear that health economics might rebound quite badly. It costs about £26,000 per year to employ a healthcare assistant who can work on her own; it costs about £44,000 per year to employ a registered nurse. There are going to be increasing cost pressures on the NHS; I would not like to see nursing squeezed out by pushing up the banding and the cost, with all nurses being graduate nurses, and then finding out that all we have done is squeeze them out. We would have to reinvent the SEN grade, which had its problems at the time.

My Lords, the noble Baroness, Lady Gardner of Parkes, has asked a most important question which needs to be addressed. I was not certain that I could be here today, but when I found that I could I arranged to speak in the gap. When severely disabled people are ill or have an operation in hospital they need the best nursing care from people who will listen and understand their special needs. They are very vulnerable for many reasons.

Years ago, when I was a new patient at the spinal unit at Stoke Mandeville Hospital and in considerable pain, I found that the high-quality nurses on the post-graduate courses were the best. The senior sister always seemed to get the pillows in the correct position, which made all the difference. With the matron and the night superintendent coming around the wards, nursing care was kept up to a high standard. In latter years, the experiences of many vulnerable, ill patients has not always been as good. Will a university degree make a great deal of difference? To some who want an academic profession, it will. Many university graduates may be attracted to work overseas as university life will encourage them to widen their horizons. Will we have enough nurses to cover the ever-increasing needs?

We need highly educated nurses for highly technical procedures, but we also need the dedicated practical nurse who will care for the skin, watch the pressure areas, control infections and not always be moving on to higher positions. Many people felt that it was not a good idea to replace state enrolled nurses with lesser trained care assistants. Even in the private sector, care assistants are dressed as nurses and patients do not know the difference.

Last week, I took evidence about care at the end of life for patients with motor neurone disease. A senior neurologist told us that we have the same percentage of neurologists in the UK as in Albania. We need far more highly skilled specialists in many specialities, be they doctors, nurses or other health professionals. But we also need good, practical nurses who, as has been said, are not too posh to wash but will also take responsibility.

My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for raising this issue in a timely fashion. More than 20 years ago, my mum was in Raigmore Hospital, Inverness, for several months—a hospital about which I have spoken previously in your Lordships' House. She was there for so long that when she left the staff threw a party for her and I am pleased to say that the consultant contributed by making a cake.

Because my mum was in hospital for a long time we went to see her every few days. One day when I went to visit she was very down. I asked what was wrong and she said, “You know, there are nurses and there are nurses, and some nurses are different”. That little observation about the way in which someone had been treated predates Nursing 2000 and the change in education about which the noble Baroness, Lady Gardner of Parkes, talked. There have always been nurses who are overwhelmingly compassionate individuals. There are others with different styles of doing their job. In reflecting on this matter, I think that we will fall into a terrible trap if we assume that professionalism is somehow the enemy of compassion. I do not believe that that is true.

The noble Baroness made an interesting comment about dentists. Tempting as it is, I will not go down the route of talking about dentists. But I will say that there was a time when dentists were barbers. Nowadays, my dentist has to know about anaesthetics, radiology, some fairly complex chemistry, and so on. My point is that medicine is becoming much more complicated. What I find worrying about this debate is that time and again we seem to come back to saying, “We recognise that medicine is becoming more complicated. We recognise that standards in all other areas of the healthcare profession are important”. However, we somehow feel that nurses have to stay in the same place and that if they do not something will be jeopardised.

That is dangerous because, as noble Lords have already identified, nurses spend by far the most amount of time with patients. In terms of improving patient care, it is important that the people who spend the most time with patients should have their status elevated so that they can bring about change and argue for change with people who often do not spend very much time with patients—for example, consultants. In some disciplines, consultants do not spend a lot of time looking at what happens to their patients. I want to make the case forcefully that upgrading the nursing profession in an objective and demonstrable way is a very important part of increasing patient care.

I turn now to degrees and training. The noble Baroness helpfully talked about the way in which nurse training has developed over the years. Since the early 1990s, nurse training has been based in universities. I understand from the briefings I have received that 50 per cent of university-based education programmes at degree and sub-degree levels continue to be delivered in hospitals, health centres, surgeries and people’s homes. When people listen to a broadcast of this debate, we are in danger of them getting the impression that all nurse education is solely academic. I do not believe that that is the case. Will the Minister confirm that, in future, degree courses will contain a great deal of practical application and that people will learn not only about anatomy and physiology, but also about patient interactions and the importance of bedside manner and communication? If that is the case, I would be happier to support some of the move towards degree-based entry.

Another important point is that nurses in this country have frequently made the observation that nurse education here lags behind the best international practice. Nursing is becoming a profession in which people are much more mobile. Fortunately, in this country we are blessed with nurses from all around the world. Nurses, just like their counterparts at practitioner level, have the right to move around and to have a common set of international standards. I understand that under European directives, degree and diploma students have to complete 2,300 hours of theory and 2,300 hours of practice over three years. I should like confirmation from the Minister that that is the case.

The noble Baroness raised a very important point about the dropout rate of students from degree courses, which is worrying. Today, I telephoned the Nursing & Midwifery Council about that. Its research found that 62 per cent of students leave their course because of financial worries. That is a serious matter and it is at the bottom of all this. Currently, as I understand it, there is funding of about £6,500 for a person undertaking a diploma, but they do not have access to student loans. Funding for degrees is £2,500, but those students have recourse to student loans, which is my key concern. Will that funding regime carry on? Will the Department of Health continue to fund the fees for the courses? As part of the monitoring following the implementation of this policy, will the department closely monitor the effect of student financing on nurses? If that does not work the terrible predictions about gaps in nursing staff made by the noble Baroness, Lady Gardner of Parkes, will come to pass.

That is the most important issue that lies behind this. We are possibly more in danger of deterring competent, caring nurses in the future if we do not get the funding base right than we are by changing the status of the education which they have to go through in order to qualify. I agree too that healthcare assistants are an important part of the workforce. There is a strong case for looking at regulation and career progression for healthcare assistants. They can make a huge difference to the experience of patients in hospital and they are vital. As noble Baronesses have already said, the hospital that treats you but does not care about you is not a very good hospital at all.

My Lords, my noble friend Lady Gardner has raised a subject of far-reaching importance—as so often she does—and for that she deserves our collective and very warm thanks. The question of whether nursing should be a degree-based qualification has been the subject of debate for a number of years. It is a debate which recently entered a new phase with the Government’s announcement last year that from 2013, new entrants to the nursing register will be confined to those who have attained a nursing degree. Those with nursing diplomas who are already on the register will be allowed to stay there, but as a route to entry, a diploma will no longer count.

My noble friend got to the heart of the question that this presents. What good will flow from this change? The justification for it, as we have heard, is the increasing complexity of the nurse’s role and the raised levels of responsibility which accompany this. It is certainly true that the job of a nurse is very different today from the way it was even 20 years ago. We have nurse specialists in many different disciplines. The noble Lord, Lord Darzi, stated in his final report that the skills of specialist nurses can help to keep patients out of hospital. Nurses can prescribe medicines; they are in charge of walk-in centres; they can carry out procedures previously reserved for doctors, such as endoscopies; and increasingly, they will be working in a diverse range of community settings. The argument runs that more and more nurses will find themselves assuming leadership roles and having to think critically as well as with a high level of technical knowledge.

All this is surely valid. We need nurses with degrees and we need more of them, not least because of the considerable number of nurses who are due to retire in the next few years. The question is whether it is wise to insist that all new nurses should have degrees. Those like my noble friend who are sceptical of the change believe that its effect will be to deter applications from people who would make good nurses but who are not suited to academic study. The RCN’s answer is that this is about encouraging more people to take a nursing degree and not about restricting entry to the profession. That is a good aspiration, but frankly, I cannot see how it can fail to restrict entry to the profession, and I therefore think that the potential shortage of recruits is a worry we need to take seriously.

What research have the Government done to convince themselves that this possibility can be discounted? We should also be worried by some of the reasons being given for the decision. The Royal College of Midwives said:

“We welcome this development, as it will improve nursing care and improve the status of nursing”.

I am afraid that I see “status” as having rather too much to do with all of this. Status is quite the wrong place to be starting. The proper starting point is to ask what it is that makes a good nurse in the 21st century and how best can we deliver it.

Talk to any senior nurse, and they will say that there are certain qualities in a good nurse which are indispensible: compassion, kindness and a caring approach. Technical proficiency is essential, but no nurse can ever be a mere technician. Good nurses know their patients; they are team spirited; they are practical people. These are qualities which either you have or you have not, they cannot be taught. Those who oppose degree-only entry say that an absence of such qualities is not the focus of a degree course and is therefore not a determinant of whether you pass or fail, whereas under the old-fashioned apprenticeship system, it would be picked up straight away.

If that is so, then there is an obvious answer. A consultation is under way, as my noble friend mentioned, on the content and structure of the new degree course. There is a big opportunity here to ensure that the character and attitude of a trainee nurse is treated with every bit as much emphasis in awarding a degree as their academic and technical proficiency. I should be glad if the Minister could say whether this is being considered—I hope it is. The suggestion of the noble Baroness, Lady Finlay, of a pre-registration year is a constructive one.

The stories that we hear about bad nursing, not least the appalling accounts published recently by the Patients Association, centre often on nurses who are thoughtless, lazy and uncaring in their approach. There is a lack of basic aptitude and competence. A large part of the argument for raising the bar as regards entry qualifications, rests upon patient safety. For me, this is where the argument for making the change is at its strongest. There is some quite compelling evidence from the United States showing that in hospitals with higher proportions of nurses educated to the baccalaureate level or higher, surgical patients experience significantly lower mortality rates.

There is another compelling reason for the change which we need to appreciate, and that is the effect of the European working time directive on junior doctors’ hours. To the extent that doctors are no longer present on a hospital ward to take responsibility for clinical decisions, nurses are now being called upon to do so in their place. There was an interesting article in last week’s Nursing Times which lays bare this whole topic. Many nurses report that since 1 August last year, which was when the 48-hour week came in, they have been under greater pressure to make clinical decisions that have major implications for the care and treatment of patients. Their complaint is not that this extra responsibility is wrong in itself: it is that very often they do not feel adequately trained for it, added to which they have less time to carry out their basic nursing duties. The net result for as many as half of those responding to the survey is that patients are being put in danger. That is clearly a worrying finding. It is also extremely ironic that an EU directive, which was intended to have health and safety at its core—albeit the health and safety of workers—should be the cause of putting patients at risk. Whether or not we like it, we are stuck with the working time directive. It follows that the mix of staff and the mix of skills on a ward are, in many environments, likely to experience permanent change, and that change has to be catered for in nurse training.

If more nurses are to assume more responsibility for more complex roles, it follows that many basic aspects of patient care, such as washing and bed pans, will fall to healthcare assistants. That implies that it does not really matter if those tasks are not carried out by qualified nurses. That worries me on two counts. First, healthcare assistants are not regulated and require only an NVQ or similar to start work, which does not guarantee much in the way of good patient care. The second worry is about why it is important for nurses to practise basic nursing. I recently received an e-mail from a retired senior nurse, who said:

“Current staff don’t seem to realise that ordinary tasks like washes, bedpans and temperature rounds were golden opportunities to develop a much better understanding of each patient and the nature of their illness; and it allowed for a build-up of trust between staff and patient. While seemingly mundane activities are being carried out, patients no longer feel isolated. They feel they can ask their questions and share their concerns without being a bother. In this way the nurse becomes the patient’s advocate”.

In other words, once you start treating basic nursing tasks as mere routine to be delegated to those less qualified, you risk preventing nurses from delivering nursing care in the fullest sense.

I hope that the work now being pursued by the Nursing & Midwifery Council to introduce a proper system of regulation for healthcare assistants can proceed apace because we need to guarantee standards at that level. I also hope that, with more graduate nurses on hospital wards, we will hear less and less of the phrases “too posh to wash” or “too clever to care”. Hospital nurses who will not give basic care to a patient or who will not ever clean up a dirty floor are simply not doing their job.

Graduate-only entry to the nursing register is a decision that has been taken. For it to work as intended, much will depend on how readily we can recreate the apprenticeship model of training on hospital wards, with proper supervision and the right disciplines being instilled in trainees from the outset by experienced nurses. Much, too, will depend on trainees who lack the right attitude being weeded out rapidly. The word “vocational” is no accident in the context of nurse training, for surely every nurse should feel that the work they do is something close to their heart and more than just a job.

Over the next few months or so, during which the new training curriculum will be designed, we will be presented with an opportunity to get the balance and content of the nursing degree absolutely right so that the aspiration which we all share of a nursing workforce fit for modern healthcare can truly be attained.

My Lords, I, too, thank the noble Baroness, Lady Gardner, for tabling the Question for this interesting debate. I shall start my response on the issue of assessment, which is central to her Question.

Assessments are made case by case where significant changes to national level education programmes or qualifications are proposed. These programmes and qualifications are regularly reviewed by those responsible to ensure that they are up to date and fit for purpose. Such reviews will take account of a range of issues: higher expectations of patients and staff; changes in demographics; changes in the nature of disease; and technological advances. Often these changes are incremental.

However, in recent times these reviews have focused on nursing and midwifery, which have needed more significant changes. In 2008, the minimum qualification to become a midwife was raised to a degree. It was only after a long period, during which increasing numbers of new midwives qualified with degrees, this non-contentious change was required by the Nursing & Midwifery Council in response to the complex and rapidly changing healthcare environment. Midwifery continues to attract more than sufficient applicants to courses.

Similarly, nursing is becoming more diverse and demanding: some types of hospital-based care will be provided in the home or within communities; technology is getting more advanced; people are living longer; and health needs are often more complex.

That is why the Nursing & Midwifery Council, following a review and consultation, announced the intention to raise the minimum academic level for registration as a nurse to a degree. The department, after considerable engagement with stakeholders, including strategic health authorities, announced in November 2009 that in England nursing programmes from 2013 will be degree level. Degree-level education will develop stronger analytical and problem-solving skills. It will preserve nurses’ hands-on caring skills and build the skills needed to be increasingly independent and innovative. It will enable nurses to assess and apply effective evidence-based care, safely and confidently lead teams, and work across service boundaries. Nurses will be able to provide increasingly intelligent care with compassion. The change in the level of qualification, combined with revised competences on which the NMC is about to consult, will ensure that new nurses can further improve the quality of care and patient safety faster and more effectively.

Our existing nurses already operate in this environment and are effective at this. They have had the benefit of post-registration development and education. Many, often supported by their employers, will have upgraded, or are upgrading, their existing diplomas to degrees. The NMC has made it clear it will not require existing nurses to have degrees in order to remain registered. The NHS values all its existing nurses; they all have important contributions to make. But we cannot leave things to chance. If we are to improve quality, prevention and productivity, all new nurses need to have the skills and qualities to tackle the changes I have outlined much earlier in their careers. Degree-level registration means benefits for care in terms of improved quality and safety. As the Council of Deans says, graduate nurses spend longer working in clinical areas delivering hands-on care and remain in the profession an average of four years longer than non-graduates.

Regarding costs, the cost of delivering a degree is substantially the same as for a diploma. Universities receive the same fee for both, and both programmes are three years long. New nurses, whether diploma or degree qualified, will continue to enter the NHS at the same pay band as now. We recognise that the change in qualification may make it harder to fill all pre-registration places once they are all degree level. We will attract a new cadre of students to nursing but will also need to actively attract talented people with the right values and develop new routes into nursing. We are exploring how we might better promote nursing careers.

We are also developing proposals with education colleagues to widen access to degree programmes—for example, through apprenticeships, NVQs and foundation degrees. These will construct routes into nursing for those without sufficient academic entry qualifications but who have the right attributes. It will also provide a clearer career pathway and support improved training for clinical support workers who are supervised by nurses and provide valuable care for patients. We are also exploring the potential for fast-tracking existing non-nursing degree-holders through nursing programmes. This builds on the NMC’s proposals to increase the proportion of prior learning that can count towards a nursing qualification. More broadly, for professional education that the NHS commissions directly, we are encouraging fairer access by providing financial incentives for universities to improve their approach to equality, widening participation, and reducing attrition. Finally, we are also tackling the student financial support arrangements to make sure they are fairer.

The noble Baroness, Lady Gardner, brought home her anxiety about the black hole, which is key to her overall concerns. There is no evidence to suggest that the position on nursing numbers in terms of workforce planning is in a difficult position. The strategic health authorities developed local workforce plans based on service needs in current demographics. These are shared with the Department of Health. Indeed, the Department of Health is about to develop a Centre for Workforce Intelligence to support the process. The introduction of it is key. Subsequently, the department has worked with strategic health authorities to develop an assurance process to establish that plans are put in place to deliver change. This has looked, for example, at engagement with universities, risk assessment and project management. As the noble Baroness, Lady Finlay, pointed out, it has happened in Wales and we accept that there are lessons to be learnt.

The noble Baroness, Lady Gardner, also raised the issue of attrition. The department recognises that there are high attrition levels on some nursing programmes. We continuously work with strategic health authorities and universities to reduce attrition rates. However, the average attrition rate for degree nurses is 17 per cent while for diploma nursing students it is currently 21 per cent. The move to degree nursing may improve things if this situation persists. Some attrition from health courses is inevitable where students are struggling to fulfil academic or, just as importantly, practical delivery of healthcare and should not progress to deliver patient care.

The noble Baroness, Lady Gardner, raised six questions. I think that I have answered them all or in part. She raised an individual case. I shall not comment on that tonight or on any individual cases, but I acknowledge that maintaining the element of personal service and compassion in nursing is of central importance to us. As the noble Earl pointed out, considerable consultation is to be had with the NMC on setting up the structure of the new procedure. A high level of involvement is a key element of that, as is building these considerations carefully and solidly into the new structure.

The noble Baroness, Lady Finlay, talked about the lessons to be learnt from Wales. She cited a student who was not ready to progress on leaving school and said that people progress at different rates. I have much sympathy with that person. I think that we do not make enough of a commitment—dare I criticise my Government?—although I am sure that we make every possible effort. Lifelong learning should mean what it says. It should mean not only under-25 learning but “all the way through” learning. I learnt just as many skills in the latter part of my life as in the early part. I have listed the various channels that we are trying to progress so that people can come in at a junior level and move on.

Compassion and caring are central to our approach. Of course, we sometimes fail—and we apologise for that—but central to nursing must be compassion and safety. High standards of practical skills will be maintained. The essence of the Question before us is whether a degree will increase the total basket of skills without diminishing the practical skills. The Government feel that the answer is yes.

On the shape of training, the Nursing & Midwifery Council stipulates the hours in the preregistration process. Students currently undertake 4,600 hours of learning, 2,300 of which are in the practice environment; for example, in wards, clinics, outpatient departments, day units, nursing homes and community settings. This will continue to be the case when nursing moves to degree-only.

The issue of risk aversion and nurses not making positive decisions was raised. If we get the graduate course right—and we do need to consult on it—it will improve the ability of individual nurses to make decisions in those critical-judgment areas.

The noble Baroness, Lady Gardner, and others spoke about two levels of nursing and said that there is a need for the practical nurse. We do not see it that way, but, nevertheless, there will be staff involved in patient care. The NMC register has one part for registered nurses; there is no intention to create a second level for assistant nurses. However, it is recognised that there needs to be some form of regulation for some support staff. It is an ongoing area of consideration.

The noble Baroness, Lady Masham, said that we need more specialists, but that we also need compassionate individuals. We agree. The need for maintaining the practical aspect is well understood. I shall not comment much on what the noble Baroness, Lady Barker, said. I think that I gave her individual assurances; I thought that her speech was brilliant and great for the Government. Financial worries are important. We are looking at how we support students as part of the consultation. Health authorities will continue to fund the fees.

The noble Earl, Lord Howe, in many ways made the case for the degree nurse. I agree with most of what he said: it should be led not by status but by competencies which improve their performance, make them work more safely and deliver better healthcare. We commit that compassion and people skills will continue to be part of that training and part of their future.

Sitting suspended.