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Volume 791: debated on Monday 14 May 2018

Question for Short Debate

Asked by

To ask Her Majesty’s Government what priority they will give to investing in nursing globally, in the light of the impact of such investment on improving health, promoting gender equality and strengthening local economies.

My Lords, it is a great pleasure to open this debate. I thank noble Lords who are taking part in it and hope that it has not disrupted too many dinner plans. I am going to address three matters in turn. First, I am going to talk about the background to the debate. Secondly, I am going to talk about why strengthening nursing globally is one of the most important things that we can do to improve health globally, and why it should be given a higher priority and greater investment. Thirdly, I shall conclude with some questions for the Government.

The background to this is that I co-chair the All-Party Parliamentary Group on Global Health, which undertook a review of nursing globally, with a review panel that I am delighted to say included the noble Baronesses, Lady Watkins and Lady Cox, and the noble Lords, Lord Ribeiro and Lord Willis, as well as Dan Poulter and Maria Caulfield, a doctor and nurse from the other place. Interestingly, nobody has done such a global review before. My focus is global, but what we are saying is also relevant to the UK, and I know that other noble Lords will mention nursing in the UK. I also say at the start that while our focus is nursing, a lot of it is also relevant to midwifery—and, of course, nurses work in teams.

As a review, we concluded three things. First, we will simply not achieve universal health coverage without strengthening nursing and the role played by the 20 million nurses and midwives globally—half the health workforce globally.

Secondly, nurses are too often undervalued and underutilised, unable to operate at the top of their licence. In other words, nurses are trained to a certain level, but then not in practice allowed or enabled to work to the level of their training. This is different in different countries but, interviewing nurses around the world, we found the same story everywhere. This is a huge waste of talent and resources.

Thirdly, the triple impact of strengthening nursing globally is that it will have an impact on three different sustainable development goals: improving health, promoting gender equity—nursing is clearly a route to women’s empowerment in Africa—and promoting a stronger economy.

These are important conclusions, but let me get to the heart of what I want to say and why I believe that now is the right moment to strengthen and develop nursing; why this is one of the most important things we can do to improve health globally; and why nurses will become even more important and influential in future. There are several reasons for this, but I want to talk about just three major ones.

The first is that diseases are changing. There is a global increase in non-communicable diseases—diabetes, heart disease, cancer and the like—and in co-morbidities in older people. As we all know, these diseases require holistic, patient-centred care, and this is at the very heart of nursing philosophy. Nurses address the whole person. They take not just a biomedical view but consider psychological, social and environmental aspects. We need a fundamental change of approach in how health services are delivered globally—new models of care—and nurses will be at the heart of that.

Here in the UK, we already have nurse-led and nurse-based services—for example, in diabetes and other long-term conditions. Those are increasing here in the UK, and there are now many similar services globally. We can see the impact of allowing nurses in South Africa to initiate treatment on anti-retrovirals, which has helped to turn around the epidemic of HIV, nurse prescribing in Botswana, the development of community services in Singapore and the strengthening of nursing in Uganda. These are all countries which understand the change which is happening. It is about improving access and quality and more cost-effective delivery of care. Nurses are very capable in all those areas.

The second big argument is that nurses are the health professionals closest to the community and, in many rural areas and slums are the first and often the only people who patients see. They are best able to help community health workers, the people in the most remote areas, to make them more effective and of higher quality.

Thirdly, this closeness to and being part of the local community also makes nurses the most effective health workers at promoting health, preventing disease, improving health literacy, early detection and tackling the social determinants of health.

I believe that those three aspects—holistic, person-centred care, reaching the most remote groups and promoting health and preventing diseases—are central to health policy in every country of the world. As I said, nurses are particularly fitted to handling it. It is for this reason that I believe that they will become even more important and influential in future.

I must say that our all-party review group thought that this was a no-brainer, but we were unable to persuade the UK Government or international bodies to act, so we started our own global campaign—Nursing Now. Here I pay tribute to my noble friend Lady Watkins, who has been with me on every step of this way, as well as offering invaluable advice as a nurse.

I do not have time to say anything about the campaign. We have a website, which I encourage people to visit. It is run in collaboration with the World Health Organization and the International Council of Nurses and supported, among others, by the Burdett Trust for Nursing, the Royal College of Nursing and THET. The Duchess of Cambridge, our patron, launched the campaign a little over two months ago, and there are now national groups in more than 40 countries, without us providing any financial support. It is clear that we have caught a tide. Our aim is to accelerate the changes that I think are under way around the world.

I turn to the Government and the question of improving the priority for developing nursing globally. I very much welcome the £5 million ring-fenced for the developing nursing within the health systems strengthening in partnership fund announced at the launch of our campaign. Here in the UK, I welcome the golden hellos to be offered to postgraduates starting in nursing in mental health, learning difficulties and district nursing. I hope that the Minister will be able to tell us about other things that the Government are doing to strengthen nursing.

However, none of these initiatives is truly strategic or embraces the need for a radical change in how we see nursing and its potential to make a major difference in the world. These are incidental, isolated issues, and they need to be brought together into a much larger programme. I am sure that we all understand and accept the importance of nursing, but do we understand how much bigger an impact it could have if it was enabled to do so? That is the crux of the matter.

I have many questions, but let me ask only a small selection. Four of them are about health. First, what are the Government doing to promote nurse-led services in countries where the Government are working with partners? Secondly, what are they doing to enable nurses to play a leading role in supporting community health workers, the people who reach into the furthest part of the African and other continents? What are they doing to support nurses to provide training, supervision and a point of referral so that the community health workers can operate to the highest level of quality, be more effective and therefore deliver universal health coverage in those countries?

Thirdly, what are the Government doing to strengthen nurses’ role in promotion, prevention, health literacy, early detection and tackling the social determinants of health? These are roles where nurses, who are close to and part of the community, could play an even greater role in future. Finally, what are the Government doing to ensure that nursing is at the forefront of the global strategies to promote universal health coverage and tackle non-communicable diseases? It is interesting to note that in those strategies, there is currently virtually no mention of the workforce, let alone nursing. The UK Government could play an important role in bringing the health workforce, and nursing in particular, up the agenda to tackle these important issues.

I have not talked about the gender aspects of nursing, but I hope that other noble Lords will. My question here is: what are the Government doing to engage and develop nursing as part of their strategy and action to promote gender equity? Surprisingly, nursing figures very little in all the strategies around the world for the development of women and gender. Similarly, I have not talked about the economic aspects. What are the Government doing to engage and develop nursing as part of their strategy and action to promote economic growth?

Strengthening nursing in the way I have described is a big and bold strategic idea. Is the Minister willing to arrange a top-level meeting for senior nurses to meet Ministers and officials from his department—or wider within government—to discuss the strategic impact of strengthening nursing globally and what the UK can do to take a lead on it?

In conclusion, I am convinced that strengthening nursing is one of the most important things we can do to improve health globally. Nursing is a profession whose time has come, and I very much hope that the Government will embrace these ideas wholeheartedly and increase their priority for investing in nursing.

My Lords, I feel privileged to follow the noble Lord, Lord Crisp, in his excellent address. Those who have followed him over many years will have noticed his real concern for development. I was always struck by his fascinating book, Turning the World Upside Down, in which he argued that we need to move beyond top-down thinking on international development towards co-development. While richer countries have a responsibility to share knowledge and investment, we must recognise that healthcare innovation from developing countries can be every bit as important for improving outcomes in the developed world.

With his excellent team—it is striking that so many of his distinguished colleagues from the All-Party Parliamentary Group on Global Health are here tonight—he has spelled out so clearly the potential impact of nursing worldwide. Of course, in the UK we have had a growing revolution. During my ministerial days, my excellent noble friend Lady Cumberlege was the one who pushed for nurse prescribing. The noble Lord, Lord Crisp, mentioned nurse prescribing elsewhere in the world. But we have been pioneers in many ways; the noble Baroness, Lady Emerton, was a formidable force in those early years. We can now see how the UK developments are spreading around the world.

I congratulate the noble Lord on his impeccable timing. This debate was delayed. Saturday was International Nurses Day and Florence Nightingale’s 198th birthday. Today marks 137 years since the death of another remarkable woman, Mary Seacole. So he has got his timing right. In Belfast today the Royal College of Nursing is meeting and discussing health in a way that is quite remarkable, from the specifics, whereby those very advanced practitioners can make a contribution, right through to the contribution of nursing in dealing with slavery and sexual trafficking. Now that nurses have come of age, they believe in their confidence and, supported by others, have a voice that must be heard. Having a chief nursing officer reappointed at the World Health Organization, this is a time to speak up and make sure that global impact is really heard.

Education and training are critically important. I have the privilege of being the chancellor of the University of Hull. Professor Julie Jomeen, head of the Faculty of Health Sciences, said:

“We are supporting nurses to become global professionals”.

This is what is changing. Education, training and research are quite remarkable. Through nurse leadership and nurse contribution, we send people on placements to Uganda, Barbados, Finland, Africa, the Caribbean and the Middle East and so forth, and we receive nurses in return from all around the world. This is expanding global outlooks. If you train and learn together, it influences your perspective and view of your professional commitment more than anything else. I am pleased also, incidentally, that the faculty has won a Burdett Coutts award for the STaR project, which tries to ensure that these newly recruited nurses stay in the health service or wherever they are and are prepared for the practice and not just the theory.

We all know that the healthcare challenges of the 21st century are very much the healthcare challenges where nurses excel. In my small contribution, I introduced the Health of the Nation, which was all about prevention and persuasion in dealing with coronary heart disease, stroke, cancers, mental illness, HIV/AIDS, sexual health and accidents. This is not about an operation or a prescription; it is about being close to the patient and the community, staying with them and using persuasion. The modern nurse has not only those skills but, increasingly, the skills of economics, politics and geography, and of beginning to see, in an empowered and enlightened way, the powerful contribution that a nurse can make in so many countries of the world.

Nurse leadership is critical, and we have to ensure that we develop it so that it can make a contribution within the system. It has always been a complex issue in the National Health Service management team. I am sure we can do more to develop the role and its contribution, rather than saying, “Oh, if only we had more nurse managers”.

More than three-quarters of the NHS is female, and the proportion of female nurses is even higher. Women have this huge contribution, not only in the UK but around the world. With our almost uniquely connected position in the international system, we can take real pride. Our international connections, particularly through the Commonwealth, link us to countries where taking the lead on co-dependents can be especially productive. In March, the constitution of the Commonwealth Nurses and Midwives Federation was approved in London. It reaffirms the commitment to maintain, facilitate and develop nursing and midwifery networks across the whole Commonwealth; to help to improve nursing standards across the Commonwealth; to support Commonwealth nurses and midwives; and to develop leadership roles in health policy. Last month, with the CHOGM meeting here in London, we had a further opportunity to make sure that this is fulfilled and delivered.

We know that nurses are more trusted than any other group. It is depressing that, apparently, only 15% of people trust politicians, but 93% of people trust nurses. This gives nurses an authority and position to influence, persuade and lead that few others groups have.

Fifty years ago, the United Nations Secretary-General, Dag Hammarskjöld, said:

“Constant attention by a good nurse may be just as important as a major operation by a surgeon”.

That sounds rather patronising today, when the world has moved on so dramatically. I wanted to take this opportunity to celebrate the individual who will be the next Lord spiritual in our House. On Saturday, Dame Sarah Mullally was installed as the Bishop of London—someone who was Chief Nursing Officer when she was 37 and went to a comprehensive school. She referred to Florence Nightingale’s birthday, saying that Florence was,

“an epidemiologist, a statistician, a social reformer, theologian and nurse. She has inspired generations of nurses. At the heart of what she did was to use the ordinary skills we all possess and can use if we are brave enough, the skill to build human relationships. If we want to improve public health today, if we want to improve the life chances of those who are still left behind and failed by our education system, if we want to reduce the horrifyingly high number of young deaths from knife and gun crime occurring in this wonderful city, we have to build relationships”.

If we take those words and apply them to all the ills, suffering and health problems in so many countries around the world, I absolutely believe that the critical force in ensuring that we deliver those sustainable development goals and promote healthcare for all is the huge, and as yet untapped, power of the nurse. I very much support the noble Lord in his Question.

My Lords, as always it is a pleasure to follow the noble Baroness, Lady Bottomley. In particular, I congratulate the noble Lord, Lord Crisp, on securing this debate and thank the noble Baroness, Lady Watkins, for the enormous contribution that she has made to the Nursing Now initiative launched just a few weeks ago by the Duchess of Cambridge.

I must confess that, little did I know, when the noble Lord, Lord Crisp, sent me an email to join his review board, that we would produce a report, the Triple Impact report in 2016, which would have such an impact. Propelling UK nursing to the fore of the challenge to achieve universal health coverage globally within a realistic timescale seemed an impossible task—but he is well on the way to achieving the impossible.

As the report emphasised, nurses are the largest single component of a global health workforce, and their skills and values make them ideally placed to lead healthcare initiatives in a variety of settings. For me, the crucial challenge of the report is to make the nurse a catalyst for change, using healthcare to build stronger local economies and improve the lives of women.

What part can or will the UK play in accepting and delivering the challenges of the Triple Impact report? I have no doubt that many UK nurses and midwives have knowledge, skills and leadership qualities to take up the challenge, despite all too often being thwarted by the pressures of daily activity and outdated clinical hierarchies. However, a cadre of newly qualified nurses is emerging, particularly those who will be trained to the new NMC standards following the inspirational work of Dame Jill Clark—and, I might say, Jackie Smith, who has just announced today that she will be leaving as chief executive of the Nursing and Midwifery Council. She is a remarkable woman who has done so much to change the face of regulation as it interfaces with nursing.

These new nurses will be particularly well suited to the global challenge, as the emphasis on leadership, independent working and problem solving becomes more prevalent. There is also a sharper focus in the work of the HEIs, as the challenge of a graduate nursing profession has become embedded in both practical and theoretical pedagogies. This point was brought home by the publication of the latest QS league tables for the world’s best nursing schools, where Manchester, King’s and Southampton are in the top 10.

The desire to search for excellence has resulted in Nottingham University Hospital Trust and Oxford University Hospital Trust being on the cusp of gaining Magnet status for nursing excellence—a prospect which I was told was totally unrealistic and impossible just a few years ago. Equally, the emergence of Health Education England’s draft workforce strategy with a full section on “the global healthcare workforce”, demonstrates tentative but welcome steps away from viewing non-UK staff as a commodity to fill vacancies and more as an opportunity to enhance care by investing in a global healthcare team. The “earn, learn and return” initiative is welcome; the global nursing partnership with Jamaica and the recent agreement with India will result in far stronger reciprocal arrangements that can be repeated around the globe.

However, the emphasis of the Government remains far too restrictive and the words in the strategy of recruiting staff,

“in a way that is consistent with wider Government policy on reducing net migration”,

is a chilling factor, particularly on the 41,962—that is the figure today—non-EEA nurses and midwives who are currently NMC registered and who hail from 73 different countries, from India and the Philippines, with the largest numbers, to Nigeria and Zimbabwe, to Belarus and Myanmar. There is somebody on the NMC register from every country in the world. Imagine what results we would get if we invested in these colleagues as part of our global campaign.

Unless we make global nursing an academic priority in our universities, we will not take advantage of our nursing heritage. It is our traditions, our excellence of teaching, and our innovative and outstanding care settings that give the UK a platform for leading the global nursing challenge—but research must be a priority and not an add-on. In 2010, the Lancet commission on education of health professionals, of which the noble Lord, Lord Crisp, was a member, recognised the need for a,

“robust, competent and professionally capable workforce”.

Professionalism and leadership were regarded as essential qualities—the very reason they are so prominent in the new nursing standards. However, nurses must be allowed to apply these qualities in challenging settings, and there is nothing more challenging that doing so alongside colleagues in developing countries or in remote areas where the nurse, more than any other healthcare professional, is the one whom people will see.

To build an infrastructure that can sustain such programmes requires resources from the Department of Health and from DfID, but also from BEIS, to allow postgraduate nurses and other health professionals to research the effectiveness of global nursing in a developing world. It is not good enough to do that research purely through a clinical lens. If they are to act globally, nurses must think and research globally. In the US, a host of leading universities not only have centres for global health but encourage nursing graduates to carry out research in the field alongside other disciplines. Johns Hopkins, through its Center for Global Initiatives, promotes nurses on international placements, links them to schools of nursing around the world and encourages interdisciplinary research promoting broader health and welfare. The University of Washington, at its Center for Global Health Nursing, disseminates and promotes global health nursing, creates strategic partnerships internationally, and promotes nursing students’ involvement in global health policy. With its collaborative global research programmes, New York University—which I know well—has established nursing centres in Rwanda, Liberia, Ghana, Tanzania and China, as well as offering its degree courses in Abu Dhabi, Shanghai and Vietnam.

The vision for global healthcare and the future of nursing looks beyond these shores and the narrow confines of where nursing has been in the past, and sees our nurses, who are the best in the world, going out and spreading their gospel around the world.

My Lords, I thank my noble friend Lord Crisp for all that he does to promote good health globally. There are very many nurses helping to promote global good health, but there is so much to do in this fragile world. The UK does give generously and many people in Parliament, and Ministers, have given their help in supporting global health.

It must not be forgotten that there was a terrible outbreak of Ebola in Sierra Leone. I pay tribute to the nurses who volunteered to look after these very infectious patients. It is important that lessons are learned from such epidemics, which can break out anywhere in the world at any time. With so many infections becoming resistant to antimicrobials, developing vaccines for such diseases as drug-resistant tuberculosis and diarrhoea is vital. Nurses across the globe are often the people at the front line. They need education, training and support. In many countries, stigma associated with infectious diseases is a problem and needs addressing. Nurses, who are so often the leaders, are the people who can do this, but they need support. The All-Party Parliamentary Group on HIV and AIDS is an active group which is helping with the campaign STOPAIDS. The group works with many countries globally that look towards the UK for support. It is important that NGOs, Governments, the pharmaceutical industry and local people work together so that prevention of ill health is high on the agenda.

A record number of nurses and midwives from the EU’s 27 countries left Britain last year. Between 2017 and 2018, a total of 3,962 such staff left the Nursing and Midwifery Council register, but only 805 joined it. The Home Office is not issuing or renewing visas for key health workers who are willing to work here. This is putting the UK in an impossible situation. Nurses who have to nurse sick patients with inadequate staffing have to bear the brunt of worried relatives and stressed patients. The RCN is supporting and actively participating in a number of nursing alliances in Europe and the Commonwealth. These not only seek to influence European and global policy but also spread advanced practice in the key role of nurses in tackling antimicrobial resistance and addressing the health of the health workforce.

I would like to bring to your Lordships’ attention the problems which nurses have been having in our prisons, especially Holme House, a Spice-riddled prison where there have been 376 medical emergencies in a year, caused by inmates smoking spliffs. Nurses have been ordered to stop tending sick patients because of the risk of breathing in mind-altering smoke in a fug-ridden wing which has become so contaminated. There is a shortage of nurses working in prisons and a problem with recruiting and retaining them. Nurses are an important part of the present workforce, as prisoners can have so many conditions, such as diabetes, hepatitis C and mental health problems, to mention only a few.

I would like to say how important specialist nurses are to people who have long-term conditions. They can become a lifeline, as so many general nurses do not understand the varied consequences if patients are not treated in the correct way according to their specialty. As president of the Spinal Injuries Association I am very grateful to some generous people who fundraise for our association. Without this help, we would not have been able to employ two specialist spinal nurses. As there is a shortage of spinal beds in the special units, these nurses go to general hospitals to advise on what is needed. They help with continuing healthcare. They also maintain links with a wide network of relevant stakeholders, including NHS Improvement and the Royal College of Nursing, which are currently in discussions with the SIA regarding bowel management and whether this can be returned to the nursing curriculum at some point.

Parkinson’s UK has 350 specialist nurses across the UK, but there are still 14 areas covering Scotland, Northern Ireland and England where people do not have access to a dedicated Parkinson’s nurse. All specialist nurses for diabetes, cancer and all sorts of conditions are invaluable.

At this time of crisis in the health service we should be grateful for volunteers, who do so much to help. It is of grave concern that the demand is greater than what is available for the care of all patients.

My Lords, I also warmly congratulate my noble friend Lord Crisp, not only on securing this debate and his comprehensive introduction but on his phenomenal commitment to the Nursing Now campaign and the Triple Impact report, in which he was so ably assisted by my noble friend Lady Watkins of Tavistock.

I declare an interest as an honorary vice-president of the Royal College of Nursing—the RCN. I also had the privilege of being involved in work for the Triple Impact report. It is many years since I was registered to practise in the UK, but I maintain a passionate commitment to nursing, especially through my involvement in a small NGO, the Humanitarian Aid Relief Trust, or HART. It was established to provide aid and advocacy for people suffering oppression, often in conflict or post-conflict regions not reached by major aid organisations, for security or political reasons. We work with local partners and always give them the dignity of choice, asking them to identify their priorities for aid, which is often the provision of healthcare—in very challenging situations.

Time permits me to give just two examples to illustrate the achievements of nursing in such challenging situations. First, in northern Uganda, while the notorious rebel Lord’s Resistance Army was still inflicting its reign of terror, we in HART visited and established a partnership with local people desperate to help orphans for whom there was no one to provide care. A key professional was the senior nurse, Pius. In addition to providing clinical care for orphans, including those with HIV, he also runs the local clinic, where he is confronted with massive clinical challenges, such as a lady who was eight months pregnant and had cerebral malaria. It was the rainy season and the nearest hospital was 40 kilometres away and inaccessible. Pius therefore carries full clinical responsibility in that area. When we invited a medical colleague with a special interest in tropical diseases to sit with Pius for a clinic, he said that Pius’ work was superb and could not be better. That initial programme has grown over 10 years from care for 39 orphans to provision of holistic nurse-led health care for over 600 HIV positive children and their families.

The second brief example comes from the little-known historically Armenian enclave of Nagorno-Karabakh, which was subjected to attempted ethnic cleansing by Azerbaijan in the early 1990s but gained a ceasefire in 1994. When we asked the Government there for their aid priorities, they identified help for people with disabilities, as there was no effective provision in the former Soviet Union, where disability was still massively stigmatised. Our partner, Vardan, was given a bomb-damaged building, from which he developed a now internationally recognised centre of excellence, staffed by nurses. The member of his nursing staff with responsibility for treatment of pressure sores initially had to contend with horrific cases. One patient with fungating sores was suicidal. Marietta treated him so successfully that he recovered and began to make exquisite wood carvings, achieving self-esteem, financial provision for his family, and happiness.

These examples illustrate the competence and achievement of so many nurses—I could give so many other examples—working in very challenging situations in remote areas, sometimes in conflict or post-conflict situations. We celebrate their achievements perhaps particularly appropriately today, on International Nurses Day.

I therefore also greatly appreciate the work of the RCN, with its support for and participation in a number of nursing alliances in Europe and the Commonwealth, which not only seek to influence European and global policy but also spread learning and experience between nursing organisations; for example, the development of advanced practice on nurses’ key role in tackling antimicrobial resistance, and on addressing the health of the health workforce.

One example is RCN co-operation with the Zambia Union of Nurses Organization on its implementation of the WHO safe surgery checklist, and raising the profile of the profession in Zambia. This work and its visibility as an organisation that seeks to improve practice means that it is increasingly a partner of choice for the Zambian Ministry of Health. It has also helped it to build its own membership as a professional nursing association as well as a trade union.

The RCN also provided background to the Nursing Now campaign by undertaking research on key trends in nursing and identifying the areas that make a significant difference to nurses being able to achieve positive changes for health, including education, professional regulation, workforce resources, a pleasant working environment and nurses’ ability to influence and improve health policy. The RCN has committed to continue to raise the profile of this significant and global initiative.

I am delighted that the Triple Impact report and the Nursing Now initiatives have helped to highlight the fundamental importance of nursing here in the UK as well as in developing countries, where they are often the only providers of healthcare for large populations. As I have indicated, I have seen many inspirational examples of nursing practice in remote and very challenging situations, and I hope there will be a greater opportunity for a two-way programme of professional visits: for nurses from those areas to come to the UK to benefit from clinical updating in the latest developments, and for UK nurses to visit their colleagues in those remote situations, where they will benefit from the inspirational resourcefulness and professional competences of colleagues.

I therefore conclude by asking the Minister whether Her Majesty’s Government will provide adequate support for these two-way professional training programmes, which will help nursing, as the primary provider of healthcare around the world, to continue its vital contribution to the well-being of people globally.

My Lords, it is a real pleasure to follow the noble Baroness, Lady Cox, in this debate. She is a renowned globetrotter when it comes to humanitarian missions in Africa and other lower and middle-income countries. It was also a privilege to succeed her as president of my old school, Dean Close.

The noble Lord, Lord Crisp, to whom we owe this debate, in his book Turning the World Upside Down, referred to by the noble Baroness, Lady Bottomley, records meeting the founder of the Bangladesh Rural Action Committee in his headquarters within sight of the slums of Bangladesh. He asked him how the world could make faster progress in reducing death in childbirth. His reply was, “Empower the women”. That single statement is what this debate is all about, for a high proportion of nurses globally are still women.

A hundred years since women got the vote in the UK, they have scaled unimaginable heights, with many in the top echelons of the NHS, in management as chief executives of hospitals, in the Department of Health or as consultant nurses. That is not so in many lower and middle-income countries. Here, I declare an interest as a member of the All-Party Parliamentary Group on Global Health, which in 2016 took evidence on the future development of nursing globally. The most telling comment in our report was that nurses,

“are frequently not permitted to practise to the full extent of their competence; are unable to share their learning; and have too few opportunities to develop leadership, occupy leadership roles and influence wider policy”.

A commonly held term that has long been rejected in the UK was that, in not being able to utilise their skills, nurses were essentially “handmaidens” for doctors and had no scope for development. There are of course cultural and social barriers within developing countries which reinforce this stereotypical view, and it is time it was challenged. More must be done to empower women, who represent 90% of the nursing and midwifery workforce.

Another aspect of the Triple Impact report by the APPG on Global Health was the highlighting of workforce issues and the impact of migration. As noble Lords will know, I come from Ghana, which after 60 years of independence has faced many challenges in healthcare. I had worked there for a year in 1973, so can attest to the improvements nationally since that time. However, this evidence from Janet Kwansah on incentives for rural service among nurses in Ghana is worthy of note. She said:

“Like many countries in sub-Saharan Africa, Ghana is faced with the simultaneous challenges of increasing its health workforce, retaining them in country and promoting a rational distribution of staff in remote or deprived areas of the country. Recent increases in both public-sector doctor and nurse salaries have contributed to a decline in international out-migration, but problems of geographic mal-distribution remain”.

Brexit will have a significant impact on the UK, as Europe currently supplies the highest proportion of overseas nurses, at 29%. Brexit will see many European nurses leave, and the UK will have to resist the temptation to recruit nurses from lower and middle-income countries, as it has done in the past. The dilemma will be how to induce European nurses to stay, while avoiding the targeting of countries with nursing shortages. I ask my noble friend the Minister what strategies the Government have in mind to overcome this problem and the concern that I am sharing with the House.

Finally, I want to mention a new initiative funded by the National Institute for Health Research—the global surgery unit. I declare an interest as chairman of the independent advisory board of that group. Its purpose is to undertake surgical research to improve health outcomes in lower and middle-income countries through developing pathways for surgical innovation. The aim is to deliver sustainable changes in surgical practice in operating theatres in three continents, supported by a consortium of three UK universities: Birmingham, Edinburgh and Warwick. It will deliver the project through five overseas limbs in central America, west Africa, southern and eastern Africa, and south Asia, and will involve 40 lower and middle-income hospitals. We hope that this will not only have an impact on front-line surgeons but encourage nurses to participate, raising their profile and encouraging others to consider a career in nursing, as nurses are seen as part of the extended team and not merely as the handmaidens of doctors.

When I was president of the college and subsequently, I was privileged to undertake various visits to east Africa—to Ethiopia, Malawi and other countries—taking surgical teams to train local surgeons in surgical procedures. One thing we always did was take a nurse with us—Judy Mewburn. She was a great asset because, while we were teaching the doctors how to carry out surgical procedures, she would take the nurses aside and show them how to set up the trolleys in a sterile way. It is that collaborative approach of doctors and nurses working together that I believe will make a big difference. We see the benefits and effects of teamworking in the UK, with nurses being much more involved in the work of doctors. I hope we will be able to take some of those messages overseas and, by doing so, empower women to take up nursing and to provide the best possible care for their patients.

My Lords, it is a pleasure to follow the noble Lord, Lord Ribeiro, and to know that, in our own ways, we strove to work collaboratively with nurses throughout our medical careers. I congratulate my noble friend Lord Crisp on this very stimulating debate. I would like to draw attention to the role of nursing in prevention and early intervention to improve mental health worldwide and to think about how nurses globally could learn from nursing experience in the United Kingdom in supporting people with learning disabilities and perhaps people with autism.

In this country, we rightly discuss the issue of parity of esteem between mental health and physical health. However, globally, the lack of parity is even more evident. The World Health Organization recognises the global burden of disease that mental health conditions produce. It reports that depression alone accounts for nearly 5% of the global burden of disease and is among the largest single causes of disability worldwide, with 11% of all years lived with disability globally. This burden is particularly great for women.

The World Health Organization also reports that almost half the world’s population lives in countries where, on average, there is one psychiatrist to serve 200,000 or more people. It states that between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle- income countries. The King’s Sierra Leone Partnership describes how, historically, there has been one trained psychiatrist in the country—although encouragingly it describes that two more have finished their training in the last year. However, for a country of six million people, this produces a very different mental health service to the one we may be used to in this country. In this country, we have 6,000 psychiatrists on the specialist register, making up 6% of all specialty doctors.

What this suggests to me is that mental health policy globally faces challenges rather different from those we face here and that the solutions will therefore also be different. The answer to addressing the mental health gap globally may lie not in the medical schools but with community nurses and health visitors identifying mental illness and delivering psychosocial interventions. Making mental health a core component of any global health policy is essential to prevent it disappearing from view, which, as we know from our own country’s history, can easily happen.

Of all nurses in this country, 16% work in mental health or learning disability services. I suggest that there is an even greater role globally for nurses to lead mental health and disability policy. However, the reports attached to the briefing for this debate referred mainly to child health, infectious diseases, cardiovascular health and the like, with very few explicitly mentioning mental health conditions. I saw reference to diabetes and heart disease and to the burden of infectious diseases such as HIV/AIDS and malaria, but I did not see references to learning disability—or intellectual disability, to use the international term—schizophrenia, alcohol dependence or depression.

I will reflect on the history of learning disability nursing in the United Kingdom and Ireland. It is a condition-specific field of nursing that has developed over a few generations now, the role and function of which is to work face-to-face with individuals with intellectual disabilities, their supporters and their families to empower them in their lives and in their encounters with health services. In the health third sector and private and public agencies, learning disability nurses deliver specialist healthcare and support to people of all ages.

In the United Kingdom, the largest majority of individuals with learning disabilities live in the community, in their own homes with support systems or with their families. But as a group, they have the poorest health, which has a cumulative effect over the lifespan, and this will be true worldwide. They have a different range and pattern of disease and differing health-related behaviours. They have differing leading causes of death —respiratory disease, congenital heart disease and cancers—when compared to the general population. Gastro-oesophageal reflux disorder, sensory impairments, osteoporosis, dental caries, accidents and mental ill-health are all more common in this population group. The average age of death in this country is 20 years earlier when compared with the non-learning-disabled population. Significantly, we know that most of these deaths are unexpected, avoidable and preventable.

There is a challenge, however: half of learning disability nursing courses in this country are considering closure, despite rising numbers of vacancies within the NHS. The nurses who are still available are increasingly working in social care settings as managers, not delivering the face-to-face nursing skills that they have acquired and which are so essential for this group of people. One of our roles could be to consistently challenge policymakers, in this country and abroad, and to ask how the strategies they formulate improve prevention and identification and care for people with mental illness, and perhaps particularly for people with learning disabilities and autism. The role of nursing in transforming healthcare globally is huge, but let us ensure that this reduces, not increases, the disparity between mental and physical healthcare.

I will finish with another challenge: how to respond effectively to both online and offline sexual abuse and its impact on mental health, and the educational and preventative work being done by community nurses in some rural communities in Africa. Nurses are highly respected in all cultures. Their contribution to prevention and their compassionate listening responses could help to reduce the longer-term consequences of sexual abuse and to rebuild the resilience that each person needs in life.

My Lords, it is a real pleasure to follow my noble friend Lady Hollins. I draw attention to my interests as outlined in the register, and in particular as president of the Florence Nightingale Foundation.

I thank my noble friend Lord Crisp for securing this timely debate, because 12 May was International Nurses’ Day, which I spent at the RCN Congress with 4,000 other nurses in Belfast. Many of them came from countries outside the UK, including nurses who trained in the EU, the Commonwealth and from other parts of the globe, yet currently work in our four countries. This collective of nurses demonstrated that we need to think about the nursing workforce as a global resource, as opposed to manpower planning being thought of in a vacuum country by country. There is evidence that, it we think and plan strategically, nurses can be key to the achievement of the universal health coverage strategic development goal.

In the excellent Library briefing for this debate, we are reminded that there are an estimated 43.5 million health workers around the world and that just under half, 20.7 million, are nurses and midwives, yet Global Health Observatory data suggests that half the World Health Organization member states have fewer than three nurses and midwives per 100,000 head of population, and a quarter fewer than one. WHO estimates that a further 2.8 million nurses and midwives will be needed in Africa and 1.9 million in south-east Asia by 2030. Will the Minister indicate in his reply how the UK will contribute to increasing the global healthcare workforce over the next decade through targeted investment?

Investing in nursing makes economic sense. As the UN High-Level Commission on Health Employment and Economic Growth argues, there are three impacts from investing in and developing the healthcare workforce: improved health outcomes for populations; global health security, particularly through the reduction of transmittable diseases; and economic growth through job creation. The report further suggests that there should be a focus on reforming aid and accountability for health system strengthening, with a focus on skilled health workers, which, it suggests, could initiate a new era of international co-operation and action for economic and human security.

My noble friend Lord Crisp has already reminded us that investment in nursing will enhance women’s equal participation in the economy, which the UK mission to the UN has already emphasised is vital to the eventual gender equality of women globally. That is not to say that we should not increase the male population in nursing too. In turn, one would anticipate a reduction in violence towards women if they are in a position to be financially self-supporting through working as nurses or other healthcare workers, thus enabling them to leave abusive relationships where they were previously held in economic handcuffs, and to work with other women in their communities to prevent cycles of abuse. How can the Government promote partnership and mutual learning between the UK and other countries to bring shared benefits?

The UN high-level commission makes a number of recommendations for reform, including at least four enabling actions: mobilising leadership, enhancing investment, aligning accreditation across the globe— as the noble Lord, Lord Willis, has implied—and strengthening global learning. I would welcome the Minister’s opinion on how we will monitor our successes and challenges in relation to the enabling actions suggested within the five-year timeframe of 2016-21. Is now an appropriate time to take stock and set some clear, measurable goals for the UK’s investment in associated issues?

This must of course include developing our own workforce, as outlined by many other speakers in the debate, rather than continuing to rely on healthcare workers from overseas to staff our NHS and social services; depleting countries where there are already severe shortages in order to assist us is, to say the least, ethically questionable. However, overseas nurses are welcome here and opportunities for exchanges, strategic partnerships and alliances should always be promoted.

We know that nurses play a powerful and effective role in a range of healthcare settings and that many work in communities where they have lived for long periods. This makes them culturally sensitive and acceptable to the people they serve. The work that nurses have undertaken in Africa to reduce communicable diseases illustrates the effectiveness of their interventions. They continue to work to reduce the level of HIV and AIDS through health promotion. Similarly, nurses work with children and adults who have experienced extreme violence due to conflict and war, assisting them with mental health interventions as well as treating physical wounds.

Nursing Now, the global campaign to raise the status of the profession worldwide, involves more than 40 countries with the backing of their respective Governments. The campaign was instrumental in influencing the World Health Organization to appoint a chief nurse to its new leadership team. How long will it be before England has a chief nurse at the Department of Health and Social Care, part of whose remit should include an international dimension? Can the Minister tell us how the Government have invested to promote nursing globally to date, and whether they will increase that investment with associated clear objectives to ensure that the triple impact of such investment on improving health, gender equality and strengthening economies may be measured? One method has been clearly identified in the interim report by the noble Lord, Lord Darzi, reviewing healthcare in this country. It states:

“Governments must stop approaching the NHS and social care as a liability to be managed and instead look at it as an investment that delivers a return. Good health is an asset”.

How can we ensure that health is really perceived as a human right through investing in healthcare workers globally? Does the Minister agree that at least in part, we must do this by further investment in our own workforce in the UK and making the nursing profession a desirable choice for young people here at home in the future? In this way, we will also become less dependent on recruiting excellent nurses from overseas and enable middle and lower-income countries to train and retain nurses in their own communities.

My Lords, the House will be very grateful to the noble Lord, Lord Crisp, for instituting this debate and I crave the indulgence of noble Lords for speaking in the gap. I must also ask for a further indulgence because this speech is not totally global in character. I speak as the former chairman of a central London independent hospital. Our experience, like that of many other hospitals and indeed of many patients, is of the excellence of nurses coming particularly from Australia, New Zealand and Canada. They have many attributes. On the whole they are very well trained in the British tradition. They have a reputation for being particularly good with patients, and of course they have the language. The attraction for them of coming to the UK is to work hard and save up for touring Europe, and certainly it has been the experience at our hospital that the limited stay is worth it for the service these nurses give during that period.

There is a distinct possibility that following Brexit, the number of nurses from the European Union will fall, and this has been highlighted in a rather depressing King’s Fund report published last October which many noble Lords will have received. This will obviously lead to an increase in demand for well-trained nurses from elsewhere. Incidentally, from that list of Australia, New Zealand and Canada, I deliberately omitted South Africa, because nurses are urgently needed in southern Africa, as highlighted by my noble friend Lord Ribeiro and the noble Baroness, Lady Watkins of Tavistock.

Currently, the expenses for nurses coming from outside the European Union and taking up work in this country are very considerable. We cannot do anything about geography but the fact is that nurses coming from the European Union at the moment have virtually no expenses, except possibly those of getting their English up to speed. I highlight the work done by my noble friend Lord Howe three years ago in getting the European Union to correct that anomaly. I ask Her Majesty’s Government, when they are formulating immigration policy following Brexit, to pay particular attention to minimising costly red tape and encouraging the valuable source of nursing excellence for the betterment of healthcare in this country.

My Lords, I join noble Lords in congratulating the noble Lord, Lord Crisp, on calling the debate and on the APPG report. It has been an excellent debate, with informed contributions from noble Lords across the House.

We are here to talk about the all-encompassing importance of investing in nursing around the world. As serendipity would have it, a Minister’s response to a Written Question popped into my inbox this morning. This was the Question:

“To ask the Secretary of State for International Development, given the UK Government’s recent recommitment to defeating malaria, if her Department will increase investment in community-based primary healthcare programmes in remote, rural communities”.

This was the response from the Minister, Alistair Burt:

“DFID supports low income countries to make faster progress towards universal health coverage, with a particular focus on improving access to good quality primary care in poorer, very often remote areas. This support to strengthening health systems helps to ensure that countries are better able to prevent, detect and treat all causes of ill health”.

I am sure that noble Lords will agree that this came as quite a useful prologue to thinking about the debate.

Who better to deliver these changes than nurses? Nurses are an integral part of the global health workforce. Universal health coverage promotes the notion that, despite where one is in the world and the economic situation people find themselves in, each global citizen has the right to quality healthcare. As a country proud of its NHS and its irreplaceable facilities, this notion is close and dear to our heart. Yet nurses around the world, including here in the UK, face 21st-century obstacles. Health systems remain fragmented and endure systemic troubles that impede the quality of care. Communities are experiencing disengagement from participating in elevating their own health. Funding is often mismanaged, misplaced or misguided. Our own health obstacles surrounding Brexit pose a challenge to staffing. Research into universal healthcare has brought to light issues that affect most, if not all, countries with a healthcare workforce: their training and education, staff shortages, problems with recruitment and retention and limited accessibility to proper resources. Some of those sound quite familiar to us here at home.

Of course, countries vary greatly from an economic, social and political perspective. That is why, to combat such issues and signal nurses’ irreplaceable status to the world, the All-Party Parliamentary Group on Global Health published a critical report on nursing’s unique Triple Impact. I congratulate the noble Lord, Lord Crisp, on again putting his finger on the pulse. The report claims that investing in nursing globally progresses gender equality, builds strong economies and improves the health of all. Equality, prosperity and health: three fundamental legs that nursing strengthens. As the noble Lord said, that is a no-brainer.

On fortifying the equality, wellness and wealth of not just our own country but countries around the world, the report sets out several detailed recommendations and the practical applicability of each: nurses as policymakers; nurses developing their own potential through the Workforce 2030 initiative of the World Health Organization; nurses as leaders; nurses driving research, and nurses being empowered and therefore empowering other women.

Let us not forget the “global” aspect of investing in nurses globally. The UK must be a willing, active and successful participant when working with, and learning from, leading global health organisations. The exchange of health knowledge only improves Britain’s soft diplomatic power with nations of the world.

The noble Lord, Lord Crisp, mentioned gender; the noble Baroness, Lady Bottomley, mentioned prescribing. I wonder whether the noble Baroness was a Minister or Secretary of State at the time, but I remember two key changes which transformed the dynamic among health professionals and improved healthcare in my home county of Cornwall. The first was the de-medicalisation of community hospitals in the 1990s, turning them into effective, nurse-led step up, step down units; and, a bit later, the establishment of effective minor injury units in those hospitals. With those two changes came the impact of nurse prescribing.

GPs, predominantly men, were suspicious of both innovations, but now, 20 years on, nurses, predominantly female, have proved that with appropriate training and support they can lead healthcare in a local setting. Thinking of a global parallel, I remember several years ago the noble Lord, Lord Ribeiro, and I joining a party to Zambia. We visited a hospital out in the bush. Much like our community hospitals in Cornwall, they were then nurse-led very effectively, with not a doctor in sight. Doctors are great, but we do not need them all the time.

I return to the global agenda. Next month, we celebrate 70 years of the NHS. Twenty years ago, I was at the NHS Confederation conference to celebrate 50 years of the NHS. One of the most impressive speakers was the Health Minister from South Africa, who implored us not to poach her nurses. That country invests a significantly higher proportion of its GDP than us in training nurses. She asked us to desist and let them develop their strengths and health services in country. That is as important 20 years on as it was then.

Sponsored by the World Health Organization and the International Council of Nurses, Nursing Now takes these recommendations and works towards creating a world community that offers nurses more acknowledgment, security and authority. Nursing Now reminds us that the great power nurses hold, especially in this dynamic and cautious time, is unmatched and has a long reach. I would be grateful if the Minister told us how DfID intends to engage in this way, and what might be the timescale and the short-term and long-term investment.

My Lords, I too thank the noble Lord, Lord Crisp, for initiating what has become a timely debate. Of course, it was not originally scheduled for now, but it has been incredibly timely, for all the reasons that noble Lords set out in the debate. I also thank the noble Lord, Lord Willis, for putting out a tweet earlier about trying to prompt a debate among nurses. At my early morning swim at 6.30 this morning I ran into a couple of nurses—it is true, I was there. I spoke to a nurse and he then subsequently tweeted about tonight’s debate and it generated quite a thread of comments, which I really appreciated. One thing I am certain about is that nurses certainly have a lot to say and are showing concern, not just about their own situation but about the global situation. The most common thing I heard was that health and disease know no boundaries. We have to address this and see it as a global issue.

A key goal of the UN’s 2030 development agenda is that everyone in the world should have access to healthcare—universal health coverage—and that nobody should be left behind. Today’s debate and the Nursing Now campaign make the case very strongly that this cannot possibly be achieved without strengthening nursing globally. This is partly about increasing the number of nurses. One thing we have heard in the debate, and certainly I read it on Twitter today, is that nurses have real concerns on staffing, inadequate facilities and resources, and the lack of effective support. All these things impact negatively on the ability of nurses to provide a safe and effective service. But strengthening nursing is also, as we have heard, about making sure their contribution is properly understood and enabling them to work to their full potential.

As the Global Health APPG report, in which noble Lords participated, said, strengthening nursing will have a triple impact in improving health, promoting gender equality and supporting economic growth. I shall return to that point later. To bring about the change we have heard we need, we really need to persuade politicians to work with the profession, addressing how nurses are perceived. Their potential is, sadly, overlooked because of strict hierarchies and engrained ideas about what nurses can and cannot do. I hope the Minister will take up the suggestion of the noble Lord, Lord Crisp, of a high-level meeting with the profession, so we can talk about these issues, not just in the context of the National Health Service but how DfID’s strategy is addressing these issues globally.

As the noble Baroness, Lady Masham, said, Ebola taught us that tackling that crisis required the strengthening of healthcare systems: growing the number of primary healthcare staff and their training; building scientific capacity in diagnostics and public health labs; and supporting public health messaging and outreach generally. Of course, this touches on education, which is such an important element of primary healthcare. Many countries have had insufficient investment in their health systems. Universal health coverage can make more countries resilient to health concerns, particularly about new diseases that may emerge, before they become widespread emergencies.

Another clear lesson from Ebola was the role of community engagement, which has all too often been regarded as a soft and relatively non-technical add-on to medical interventions. A good example, which I know I have raised in previous debates, was the DfID-funded social mobilisation action consortium in Sierra Leone, which brought together the local BBC Media Action group, the Centers for Disease Control and Prevention, Focus 1000 and Restless Development. Through their activity those NGOs, working with community and religious leaders, and partner radio stations covering every district in Sierra Leone, achieved tangible behavioural change around safe burials, early treatment and social acceptance of Ebola survivors. The stigma of disease is another issue that we have to address through education.

As noble Lords have said, the health professionals closest to the communities are the nurses, who are promoting good health and preventing disease as well as providing care at the community level. They are at the heart of most health teams. They support and supervise community health workers and link to more specialist care when needed.

The noble Lord, Lord Crisp, spoke about the £5 million which is certainly an extremely welcome grant from DfID. However, I want to hear from the Minister tonight just how DfID is translating the lessons that we have learned from the Ebola case, for example. How are we translating those lessons into specific action, particularly in Africa? We have heard about ageing populations and the rapid rise of diseases such as diabetes and heart disease, which are putting all health systems across the globe under strain. But in poorer regions, that comes on top of the burden of infectious diseases such as HIV/AIDS and malaria. The global shortage of health workers means that there simply are not enough to tackle these threats.

This debate has highlighted not only the importance of nursing but the work of our international development strategies. It has highlighted the fact that we do not deal with health simply in isolation. We must see these as global threats but also as having global solutions. It is not only that other countries can learn from us but more importantly, as the noble Lord, Lord Crisp, has said, that some of these innovations, particularly in Africa, are ones that we can learn from. That is why we should be focusing on this issue, and I welcome this debate.

My Lords, I, too, welcome this debate and join others in paying tribute to the noble Lord, Lord Crisp, for securing it and for the enormous personal contribution which he has made to raising the profile of nursing both here in the UK and around the world. The debate has drawn on the immense depth of expertise that resides on this subject in your Lordships’ House.

It is worth noting, for the record, as I found when I prepared for the debate, that contributions have come from two nurses—crucially, I start with them—but also from a former Permanent Secretary and a former chief executive of NHS England, a former Secretary of State and Minister of State for Health, as well as a fellow and an honorary vice-president of the Royal College of Nursing, a former president of the Royal College of Surgeons, a former president of the Royal College of Psychiatrists, a professor of nursing and a former hospital chairman.

Swimmers, of course, are doing health promotion, and we pay tribute to the noble Lord’s work in this area.

This has been an excellent debate and I will respond to some of the points. The noble Lord, Lord Crisp, set the tone by reminding us of the critical role that nurses play in ensuring the delivery of holistic, patient-centred healthcare. The noble Baroness, Lady Bottomley, reminded us that nursing is the most trusted of professions. That carries wider benefits to health efforts. The noble Lord, Lord Willis, reminded us that nurses can be a catalyst for change in developing countries. The noble Baroness, Lady Masham, reminded us of the courage of our NHS volunteers who went out to tackle the outbreak of Ebola in Sierra Leone. The noble Baroness, Lady Cox, gave many powerful, practical examples of nursing achievement in delivering clinical care in remote and challenging situations. My noble friend Lord Ribeiro hit the nail on the head when he spoke about the role that nursing has in women’s empowerment, which is critical across so many areas.

The noble Baroness, Lady Hollins, talked about how nurses could be there in early intervention in mental health conditions. The noble Baroness, Lady Watkins, spoke about seeing nurses as a global resource in delivering the sustainable development goals relating to health. The noble Viscount, Lord Bridgeman, reminded us of the costs and administrative burdens faced by those coming to study nursing in this country. The noble Baroness, Lady Jolly, summed it up by saying that nursing delivers equality, prosperity and health. The noble Lord, Lord Collins, reminded us that, in these matters, the issues of health and disease know no national boundaries in the way they operate and therefore that they demand a different set of solutions.

I congratulate the noble Lord, Lord Crisp, and the noble Baroness, Lady Watkins, on their leadership on this issue since the launch of Nursing Now, which, the noble Lord, Lord Willis, reminded us, was attended by Her Royal Highness the Duchess of Cambridge and was a great success. I am delighted that my colleague, the Minister of State at the Department for International Development, Harriett Baldwin, attended and used that opportunity and platform to announce our support for nursing globally and for the campaign through our health partnership programme, starting in 2019. It is a £5 million programme that a number of noble Lords have welcomed. It will be allocated to focus on nurses and midwives. The programme is designed to address the priorities identified by countries and will focus on nurse leadership where it is part of a country’s health workforce strategy.

Through these partnerships we will work with countries to build comprehensive and effective healthcare systems, not just to deliver separate projects. The programme brings benefits to developing countries and to the UK health system from the increased skills and motivation that UK health workers acquire when working overseas. That is why this campaign recognises the vital role of nurses at the centre of every health system around the world. Nurses account for nearly 50% of the global health workforce. Their knowledge, skills and motivation are crucial in delivering health services to all, including to the poorest.

As the Triple Impact report and the Nursing Now campaign highlight, many countries are grappling with enormous challenges, including shortages, skills, gaps in leadership and challenges mentioned in particular by the noble Lord, Lord Crisp. In the UK, nurses are at the heart of our NHS. We want to keep these hard-working staff and build a workforce fit for the future. My noble friend Lord Ribeiro and the noble Lord, Lord Willis, among others referred to concerns they had about our capacity to train the nurses we need. We have announced 5,000 more nurse training places from 2018, alongside new routes into the profession and continuing measures to improve the work/life balance.

Globally, the World Health Organization and the World Bank estimate that countries will need to create around 40 million new health and social care jobs by 2030—a point raised by the noble Baroness, Lady Watkins. Low-resource countries, where these are needed most, face the greatest shortages of 18 million health workers. We must support them to train and deploy the health workers they need so they can access essential health services.

The noble Lord, Lord Ribeiro, spoke about the importance of the retention of trained staff in Ghana. The noble Baroness, Lady Jolly, spoke about her experiences at the conference and talked about the importance of the retention of staff in South Africa. The noble Baroness, Lady Watkins, rightly raised ethical questions about recruitment from some developing nations. That is why the UK Government support the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel, which ensures that developing nations that are experiencing critical shortages of healthcare staff are not targeted for recruitment.

As the noble Lord, Lord Crisp, has argued, this is not just about health services. Investments in the health workforce go beyond improving health. The health sector offers employment opportunities for women and strengthens local economies. The UN High-Level Commission on Health Employment and Economic Growth, which the noble Baroness, Lady Watkins, referred to, found that in 123 countries women make up 67% of workers in health and social sectors. The noble Baroness, Lady Bottomley, and the noble Lord, Lord Crisp, referred to this as well. The commission has estimated that women would take between 59% and 70% of additional jobs created in education, health and social services. These opportunities will be even more important in low-income countries, where women are often excluded from formal employment.

To promote these opportunities in the health sector, a DfID programme in Bangladesh, for example, is aiming to ensure that 4,300 licensed midwives are employed. Some 30% of these will be in remote areas, providing opportunities to young women where other formal employment opportunities are scarce. To deliver and sustain this triple impact, the Government remain committed to working in partnership with countries to strengthen their health systems by improving their health workforces, including addressing the global shortage of nurses and midwives, to ensure that no one is left behind. DfID improves access to and the quality of health services by supporting training, mentorship and supervision for health workers; for example, in Kenya we have trained 7,000 nurses and midwives in emergency obstetric and newborn care. This has already resulted in a 10% reduction in maternal deaths.

Our programmes also invest in nurse leadership, which the noble Baroness, Lady Bottomley, referred to. Through a UK partnership, 20 nurses in Uganda have been trained by UK volunteers in nurse leadership for palliative care. I think the noble Lord, Lord Crisp, referred to this programme. These nurses have supported the training of 154 other health workers and empowered them to take on care traditionally delivered by doctors and to broaden access to palliative care.

In the time available I will turn to some of the questions that were raised. If I do not cover them all, I will of course write. The noble Baroness, Lady Masham, and my noble friend Lord Bridgeman asked about EU nurses leaving after the referendum. Overall, there are 3,600 more EU staff working in the NHS since the referendum. We have seen a small reduction in the number of EU nurses working in the NHS over the period. However, this is due mainly to the introduction of new language tests by the Nursing and Midwifery Council.

The noble Baroness, Lady Cox, asked about healthcare in challenging conflict situations. The UK Emergency Medical Team, including nurses, spent over six weeks training more than 3,000 Rohingya people, with local Bangladeshi nurses working alongside them, learning vital infection prevention and control skills. The local nurses are now tackling diphtheria in the Cox’s Bazar camps.

The noble Lord, Lord Willis, was right to pay tribute to Jackie Smith, the Nursing and Midwifery Council chief executive, who has announced that she is retiring. We join the noble Lord in paying tribute to her leadership of the NMC over the past six years and wish her every success for the future.

The noble Baroness, Lady Watkins, wondered, after the World Health Organization’s appointment, how long it would be before there was a chief nurse at the Department of Health. The Chief Nursing Officer for England, Jane Cummings, advises the Government on nursing workforce issues. We are delighted that her office is working with the noble Lord, Lord Crisp, and the noble Baroness, Lady Watkins, on the Nursing Now campaign.

The noble Baroness, Lady Bottomley, spoke about the Commonwealth connection. I am pleased to confirm that Nursing Now representatives took part in a recent Commonwealth summit event through the Commonwealth Nurses and Midwives Conference.

The noble Lord, Lord Crisp, asked whether nurses were at the forefront of health strategies. The UK recognises the critical role played by nurses. Our bilateral programmes, our support for the World Health Organization’s leadership and our investments in strengthening health systems all promote this essential role.

The noble Baroness, Lady Hollins, asked about mental health and specialist nurses. We recognise that nurses deliver specialist services. The UK funds a research programme called PRIME and a programme in Ghana, improving the care of patients with mental health issues. The disability summit in July this year will highlight the need for services to be inclusive and cater for all needs so that no one is left behind.

There is a wealth of expertise in this area in this House which has been demonstrated in this Chamber today. We remain open to other ideas on how we can build on our commitment to support nurses and midwives through health partnerships.

The noble Lord asked me a specific question on the round table. I will take that back and talk with my ministerial colleagues about it. It seems a sensible way forward and I know that the Ministers Burt, Baldwin and others have appreciated their engagement with him on the Nursing Now campaign. Through DfID and other departments we are committed to playing a part in enhancing the vital contribution of nurses and midwives in healthcare and prevention for all, especially for the poorest people in developing countries.

House adjourned at 9.11 pm.