CLAUSE 6.—(Prohibition of unqualified persons acting as maternity nurses for gain.) (Hansard, 15 April 1937)

§ Mr. Westwood
I beg to move, in page 9, line 9, after "undergoing," to insert "and having undergone at least three years."
We are doing what we can to prove that representatives of the Scottish constituencies can get through their work speedily as well as efficiently. The purpose of this Amendment is to strengthen the prohibition of unqualified persons from acting. Under the Clause at present before the House we feel it would be possible for a young medical student just entering on his studies, or for a temporary nurse just starting on her training, to be able to take control of a case. We say that that is altogether unsatisfactory. Both student and nurse ought to be given a period of training before having the responsibility of dealing with maternity cases. We suggest a period of at least three years' training. Exactly the same applies in the case of a nurse undergoing training. We feel that a woman who has just entered upon her training should not in the first week or two of that training be given the responsibility of dealing with a case. We know that it takes three years to turn out a qualified nurse, and we think that she ought to have served three years of her training before dealing with a case of this kind. We do not wish to place unnecessary obstacles in the way of training either students or nurses, and we 1273 know that there is a time when full responsibility must be accepted, but we claim that the Bill would make it possible for them to be given the responsibility of dealing with a case after a week's or a fortnight's training. Unless we can get a satisfactory explanation we shall be compelled to carry the Amendment to a Division.

§ Mr. Watson
I beg to second the Amendment.
I do not propose to go into the matter in detail, as my hon. Friend has made it quite clear what the purpose of the Amendment is.

§ Mr. Elliot
Again, we had a considerable discussion upon this general point in Committee, and I think the House will follow the discussion because hon. Members who were upon the Committee will remember the practice which existed when the hon. Member for Bridgeton (Mr. Maxton) and myself were both students in Glasgow, and when students were able, on certain occasions, to go out at an earlier stage in their curriculum than is now permitted. I do not think it will be wise for the House to consider the matter as it then stood. Neither medical students nor pupil midwives can now undertake a domiciliary case until they have had a complete theoretical course and adequate practical instruction, including the delivery of women in labour, under qualified supervision in an institution. I beg hon. Members to realise that the existing safeguards go further than the statutory form of their safeguard would carry them. The provision that students are not to undertake any domiciliary case until they have had adequate practical instruction under qualified supervision, and including delivery, goes further than the letter of their Amendment. The general purpose of their Amendment is that a man or woman should have had an adequate training, but hon. Members are perfectly willing to leave it to the authorities to say what that adequate training should be. The only difference is that hon. Members say that students should have had adequate training for a considerable period, and the period they regard as adequate is three years.
The actual conditions go further than that. Under the rules of the General Medical Council, no medical student may 1274 undertake practical midwifery until the last term of the fourth year of his curriculum. I wonder whether hon. Members will be willing to take that assurance as the definite pledge for which they seek? I might go further. The whole matter is governed by schemes, and I undertake, in scrutinising those schemes, to give my personal attention to them arid to ensure that no danger should arise of medical students going out to cases earlier than that period which they have put forward. I do not wish to put the matter into the Statute or to make it too bound and rigid. I am certain that the General Medical Council have no intention whatever of relaxing their rules, and it might well be that their rules will be made stiffer. I do not want to undertake that men shall not go out under three years when the General Medical Council are saying that they shall not go out until the last term of their fourth year. I do not want to make the law less stringent than the professional body concerned consider necessary. I shall certainly scrutinise any such schemes and consider them in conjunction with the rules of the professional bodies which govern the matter, and I will take it as an honourable understanding between the two sides of the House. I can give it with perfect safety because I see no chance whatever of the General Medical Council weakening their provisions. There is actually a tendency that they will heighten their provisions. I hope that the House will consider that my suggestion is adequate, and, if that is so, I will regard that as dealing with the first part relating to medical students.

§ Mr. Maxton
I want to be quite clear on this matter. I did not understand that the right hon. Gentleman was quoting from the rules of the General Medical Council. Do I understand him to say that not only is the medical student at the present time not permitted to take his midwifery courses until he is in his fourth year, but that he is not permitted to do domiciliary work until he has completed his practical course in the hospital?

§ Mr. Elliot
Yes.

§ Mr. Maxton
He must complete his hospital course before he is allowed to go out to a case in a home?

§ Mr. Elliot
Yes. To be perfectly accurate I will read what it says: 1275 …until he has had adequate practical instruction, including the delivery of women under qualified supervision in an institution. I shall not say "until he has completed his course," because that course might go on for a long time, but those in charge are responsible that no man goes out to a domiciliary case until they can guarantee that he has had adequate practical instruction as well as his theoretical course.

§ Mr. Maxton
Perhaps, in the circumstances, my hon. Friend might decide not to pursue his Amendment. The Secretary of State has stated that the existing position is a better safeguard than the Amendment as framed. The intention of all of us upstairs in discussing this matter was to get a safeguard. The purpose of the Bill is to try to secure that the terrible maternal death rate, and to some extent the infant death rate, shall be substantially reduced. This Bill expresses the belief that that can be secured by the best possible medical and midwifery service at childbirth. That is the idea that led to the Bill being brought forward. This provision to make—

§ Mr. Deputy-Speaker (Captain Bourne)
The hon. Member is going a little far in his interruption. Perhaps he had better wait until the Secretary of State has finished his speech.

§ Mr. Maxton
If I am only making an interruption, I will sit down at once. I understood, however, that the Secretary of State asked the House whether they were satisfied with his statement on the medical aspect, and suggested that, if they were, he would proceed to the nursing aspect, but that if not he would conclude his speech at that point and allow us to discuss the medical aspect.

§ Mr. Westwood
That is the point that I was going to ask the Secretary of State to deal with. The whole of his explanation has been directed to the medical student; he has said not a word so far in relation to the training of the nurse who is to complete her course and get a certificate as a midwife. I would like to ask what explanation he proposes to make with regard to the proposal of the second Amendment, which deals, not with the medical student, but with the nurse.

§ Sir Robert Tasker
Could my right hon. Friend assure the House that medical students as such will not attempt cases outside the hospital until they are fully qualified, and that nurses will hold a certificate equal to that of the Central Midwives Board?

§ Mr. Elliot
It was agreed, of course, that on the whole the Amendments should be discussed together, but perhaps, as the discussion has developed, it might be more for the convenience of the House, if I have satisfied hon. Members on this point, that a further discussion should take place on the case of the midwife. We have been reproved by you, Mr. Deputy-Speaker, for turning the Report stage of a Bill into a Committee stage, and I am anxious not to transgress the Rules by speaking more than once, even with the leave of the House, upon an Amendment. Therefore, I would say that it seems to me that the explanation I have given might reasonably satisfy the House on the first point, with regard to the medical student. I do not know whether it will fully satisfy the hon. Member for Bridgeton (Mr. Maxton), though I rather gathered from his remarks that he thought it was satisfactory from that point of view.

§ Mr. Maxton
I was going, if I were making a speech and not merely an interruption, to take the view that the Secretary of State's reply disposed of the Amendment on the Paper, but did not dispose of the problem that we were trying to meet upstairs, and I would have urged him to look at this matter again with a view to getting inserted, before the Bill finally becomes law, some provision to secure that no woman in a poor home in the worst districts of our big cities in Scotland should be delivered of a child by some student who was for the first time facing in home conditions—in slum conditions—the task of a serious midwifery case. I do not wish to injure his training in any way, but I do not want to see women become merely experimental ground for the training of medical students, and, therefore, I want to see some regulation under which, in every case he takes, he should be accompanied by a qualified experienced medical man. That is all I would ask in the way of safeguard.

§ Mr. Westwood
After the explanation of the Secretary of State, and the pledge he has given, which will be recorded in the OFFICIAL REPORT, I am, with the consent of the House, prepared to withdraw the Amendment.

§ Mr. Deputy-Speaker
I would ask the hon. Member whether, in view of the discussion, he would like to move his next Amendment formally, in order that the Secretary of State may give an explanation?

§ Mr. Westwood
I beg to move, in page 9, line II after "or," to insert: who, while undergoing and having undergone at least two years' training with a view to becoming. I formally move this Amendment because up to the present we have received no explanation concerning the nurse. The right hon. Gentleman's explanation on the training of the medical student was quite satisfactory, and the House has accepted his pledge, but I think we are entitled to an explanation with regard to the nurse, because, unless there is some good explanation, it will be possible for a nurse just entering upon training to have the responsibility of dealing with a case without having received adequate training.

§ Mr. Elliot
The hon. Member will realise that this Amendment stands on a somewhat different footing from the previous Amendment, since it deals essentially with the subordinate, who would not regard herself as being in charge of the case, while the previous Amendment, quite rightly, dealt with the responsible position of a medical man, or someone acting as a medical man, who would be rightly expected to take full responsibility for the case.

§ Mr. Westwood
Is it not a fact that, even under the proposals of the Bill, a midwife can take full responsibility in connection with a case, and that, even under the Bill, there is no compulsion on a midwife to call in a fully qualified medical practitioner?

§ Mr. Elliot
I am not speaking so much of the statutory position as of the fact that a midwife can rightly put responsibility on the shoulders of the medical 1278 practitioner, and it is generally admitted that a greater responsibility falls on the fully qualified medical practitioner than on the midwife. I do not wish to stress the matter, but it is understood that the midwife, if she finds herself in any kind of difficulty, is expected to call in a medical practitioner, whereas it would be quite wrong for a medical practitioner who found himself in any kind of difficulty to be expected immediately to call in some other medical practitioner. I go no further than that. Starting from that point, let us see what the present position is. The full course of the midwife's curriculum under the rules of the Central Midwives Board extends over only 12 months, and, therefore, I do not think the Amendment would be possible in practice. The Central Midwives Board contemplate an extended period of training, but not, I think, to the extent which would render this Amendment practicable. Women who are already registered nurses under the Nurses Registration Act qualify as midwives after a six months' course, but, of course, being registered as nurses, they have had a long training already. I think that the hon. Member has more in view people, A ho are working for the full course of the midwife's curriculum under the Central Midwives Board. Looking at the matter from that point of view, it would be difficult for this House to start amending by Statute—because that is what it comes to—the rules of the Central Midwives Board. I think that an Amendment which would work within the limits of the curriculum laid down by the Central Midwives Board would be sound, and that is really what the Central Midwives Board try to make sure of—that is to say, that no one should be asked to undertake this tremendous responsibility without having gone through a course, which the responsible professional people thought was a proper course to fit them to undertake the responsibility. I think that is the point of view of the hon. Member for Bridgeton and I am sure it is the point of view of the Mover and Seconder of the Amendment.

§ Mr. Westwood
Even if these words cannot give effect to that principle, there is time between now and the later stages to get the principle inserted in the Bill. Will the right hon. Gentleman give a guarantee that he will look into it and give effect to it?

§ Mr. Elliot
It is, I think, admitted that the Amendment as it stands would not be practicable, because it goes further than the rules of the Central Midwives Board. I should, however, be very glad to look into the question whether there is any loophole or gap by which comparatively untrained persons could be faced with this very great responsibility. My belief is that that would not and could not arise. My information is that, even if a woman undergoing training under the Central Midwives Board was also a pupil midwife, she would not be allowed to undertake a domiciliary case unless she had had a complete course of theoretical instruction and had had adequate practical instruction, including experience of the delivery of women, under qualified supervision, in an institution. I am not quite so familiar with the conditions of the training of midwives as with the training of doctors, therefore, I will undertake to look into it. But all that could be secured in the schemes if necessary, because the schemes have to be framed in conjunction with the local authority and, furthermore, they come before the Department and they are subject to its consideration and approval. If my experience goes for anything, the woman would be rather too anxious, if anything, to summon expert assistance from outside if there were the slightest sign of anything going wrong. The first time one is confronted with this emergency, one's tendency is always to run for help rather than to face up, as some day or other one has to face up, to the responsibility alone. The danger is far more that they will delay and shirk the responsibility that they are asked to assume, rather than lightly or rashly undertake it. If the House will take it from me that I will look into this matter and that I take the responsibility on myself to see that in this great public service untrained people do not get the opportunity or the risk of experimenting upon those for whom we are passing this Measure, I am sure they will not regret it.

§ Mr. Pethick-Lawrence
I should like to get the Minister's assurance a little clearer, but may I first say a word with regard to the point about the natural inclination of a half-trained person to send for assistance? I think it slightly misses the point. The point is not whether an untrained woman, attending as a midwife, 1280 will not in the hour of emergency send for someone else, but whether some institution shall or shall not send to attend on a case a person who is not fully qualified. The question whether in an emergency she might get out of her responsibility is not a primal factor. The question is whether she shall be sent at all. I understand the right hon. Gentleman is going to look into the matter with a view to discovering one or two things, first, whether he has the power himself to ensure that the regulations that are made fulfil the wishes of the House, in which case he is giving a pledge that he will insist that that is done. If he finds, on the other hand, that he is not in that position, I understand his pledge to mean that he will consider whether, in another place, he can get an Amendment inserted which will give expression to the wishes of the House, with which, I think, he is in full accord.

§ Sir R. Tasker
Might not apprehension be removed if, instead of saying a nurse shall have six months training, we say that she should possess the Midwives Board's certificate before she is permitted to attend?

§ Mr. Elliot
I doubt whether that would be possible. It would be like saying, "You must not go near the water until you can swim." There must be cases in which a person is not technically fully qualified, though we believe him to be morally qualified to attend upon a case. After that, they get their certificate, which enables them to go out and work on their own. I believe the position to be satisfactory from the point of view of the spirit of the Amendments which are being pressed upon us. Technically, the Amendment is impossible, because it would impose a length of service which is not demanded under the rules of the Central Midwives Board. My impression is that adequate and full safeguards are provided by the existing practice under rules laid down by a statutory body, in the other case the General Medical Council, and in this case the Central Midwives Board. I undertake to look into that and if, as I believe, that practice is satisfactory, I shall see that there is no way in which proposals can be made which would give less safeguards than those that exist at present under the rules 1281 of these statutory bodies. If, for any reason, the position is not fully safeguarded, I will undertake to look into it, with a view to having an Amendment inserted in another place. I cannot say that an Amendment will be inserted, but I will hold myself morally bound to go into it, and if I find it cannot be done, I will come back to my hon. Friends and do my best to convince them of the reasons that have led me to that conclusion.

§ Mr. Maclean
Does not the right hon. Gentleman consider that what is looked upon as a practice is very often evaded, whereas, if it is made statutory that such and such a thing must be done, failure to do it would entail loss of the certificate? If the apprentice or student midwives are only to be told "This is the custom" or "This is the practice" instead of "This is the law," which means that they are liable to prosecution and also that their certificate will be taken away as a fully qualified midwife, it is a very different matter. Should not that point be considered also?

§ Mr. Elliot
We are considering persons who are undergoing a course of training with the object of obtaining a certificate. In these circumstances I believe that the discipline of the professional body is much the greatest safeguard which the public and this House can have. They are statutory bodies and the danger of ignoring the rules of a statutory body is quite as great from the point of view of the penalty which the hon. Member suggested as the danger of ignoring a Statute, because if they did not fulfil the rules of the statutory body they would be deprived of their certificate and be subjected to tremendous professional penalties, so severe that very often hon. Members of this House have protested against their severity. I think that a professional body will discipline a professional person as severely as any court of law could do. I believe that the course I have suggested commends itself to hon. Members opposite, and, if so, can we not leave any further discussion?

§ Mr. Maxton
My difficulties are not fully met in this matter, because the right hon. Gentleman says that he is relying upon the appropriate professional organisations to see to this matter. I 1282 would point out that the evil we are trying to combat has grown up under existing professional organisations.

§ Mr. Elliot
In the experience of the hon. Member and in our own experience the evil to which he refers has been combated and is in process of eradication under these professional bodies. What we have in mind is whether junior medical students are going to be sent to cases. I think that has been entirely abolished. We are now discussing the question of midwives, and I do not think the danger is so great there. I think the professional bodies are tightening up their regulations almost every year in regard to these things.

§ Mr. Maxton
I can still see from the explanation given by the Minister the case of a woman in my division, living in a single room or a two-apartment house, living in poverty and on public assistance, having to face childbirth and having as attendants a medical student doing his first domiliciary case and a midwife student doing her first domiciliary case. I am referring to my division and not to the West End. I have in mind one of my municipal wards where the infantile death rate is the highest in Glasgow. It is there that I want the death-rate reduced and the maternal death-rate reduced, but that is the very place where, when an S.O.S. is sent to a maternity hospital for help, that a woman is going to have a baby in such and such tenement, down will come posthaste two very eager people, a young medical student and a young nurse, neither of them having had any experience on their own of domiciliary treatment of a childbirth case. I want to make sure about this matter.
I heard the answer of the hon. Gentleman the hon. Member for Holborn (Sir R. Tasker) that it was like saying people must not go near the water until they had learned to swim, but I would point out that most people who are teaching their young folk to swim take care that they do not go into deep water until they have attained reasonable proficiency in swimming and there is standing by an experienced swimmer. What I want, although it may not be possible to get it on the Statute Book, but possibly it may be possible to get it into the local regulations, is that in my constituency the poorest people—whatever happens in the 1283 West End, where they have money and can make what arrangements they please —shall be guaranteed that if there is to be an apprentice nurse and a student doctor in attendance there shall also be a fully qualified doctor standing by.

§ Mr. Elliot
The statutory position of the Central Midwives Board is such that the Minister himself has to approve the rules of that board. They are also submitted for criticism to the General Medical Council. I have undertaken to look into the question whether there is a possibility of a practice such as the hon. Member described. I am told that there is no such possibility. If I am satisfied of this I shall consider myself to have discharged the undertaking that I have given to the House.

§ Mr. Westwood
After the very clear explanation given by the Secretary of State and his further promise, which was made still more definite in reply to my hon. Friend the Member for East Edinburgh (Mr. Pethick-Lawrence), that he will insist that any person not fully qualified shall not be allowed to take sole control of the delivery of a child, I am prepared to accept his undertaking and to ask leave to withdraw the Amendment.

§ Mr. Elliot
I beg to move, in page 9, line 26, to leave out sub-paragraph (iii).
This is an Amendment which has been laid on my doorstep, and I have taken over the paternity. No doubt it will commend itself to hon. Members opposite, just as it has commended itself to me.

§ Mr. Pethick-Lawrence
I thank the right hon. Gentleman for adopting the paternity of this Amendment, and also of the next Amendment, which stands in our joint names. We thought that there was no ground for the exemption in the Bill as it stood, and I am very glad that the right hon. Gentleman has adopted our view and that he is accepting these Amendments.

§ Mr. R. Gibson
I also wish to congratulate the right hon. Gentleman. We discussed this matter in Committee, and I put certain questions on the Order 1284 Paper for written answer, and I have no doubt they assisted the right hon. Gentleman to take up the position which he has now adopted.