The health secretary wants to reform nurse education - and integrate it with changes to professional roles and the pay system. Barbara Millar reports

Arch-moderniser Alan Milburn last week set his seal of approval on plans for an overhaul of nurse education, trailed variously as 'breaking down the barriers' between professions and as a 'back to basics' snub to the academics.

The health secretary's speech to a conference at King's College, London, linked the reform of nurse training with plans to scrap old pay systems, and pledged a 'fundamental and far reaching' look at the roles of doctors, nurses and other professionals.

In the immediate future, he said, 16 sites - covering a third of nurse training - will fast-track a 'more flexible, modular' system aimed at 'opening up access' and making the workforce 'more representative of local communities' from September 2000.

The initiative has been widely welcomed, and there is enthusiasm about plans already under way for nurse consultants and other initiatives which extend nurses' roles.

But some fear that the new training model is flawed. 'Our experience of practice development in primary care and trusts shows that nurses are very capable of delivering new and better ways of meeting the needs of patients, ' says Gayle Garland, programme director at Leeds University's cent re for the development of nursing policy and practice.

Christine Hancock, general secretary of the Royal College of Nursing, agrees. But, she warns: 'The government must address nurse shortages because the experienced nurses needed to make this vision a reality are currently struggling just to keep the NHS afloat.'

And Susan Osborne, director of nursing and quality at Luton and Dunstable Hospital trust, warns that the new model of nurse education may backfire by placing an even greater burden on nurses.

She fears the 'step on, step off ' form of training proposed might encourage people to step off at the end of the first-year common foundation programme - perhaps because they find it too academically rigorous - and not step back on again.

Such people will have had a year's basic nurse training and will be able to undertake tasks such as feeding patients and taking them to the toilet.

'What would then happen to them?' she asks. 'Would ministers feel that, because they had had basic training, they should be employed in the NHS?

This could mean we ended up with a three-tier nursing hierarchy.'

If people do drop out of the training scheme it will also leave the NHS without the number of registered nurses it thought it would have to meet service needs and for which it planned, she adds.

Mr Milburn's promise of legislation to create a new nurses council by September 2001 gets a positive response from the UK Central Council for Nursing, Midwifery and Health Visiting.

A spokesperson welcomes the move to ensure that NHS-funded education is subject to the same quality assurance system as other university provision, through the Quality Assurance Agency.

And Rosaline Steele, director of education and practice development with the Royal College of Midwives, adds that the new education and training unit to be set up in the NHS Executive 'will mean the NHS taking a more active role in looking at the standards and quality of education'.

But some doubt the whole modernisation programme.

Bob Sang, strategic adviser to the Patients Association, believes it could turn into 'a truly modern mess'.

Mr Milburn has got it 'half right', says Mr Sang. 'A lot of what he is proposing needs to be done. But the way he is going about it is hardly modern. It is traditional, macho command and control, and will lead to a tension between the medium and the message. Patients have to be seen as co-operative redesigners of a modern NHS, not as dependent victims.

'If we are going to break the culture of doctor or nurse knows best, there has to be real direct involvement with patients in creative and relevant ways.

The NHS is, at the moment, still stuck in bureaucratically managed ways of engaging people.'

On pay reform, Karen Bell, president of the Association of Healthcare Human Resource Management, agrees the current system is 'archaic' and does not give the flexibility the service needs. It is also an indefensible system, because of anomalies over equal pay, she adds.

'But, although we need a proper job evaluation system, it is not cost neutral and could add between 5 and 6 per cent to the pay bill, ' she warns.

'Given the financial situation of the NHS we need to be sure that the Treasury is going to set aside money for this process, so that its introduction does not impact on clinical services. Otherwise it will simply not be affordable.'