NURSING SERVICES.

HC Deb 18 April 1939 vol 346 cc203-81

3.58 p.m.

Sir Francis Fremantle

I beg to move, to leave out from the word "That" to the end of the Question, and to add instead thereof: this House, taking note of the Report of the Inter-Departmental Committee on Nursing Services, recognises the inadequate supply of nurses to meet the increasing demand for their services and the urgent need of reform in their training, registration, and conditions of service both for institutional and domiciliary nursing. Nursing is no longer merely a personal service; it serves a national need. It is of national importance; it serves, incidentally, every Government Department in one form or another; and, above all, from the nurses' training schools nurses go out into every part of the world and serve the Empire. I think, therefore, that it is proper to regard it as coming within the purview of the Civil Estimates. I should like to deal with this matter from the nurses' point of view. There is a rising storm of complaints, which have been freely circulated in the Press, and which show instances, all too frequent if not general, of nurses being over-worked and under-paid, of excessive discipline and restrictions and inferior accommodation, while at the end of their life's service it may happen that nurses' pensions are not interchangeable, and they may not be able to get the pensions to which they started to contribute.

From the public point of view the matter is of national importance. Let me refer first to the shortage. In many cases there is a deficiency of nurses, especially in the nursing homes; and there is the rising competition of business jobs which account very largely for the shortage. In 1932 we had the very well informed report of the "Lancet" commission, which resulted in many of the improvements which have taken place since. Last year we had the report of the Alness Committee in Scotland, and in January of this year we had an interim report from the Athlone Committee for England and Wales. The shortage of nurses, obviously, depends on the relationship between supply and demand. Let us consider the question of the supply of nurses throughout the country. Roughly speaking, the number on the General Nursing Register is 74,000; but there are supplementary parts of the Register containing the names of those who are registered only for the purpose of fever cases, sick children and mental defectives, and male nurses, and, adding these, we get a total of 90,000 on the Register, of whom 54,000 are qualified by examination.

It is interesting to those who are only beginning to study the subject—that applies to most people—to note that the entries into the profession have been increasing very definitely of late years. During the past 12 years the number entering for the preliminary examination for the Register has increased from less than 6,000 to nearly 10,000, an increase of nearly 50 per cent.; and the numbers entering for the final examination have increased by something like 100 per cent. From 25 to 35 per cent. of the probationers have fallen out in the first year. Therefore the recruitment at the present rate requires not only the 9,000 who enter for the final examination, but the 3,000 who have dropped out on the way. At the present rate we require 12,000 entrants into the profession yearly for training. But, even so, at the present time there is a shortage. The London County Council, with its very able and efficient and strong organisation, reports that in December, 1937, in their general hospitals in an establishment of nearly 7,000 nurses they had 611 vacancies for staff, first grade; that is vacancies for nearly 10 per cent. They had to fill up half that number with 300 first-year probationers. Take a council like the Surrey County Council. There we find that a quarter of their authorised posts for female nurses were unfilled. Most hospitals and institutions for nursing the sick report a similar relative difficulty in obtaining the numbers required, even under the present standard.

One of the obvious suggestions for dealing with the problem has been the use of foreign women nurses from abroad. The addition of foreigners of either sex has to be limited, I fear, by certain other considerations, but the Home Office have not been averse to considering whether they can stretch a point in favour of those who can do useful service in the nursing world, and although in 1935 the number so admitted was 72 only, it had trebled in 1937 to 215. It is not a large number and I do not know how far it can be increased, but it is obvious, from the patient's point of view as well as from the point of view of the volunteers, that it is not easy to get women who could give suitable service to the patients. Wastage always has to be remembered in such an arduous service. A probationer perhaps finds the work unsuitable, or individuals are found by the authorities to be ill-adapted for the work. Many are weeded out by examinations and many by the happier result of marriage.

If that is the position as regards the supply of nurses, let it be remembered that there is not only the question of supply, but that the increased demand occasions the difficulty at the present time. The increased demand arises from various factors. There are six factors that have to be considered. The first is that in voluntary hospitals the number of beds has increased by no less than 1,500 a year in recent years, and that they require the services of 500 extra nurses a year. That is a very satisfactory measure of increase. The second increased demand has come from the passing of the Local Government Act, 1929, and the transfer of the Poor Law to the local authorities, the result having been that the Poor Law institutions have been turned by degrees into very well run, and in some cases extremely well run and equipped municipal hospitals, with a corresponding increase of staff. For instance, the nursing staff of the Surrey County Council hospitals increased in the eight years from 1930 to 1938 from 369 to 700. Then there are the returns sent in reply to a questionnaire sent out by the Society of Medical Officers of Health to county and borough councils. As to the trained nurses and probationers serving in general hospitals, fever hospitals and tuberculosis hospitals, the returns received show an increase in the last 10 years from 9,150 to 13,900, or nearly 50 per cent.

The third factor in the increased demand comes from the growing public demand for hospital treatment in acute sickness- As a result of the housing shortage, accompanied by the modern standard of very small rooms in new houses, accompanied also by various other conditions of the present day, there is a greater demand for hospital accommodation and therefore for nursing services. The fourth factor, as many of us know, is due to an increased demand for domiciliary nursing, whether under an authority or under the Queen's Institute of District Nursing or in private homes. When sickness comes into the home, especially long continued sickness, we all know the inestimable advantage of visits by the district nurse or by the local authority nurse, or the advantage of being able to employ a nurse on our own account. Therefore the shortage of nurses and the standard of nursing are matters of first importance.

I would like to make an appeal for a greater use as a matter of policy of domiciliary nursing. The hospitals all over the country have grown up as separate institutions. The patients come into them from outside unknown, and they go out from them to the outside to face the world alone. By a greater linking up of the system of domiciliary nursing with the hospitals, by an organic linking up, we would enable the nurses themselves to advise patients when to go into a hospital for treatment, and at the same time we would prevent them from going to the hospitals when they could be treated at home. That policy would enable the hospitals to discharge them earlier to their homes, with the knowledge that they would be under nursing care which could be trusted. There is a definite point of public policy which one may commend alike to the governing bodies of hospitals and of local authorities.

The fifth factor in the increased demand for nurses is the development of medical technique. There are the needs of X-ray and heat therapy. There is one hon. Member, a heart case, who has for some months been fortunate enough to obtain the services of a nurse every hour and every minute, day and night, and there are still in attendance on him three nurses day and night. I know of a case in St. Thomas's Hospital calling for the most delicate apparatus for dealing with blood poisoning. Heat therapy is required and instruments have to be adjusted constantly day and night according to the patient's requirements, and the constant attendance of two nurses is called for. That is an instance showing the increased demand for nurses. There is a sixth factor. Greater efforts have been made by hospital authorities in recent years to reduce the hours of nurses. A reduction of the hours has meant an increased staff and therefore an increased demand. For instance the proposed 96-hour fortnight, apart from everything else, calls for a 20 to 30 per cent, increase in establishment. That is according to the report of the Departmental Committee.

To sum up, whereas the 9,000 entrants a year now sitting for the final Register examination require 12,000 entrants for training, the needs which I have outlined require 20,000 entrants a year. That is another 8,000 a year, apart from the future expansion of needs. Let us consider the sources of recruitment. Four main sources come to one's mind. The first is a suggestion that by lowering the age of admission you will entice a larger number of girls to come into the profession—girls who otherwise would be fixed up elsewhere. Before the War it was considered unwise, if not indelicate from the point of view of the patient, that a nurse should be given work in the wards until she was 21 or 23—the ages differed, but 21 was the minimum. Now such is the reduction made, that 18 is the age generally considered as a minimum for entering the wards, and in fever hospitals and children's hospitals many have reduced the age to 17 and even less. The Departmental Committee considered that the age of 19 was the minimum desirable, but that in present circumstances it might be reduced to 18, and even in exceptional cases, under special rules and regulations, to 17 years for fever hospitals and children's wards. Do not let us forget the harrowing experience that may come to a girl of very sympathetic disposition at the age of 17 or 18 when she goes into a children's ward and is face to face with the questions of life and death and human suffering.

The second source of recruits is the secondary schools. It is the ideal source in general for the higher standard of nursing at which we aim, but the total output of the State-aided and other secondary schools is something like 46,000 a year, of whom some 12,000 stay on to the age of 17. Therefore, we cannot possibly supply the 12,000 a year now required, still less 20,000 a year. A large proportion of those girls are inclined to go elsewhere. The secondary schools may produce a larger source of supply when we improve conditions, but even then they will not be able to supply anything like the large number required. Then we come to the third source, which is the elementary shools. Now, under the Hadow scheme, with the senior schools, we have a large supply of girls leaving school up to the age of 15—something like 280,000 a year. They are classified into three grades. The highest grade is that which provides girls suitable for recruitment for the nursing service. The Departmental Committee, after hearing much evidence on the matter, recognised that the second grade may also supply girls of suitable experience and training to qualify, even if we leave out the third grade as being rather unsuitable.

But the question is, how to fill the gap between the age of 15, when the girls leave school, and that of 18 or 19 when they may enter the ward and how far are examinations and training a deterrent? I think everybody recognises the necessity of examinations and training, although they require modification from time to time. Let me recite the course of examination and training required. The course for fever nurses is two years, and for other nurses three years at a complete training school, or four years at an affiliated training school. The minimum age for the final examination is 20 in the case of fever nurses, and 21 in the case of other nurses. The examinations are a series of hurdles which they have to leap. The first hurdle is their acceptance at a recognised training school and a test examination, or the school certificate in lieu. To ensure the minimum standard two papers are set, one in English and general knowledge and another in arithmetic. The arithmetic is extremely necessary for those who have to read doctors' prescriptions and for other requirements of the nursing service. Some modification of the examination is suggested by the Departmental Committee. In most cases the test examination is found to be unnecessary, because the suitability or otherwise of the candidate on those particular matters will be found out in the course of the later training.

The second hurdle is the Preliminary State Examination. This is divided into two parts. The first part deals with anatomy, physiology and hygiene. Courses are being arranged, and I hope will be arranged to an increasing extent, under the local authorities, so that girls can take them before the time at which they would start work in the hospitals. The pre-nursing course, I may say, is particularly important for filling the gap after the elementary school girl leaves school. She cannot devote herself to whole-time study in anatomy and hygiene as required, and the Departmental Committee proposed a greater use of technical institutes for evening classes, so that while the girl is earning her living in other ways she can study these subjects in her spare time. The second part of the preliminary examination is the material practice of nursing, which is given her by the sisters in the wards while she is doing her hospital work. Those responsible for administration must try to avoid giving the rather wearying instruction to tired nurses after a hard day's work. The third, and more important hurdle, is the final examination, of which there has been much criticism. The Departmental Committee are deferring their suggestions with regard to this examination The main criticism is that many women who are entirely suited to nursing, not merely because of their kindness of heart and devotion to duty but in respect of intelligence also, cannot pass an examination, so that the examinations in themselves are keeping out women who are quite capable of doing the work of nursing. My own wife, for instance, after going through the A.R.P. course and being, as I know, a very good nurse up to a point, is confident she cannot face the examination, and has come up to town to avoid it. I am not myself dealing with the question of assistant nurses. That will be referred to by my hon. and gallant Friend who is to second the Amendment.

I come to the question of conditions of service, which has aroused such intense interest in the community. In general, I may say that many statements that have been made in the Press and elsewhere are exaggerated or quite unjustified. Great improvements have taken place in the last few years in nurses' conditions, their food and their hours of duty, especially in some of the bigger hospitals. But in many of them conditions remain which require to be improved: first, in the interests of good nursing; second, in the individual interests of the nurses; and third, as a means of dealing with the problem of recruiting. There is clear evidence that, together with the poor financial prospects, the long hours of work are the chief factor in that problem. The result is chronic tiredness, which is bad both for the health of the nurses and for the patients. The Departmental Committee say that the nurses are suffering under a strain which cannot be paralleled in any other profession. This affects all grades, from the matron down to the first-year probationer. Most hospitals are trying to reduce hours, but are handicapped by the shortage of recruits. So we have a vicious circle: until the hours are reduced there will not be enough recruits, and until there are more recruits it will be impossible to reduce hours. We have to break that vicious circle.

The present practice is for nurses to work something like 13 hours a day. Beginning at seven o'clock in the morning and working until eight o'clock in the evening is common; although it is also a common practice to allow two hours off in the afternoon and one hour off for meals, bringing the total on duty down to 10 hours. There is now a demand for a 96-hour fortnight. That would be a pretty heavy tax in itself, but it is the utmost improvement we can look for. That is exclusive of meals, but must include compulsory lectures, which are quite as hard work as the other work. How can this limitation be achieved? The nursing profession, almost without exception, is opposed to its imposition by Statute. The improvement must be gradual. It is quite true that the bigger hospitals and the local authorities can be expected to reduce their hours to that limit within the next few years, but, if so, they will do it at the expense of the smaller provincial hospitals, which are unable at present to make that limitation. In that case the big hospitals will attract the nurses, and we have to look after the smaller hospitals as well as the bigger ones in asking for our reforms.

It would be better than having a statutory limitation of hours to do it through the method of grants, and to say that grants from whatever source should be conditional on reasonable hours being worked by the nurses. Another way would be to relieve nurses of domestic work through the greater use of ward-maids and orderlies. Then there is the question of off-duty periods, which are as essential to nurses as a shorter day's work, and proper notice of such off-duty periods should be given to them beforehand. With regard to annual holidays, the Departmental Committee report that the least holiday which should be considered is four weeks for all grades, of which two, and if possible three, weeks should be consecutive. I am not going to give instances, but there are many which I could give, of nurses' conditions, which would be very harrowing.

I come to the second matter which is of immense importance—that is, salaries and pensions. However philanthropic a young woman may be in choosing her profession, her parents are often driven, naturally enough, to consider the prospects if the girl does not do so herself. There is the question of competition, especially when it is the case of parents of girls from elementary, schools, in respect of better-paid openings in private life, the expansion of women's employment in education, industry and the professions, and not the least in my own profession of medicine, which has drawn off a certain number of girls who, I believe, in the end, would have been better suited for the nursing profession than the medical profession. Therefore, in view of this competition, it is very necessary to consider financial prospects. It is because it is so necessary to dangle financial prospects before the recruits that we have the system of proportionately higher salaries being paid to the younger nurses. It is shown in the report that many probationers up to the age of 23 at present receive a salary as high as that of a certificated teacher. But nurses as a class especially considering the responsibility of their work, are badly underpaid, notwithstanding board and lodging and emoluments. Nursing is the only profession in which the principle of the maximum salary being more important than the minimum is ignored. The salaries of nurses require revision, especially in the higher grades. Statistics in regard to this matter are being prepared for the final report of the Departmental Committee, so that we need not go into them in a general review this afternoon. The position of salaries and pensions is unsatisfactory. The important matter of interchangeable pensions I leave to my Seconder.

It must be remembered that local authorities and voluntary hospitals are competing at present for recruits, and therefore there is need for the question of recruitment to be considered on a national basis. It is proposed that there should be a central system of recruitment, and anything in that direction would be of advantage. The position is very analogous in many ways to that of the teaching profession 20 years ago. Many of us will remember the problem that was then before this House and outside. How was that met? It was met by the establishment of the Burnham Committees, and it is suggested that a similar organisation should be provided to deal with the question of the salaries of nurses. It is necessary to begin by holding conferences between employers and employed, and I ask the Minister of Health to give us an assurance that he will take the initiative in order that conferences may be held with a view to the establishment of some such committee or organisation.

The third disadvantage that must be remedied is that of the accommodation provided for nurses. Accommodation has been much improved in recent years at very great expense, but still it is often far short of the minimum requirement, which is, a bedroom for each nurse, properly heated and lighted, bathroom and w.c. for every six nurses, good dining-room for the serving of hot meals, a recreation room, and at least one room for the entertainment of friends; also in training schools, the provision of proper class and study rooms. There are many instances, I am glad to say, of good hostels where nurses can secure satisfactory living accommodation out of the hospital atmosphere itself. Another suggestion that requires a great deal of forethought is that of allowing nurses to live out, which is very essential in some cases, particularly perhaps with regard to a widowed mother able to look after her daughter at home, thus enabling the daughter to attend to her work in hospital quite well. Some of the senior nurses, similarly, might be allowed to live in private life away from the hospital atmosphere. Obviously, very careful regulations would have to be made in order that the efficiency of the work in hospital should not suffer. The fourth disadvantage relates to the question of discipline and restrictions necessary for the efficiency of the hos- pitals, but which may be unreasonable, and, in many cases, are unreasonable. They have a deplorable effect upon recruiting, especially when magnified, as is often the case. The report sums up the position very well that where sense of freedom is retained, loyalty can be relied on more truly than under a system of irritating restraints. The new rules of the London County Council hospitals are an example of enlightened reform, and the establishment of nurses' councils corresponding to Whitley Councils, representing the staff on one side and the governors or local authority on the other, is recommended in every hospital.

There are other points with which I have not time to deal to-day. There is the question of pensions, the health of nurses, their food, recreation, social life, all of which are important, and comprehensive statements and detailed working-out of suggestions have been left to be dealt with by the Departmental Committee in their final report. Therefore, we can deal only with generalities at the present time. Enough has been said, however, to show the urgent need for improved conditions and increased recruitment. Fully qualified and efficient nurses are too precious to be wasted in doing certain duties which, under proper supervision, can be done by others, and I repeat that the essential need is to have a properly controlled, qualified and ordered system of assistant nurses, which, if not controlled and limited, will be liable to abuses. There is the question of the monopoly of title, uniform practice, as in the case of midwives under the Midwives Acts, and of dentists, but not of doctors. The question of monopoly of practice has to be considered. It has not yet been reported upon by the Departmental Committee.

These requirements, if the House agrees, as I hope it will, will necessitate the expenditure of money, but we cannot to-day deal with the question of how the money is to be found. The question of education and block grants to local authorities, and increased voluntary efforts, will have to be considered later on, but I ask the Members of the House to show, by accepting this Resolution, their recognition of these needs. I am sure that we all recognise the great debt of the country and of the nursing profession to the General Nursing Council that has, with admirable statesmanship, steered the nursing profession into a homogeneous whole in its early days of State recognition. We all recognise the splendid devotion to duty and the self-sacrifice and loyalty of the nursing profession. They are the inheritors of a great tradition. We have traded too long on their good will, and it is our duty, our interest, desire and determination to give them the conditions essential for their service under the changed conditions of to-day.

4.40 p.m.

Colonel Ponsonby

I beg to second the Amendment.

I am sure that all Members of the House will be grateful to my hon. Friend the Member for St. Albans (Sir F. Fremantle) for having introduced this subject. He has great knowledge of it, and he is also a member of the Departmental Committee. I remember some time ago asking a Master of Hounds what he could tell me about scent, a very difficult subject. He replied "Je ne connais pas la Rose, mais ĵai vécu près ďelle." I am rather in the same position compared with my hon. Friend. I have not the great knowledge that he has of this subject, but I have lived near it as I have been a member of the London Hospital House Committee for the last 13 years.

Mr. Tomlinson

Will the hon. and gallant Gentleman please translate?

Colonel Ponsonby

"I do not know the rose, but I have lived near it." It has been suggested that as this report is only an interim report, this Debate is unnecessary to-day, but I feel that the Committee would not have published an interim report if they did not think that the matter was vital and urgent. It is equally obvious that a Debate on this subject to-day is vital and well timed. Perhaps I can say what my hon. Friend could not say, and that is how much we welcome this report. It is one of great interest and is most interesting to read, and perhaps I may be allowed to congratulate the hon. Lady the Member for Anglesey (Miss Lloyd George) and the hon. Member for Westhoughton (Mr. Rhys Davies), who is not here, on also being Members of the Committee who have produced what is really a new chapter in nursing history. Those of us who know about hospitals are agreed that there has been a gradual improvement in conditions, but there is still a great deal to be done.

My hon. Friend referred to the agitation which was, to some extent, the origin of the appointment of this Committee. I am glad to see that the Committee state that, as regards the agitations which started the whole subject, they are satisfied that statements made in the Press and elsewhere contained exaggerations and unjustified generalisations, which have had a deplorable effect on recruitment, and that important reforms have been carried out in many of the larger hospitals in recent years It is true, as my hon. Friend stated, that there is a shortage of nurses, but that shortage is largely due to the increase in the demand. As the report says: Twice as many nurses were admitted to the Register in 1937 as in 1926, and the real shortage is due to the fact that the demand has far outpaced supply I will not repeat again the reasons given by my hon. Friend, but there was one which he did not touch upon, namely, that the shortage was partly due to the rise and fall of the economic barometer. If one looks at the figures from 1926 to 1931 and compare them with the figures from 1931 to 1934, it will be seen that, in times of moderate prosperity, the number of applicants for the profession fall off and in times of adversity they improve. The Committee have recommended a number of changes in conditions, and I would only say in regard to the conditions that those who are interested in the recruitment of nurses may emphasise too much the question of conditions, important though they may be. They are being improved and will be improved still more. I heard recently of a lady of eminence in the nursing profession who went to lecture to the girls at Roedean College. She laid a certain amount of emphasis on the improvement of conditions, on the swimming baths, on the tennis courts, improved food, and so on, but the girls said: "We want to know about patients and how to nurse them"

The Committee recommend various changes, but I only wish to deal with one matter referred to by my hon. Friend, and that is the question of shortage and how it would affect hospitals, financially and otherwise. I will give the House one case to illustrate the effect which an improvement in working hours would have on one hospital. In the London Hospital at the end of December there were 490 nurses working, apart from the private nurses. The hours of day duty for those nurses average 105 hours per fortnight. It is suggested by the Committee, and I think it is agreed all round, that as soon as feasible the hours should be reduced to 96 hours per fortnight. In this particular hospital that change would necessitate five extra staff nurses, 10 four-year nurses on ward duty and 90 probationers, spread over four years. That would eventually mean 105 extra nurses. The cost, assuming that salaries remain as they are and the cost of food and maintenance remain as at present, would be about£11,500. That is entirely apart from the provision of the extra accommodation that would be necessary.

If all hospitals in the same or worse position have a 20 per cent. increase in their nursing staff, it is obvious that it will hit them very much financially. The extra cost would fall on the grateful and generous supporters, rich and poor, of the voluntary hospitals, and in the case of the municipal hospitals it would be extracted from unwilling ratepayers, rich and poor. It is impossible to do all this at once. First the shortage would have to be made up. It would be necessary to train the additional staff, and then there comes the question of expense. It must be remembered, as my hon. Friend mentioned, that the case of the smaller hospitals is different from that of the large hospitals. That particularly applies to buildings because in the case of many small hospitals there is probably no room for expansion.

I will now deal with the two points which my hon. Friend omitted from his interesting speech and left to me. The question of the interchangeability of pensions and the question of assistant nurses. I think we are all agreed with the report of the committee that we want a universal nursing service, if we can get it, at home, in the Colonies and, if possible, in the Empire. It is essential to make the nursing service homogenous but, unfortunately, when we consider the subject we find that it is the question of the interchangeability of pensions which interferes with this ideal. The committee say: We agree that nursing should be pensionable service and that pensions should, if possible, be universal. It has been brought to our notice, however, by all our witnesses that the variation in conditions under which nurses qualify for pensions in voluntary hospitals and in the municipal nursing services is one of the great stumbling blocks in the way of attaining that most desirable end, the making of the nursing service a homogeneous one. We are also informed that pension difficulties handicap the free transfer of nurses to and from the services There are at present two schemes. Under the Voluntary hospitals there is a Federated Superannuation scheme for nurses, which is contributory. This has been adopted by 82 per cent. of the voluntary hospitals (reckoned by beds) and, where possible, by the Ministry of Pensions for its nurses, the Office of Works and the Admiralty; by 700 county and district nursing associations in Great Britain and the Colonies and by the Colonial Office, and some Colonial Governments all of whom undertake to keep the members of the scheme in full benefit while employed. This scheme is welcomed by the nursing service and could be made of world-wide application. In connection with the municipal hospitals, however, the superannuation is under the Local Government Superannuation Act, 1922, or in the case of asylums under the Asylum Officers Superannuation Act. If any hon. Member likes to study the subject closely I could not do better than refer him to the excellent memorandum on the subject by a Government official at the end of the Departmental Committee's report.

The result of the difference between the superannuation arrangements between municipal and voluntary hospitals is that there is no free transfer between the two. The nurse who transfers from a municipal hospital to a voluntary hospital loses her pension rights, except the return of her contributions. A nurse from a voluntary hospital going to a municipal hospital can carry her paid-up policy, representing the contributions paid to the date of her transfer. That is not satisfactory. The whole position is held up mainly by this difficulty. Therefore, I am glad that in their report the committee say: Pensions for nurses should as far as possible be universal, and interchangeable between all branches of the service, and we recommend that discussion should take place between the parties interested, without delay, in order to effect the mobility of transfer between one type of service and another If the nursing service is to be national it is essential that the superannuation scheme should be national also. It might mean that actuaries and accountants could sit down and weld the two schemes together, but they are extremely complicated, and I am afraid that that might be almost a superhuman task. I wonder whether it would be possible for the local authorities to adopt the federated superannuation scheme, based on insurance. I understand that there would be very little extra cost, and it would be of great benefit to the nursing service at large. We have to aim at the big idea, which is to remove the obstacles to nursing as an essential national and homogeneous service. I believe the subject was discussed when the Middlesex County Council (General Powers) Bill was brought forward in 1928, but an agreed clause was withdrawn on the ground that the matter was being referred to an Inter-Departmental Committee of the Ministry of Health. I would ask the Minister of Health what is the present position about that?

I now come to the more controversial subject of assistant nurses. Under the Nurses Registration Act, 1919, nurses are registered with the General Nursing Council at a fee of 2s. per annum. They are State registered nurses. There are, however, a very large number of assistant nurses in the country who are not registered in anyway. Many of these assistant nurses are helpful, well trained, valuable and devoted, competent for hospital or domiciliary nursing; but there are others completely untrained, unregulated and unsuited for hospital or domiciliary nursing. These nurses receive fees of perhaps two and a half to three guineas a week, of which I2½per cent. goes to the co-operation or agency which employs them. I have received particulars of a number of extraordinary cases of these assistant nurses who call themselves nurses. I will quote a few cases. At a meeting at the Caxton Hall, on 26th March, the story was told how the matron of a hospital was rung up and informed that a patient was being nursed by one who claimed to come from her hospital, and who was a terrible woman. She turned out to be a woman who had been three months in the hospital and had been sent away as untruthful and unreliable. In another case a nurse was sent by a co-operation to a municipal hospital. She was found to be only 17 years of age, and she said that she had had six months' training. When complaints were made of her age and inefficiency the matron was told that the girl was a very willing worker and useful for cleaning. In another case a female attendant at an institution left because she was pregnant, and generally unsatisfactory. She came back again later, from a co-operation as an assistant nurse.

As long as these assistant nurses are working under a matron in a hospital, they may to some extent be supervised, but I need hardly point out how dangerous they are in private nursing, when often they are solely responsible for the treatment ordered. In many cases they are a menace to matrons, to wards and to patients. They are on no roll, they are unregulated, they are unqualified, and yet they are nursing for gain. Something ought to be done about this. Some protection ought to be given to the State registered nurses and the public. These unqualified and untrained women bring nursing into disrepute and they may risk the lives of their patients. It has been suggested that there should be a special roll for these assistant nurses, perhaps under the General Nursing Council, quite different from the State register for trained nurses, that they should have two years' training, theoretical or practical, and that possibly they should be described by another name. There is a certain amount of controversy about this. It is suggested that they might be called approved invalid attendants or nursing orderlies. It does not much matter about the name because as between the patient and the woman she would still be the nurse, but for the protection of the public a change of name would be advisable.

It is also suggested that they might have a special badge to distinguish them from State registered nurses. After all, midwives are registered so why should not assistant nurses be registered? I see no reason why there should be any objection on the part of State registered nurses to such a proposal, because assistant nurses would be on a different roll; they would have to qualify by a two years' training and the proposal would avoid bringing the nursing profession into disrepute. As a subsidiary suggestion the matter could be attacked through the Nurses Co-operations. There are I believe at least 700 of them in the country. Some are good and take considerable trouble to see that they have only nurses who are well qualified on their books; and they are prepared to show the qualifications of their nurses to their clients. Others are not so good; they are uncontrolled and unregulated. I believe that some local authorities have by-laws which allow for their inspection, but this is by no means universal, and it seems to me that local authorities should have power to license and register and inspect all these agencies just as they have the power to license and inspect nursing homes.

A Bill is going through the House in connection with sharepushing, to stop the pushing of shares by illegitimate means. That Bill is not objected to in the least by the genuine investment broker and by banks and the like, and I do not see why something on the same lines should not be done to control the foisting on to the public of untrained, unqualified nurses. I should like to emphasise that this matter requires tackling without delay. Owing to the present emergency many girls who are trained as nursing auxiliaries will be available, and they will have done a little nursing and be able to pose as assistant nurses. But I will leave that matter to be dealt with by the Minister of Health.

As I have said, the report is exceedingly valuable, and it may be impossible to implement it all at once. Some of the alterations suggested may be carried out by arrangement; others may require legislation. The Minister of Health was at one time Minister of Agriculture and I suggest that he should follow the precedent now being established in regard to agriculture whereby before legislation the Government consult the National Fanners' Union. I hope that when legislation regarding nursing takes place the Government will consult the General Nursing Council, the College of Nursing and other bodies who are fully conversant with the subject, so that agreed legislation may be brought before the House. But whether it is by legislation or by arrangement, it is essential that many of the recommendations in the report should be carried out. There would be no greater benefit to the nation than that this essential national service should be placed on a secure and sound foundation for the future.

5.11 p.m.

Mr. Frankel

It is as well that this subject should be raised in the House this afternoon in view of the fact that in the last few years increasing attention has been paid by the public to the nursing question. That interest comes at the moment from quarters which were deaf and blind on the subject only a few years ago. Many of us have been trying to direct public attention to the importance of improving the conditions of nurses in our great municipal and voluntary hospitals. I am proud to say that I was a member of a local authority which controlled three public hospitals, which introduced a 96-hour fortnight in 1927. There are other authorities in this country which at that time, or about that time, also introduced improved conditions from the point of view of working hours, salaries and emoluments. We have gone a long distance since then, and especially during the last few years greater attention has been concentrated upon the question of nurses, for more than one reason.

I believe that the shortage of nurses is due to more than one cause. It is not only a question of the conditions, or the salary or the amenities. One has to recognise the change that has taken place in the desire of women to become nurses since the War. I can speak with some authority, because I am partly responsible for the London County Council nursing service. Our experience at County Hall has been that there is no shortage materially of probationers, no shortage materially of those who wish to enter the service. As a matter of fact, in the last year the number of probationers wishing to enter the service outnumbered three or four times the number which the county council required. The real shortage is in trained staff. Our experience has been that after they have been trained for four years and become staff nurses many of them have left our service, and we have to ask ourselves why nurses who are adequately trained and who have become staff nurses, and may probably become sisters and assistant matrons, should want to leave our service.

There is more than one reason. It is at that point I believe that the problem has to be met. We have to consider whether the amenities which are given and the salaries which are paid are good enough to keep them in the service. At this point I should like to say a word as to the nurses co-operation and nursing agencies. It is a lamentable fact, but our experience is that after leaving us they come back a few weeks later from the agencies at four guineas per week, and this runs the public authority into many thousands of pounds extra cost during the year. Without stressing it too much I want to say to the Minister that it seems that the question of these so-called nurses co-operations will have to be carefully looked into. Some of them may be very good, but I have some doubts about others. I have a suspicion that some of them exist only for two reasons, some to exploit the nurses and some to exploit the public. I do not say that about any but the minority, but I think the matter should be carefully looked into. I am sure the House will forgive me if in what I say I deal mainly with those matters of which I have a personal knowledge rather than the general question as it affects the country. I think I can speak with a little authority for London. We have tackled the question of amenities in no uncertain way. Some of the things may be considered small and unimportant, but they are not small and unimportant to the nurses.

There is the question of freedom during time off. We have the spectacle still in London, and also in many parts of the country, of sisters and staff nurses having to go, I do not say cap in hand but poke-bonnet in hand, nurses with mature experience, to ask to be allowed on two nights of the week to stay out until 11 o'clock at night. That is really farcical in the case of trained and responsible nurses. It is one of the things complained of by the nursing staffs, and I am glad to say that the authority on the other side of the river, as well as many other authorities, have abolished that sort of thing altogether. In my view the London County Council were wise in deciding that all trained staff should be able to use their own discretion as to when they returned to the hospital in their night's off-time. It was an experiment which was started last year and, as I expected, I am glad to say that it has not been abused; it has worked very well. The nurses realise the importance of the work they are doing and respond very well to the trust we are placing in them. The only people on whom we place any restrictions are the one, two and three-year probationers. In their case we, like other authorities which employ them, recognise that we are, in fact, for the time being acting as their guardians. They come from many parts of the country to the district in which they work, and in many cases have no friends or relatives.

Having stressed the point that the shortage of nurses is not among the probationers I think we must examine why it is that higher up in the scale we are losing considerable numbers of staff. Here the question of non-residence or residence must arise. This is a subject upon which the Inter-Departmental Committee have not yet reported, although I presume they will report upon it in their final report. It is a question on which, perhaps, I do not hold the same views as a good many hon. Members. I still favour residential service. I know that it is now supposed to be unpopular with modern girls, as interfering with their rights of freedom, but I think that is a difficulty which can be overcome. I believe the reason for the dislike of residence is not only that the nurses are disciplined in the hospital, but also in their own nurses' club, that they are still under hospital control in their leisure time in the nurses' home, and also that in many cases the nurses' home is completely unattractive and undesirable in every way, from the point of view of accommodation and the possibilities of recreation.

It would be very unwise of me to suggest that the authority with which I am connected has solved all these problems, but we are attempting to do so, and in some hospitals I believe we have succeeded. Recently, we have tried an experiment in one of our greatest hospitals in London, where a new nurses' home has been built. That home is not under the control of the hospital, but under the control of the nurses who live in it, through a specially appointed warden and assistant warden, who run the home with the help of a committee of nurses of every grade, from probationers to sisters. I am hoping for the success of that scheme, because I believe that if there is an improvement in nurses' conditions in the hospitals and in the nurses' homes, together with possibilities of recreation and of being able to ask friends to come and see them, and proper facilities of that sort, in the long run that will be an answer to non-residence, and will prove to be more attractive to the nurses than living out. I could tell the House of a good many instances that have been brought officially to my notice of the conditions in which nurses live in non-residence. I hesitate to raise the question whether or not women look after them selves well enough when living in rooms—I am terrified of saying more than one or two words on that subject—but it has been brought to my notice officially that in one case three sisters were living in one room in non-residence, and evidence has also been brought before me of non-resident nurses who have not been properly fed as a result of their living out of the hospital. I think it will be generally recognised that this applies not only to nurses, for it is common talk that where people live away from a hostel or home—

Mrs. Tate

Does not the hon. Gentleman know that when women are paid adequately they will eat adequately, and that while they are underpaid, they are likely to spend money on things which amuse them more than food? That is the answer.

Mr. Frankel

I entirely agree with the hon. Lady, but that does not improve my opinion of those ladies who spend money on things that amuse them rather than on food. I believe that from the point of view of the patients, every hospital has a right to make sure that the nurses shall be fit and capable to do their work, and it seems to me that the only way a hospital can be sure of that is by making certain that the nurses are provided at least with good meals, and have proper medical supervision. I believe that can be done better by residence than by non-residence. After a fairly long study of the subject, I feel that, even with improved conditions and improved salaries for nurses, one can never make a good nurse of a person who really has not a calling for the work. If one grants that it is necessary to have some calling for the work, I feel that such a nurse will want to identify herself with the hospital and its work.

The question of money has been mentioned by the hon. Member for St. Albans (Sir F. Fremantle). I want to say a few words on that subject on behalf of local authorities all over the country. The time must come when the House will have to stop placing further burdens on the local authorities by law, which are not met in some way by Government grants. We have had experience of that sort of thing more than ever during the last few years. As far as the London County Council are concerned, they have anticipated the report of the Inter-Departmental Committee. A year ago they introduced the 48-hour week or the 96-hour fortnight. This has involved considerable extra expense, for which the council do not get one penny of grant. I know that the Minister of Health will say that that is taken into account in the block grant, but my experience of that proves what I have said, that we do not get a penny for it. Therefore, while I am glad that this Debate is taking place and that public opinion is being focused on the nursing profession, I would like to say that there are local authorities which understand the difficulties and are trying to meet them, and we hope that the Government will help us in the work we are proposing to do.

5.23 p.m.

Miss Lloyd George

I feel diffident in intervening in this Debate after the speeches of the Mover and Seconder of the Amendment, and the hon. Member for Mile End (Mr. Frankel), who has had practical experience of these matters on a local authority. The hon. Member for St. Albans (Sir F. Fremantle) spoke with authority and experience on these matters, as a medical officer of health, a doctor and a member of the Inter-Departmental Committee; but I can say, with the hon. and gallant Member for Sevenoaks (Colonel Ponsonby), who seconded the Amendment, that I, too, have lived near the rose during the last two or three months, as a lay member of the Inter-Departmental Committee, and in that capacity I would like to make one or two general observations.

In the first place, although this is an interim report, it seems to me that the main facts have been established and the main conclusions reached. I stress that because I hope the Minister will not even await the publication of the full report before he implements some of the recommendations to which the committee already have unanimously agreed. The situation is a very serious one. Hon. Members who have spoken so far have gone into the question of the acute shortage of nurses. We have heard of a shortage in the London County Council and other county hospitals, and we know that it exists in hospitals all over the country. That is the position in peace time, but it takes no account of the very grave situation which might arise in the event of an emergency. The other day, in a Debate on air-raid precautions, the Minister of Health said: As to nurses, I agree that there is an urgent need. Eighty thousand are available, but it may be that three times that number will be required before the war is over"— [OFFICIAL REPORT, 5th April, 190; col. 2878, Vol. 345.] I do not know whether the right hon. Gentleman was referring to State-registered nurses, or whether he included in that number the auxiliary register of nurses, of which he spoke; but I should have thought that, in the main, he included in the number the State-registered nurses. This shows the serious situation which might arise in an emergency. The report reveals how very serious is the situation. It is a national problem which must be tackled without delay. The hon. Member for Mile End mentioned some of the restrictions that are imposed upon nurses. There is no doubt that the committee—and the hon. Member for St. Albans will confirm me in this—received evidence which went to show that there are conditions still existing in hospitals which would not be tolerated in most occupations open to educated women. I will quote only one example—which no doubt will be familiar to hon. Members who have read the report—of the kind of atmosphere that is sometimes created in a hospital. It is evidence given by a nurse who had an excellent report both from her headmistress and the matron of the training school, so that there can be no suggestion that she was a failure, and an inefficient nurse with a grudge. She said: I was told the first day I entered hospital that I must regard it as the Army, matron as the commander-in-chief, the sisters as officers, the staff nurses as non-commissioned officers, and the probationers as privates. This military atmosphere created in me a strong feeling of fear of my seniors which I think accounts for the dislike of sisters shown by many nurses No one would suggest that is universally the case in hospitals, but that it does exist in some is certainly a fact. The committee was also told of late leave being cancelled because the probationer was three minutes late for breakfast. I wonder how many of us would survive that test? There is no doubt that in no profession is discipline more vital than it is in the nursing profession, but there is a world of difference between discipline and irksome and irritating restrictions. I am convinced, as anyone who heard the evidence must be convinced, that these restrictions act as a definite deterrent. Other very valuable evidence was given on this point, which I think should be quoted as showing how different is the spirit in most of the schools in the country from the spirit prevailing in some of the hospitals. It was evidence given by the Association of Headmistresses. They said: Many hospitals appear to give too little consideration to the trend of modern psychology and modern training, and fail to recognise that young people to-day will often loyally adhere to principles, the reasonableness of which has been proved, while they are goaded into rebellion by prohibitions for which they can see no good reason, and which suggest merely a too tyrannical authority That is a maxim which might well be adopted not only in schools and hospitals, but sometimes in political parties as well. [Interruption]I am sure hon. Members would never accuse me of meaning the party above the Gangway. The London County Council has introduced new rules which seemed to the committee to be eminently reasonable and might well be copied by other employers of nurses. I would ask the Minister whether he is prepared to circulate either that set of rules or any other set of rules which he may, after consultation, consider to be better, to the hospitals as suggestions? It is true that nineteenth century restrictions deter twentieth century girls from joining the profession, but, on the whole the restrictions form but a small part of the problem. I believe the two principal factors to be long hours and low salaries. Dame Agnes Hunt, in her very remarkable autobiography, tells us that when she first became a probationer many years ago the hours in her hospital were from 8 a.m. to 8 p.m. with two hours off every other day—if they were lucky. Those are conditions which she quotes as belonging to a past which is long past, but, as a matter of fact, although there has been an improvement, it is staggering to find how small that improvement has been. As a lay member of the committee who had, I am ashamed to say known very little about these conditions previously, the one thing which struck me most forcibly was the scandalously long hours which nurses are expected to work. I quote one section of the report upon that point. The committee say: We have reason to believe that at the moment 9 to 10 hours' on duty' per day for at least six days of the week is not uncommon in hospitals, although there are many which have reduced their hours below this figure and some in which the nurses work considerably longer That there should be any hospital at this time in which more than nine or ten hours per day are worked is really a scandal. There are not many of them, but that there should be any at all is, as I say, a scandal and ought to be put right. No doubt things have improved, but when we consider the enormous improvement which there has been in hours of work in other trades and professions, the improvement in the nursing profession is seen to be very slow indeed. Nursing is work which puts a heavier physical and nervous strain on the individual than the work of most other professions, and therefore it is little wonder that nurses suffer from chronic over-tiredness. This chronic over-tiredness affects every grade in the profession from the probationer up to the matron. They are all overworked from the highest to the lowest. Recommendations have been made in the report that a 96-hour fortnight should be introduced as soon as possible in all hospitals. That is a very proper recommendation, and it is most urgent to see that it does not remain a recommendation but is carried into effect.

Stress was laid by many witnesses on the progress already made, and it was pointed out that the principle of the 96-hour fortnight had been adopted in the London County Council hospitals. I do not know, however, in how many of them it is being carried out and I think that, as regards the actual reduction of hours, progress generally is exceedingly and painfully slow. The report recognises that there may be, and probably will be, a great many instances in which hospitals may be reluctant or unable to carry out these recommendations. It has, therefore, been decided that the public grants which are to be given to the hospitals towards the carrying out of these reforms should be used to coerce the: hospitals into carrying out the reforms. I am not clear in my mind how that will work or whether it will work at all.

Take, for example, the case of a small hospital which has very poor resources and is unable to reduce hours of work. What is to be the position of the Ministry of Health? Is the Ministry to refuse the grant which would be necessary in order to make it possible for that hospital to pay increased salaries to the nurses who are already upon its register? It seems to me that would be an impossible position to take up. But if the Ministry do not take that position, then they have no coercive power left and this proposal becomes a dead letter. It was for this reason that five members of the committee put in a note of reservation in which they said that they did not think it would be possible to reduce the hours without legislation. I realise that that is a subject which cannot be discussed to-day. All I say is that I am sure that the coercive power suggested in the report will not make it possible to carry out the recommendations within a reasonable time. If we are ready to wait until the end of the century, perhaps we may get this reform in the majority of hospitals then, but if we want to see it done now, it is only possible, I think, by legislation.

The second factor to which I would refer is that of salaries. This question has already been dealt with by several hon. Members. In this connection I hope the Minister will, as soon as possible, set up a salaries committee representative of nurses and employers as suggested in the report. This committee, it is suggested, should be established to negotiate standards of salaries which would approximate to those appertaining to other comparable spheres of employment. With regard to the suggested grants, these indicate a new departure. It has been recognised by the Committee that these reforms, which are vitally necessary, can only be carried out with the assistance of public money and this, it is also recognised, would involve a measure of public control. I hope this may be the beginning of a new relationship between the hospitals and the State. Speaking for myself, I may say that the more evidence I heard upon this matter, the more convinced I became that the hospitals cannot be run efficiently—I mean this only in a financial sense; I make no other suggestion—on a voluntary basis.

An hon. Member above the Gangway said he did not think it right or proper that at this time further burdens should be put on the local authorities. The report recommends that grants should be given to voluntary hospitals, but there was a feeling—and some of us signed a reservation to that effect—that the position of the local authorities and the burdens imposed upon them, would be intolerable if they were expected to carry out these very large and expensive improvements. Therefore, it seems vital that the National Exchequer should bear either the whole or part of the additional financial burden. That would only be equitable. May I again urge the Minister to put the recommendation of the report into effect as soon as possible, and not to await the publication of the full report? This is a matter of vital national importance, and it is none the less so because it has been neglected for so long. It has been said to-day that no profession in the country has a finer tradition than the nursing profession. I am sure we must all deplore the conditions which have been revealed in this report, and I believe support will come from all parts of the House for the proposition embodied in this Amendment. I only hope that that support will be followed by swift action on the part of the Government.

5.42 p.m.

Mrs. Tate

As the hon. Lady the Member for Anglesey (Miss Lloyd George) has said, this matter is one of real urgency. In this report, and in every speech which has been made this afternoon, we have had presented a most unsatisfactory picture. From the point of view of the nurse we have had a picture of over-work, inadequate food, a life hedged in by petty restrictions, bad attention to health and— one aspect which has not, I think, been sufficiently stressed—a very poor prospect at the end of a long and arduous training. The hon. Member for Mile End (Mr. Frankel) spoke of the improvements which had been made by the London County Council, and I would like to add my tribute to that body for what has been done, in improving conditions for nurses. But I cannot agree with all he said. The hon. Member spoke very strongly in favour of residence in the hospital for trained staff, and said that he desired this on the ground that women who lived on their own outside the hospital, would not pay sufficient attention to their food, and would not be able to do their work properly or do justice to their patients as a result. I cannot believe that the hon. Member who knows a great deal about the subject can have omitted to note the reference on page 59 of the report to the question of food in hospitals. The Committee say: It is quite clear to us, however, that the quality of the catering provided by different hospitals at the present time varies within very wide limits and that in a considerable proportion of hospitals, it falls well below what may be considered a reasonable standard. I do not think that residence in hospital and getting meals there, necessarily ensures to the nurses the standard of nourishment which they ought to have.

I turn for a moment to the other side of the picture, namely, the present position of the sick. No one can suggest that either inside or outside hospital the conditions as regards the patients are satisfactory. If in the hospital the patient is nursed by a perhaps rather ill-fed, perhaps slightly dissatisfied, certainly very over-tired woman and by a staff which is constantly hampered because of shortage of numbers. Outside the hospital the conditions for patients may also be unsatisfactory. We have heard from two or three hon. Members of the conditions which prevail in some of the nursing cooperation societies which send out nurses. Many of them are admirable and their nurses are competent and fully trained, but the number of cases in which the patient has no guarantee that the nurse is either a suitable woman or is properly trained are all too frequent. It does not stop with the nursing co-operation societies. Conditions in London nursing homes which I have referred to on many occasions in this House, are equally unsatisfactory. There are many nursing homes in this country where conditions are unhygienic and where, again, the patient has no guarantee that the nurse incharge is a really trained or competent woman. I regret to say that I believe one of the reasons for conditions in the nursing profession being unsatisfactory, and for it being so underpaid a profession, is that it is a profession which has been almost entirely reserved for women. It was indeed for many years almost the only profession which was open to women.

I was very distressed to hear the hon. Member for St. Albans (Sir F. Fremantle)—he very wisely turned his back on me while he said it—say that he would like a larger number of women enter this profession, which was perhaps much more suitable to them than the medical profession. I thought it a most extraordinary remark. I do not agree with it in the very least, and I can only say that when I had the honour of representing West Willesden there were in that constituency—a very poor constituency, where the fees paid are never very high—at least three women doctors, all of whom were doing extraordinarily well, earning devoted gratitude from their patients and comparing very favourably with their male competitors. I therefore think it is curious that any hon. Member in the year 1939 should get up and say, in effect, that the nursing profession is more suitable for them and that they should leave the medical profession, with, of course, its higher emoluments and status, to that wonderful being the male.

Sir F. Fremantle

The hon. Lady did not quite pay attention. Every word that I said was very carefully chosen, and I said that many women would be better suited to nursing probably, and probably many men, whereas others are admirable members of the medical profession.

Mrs. Tate

I am glad the hon. Member thought over his words. The impression that he gave at the time was quite definitely that women were better nurses than doctors, but I am very sorry if I did not do him justice. I agree with the hon. Member for Anglesey in feeling very grave disquiet over this question of the recommendation of grants to hospitals in order to enable them to engage a larger number of nurses and, therefore, confine the hours of work to 96 in the fortnight. In my opinion, that is a dangerous suggestion, for this reason: Why should you give a grant to voluntary hospitals for this one thing? Do you not open the door to many other demands? Are you not going to say that where a hospital needs a better nurses' home, better X-ray apparatus, better theatres, it must apply for a grant? I agree with the hon. Lady, and, much as I regret it, I believe that the life of the voluntary hospital is coming to an end.

Sir F. Fremantle

Oh, no.

Mrs. Tate

The hon. Member says, "Oh, no," but there is not the smallest doubt, if you look ahead, that it will not be possible for ever to maintain satisfac- tory voluntary hospitals in this country, much as I regret it from very many points of view. I believe that if we start giving a grant in order to enable hospitals to take on a larger number of nurses, we are opening the door and making a rather invidious choice of one particular thing for which they can have a grant. I believe that you would have a larger number of women entering and remaining in the nursing profession if you had better opportunities and better pay for them when they were trained. The pay of a nurse at the present time, when she has completed her training, is wholly inadequate, considering the training which she has had to undergo and the work that she is called upon to do, and that is, in my belief, the real reason for the shortage, in addition, of course, to the restrictions placed upon nurses during training, which are, as many hon. Members have said, quite ridiculous and would not be tolerated by the other sex or in any other profession.

The suggestion that you should register assistant nurses for general nursing I believe to be one very detrimental both to the nursing profession and to the general public. It is quite true that at the present time you have unqualified women going about with the name of nurse and nursing the sick, but because you have an unsatisfactory condition of affairs today, that is no excuse for having an unsatisfactory condition of affairs in the future. I agree that many of these partly trained women are doing magnificent work and that there are very many cases, for instance, among mental defectives, in mental hospitals, among the chronic sick, also perhaps in fever hospitals, and even outside among the public, where you do not need a fully trained nurse. In that case let us have, by law, a definite type of case which may be nursed by an unqualified person, and by all means let us have salaries legally laid down, but do not introduce the dangerous principle of allowing an assistant nurse to compete with a State-registered nurse in the open market. If you do, it will inevitably mean that the very poor will go into hospitals where we hope the conditions will gradually become better and better and where they will receive good nursing; and the rich will be able to afford the State-registered nurse, who, we hope, will be a very highly qualified woman. The body of people in between—the middle class— however ill they are, will inevitably fall back on the assistant and partially trained nurse, for reasons of economy.

I do not think you will improve the status of nurses by registering untrained women, and I think it is grossly unfair to the woman who has become a State-registered nurse, who has given up many years of her life to that exceedingly arduous training, to find herself in competition with a woman who is recognised as a nurse, but who has not actually completed her training. I do not think the public will be able to differentiate between the two sufficiently clearly if you accept them both for public nursing. I would have no objection to the assistant nurse in any institution where she could be partly under the control of really trained people. I only think she is a danger, however good many of them may be, when allowed to go out and nurse people in their own homes in competition with registered nurses. I therefore very much hope that that recommendation will not be accepted by the Government in its entirety. I also hope that the Minister will take an early opportunity of improving London's nursing homes and of seeing that a sufficient number of their staff are at least fully trained women. I also hope the question of the nursing cooperative will be very carefully looked into and that where an untrained woman is sent out, both the doctor and the patient will always be informed of the fact.

I do not wish to see the age at which women enter the nursing profession lowered, but I think it might be possible to find work in hospitals for girls who are very anxious to enter the nursing profession, and who cannot quite bridge the gap between the school-leaving age and the age at which they can actually begin nursing, by some form of work in the hospitals which would greatly relieve the present staff and which might not be unsuitable work for such young people to do. In any case I feel sure that the setting-up of the committee was a very valuable and much needed step, and I sincerely hope that its recommendations, most of which all of us will agree are admirable, will be put into effect without delay. It is a tragedy that this profession should ever have been allowed to get into its present condition. I do not refer to the standard of nursing. I think it is a miracle that the number of women wishing to become nurses should be as great as it is, and I believe that the standard of nursing and the conscientiousness of our nurses is a wonderful testimony to our women. It is a matter of pride to this country that it has not deteriorated under conditions which, in many instances, are well nigh intolerable.

5.56 p.m.

Dr. Edith Summerskill

There are many Members in this House who, on looking at the Order Paper, will perhaps feel that this Amendment has very little in common with the important questions which face us during this week, but I feel that the service we are discussing is one which will be of the greatest importance in the event of any hostilities. In fact, it will be a most important branch of our Civil Defence, and I ask the Minister of Health seriously to consider putting into effect immediately at least some of the recommendations of the interim report. I feel that my colleague the hon. Member for Mile End (Mr. Frankel) made a very important statement to the House when he said that it had to be remembered that we were not in need of probationer nurses, but that we were in need of fully qualified nurses in our hospitals. In fact, the important point is—and those who are familiar with hospital work know this full well—that it is after training that the nurses decide to leave the hospitals. Therefore, what recommendations should we immediately put into effect?

I am surprised that the Seconder of the Motion said that we should not stress the conditions of nurses. He said that a friend of his had been to Roedean and had told the girls about the nursing profession, that he had told them of their salaries, of the living conditions, and of the lives they led, and that the girls had got up and said, "We don't want to hear about the conditions; we want to hear about the work." I can only suggest that those girls are supernatural. Never previously have I heard of a potential body of workers of any kind who wanted to hear only about the work and never about the conditions. I might remind the hon. Member that Roedean is not the recruiting ground for nurses. I think these young girls at Roedean, excellent children and very fortunate children, were very interested in nursing and wanted to know about the life of nurses objectively perhaps, but not subjectively, and I want to tell the hon. Member that it is because many people—and I say this very kindly—think as he does, that perhaps conditions are not all important, that they have failed to change the conditions of the nurses in the last century.

The Mover of the Amendment said that the most controllable factor, when thinking of how we should change the conditions, was that of the hours. Again I disagree. It has already been pointed out in the House that it is very difficult in many hospitals to shorten the hours because there are not sufficient nurses to take over the extra work that would ensue. I want to stress two important points which arise from the fact that we want to make conditions so attractive that our staff nurses, our fully trained nurses, will be satisfied to remain in hospital. One of the most important recommendations is that the nurses should be allowed to live out. This has already been discussed, perhaps ad nauseam, and there is some controversy about it. My hon. Friend the Member for Mile End, on the one hand, talked about fully qualified nurses as being responsible people and thought they should be allowed to come in at any time at night without feeling that there would be an inquisition on their return. I agree with him. On the other hand, however, he says that if these responsible people are allowed to live out it will be found that they are not being fed properly and, in fact, that they will not be able to find proper accommodation. On the one hand, my hon. Friend talks of these nurses as responsible women, and, on the other hand, treats them as though they were adolescents who come to London from the country and are incapable of finding proper accommodation.

Mr. Frankel

The responsibility of the nurses to which I referred exists, I believe, in every other respect except in the one I mentioned.

Dr. Summerskill

When my hon. Friend talks in this way of nurses, who are chiefly women, I hope he does not also feel that men are as incapable of finding accommodation, and that every man who is not blessed with a wife is incapable of finding proper accommodation for himself. If he does, it is a reflection on every landlady in the country. If a woman is capable of leaving home, as many of them do when they become nurses and undertake this arduous and responsible work she is capable of finding adequate accommodation for herself. The reason why the three sisters referred to by an hon. Member lived in one room was that they were unable to afford better accommodation. The question is an economic one. If the women are paid better they will get better accommodation. The hon. Member for Frome (Mrs. Tate) said it was significant that those jobs where women were employed were inevitably low-paid jobs. It is true that directly a woman's job becomes well paid it is taken up by the male sex. That has been found in hairdressing, dressmaking and cooking. Another interesting point is that the women are not well organised.

The question of living out is one of the most important points that have to be considered if we want to improve the nursing service. Women will not tolerate the conditions to which they had to submit at the end of the last century. When I am told that if our nurses are given good food, a good home and better pay they will want to live in the hospital, I ask why is it that there is this perpetual wail over domestic service. I shall never forget an advertisement I read in the "Times" a fortnight ago. A bachelor wrote that he was one in family, had seven servants, was very little trouble and never entertained, and yet he could not get a kitchen maid, although he offered her good wages, good food and a good home. I can understand why that man is a bachelor. He certainly does not understand the modern woman in any strata of life. The fact is that, although a woman wants good food and good wages, she insists on being the captain of her soul outside working hours. Although my hon. Friend the Member for Mile End, who has such a lot to do with nursing services, might succeed in a few years' time in improving wages, food and living conditions, he would still find that by the time nurses are qualified to choose for themselves, the same difficulty will arise. They will leave the hospital to live outside and either go into a co-operative organisation or do something of that kind.

It is strange that no mention has been made of the question of nurses having to resign on marrying, and I hope the Minister will take it seriously. It is another survival of the nineteenth century that a nurse, after she has undergone an arduous training of four years, has to resign if she decides to marry. It is a stupid waste of excellent material. You have a charming and efficient young nurse and she is to be penalised because she obeys a fundamental instinct and because she wants a home and children. She then has to leave the profession for which she has worked so hard. Surely marriage does not unfit a nurse for her particular work. Now that we are allowing nurses to live out, what objection is there to married nurses remaining in the service? This restriction is a survival from the time when all nursing was done by nuns and convents were used as hospitals. An anomalous position has arisen today. On looking at the hoardings last week we saw the head and shoulders of a beautiful young woman dressed as a nurse. It was a poster appealing to the young women of this country, single, widows and married, to join the Civil Defence nursing service. During the week 100,000 young women have been asked to join this service. They will have a short training in a hospital, and the anomalous situation will arise in which we shall have young married women in our hospitals—I agree on a temporary basis—and in the same hospitals fully qualified nurses who will be forced to resign if they dare announce that they are to be married. When we are discussing these changes, which no doubt would be regarded as revolutionary by Florence Nightingale, we should change this old-fashioned restriction and allow our nurses, who are now to be allowed to live outside the hospital, to get married and remain in the profession.

The controversial subject of assistant nurses has come up. This question is causing a good deal of unhappiness and anxiety among the State-registered nurses. I feel, however, that there is some misapprehension on the subject. The seconder of the Amendment told the House of cases where girls of 17 and undesirable women had been sent out by co-operative organisations. Most nurses, if they are not qualified, are called assistant nurses, and the object of the recommendation of the committee is to put into this role women, like the wife of the hon. Member for St. Albans (Sir F. Fremantle), who he said, hated examinations but loved nursing. The new role would include women who have not the same intellectual equipment as those who can pass the examination needed for the State register, but who have those attributes of kindliness, sympathy and understanding which are so essential for good nursing. The object of this role is to include such women, after they have had two years' training, as second-grade nurses. I have always regarded these women as the Cinderellas of the nursing profession and I welcome this recommendation.

I hope that the Minister will not allow the rather violent feelings which have been aroused among State-registered nurses to interfere with this role, and that he will be able to arrive at some amicable arrangement so that these two grades of nurses will work together. I know that in saying this I shall probably provoke all sorts of people to write to me and tell me that I am wrong, but I speak as one who knows hospital life very well and who has watched these assistant nurses dealing with what we in hospitals call "the old chronics." There is nothing more heartbreaking than dealing with the old chronic—the old paralytic, the old man who has had a stroke and is too much trouble at home and has to be looked after in hospital. The old chronics are always given to the assistant nurses, who have to be kind, patient and pleasant in all circumstances. In giving them this role, therefore, we are only meting out justice to a category of nurses who deserve the very best we can give them.

I would like to ask the Minister of Health to consider making provision for nurses in the event of hostilities. I wonder whether it has ever occurred to him to inquire whether air-raid precautions committees, which have been set up by the county authorities and which have to provide shelter for those working in hospitals, have made any provision for the nursing staffs. I agree that a nurse or doctor or anybody on duty during an air raid has to stay by the patient whatever happens. In our hospitals, however, only about one-third of the nursing staff are on duty and our shift system operates so well—in, for instance, the county of Middlesex—that two-thirds of the nursing staff are not on duty. Therefore, during an air raid these workers, who must be regarded as key workers, are completely un provided for. Many of them might be in a nurses' home. If it happened that the nurses' home were bombed we should immediately lose workers who are of tremendous importance. Indeed, if the hospital were bombed and two-thirds of the staff were saved it would mean we could immediately put into operation a skeleton service.

In Middlesex we have provided dark blinds for the hospitals and also surveyed the mortuary accommodation—the mortuary accommodation was the first thing surveyed—and are putting up huts for extra casualties, but we have made no provision for the staff. It occurred to me the week before last, when we were discussing the Bill which makes it obligatory upon employers to provide adequate accommodation for their staff if it numbers more than 50, that it ought also to be obligatory upon local authorities to supply protection for the nursing staffs of the hospitals. I hope the Minister will consider this point, and give the employés in our hospitals the same consideration as the employés of private firms are to get.

6.17 p.m.

Mr. Liddall

I appreciate the privilege of being permitted to follow the "three Graces" who have given us most interesting and informative speeches, but not one of them told us whether or not it was at Roedean where they were trained to become such delightful speakers and such perfect young ladies. We are also most grateful to the hon. Member for St. Albans (Sir F. Fremantle) for calling attention to-day to the nursing services and the inadequate supply of nurses to meet the increasing demand. The youngest age at which nurses are permitted to sit as probationers has been stated to be 16, 17 or 18, but no one has yet mentioned the age limit at which a woman is prohibited from sitting for the probationers' examination. I believe that the limit is round about 30, and that in possibly the majority of London hospitals it is even below that age—that is, the age limit for general training. In the present uncertain state of the world surely this state of affairs should be altered. Circumstances often prevent a woman when young from taking up the nursing profession as a career, and doubtless there are large numbers of women who have been left childless widows who would, if it were possible for them to do so, gladly become probationer nurses

. If it is contended that a woman of 30 is too old to be trained as a nurse what should be the age limit for a doctor? Professor Kirk is alleged to have stated at University College this year that no man is ever too old to become a medical student, so long as he can pass the preliminary examination; and I have a newspaper cutting which states that a former town clerk is burning the midnight oil, at the age of 72, in order to obtain his doctor's degree. If the medical profession, with their abundance of knowledge and in the light of modern thought, can admit a man of 72 as a student, why should the nursing profession turn up their noses at the woman of 30 or 40 who is desirous of being trained to render a service to the community and at the same time to earn something towards her own living?

To-day, we are told, there are about 100,000 women of from 18 to 55 wanting to be trained as nurses for work in the event of war. We are also told that some hospitals are already so short of nurses that they are inviting refugees to become probationers. Is this because our own girls are not sufficiently intelligent to pass the test examinations of the Nursing Council? What a slur on British womanhood. What a slap in the face to public generosity through voluntary hospitals. If this be true, I suggest that the Nursing Council are step by step building barriers of class distinction around what they romantically term "a noble profession" Its Victorian outlook, derived from the days of the cloister, is cramping the growth of what is one of Britain's most essential services, not only now but for all time. I was delighted to hear the hon. Member for St. Albans refer to the examination and how difficult it was for some people to pass it. I have here a few questions taken from the recent General Nursing Council test education examination, which no doubt the Nursing Council will say is merely a test of intelligence or of the standard of education. Question No. 3 runs thus: Two names are always coupled. Example: Balaam and the ass. Re-write the following names, dealing with 10 only, and adding the second: Jack and—, David and—,Tweedledum and—,Pyramus and—, William and—, Abraham and—. And so it goes on. I ask hon. Members if they honestly think that a sick or dying man would mind if his nurse could not couple the names of Tweedledum and Tweedledee. Hitherto emphasis has always been laid on the fact that a nurse's life is full of sacrifice. I was glad to hear the hon. Member for St. Albans say that we have traded far too long on the traditions of her profession. That is another relic of the past and it should be scrapped. From the psychological point of view it is surely wrong for a person to be encouraged to cherish ideas of martyrdom in what has been voluntarily selected as a career. Every year the public pays more and more money in hard cash for education, which means or should mean a higher standard of reasoning power in adolescence. The result is that the modern young woman chooses nursing as a career chiefly as a means of livelihood. She expects her full share of pay and leisure, as does every sensible member of society, and if she has been reared right she will tolerate neither snobbishness nor favouritism, which appear to be the evils most likely to arise from the suggested double register. In my considered opinion the nursing problem will not be satisfactorily solved until there is a complete overhaul of existing machinery. The ridiculous tests to which I have referred should be abolished, probationers should be better paid, examination fees should be reduced and there should be less control in the matter of dress when off duty. Given improved conditions there will be more recruits, and happy, healthy and contented nurses will be more ready to respond to the call of duty and be better able to administer to suffering humanity.

6.26 p.m.

Sir Ernest Graham-Little

I propose to confine my remarks to the part of the subject with which I am most closely familiar, and that is the conditions of service of nurses in the voluntary hospitals. I do not think sufficient attention has been paid to the complete change which has taken place in the last 30 years in the whole aspect of the nursing profession. In that period nursing has become a profession, and the obvious symptoms of that are that the same amount of attention is being paid to the education of the nurse as has been paid to the education of the medical student. I am glad to say that the movement originated and has been much more efficiently carried out in the voluntary hospitals than anywhere else. The first step in that direction, a very important one, was taken in 1895 when it was decided that there was to be a preliminary training for the probationer on reaching hospital. The young girl coming to the hospital is not thrown at once into the wards, as was the case when I was a student, and left to find her feet experimentally in that way. She is now carefully trained and is not allowed to go into the wards for three months after joining the hospital.

Then comes another very important part of the training, and this is undertaken by an officer who is now known as the sister-tutor. That system was introduced in 1914, and in my own hospital the arrangement now is that there are three full-time professional sister-tutors who are commissioned to instruct probationers in the very intricate duties of a nurse. It is no longer left to the probationers to pick things up as they go along. They are carefully trained. These professional sister-tutors have diplomas from King's College or the University of London. It is useless to say that you must go back to the uneducated nurse; you must have educated nurses who can keep in touch with developments in nursing at the present time.

Now let me say a word about improvements in the housing and other amenities of nursing. Hon. Members will probably be surprised at figures which I will give of the expenditure on nurses' homes, incurred by voluntary hospitals out of voluntary funds during the last 10 years. In London, more than£500,000 was spent on buildings and£27,000 was spent on equipment. In the provinces,£1,250,000 was spent on buildings and£96,000 upon equipment. In Scotland,£99,000 was spent on buildings and£5,000 on equipment. In Ireland the respective sums were£119,000 and£6,000. Perhaps I might also give figures, with which Londoners are perhaps more familiar, showing the expenditure by London hospitals upon nurses' homes. At Middlesex Hospital£250,000 has been spent in that way in the last eight years, at St. Thomas Hospital£110,000, at my own hospital£100,000, at Great Ormond Street£105,000, and at Westminster Hospital£180,000. As a result of all that expenditure, nurses in the great hospitals are in a very different position from that which has been pictured in many speeches this afternoon.

Much harm has been done to the recruitment of nurses by the totally fallacious statements that are sometimes made, for example about the underpayment of the profession. Let me give the figures in relation to probationers. A probationer joins a hospital to learn a profession. Usually the person who wishes to learn a profession is asked to pay for that learning. The parent who wishes to put a boy or girl into the medical profession has to pay at least£1,000, but the probationer at the hospital is taught her profession all the time and is paid quite reasonably. That fact seems to put her into a totally different position. In no other profession that I know of does the person who is being trained get paid for learning; that is part of the bargain with the probationer nurse which ought to be kept in view very closely throughout this Debate. In point of fact, voluntary hospitals are aggrieved because municipal hospitals pay far more money to probationers than do the voluntary hospitals. Notwithstanding that fact, there has been no dearth of applicants at the voluntary hospitals, and my own hospital has a very long waiting list. It is, therefore, not desirable to represent the profession of nursing in that way and I hope that the aspect which I have presented will be far more carefully considered and kept in mind than it has been. The probationer is learning a very arduous and difficult profession all the time that she is in the hospital, and in my own hospital—

Sir Joseph Nail

Would the hon. Member be good enough to tell us what hospital that is?

Sir E. Graham-Little

I ought to have said that before. It is St. Mary's Hospital, Paddington, London. It has now a very complete installation for nurses, of which I will give just a few details. Every nurse has a bedroom entirely to herself with hot and cold water and adequate cupboard room. Recreation rooms are available to the nurses at any time, and several rooms are allocated to the private reception of any guests whom the nurses can invite. There are facilities for recreation, including a recently erected tennis court. In the main nurses' home there is a splendid recreation room. At Aldeburgh, there is a convalescent or rest home with excellent accommodation, placed at the use of the nursing staff entirely without cost because it is sufficiently endowed to allow of that being done. Probably most hon. Members know there is also one of the finest swimming baths, placed at the disposal of the nurses as well as of the medical students. Those details give a far more accurate picture of what is being done for the nurses in the nurses' homes.

Captain Elliston

Would the hon. Member say how much is paid to the probationers? I think he said he would give us some details.

Sir E. Graham-Little

The probationer nurse, during her period of training, is paid, I think, at the average rate of£26 a year. That, of course, includes board and lodging and, as I say, tuition supplied all the time.

The whole position of the nursing profession has changed. It is regarded now as a very serious profession for highly educated girls, and that makes for some difficulty in getting recruits for it. Nursing is becoming more and more a skilled profession, rightly and properly, and because it is a skilled profession many women who enter it are very keen upon following it. Anyone with experience of men and women knows the great danger which arises with the keen student who works too hard and does not get sufficient recreation. It is difficult to restrain the keen student from doing too much in her nursing time. That is all to the good and arises because the nursing profession is now upon an equality with the medical profession. I like to think that that change has come because the voluntary hospitals have taken the lead in bringing it about.

6.37 p.m.

Mr. Tomlinson

I hesitate to cross swords with the hon. Member for the University of London (Sir E. Graham-Little) upon a subject which he knows so well, but it seemed either that he was generalising from the particular instances he gave of his own hospital and drawing conclusions which were out of all proportion to the problem with which he was dealing, or that the hon. Member who moved the Amendment gave us an entirely wrong picture and that the Inter-Departmental Committee had been spending its time upon a problem which did not exist. The hon. Member gave us particulars of his own hospital—as he called it—but because of the list of conditions which he read out he seemed to come to the conclusion that there was no problem elsewhere. Having solved the problem in his hospital by doing what it is suggested should be generally done, he assumes that there is no problem left. He said he regarded the nursing profession as now upon an equality with the medical profession, and suggested that because their position when training is similar to that of the medical student they should therefore expect to pay for that training. That argument would be good if we were seeking to set up a close corporation limited in number, but the nursing profession has to meet the requirements of the country with much larger numbers than we have yet thought of, and the argument used by the hon. Member therefore breaks down. I do not find, moreover, that nurses put themselves upon an equality with the medical profession, particularly in respect of remuneration and payment for services.

I have intervened in this Debate, in spite of my lack of knowledge from medical or nursing points of view, because I have developed for a number of years an interest in children seeking to enter the nursing profession. We have been told this afternoon of many of the problems in relation to that profession and several suggestions have been made why the profession is not popular. I think that the problem is, generally speaking, an economic one and, from my own experience, I believe that the social standing given to the individual by the wearing of nursing uniform has had to be accepted instead of wages. The position occupied by the nurse as an honourable member of a very delightful profession has been taken to mean that the profession was particularly exclusive, and I am not sure that something of that feeling is not still retained. There is an exclusiveness about the nursing profession which prevents individuals who would make good nurses from going into it.

The hon. Member who opened the Debate said there was a considerable shortage of trained nurses, and I believe he was right. In that case we have not only to inquire into the difficulties of the nursing profession and to see where we can overcome them, such as the question of living-in or living-out and the conditions which exist in the service, but we have to get down to the problem of recruitment. When the hon. Member spoke of the various sources from which nurses could be recruited he seemed to put his finger on the place where the difficulty actually lay, but he did not, nor did the Committee in its interim report, deal adequately with that aspect of the problem. I regularly meet secondary-school leavers, and hon. Members can take it from me that the nursing profession is not one of their first choices. I am not blaming the girls for that. The nursing profession is, perhaps, third on the list. When the girls have failed to obtain admission into one or two other professions or branches of industry they are prepared to consider nursing, almost as a last resort. They are then at an age when they can go as probationers, at only 17 years of age. If the leeway is to be made up and the problem of recruiting is to be solved, the profession has not only to be made more attractive, but has to be made available for the elementary school child to enter.

What is the position at the present time? No father earning less than£4 a week can afford to allow his child at the age of leaving the elementary school to qualify for entrance into the nursing profession. There is a gap between 14 years of age, on leaving school, and the age at which a child can go as a probationer nurse, and that gap has to be bridged. There is a suggestion in the report for bridging the gap in the case of secondary schools from the age of 15 years, and the Committee also point out theoretically how other difficulties can be overcome. I am not speaking of the bridging of a theoretical gap but of practical methods of overcoming the economic difficulty between the age of 14, at which a girl leaves school now, and the age at which she can become a probationer.

Sir F. Fremantle

The matter is dealt with very thoroughly in the report.

Mr. Tomlinson

Perhaps the hon. Member will be good enough to give me the reference. I am speaking of bridging a gap which, in my experience, I know to exist in the case of children from elementary schools who are desirous of entering the nursing profession. I remember that, when we were appointing helpers in our nursery school in my district, it was suggested that, after being there for two years, they would make excellent probationers for our hospitals. That was one way in which this gap could be filled, and in every case when these children who were taken into that nursery school as helpers reached the age at which they could become probationer nurses they were ready and willing to do so.

To make it easier for the child from the elementary school to pass forward into this circle, the Minister of Health will have to take as much interest in the development of the nurse as the Board of Education takes in the development of children who are to become teachers. That will mean an alteration in the code, and the Minister will have to insist, also, on some assistance being given to these children. Why should not a child of 14 plus from an elementary school be given a bursary which would designate the child for the service which the State requires? From my own experience I feel certain that there would be a great many applicants for a bursary of that kind. Then the training could be continuous, and the difficulty would not arise of the children having to answer the silly questions read out by the Member for Lincoln (Mr. Liddell). I think he must have picked out the simplest of them for fear of going wrong. His reading of those questions gave us a clue to one difficulty with which the child of the working man is faced. After the initial difficulty of the interim period has been got over, and the applicant seeks admission to the profession at the age of 18, the question of passing the preliminary test arises, and I understand that for that a fee of£2 is required. It may be that, as the hon. Member for London University suggested,£2 is a small sum for entrance into a noble profession, but£2 when you have not got it is a very considerable item, and£2 stands between many an individual who is seeking to acquire something and the acquisition of it. All those things which have been spoken of as essential for a nurse are just the things for which the elementary school child in the main is well adapted.

No one has suggested in this Debate, although the hon. Member for London University inferred it, that we want an uneducated nursing profession. I realise that other things are necessary, although I hesitate to agree with my hon. Friend the Member for Mile End (Mr. Frankel) when he suggested that it was a calling, and that, no matter how much education you had, unless you had a call for it you did not make a good nurse. The idea of a call is always mixed up with economics, and we forget that at our peril. The Seconder of the Amendment pointed out that in times of depression the number of applicants for the nursing profession increased, but that is also true with regard to curates. People go into those professions which are least desirable or remunerative when other avenues are not available. It is, however, for the child of the working man for whom I want to plead. Opportunities should be afforded of developing the child's latent talents.

I hesitate to go into the question of assistant nurses. I think that at any rate all the married men Members of this House are in that category. I look upon myself as an unregistered assistant nurse, and when the hon. Member for St. Albans (Sir F. Fremantle) was insisting on the necessity for some education, particularly in arithmetic, in order that the prescriptions of doctors could be read, it seemed to me that what was needed was not so much lessons in arithmetic as some sort of C.I.D. training in decoding, which would certainly be much nearer the mark, judging from the doctors' prescriptions that I have had the privilege of attempting to understand. In my judgment it is the child from the working-class home who will be best able to meet what is required for the building up of this profession. The reason why applicants are not coming forward is just that, economically, they cannot afford to do so. We must not only improve the present conditions, but, above all, we must make it easier for such children to pass on. The problem will not be solved by the recruitment of secondary school children. Unless either all children are given a secondary school education, so that they can pass automatically into this profession, or it is made possible for the elementary school child, the nursing profession will be faced with a great need for recruits and will not know where to get them.

6.52 p.m.

Captain Elliston

We are very much indebted to my hon. Friend the Member for St. Albans (Sir F. Fremantle), not only for opening a very interesting Debate, but also for testing the feeling of the House on a number of points which have been considered by the Departmental Committee. It has been asked why we should be discussing this interim report rather than wait for the final report, so that we could deal with the problems all together. Personally I think it is a great advantage that opinions should be expressed here to-day which will indicate to the Committee the points of view held in this House and the difficulties that might delay any necessary legislation. The subject has been very well covered in the Debate, but I should like to take up the point made by the hon. Member for Farnworth (Mr. Tomlinson). I agree with him that this is almost entirely an economic question. We have to recognise that recruitment for the nursing service has broken down. We want 20,000 probationers a year, including at least 12,000 for the great voluntary hospitals. It is notorious that the hospitals are at their wits' end to get applicants for these vacant posts. The report states that in the Official Journal of the College of Nursing, where most of these vacancies are advertised, the number of such advertisements increased from 6,400 in 1934 to 17,000 odd in 1937. That indicates that advertisements have to be inserted again and again, at great expense, and that applications for these posts are not being obtained.

We have to admit that the old idea of nursing as a vocation, almost a religious vocation, calling for nothing more than nominal payment, has gone. Parents today look for a profession for their daughters where the pay and conditions of service offer a reasonable chance of security in a pleasant occupation. Yet, as we know, many senior nurses in our great hospitals are still less well paid than domestic servants. Even highly qualified and experienced ward sisters can rarely expect to draw a salary of£120 a year—a salary less than many Members of this House pay to their cooks. That is not good enough to-day for parents who wish to launch their daughters on a useful career. I am not going to repeat what has already been said on such matters as discipline, holidays, recreation and accommodation. All these are very important, but I shall concentrate on certain fundamental matters in which I believe the solution of the problem lies.

First and foremost, if we are to implement this report and achieve any result at all, we have to recognise that adequate salaries must be paid, so that nursing shall offer opportunities comparable with the other occupations which now attract educated women. It may be that the teachers' scale will be taken as an example, or that of some other profession where it is thought comparable, but in this campaign the question of adequate salaries is fundamental. That will mean the establishment of some such committee as the Burnham Committee, which solved the difficulties and removed the friction in the teaching profession after the War. That subject is dealt with fully in the report. I hope that the Minister will tell us to-day that we can rely on the formation of separate committees or sub-committees for the specialist services. In the public health service for health visiting, school nursing, tuberculosis and so on, we have upwards of 7,500 nurses, and their conditions of living outside, their working hours, and so on are so different from those of the hospital nurse that obviously a separate committee is required for them. The success of a committee of this kind has been proved in the Conciliation Committee which was constituted by the Mental Hospitals Association and the Mental Hospital Workers' Union about 20 years ago. That Conciliation Committee has solved a great many difficulties, has removed a great deal of friction, and has worked fairly to all concerned without any undue embarrassment to the local authorities responsible for mental hospitals.

The next essential requirement to which I desire to refer is the adoption of standard hours of employment. That matter has been discussed at length, and I think there is general agreement that we should aim at a 96-hour fortnight for all nurses. The majority of the Members of the Committee believe that that cannot be made the subject of legislation. I do not know whether it was in their mind that it would put an unreasonable strain on the hospitals—the voluntary hospitals especially.—or whether they wished to emphasise the point that the nursing service is really an emergency service, and that the nurse cannot be bound by a rigid timetable, which might mean leaving her patient at a critical time. But, if the Committee were thinking of the 96-hour fortnight as a whole, I cannot agree with them that it can be brought about without legislation. No doubt it would be adopted by a great number of municipal and voluntary hospitals at once, and it would not be unreasonable to expect others to fall into line if the "appointed day" was fixed for three or four years ahead, thus giving enough time for the necessary adjustments. The third essential requirement is that nursing must be made a pensionable service. At present the pension schemes are incomplete. It has been explained that voluntary hospital nurses are covered by the hospital nurses federated scheme, and that municipal nurses depend on the Local Government Superannuation Act. It was suggested that municipal hospitals should surrender their superannuation scheme and join up with the federated hospitals. I am not competent to discuss the merits of the federated scheme, but there are 50,000 nurses employed in municipal hospitals and the total number in voluntary hospitals is only 24,000. So that to suggest that the municipal superannuation should give way to the federated scheme looks rather like the tail wagging the dog. Those who have studied the interim report have seen with great satisfaction that the Government actuary, in Appendix III, indicates that the linking up of the existing schemes is not impossible. I very much hope that the Departmental Committee, when they produce their final report, will expound that recommendation further for the guidance of the House and of the Minister.

Having secured these improvements that we are asking for—decent conditions of employment, decent salaries and proper pension schemes—what further steps are necessary to enrol 20,000 recruits a year? That is a very large number. Those who are most concerned about the officering of hospitals are, of course, desperately anxious to secure a supply of educated girls. They believe that, with improved salaries and conditions, they will get them in larger numbers than they are getting them now. But the total output of public, private and secondary schools is barely 40,000 girls per annum, and we want 20,000 for the nursing service. Now the public and secondary schools have to supply workers for commercial life and for the various professions, so that you cannot expect to get a sufficient number of recruits from that source. Obviously we have to look to the elementary schools for a very large percentage of the entrants. Unfortunately in these hard times—I know it very well as Member for a Lancashire Division—it is a necessity for very many working-class parents that their children should go to work as early as possible so that they can make some contribution to the family budget. That is a great handicap to those girls who have any ambition to undertake nursing.

On the other hand, I know very many persons of small means in my constituency who make tremendous sacrifices to send their children to universities and technical schools and other places of higher education. Their self-denial in this connection is above praise. The hon. Member for Farnworth seemed to think it impossible at present for these parents to get assistance for their daughters by which to enter the nursing profession. My impression is that there is machinery at present by which children from elementary schools can obtain preliminary training for the nursing service. I have always understood that scholarships to local technical schools, with maintenance, were available to girls between 15 and 17 and those who have to go to work in order to earn money can put in part-time attendance at evening schools to prepare for the preliminary examination. It may be hoped that when we have made nursing an attractive profession, parents will take advantage of these courses and that a large body of recruits will be forthcoming.

The increase of salaries and of staffs, of course, means expenditure which few hospitals can face, but I feel that the parents of probationers, who are at present the best-paid people relatively in the nursing service, will be quite glad to pay something towards the cost of the training. I see no more reason why the State should pay to educate hospital nurses than doctors, dentists or architects. Indeed, the training hospitals will get considerable revenue from their pupils when the profession is made a safe one. In Ireland large fees are charged for training of pupils for nursing—in the case of one hospital 60 guineas, in others from£50 downwards. In that way the cost of training the girls may be met. The proposal in the report is that hospitals recognised as training centres should receive a State grant. The expense of increased salaries and necessary extension of residential quarters etc. would be assisted in the case of voluntary, but not in the case of municipal hospitals. If nursing is a national service, surely their extra expenses should be a national charge. I can see no excuse for excluding local authorities from the grant offered to voluntary hospitals.

Finally I doubt whether those who have protested against a register of assistant nurses have read the report. It seems to me to be not only an advantage to the women themselves, and a protection to fully qualified nurses, but above all a protection to the public. The public want to know, when they send for a nurse, whether she is qualified or not, and the only way to do it is by having a register. But in compiling that register we should respect the wishes of the College of Nursing, and designate them assistants or invalid attendants or by some other title which would indicate to the public that they were not fully qualified, and which would prevent their improper employment by commercial nursing agencies. For this and other suggestions, the House is indebted to the Departmental Committee, whose admirable report has been received with such general acceptance.

7.11 p.m.

Mr. Ede

I take a sort of paternal interest in this report, because it was during a visit to my constituency to open a new health clinic that the right hon. Gentleman's predecessor in office announced his intention to appoint the Inter-Departmental Committee the result of whose labours is before us now. On the whole it is a report which will be thoroughly welcomed by the House and the country. Those of us who have been engaged in the administration of municipal hospitals since the Local Government Act of 1929 made the county councils responsible for the maintenance of those hospitals know how serious a problem this is. All our efforts to improve the conditions in hospitals are, at any rate, slowed up by inability to get a sufficient supply of trained nurses and, while it is true, as the hon. Member for West Fulham (Dr. Summerskill) said, that Middlesex have managed to steal a march on a good many of the rest of us, after all the fact that they have made their service so attractive is only accentuating the difficulty for other people. It is exceedingly necessary that there should be in this nursing service something in the nature of the Burnham system which shall secure an even spread of the available human material for the services throughout the country. It may be a good thing for Middlesex that they axe taking nurses from Surrey and London, but it is no very great assistance to the authorities in Surrey and London when they find that their service is being so handicapped.

I want to emphasise the point made so graphically by my hon. Friend the Member for Farnworth (Mr. Tomlinson) with regard to the problem of bridging the gap. Some five or six years ago I was a member of a sub-committee which prepared a scheme whereby we would offer to all girls leaving secondary schools in Surrey who desired to become nurses hostel accommodation and a bursary and the appropriate preliminary training to enable them to prepare themselves to become probationer nurses when they reached the appropriate age. We were faced with great difficulties. In the first place, as I understand it, those responsible in the nursing profession itself for the admission of recruits declined to accept any of that training as counting towards the examination. That is a very short-sighted policy. I know that the Departmental Committee have recognised that, but I want to emphasise it as really being one of the things that ought to be done away with at the very earliest possible moment. It is quite wrong to think that working-class and lower middle-class families, the kind of people who send their children to secondary schools—they are very much the same all over the country—the lower paid clerical workers, the higher paid artisans and small shopkeepers, can afford to see their daughters spending a year, 18 months or two years in a place like that and then being no further forward with regard to actual technical qualifications than they were at the beginning of the time. It makes a very poor competitive attraction when you compare it with what a girl can get as a shorthand typist, or in a similar occupation open to the same type of girl. I sincerely hope that the Minister will take such steps as are necessary to remove that handicap.

Then we were faced with this amazing thing, that even if the parents were willing to a sacrifice of that kind being made by their daughters, the Board of Education declined to give any grants towards educational institutions for the purpose. That is ridiculous. Such grants are given for the training of teachers. That is a well-recognised way of preventing people getting out of the teaching profession when you have caught them young and treated them rough. To debar the local authority which is both an educational authority and a hospital authority from undertaking that work, by refusing grants, is completely wrong. I am sure such a scheme would be very advantageous to the girls. The idea was that while they were carrying on their scientific training and acquiring the necessary knowledge they would be allowed occasionally, once or twice a week for instance, to visit the local authorities' hospitals—just for observation purposes. I am not one of those who think you can usefully introduce such girls into the hospitals to do some of the work. My view is that at that age such of the work as they could be put to do would be, on the one hand, too heavy, and, on the other hand, too unattractive to be of any real assistance to them. But I hope the Minister will take such steps as art-possible to bridge this gap.

I would reinforce the plea made by my hon. Friend the Member for Farnworth and by the hon. Gentleman opposite with regard to the elementary school girl. She has to have provision made for her for a longer time, and frequently she is a better wage-earning asset for the family than the secondary school girl. Unless some serious step is taken to meet the needs of this class of girls, they will drift off into other occupations—and I do not share the view of the hon. Member for Lincoln (Mr. Liddall) that after a girl goes into some other calling she is likely to come back into the nursing profession. She has, after all, forfeited years of seniority, and she may have got into some position of authority in the other profession, which she will have to sacrifice. Also she would have to start studying, and when she has been in some profession where study is not essential that would make demands upon her to which, I think, few girls would agree.

There is another matter which nobody has mentioned yet. I have no doubt I shall bring a great deal of trouble down on my head by alluding to it, but that has happened before, and my head is pretty well thatched. I think that a great deal of the problem—and I speak as one who has had several years' experience in dealing with the problem—is due to the difficulty of finding suitable matrons. I have, on several occasions, had to take part in inquiries into difficulties that have arisen in institutions, and the attitude of a woman head, generally, is entirely different from that of a man head. Men have had generations of shouldering responsibility. Generally, if you go to an institution—I do not care whether it is a school or a hospital or a department of a municipal body—where there is trouble you go to the head of the department, and he expresses his regret that there has been trouble, accepts the responsibility, and says, "I will take steps to see that it is rectified." But usually when trouble occurs in the institution of which a woman is head, one of the junior staff is immediately produced as the appropriate victim. If there is a lady at the head—I am speaking from a very wide municipal experience— and if the lady is slightly over 50 years of age, the victim is usually the best-looking young woman on the staff. [Interruption.] I did not interrupt the hon. Member for West Fulham, provocative as she was—and as she always is—and I hope to be allowed to develop this on my own lines. I am not the hon. Member's husband.

The hon. Member opposite said that some hon. Members here pay their cooks far more than nurses are paid. My cook gets the whole of my salary, and so do the cooks of most hon. Members on these benches. I am sure my hon. Friend the Member for West Fulham was right when she said that marriage ought not to terminate a nurse's career. I am sure that the difficulty of these ladies of rather more than middle age in positions of authority is very largely due to the fact that they are almost entirely spinsters. I cannot imagine any institution other than a monastery, entirely staffed by men, that would be adequately and appropriately staffed if the whole staff were bachelors, and I cannot believe that any institution, especially where there are relations of discipline between the members of the staff, is adequately and appropriately staffed if all the staff, especially those in positions of high authority, are spinsters. I sincerely hope that the right hon. Gentleman, in the negotiations he will have with various people over this report and its effect, will realise the difficulties that now exist from a disciplinary point of view in those institutions which are entirely staffed by spinsters.

I had this experience the other day. A woman teacher came up for appointment at what she thought was a mixed school, under a headmaster. Between the time when the advertisement was issued and the time when the post had to be filled the school was divided into a boys' department and a girls' department. She was offered the post, but told that she would be on the girls' side, under the headmistress. Without waiting to see the headmistress, she said, "I desire to withdraw my application." I do not care what regulations the London County Council or any other county council draft; what matters is the way those regulations' are administered by the people in charge of an institution. It all depends on what happens from day to day in the interpretation of the regulations, and in making sure that they are made to fit human beings rather than human beings being made to fit the regulations. There can be no doubt that, from the point of view of the local authorities, the reforms advocated by the Departmental Committee are of vital urgency, and I believe they are also vitally urgent from the national point of view. I hope the right hon. Gentleman will not be debarred by any scruples about treading on people's toes from dealing drastically and speedily with the evils which the House has been considering to-day.

7.26 p.m.

Mr. H. Brooke

I am fortunate in having in my constituency one of the important children's hospitals of London. This hospital, the South-Eastern Hospital for Children, has had two of its wards closed, purely owing to the shortage of nurses. I hope that the Inter-Departmental Committee, before it completes its valuable work, will take steps to obtain special evidence from the authorities of children's hospitals, because they have some distinctive problems of their own. The shortage of nurses has hit them doubly hard, because in old days, when the best general hospitals refused to admit probationers until the age of 20 or 21, it was a very common and sensible thing for girls wanting to take up nursing to go to a children's hospital at the age of 18 or 19 and gain experience there until they were of an age to enter adult wards. Now the shortage of nurses has compelled the general hospitals to bring down their age of entry to 18, or even lower than that, and consequently the children's hospitals are starved of their former natural source of recruits. That is a most unhappy thing, because not only is children's nursing an art in itself, but also there can hardly be a better introduction to general nursing work for girls than experience in a children's hospital.

I am certain that not only this House but the whole country agrees with the Inter-Departmental Committee when it says that the conditions of the nursing service must be altered so as to render nursing a career which can compete on equal terms with the many other avenues of employment now open to women and so attract, in sufficient numbers, the type of girl best suited for this work. As soon as that is recognised and acted upon, headmistresses need no longer feel any qualms about urging girls to consider nursing as their career. Ought there not to be some body supplying first-class lectures and films on nursing to schools, to be augmented by much more frequent school visits to hospitals than at present? The most suitable hospital of all for that type of visit is surely the children's hospital.

Thousands of nurses and tens of thousands of patients will have cause to bless the House of Commons if this Debate results, as I hope and believe it will, in marking a new epoch in the English nursing service. Ever since the Florence Nightingale reforms, the advance of hospital practice has tended to throw more and more duties of a semi-scientific nature upon the nurse in addition to all the other things she has to learn in her training. At the other end, she has been relieved of not nearly an equivalent amount of the purely domestic and obvious work, besides which the tradition of endurance for endurance sake, or it may possibly be for economy's sake, is still very much alive. It was Florence Nightingale herself who said that "a good nurse of 20 years ago had not to do the twentieth part of what she is required by her physician or surgeon to do now"; and as that was said 45 years ago, what is the case to-day?

We look for a solution, and surely there is no other rational solution except the deliberate training and certifying of different grades of nurses. The Inter-Departmental Committee seems to me to recommend the recognition of a grade of assistant nurses more or less as a regrettable necessity. I cannot help feeling that, if the analysis is pursued further, it will be seen as a logical development. In most hospitals division of functions still needs to be carried a long way. It is an important thing for a trained nurse to understand how to scrub a bed-mackintosh, but when a hospital first of all requires a high standard of education in its probationers, and then sets them for an hour and a half on end doing nothing else but scrubbing bed-mackintoshes, and then complains that there are so many things for the nurse to learn that she cannot properly be taught them all in the time available, and then finds that there is a shortage of entrants to the profession, it requires no very great shrewdness to see that, at whatever cost, the different qualities of work and the different qualities of recruits must be brought into relationship.

I wish that the Inter-Departmental Committee had taken the bull by the horns and recommended the immediate abolition of the test examination. To my certain knowledge that examination is now having the effect of turning away girls, whom the matrons by whom they are interviewed would be willing to take and train into good nurses. Like the hon. Member for Lincoln (Mr. Liddall), I armed myself with some copies of test examination papers. I will not worry the House with them, but I fail to understand why a candidate for nursing should be asked. What place in the British Isles is famous for buttons? I do not know how many hon. Members could deal with the next question:—Who said, "Be angry with your little boy and beat him when he sneezes, for he can perfectly enjoy the pepper when he sneezes" If hon. Members were thinking of Lewis Carroll they were wrong; that is a misquotation from "Alice in Wonderland," and the examiners either set a trick question or failed to verify their reference. It is not on those grounds only that I argue for the abolition of the examination. It is not warranted by present circumstances, and the sooner it goes the better.

I hope that my right hon. Friend will give a lead towards the systematic inspection of training schools. I have no reason to believe that that is done at the moment. In principle: that omission seems to me to be wrong. Nearly all hospitals are in the grip of this nursing shortage, and nearly all of them would welcome any suggestions based upon experience elsewhere, if only that would help them over their difficulties.

There has been very little reference this afternoon to the outstandingly valuable report of the "Lancet" Commission seven years ago. I will read one passage: In some hospitals the nurse must also learn to subdue her critical impulses and even her curiosity. It is assumed that she will never make a good nurse unless she regards her time as the hospital's and not her own, and her training as incidental to the work she does as employé.… But in the process of acclimatisation she is liable to adopt blindly the traditions of her seniors … and to become as impervious as they are to the fact that the educational methods practised in hospitals have been largely superseded elsewhere by methods which rely on arousing, instead of damping, curiosity and initiative. Of some hospitals I am afraid that continues to be very true.

I will not weary the House with further arguments on the point of petty disciplinary rules, but there is a hospital which must be known by name to every hon. Member of this House where a nurse is allowed to smoke only in her off-duty time in one particular room of the hospital. She is not allowed to smoke in uniform, and she is not allowed to go about the hospital in mufti unless she wears a hat. If she wants a cigarette, therefore, she has to go to her bedroom, change into mufti, put on her hat and go across to the smoking-room. In some ways it is almost reminiscent of the restrictions in the Palace of Westminster. In that hospital too, I believe, it is still the case that a nurse, when she comes off duty in the evening is not allowed to go out of the hospital for an hour or two between 8 and 10 o'clock without asking somebody's permission. That again comes home to hon. Members.

Can it be brought home to every hospital in the country that the nursing profession will not be recruiting worthy future leaders and administrators so long as the "Theirs not to reason why" attitude in face of their seniors is insisted upon, and so long as it is conceivable that any one can be told, as a friend of mine was told by a person distinguished in the nursing profession the other day, that until a girl's spirit was broken she was going to be no use to the hospital.

Whether the training of nurses should rightly be called a national service or not interests some members of the Inter-Departmental Committee more than it interests me. I see the thing quite simply. There is this acute nation-wide shortage of nurses. It has to be made up. That will cost, among other things, a certain amount of money. That money has to be found. The money side of it, as far as this House and the country are concerned, is consequential. No objection to this or that recommendation of the committee is valid, unless supported by some alternative suggestion for meeting the urgent and growing need. As hon. Members have insisted, there is no time to be lost. It is seven years since the "Lancet" Commission reported strongly about the need for interchangeability" of pensions, and we are still talking about that to-day. I hope action will follow very quickly.

I should like the Inter-Departmental Committee, when it has received back all the questionnaires which it has sent out, to consider making personal visits to those hospitals where the shortage of nurses is least felt, so that it may gather from them a pattern of what a hospital should be if it is successfully to attract nurses. I hope also that my right hon. Friend will seriously consider the suggestion that has already been made to commend to hospitals a draft set of model rules—he is familiar with the utility of model by-laws in other fields—for the regulation of nurses within the hospital. It was suggested by an hon. Member that the London County Council rules should be circulated; the Inter-Departmental Committee, when it has finished its inquiries may well be able to improve on the London County Council rules themselves.

Lastly, I wonder if the Minister would consider the case for a Standing Advisory Committee on the supply and training of nurses, to include responsible men and women with practical experience outside the nursing world, if the difficulties are of such magnitude that, as seems likely, the nursing profession cannot solve them unaided.

7.44 p.m.

Mr. Ammon

We are indebted to the hon. Member for St. Albans (Sir F. Fremantle) for tabling an Amendment which has given rise to such a very interesting and informative discussion. It comes by way of relief to some of the discussions we have had recently, and it brings us face to face with some very real and practical problems. Seldom has the House of Commons, with which I have had a fairly long association, been able to discuss a report which has met with such general consent from all sides of the House, and on which there is little or no dissention. There is the hope that everything will be done to implement it as soon as practicable. Therefore, for the first time in my life I am able to say that, on the whole, I am in full agreement with the hon. Member for St. Albans. The only point on which I would enter a small caveat against what he said was when he expressed the hope that something would be done to extend further domiciliary treatment. Whatever may be our wishes in regard to that, it occurs to me that more and more the desire is to use our hospitals, which are no longer confined to use by the poorer sections of the community. All sections of the community are now beginning to take advantage of the hospitals and to use them. The London County Council have already indicated that they want, as far as possible, to extend domiciliary treatment, particularly after first midwifery cases, but whatever may be our wishes in that direction, I am sure that the use of our hospitals is bound to expand.

In the report I have been struck by the fact that the members of the committee were rather afraid as to where their investigations were going to lead them. They realise quite clearly that the hospital services must become a national service, and although they are afraid to say so, they admit that, in effect in their report. There is a somewhat amusing comment in one of the reservations made, and that is that whilst putting forward an objection to the voluntary hospitals being helped out of national funds, they put in another reservation indicating that they wanted to modify the former reservation. I think the hon. Member for Anglesey (Miss Lloyd George) and others have come down on the other side.

The fact is that more and more, in spite of any particular wishes, the nation is being pushed towards a State service so far as our hospitals are concerned. That fact is still further strengthened by the increasing burdens that are being placed on local authorities, burdens that are becoming almost too grievous to be borne. The problem can, in fact, be solved only by the State recognising its obligations in regard to this service. In paragraphs 16 and 17 the report says: We understand that the voluntary hospitals are prepared to receive assistance from public funds. It is clear that the acceptance of grants of this kind must also involve the acceptance of such measure of public control as may be necessary and appropriate. … Since the training of the nurse is a service performed for the country as a whole, we consider that grants in respect of such training should be made from national funds to hospitals recognised by the General Nursing Council as training schools. There we have an admission of the principle that, sooner or later, we shall have to accept the suggestion of a State-controlled hospital service. My hon. Friend the Member for Farnworth (Mr. Tomlin-son) drew attention to the gap between the school-leaving age and the age at which candidates are eligible for training. That may be met in some way by the recommendations of the report but there is still the difficulty in regard to the economic problem of the young person who is being called upon to undertake these duties, and who, for the time being, is not contributing to the family exchequer. Somehow or other means will have to be found, and they should not be insuperable, of overcoming that difficulty. I do not agree with the hon. Member for London University (Sir E. Graham-Little) who inferred that probationers are trained wholly at the public expense. That is not quite accurate. In the second part of their training they give a considerable amount of work as assistants which pays to a large extent for part of their training. It is not accurate to suggest that they are entirely a liability in this respect.

The hon. Member spoke as if everything was well with the voluntary hospitals, and he gave a glowing account of his own hospital, St. Mary's. There are 1,333 voluntary hospitals, and much as one would like to feel that the hospital of which the hon. Member spoke represents the whole, we know that the facts are very far from that. We must also remember that there are 528 municipal hospitals and many of these, as the hon. Member for Anglesey said, are; under local authorities who have very limited funds at their disposal, and whose rateable value is such that they would not be able to meet the cost that would be imposed upon them by carrying out fully the recommendations of the report. That brings us back once more to the fact that the State will have to shoulder a very much larger proportion of the financial burden than hitherto. The hon. Lady asked how many of the hospitals under the London County Council have adopted the 96-hour fortnight scheme. Three-fourths of them have done so, and the ultimate cost of the whole to the county council will be£125,000 a year. We have only to estimate what the burden will be in regard to the smaller municipalities to get some idea of the burden that will be imposed upon the local authorities if it is suggested that they should shoulder all or most of this liability.

I should like to make reference to the shortage of the supply of nurses. It is well to point out that the shortage does not arise because there is a falling off in the numbers coming forward compared with previous years. There has been an increased demand, and new services and different conditions have grown up. At one time it was thought that one could get a sufficient supply of nurses from young persons who went to it as a vocation, and as doing the Lord's work. It was thought that 5 they were doing the Lord's work they could be offered remuneration that would not be offered for any ordinary commercial service. That sort of thing has largely passed away, and it brings us face to face with other conditions. The reduced hours of work have made a difference. There is also the increase in the health services, and higher and improved standards of municipal services, especially in regard to Poor Law assistance. All these things have tended to bring about a shortage of supply. Then there is the increasing use of hospital services which has grown very considerably during the past few years.

The Committee have pointed out that if their recommendations are adopted in regard to meeting the shortage of nurses it will be something like five years before it will be possible to catch up to the supply that is necessary. We must take note, also, of another important factor, which was referred to by the hon. Member for West Fulham (Dr. Summerskill). One sincerely hopes that it may never be required, but we cannot shut out from our consideration the state of unrest and disturbance there is throughout the world which may bring about conditions which will call for a very large reinforcement of the nursing services, when we shall want a very much bigger supply than can possibly be foreshadowed. We should like the Minister to tell us to-night that the Government are prepared to go full speed ahead to implement the recommendations of the report. Apart altogether from the normal circumstances of hospital treatment, we have to bear in mind the possible contingency, which we hope will not be realised, which calls for greater haste than would otherwise be necessary.

With regard to filling up the gaps and getting the necessary supply of nurses, there is in paragraph 52 of the report the suggestion that some central organisation or authority should be able to tell those who are applying exactly where there is a shortage of nurses, where there are vacancies and where the hospitals are fully equipped. That would reduce the disappointment that may come to those people who may apply and find there is no opening for them, and therefore lose heart. It is well to note, having regard to present day circumstances, that among the hospitals that are adopting the recommendations of the report are the Jewish hospitals in Manchester.

The sub-committee of the National Advisory Committee to the Nursing Profession wish to stress certain points. In regard to finance they suggest that all hospitals should become public institutions and should receive Government grant to meet increased expenditure but the grant should be withheld from those employing authorities that fail to observe the recognised scales and conditions of service for their nursing staffs. When it is put that way one has to recognise that these things cannot be done all at once, but they should give an undertaking of their intention as soon as practicable to fulfil the conditions laid down. I hope the Minister will be able to give us some idea when we may expect that the extra cost will be met by national grants, if not the whole, at any rate a large proportion of it, so as to make it possible for the hospital authorities, voluntary and otherwise, to go forward as soon as possible.

The question as to the establishment of a Burnham or Whitley Council for the hospital service is of first-class importance. I speak with some knowledge of somewhat analogous conditions. For many years it was my privilege to be in the Post Office service. In those days the House was troubled every year by long Debates, taking a whole day or several days, Members were lobbied, and a campaign was carried on by Post Office servants in regard to their grievances, whether financial or general conditions of service. A way out was found by the establishment of a Whitley Council. Since then there has been very little question raised on the Floor of the House as far as the conditions of employment and the remuneration of Post Office servants, because representatives of both sides are on the Whitley Council and are able to meet in discussion round the table, and there is arbitration machinery to decide particular points. If this could be done in regard to the nursing profession it would go a long way to improve the conditions. I hope the Minister will be able to hold out some hope that machinery of this description will be inaugurated, so that the nurses can feel that there is none to make them afraid and that their problems will be fairly and freely discussed. It is equally of importance that the 96-hour fortnight should be established as soon as possible. There is a reservation on that problem in the report: We are of opinion that only by legislation will it be possible to ensure that a 96-hour working fortnight can be carried on in all hospitals at a reasonably early date. It is no good leaving this question to the hospitals to carry out when they think the time is ripe. It must be a statutory obligation laid upon them, and I hope the Government will not shrink from facing the question as soon as possible.

Then something also should be done in regard to superannuation. I know the difficulty which arises because some nurses are under public control and some under voluntary organisations, but it ought not to be beyond the ingenuity of the Department to devise a scheme whereby there could be a carryover or transfer of nurses from one service to another with their pension rights in full. If that is done, then one of the great difficulties in getting the number of recruits which are required will be removed. They are practical proposals which are put before us by the Committee. The fact that a committee of experts of all shades of opinion has given us so progressive a report is a matter for comfort and cheer, and certainly the Government ought not to fall behind in implementing it to the fullest. I know that it will take a very long time before its effects will be fully appreciated and felt throughout the service, even when the report is implemented, but the very fact that it will be known that attention is being given to this matter will do a great deal to ensure a larger flow of recruits to the service. I hope the report will not suffer the fate of so many Departmental reports which have been received, discussed, debated, pigeonholed and forgotten. Now that the Government are aware of the sense of the House, I hope they will implement it at the earliest possible moment.

8.4 p.m.

Sir Joseph Lamb

We have had a very full and interesting Debate on this extremely interesting report, and I do not wish, except for a very short time, to stand between the House and the reply of the Minister. I should like to make a reference to something which was said by the hon. Member for South Shields (Mr. Ede). I thought he made an admirable speech until he came to the end when he made some stringent remarks regarding matrons.

Mr. Ede

Out of bitter experience.

Sir J. Lamb

I cannot deny the hon. Member's bitter and varied experience, but I hope he will realise that his remarks should not be made too general. There are exceptions I know, but I do not think the exceptions justify the references which he made to matrons in general. They are not here to answer for themselves, and therefore I should like to say a word in their defence. I do not think many people realise the difficulties with which they have to deal or what wonderful results they achieve sometimes in very difficult circumstances.

I should like the Minister of Health to tell us when he anticipates to receive the final report of the committee. I am aware that I cannot ask him to foreshadow the legislation which may be introduced, but I would like to point out that if he is going to wait until the final report is received before legislation is brought in, it will be a disaster. At the present time there are many local authorities who are willing and desirous to make alterations where they can be made in the nursing service, but they are waiting, quite naturally, for the Minister to give them a lead as to what they can and what they should do. If he can tell us when he is likely to receive the report and take some action upon it, it will be a very great advantage to the municipalities and to the service itself.

In speaking of the nursing service there is a danger sometimes of speaking too generally. Nurses vary considerably in their qualifications. Some are highly trained, and probably most patients would be quite safe in their care without the attention of a medical man. Some of them with their first-class experience are capable of giving equal attention to that which can be given by a medical man. But there are others who, although they may be termed nurses, are not in that category. They are highly qualified for the work which they may be called upon to do. There are some patients who do not require medical attention; they require attention which is of a purely nursing kind. I think it should be possible for some means to be devised whereby they can be registered without giving cause of complaint to those who are highly qualified that they are being injured in any way.

With regard to salaries, I believe the difficulty does not arise in the case of salaries paid to probationer nurses. The difficulty is that there is no prospect of their getting a salary comparable to the salary in another occupation later on. It is in that sphere that we can look for an increase in nursing. The question of hours is one of great difficulty. Long hours are not sought by anyone, but it is impossible for local authorities to decrease the number of hours unless there is an addition to the staff. The patients are there and have to be nursed. The great increase in the demand for nursing services has been partly due to the advance in our social services. They have been so rapid and extensive that the average person does not realise what they mean. I should like to have referred to many other interesting topics in the report, but as there are many other hon. Members who desire to take part in the Debate, I do not propose to say any more at the present.

8.11 p.m.

The Minister of Health (Mr. Elliot)

The hon. Member for St. Albans (Sir F. Fremantle), to whom we are indebted for the occasion of this Debate by reason of his good fortune in the Ballot, has once before drawn our attention to this subject, and as he is part author of the report which has been received with such universal praise this evening, he is entitled to felicitations as author as well as debater. There have been apart from the "Lancet" report to which hon. Members have referred, three reports on nursing services—the Athlone Report for England and Wales and the Black and Alness Reports for Scotland. To-night we are reviewing the whole of the nursing services for the United Kingdom, and these reports have to be considered. It is true that certain matters are reserved by the Athlone Committee for further consideration, but these reports cover the large ground of recruitment and conditions of service, including pay and hours of work. Here I would say in answer to the hon. Member for Stone (Sir J. Lamb) that we do not intend to defer all action until a final report has been delivered. I cannot say when it will be delivered, but the committee was specially asked to make an interim report so that its findings could be available for action if it were found possible to act upon it. All the three reports to which I have referred stress the importance of the nursing profession and its special value to the community. It is unnecessary, therefore, to stress that value to-night.

But the reports also mention that the nurse is not only a ministering angel but one whose devotion to duty should be adequately rewarded as regards not only remuneration, but in respect of conditions of service also. I may say on behalf of the Government that we accept these general conclusions. We recognise the high value of the nursing profession to the nation and the importance of all suggestions in these reports, calculated as they are to improve the position of nurses. We recognise that, as many hon. Members-have already said, the demand for hospital accommodation is growing throughout the country and has not yet by any means reached the end of its growth. That is a social factor in the situation of great importance; people are more ready, indeed more anxious, than they were to take advantage of hospital facilities. Let me give one interesting fact. At least 30 per cent. of the notifiable births in this country last year took place in institutions, a figure which is an increase of 10 to 15 per cent. in the last 10 years. That is only one of many figures I could give to show the increasing advantage which is being taken of hospital facilities.

Furthermore, the growth of medical science in recent years has meant that facilities have become far more numerous. New services of many kinds are now finding their place in our hospitals and are rapidly developing. All this has increased the demand for nurses, and has increased the demand out of proportion to the actual increase of beds, considerable though that increase is. Better service is being demanded, and specialised services are coming very rapidly into being. To take one example, orthopaedics, which all members of the medical profession will recognise as of especial importance in these days. We are on the eve of a great development in the treatment of fractures, and we are eagerly awaiting the report of a committee on fractures. Clearly, no service can be more useful to the nation than the rehabilitation of those suffering from fracture injuries, and no service requires more specially skilled nursing attention. We have to recruit and train now those who will subsequently find their employment in the fracture clinics which no doubt will be set up in future.

I would like to repeat—because it is very desirable to make it clear—what many hon. Members have already stressed, namely, that the shortage of nurses is not due to a weakening of the fibre of the nation, to a shirking by the women of the nation of these arduous and responsible jobs. I want to repeat what has been said by one or two hon. Members—for it is worth while stressing it— that the shortage arises from the increased demand, and not from any falling off in the numbers of entrants to the profession. Figures were given by my hon. Friend the Member for St. Albans and by other hon. Members. In England and Wales the numbers who took the final State examination—not the preliminary examination but those who continued right through to the end—rose from 5,275 in 1927 to 9,516 in 1937. In Scotland, although the increase was not so striking, the number of nurses registered in 1928 in that country was 800, and in 1937, it was 1,092. Therefore, it is fair to say that, roughly, the number of nurses qualifying in Great Britain has risen in ten years from 6,000 to 10,000. It is interesting to note that the increase was greater in England, where admittedly employment was better, than in Scotland, where not so many competitive occupations were available.

Mr. S. O. Davies

Is it not the case that very often girls coming from the distressed areas, such as South Wales, are trained as nurses in England, so that the figures relating to them are locked up in the English figures?

Mr. Elliot

The whole of South Wales and the North Country come into the English figures.

Mr. Davies

The right hon. Gentleman referred to England.

Mr. Elliot

I most specifically said that my figures related to England and Wales. There has been a very considerable increase in the number of nurses qualifying, and I think it is fair to point out, for the honour of our country, that the present shortage of nurses is not primarily due to slackness, or to the fear of hard work, or to the drag of better-paid occupations. The demand for nurses is increasing at a very rapid rate, a rate which is more rapid than the increase in the supply. The fact is that the increase in supply has not been sufficient to meet the increase in demand. We have to consider the recommendations which these committees have made towards increasing the supply. Those recommendations are presented as measures to meet an urgent situation in the ordinary peace-time nursing service of the nation. Before I conclude my remarks, I shall refer to the war danger, which several hon. Members have mentioned, and the great need which will arise for a very great increase in the nursing strength of the nation if war should come.

It is true that present methods of recruitment are ill-fitted to the educational system of the country. Reference has been made to an unfortunate gap which exists between the school-leaving age and the age of entry into the hospitals. The Board of Education and the Scottish Education Department are very sympathetically considering how best to organise arrangements which will provide the most suitable forms of preliminary training both for ex-elementary and ex-secondary school-girls. It would be wrong to say that the hospitals are staffed entirely by ex-secondary school-girls, for even to-day over 50 per cent. of the London County Council nurses are not ex-secondary school-girls. These arrangements would fit in with the proposed division of the preliminary State examination into two parts. Special courses have been provided, and these will make the division of the examination applicable. The General Nursing Council have submitted a rule to me to enable this "splitting" of the examination to take place, and as soon as certain details have been settled I propose to approve the rule. The "splitting" has already been effected in Scotland, so that it is not necessary to do anything there.

The hon. Member for Farnworth (Mr. Tomlinson) and other hon. Members suggested that special bursaries earmarking children for future entry into the nursing profession should be given on leaving the elementary schools. The Committee examined that suggestion and most definitely recommended, in paragraph 48 of their report, that it would be unwise to attempt to reverse the trend of educational policy by establishing special scholarships earmarking children for this special employment until at least the remedy had been tried of making the employment in itself more attractive. The committee said that there should not be an attempt to get "tied" scholars who would go forward to nursing, and that employment only. Certainly, I think that the improvement of the conditions of the nursing profession is the first line of advance we should undertake.

A great many hon. Members, including my hon. and gallant Friend the Member for Sevenoaks (Colonel Ponsonby), who seconded the Amendment, spoke of the registration of assistant nurses. I think it is clear, from the argument that has taken place in the course of the Debate that this is a contentious subject—in fact, so contentious that the Athlone and Alness Committees, after a full examination of the problem, came to opposite conclusions. The Alness Committee recommended against the initiation of a roll for assistant nurses, and the Athlone Committee were in favour of it. This is a question on which both the Secretary of State for Scotland and I are desirous to gather opinion. We will pay the greatest attention to the opinions expressed. But it is clear that further consideration and indeed consultation are desirable before any definite steps are taken. In any case, if registration of assistant nurses were determined upon, legislation would be necessary, so that it would be out of order for me to pursue the subject further now.

A great many hon. Members have referred to the conditions of service of nurses. I think we should agree with the Athlone Committee that many of the accusations are exaggerated. Mention has been made in the Debate of what would appear to be unreasonable conditions, and the hon. Member for West Lewisham (Mr. Brooke) and other hon. Members gave instances which were within their own personal knowledge. I do not think anyone would deny that there is still scope for improvement, but let it be remembered that, in spite of those conditions, recruitment has gone up 50 per cent. in 10 years, which is a sign that, in general, conditions are not such as to deter those who are genuinely anxious for employment in this calling. I think there is a great deal to be said on the credit side. The hon. Member for North Camberwell (Mr. Ammon) referred to the fact that many authorities have instituted the 96-hour fortnight. As to what one might call the housing conditions of nurses, there have been great improvements, as many hon. Members know from their experience. I looked to see whether I could find any figure which would indicate that. The only figure I could find was that relating to loans specifically sanctioned for nurses' homes, that is, loans which local authorities had been authorised to raise solely for the provision of new accommodation for nurses.

That figure, of course, leaves out all the great improvements in conditions in the voluntary hospitals. It also leaves out improvements in conditions which have been made as part of wider schemes. Yet that figure alone shows that progress went on in the last five years at more than twice the rate in the preceding five years. Between 1931 and 1935, new accommodation to the extent of 1,170 beds was provided for nurses. Between 1935 and 1939, 2,675 beds were provided in new and up-to-date accommodation.

That is only a rough figure indicative of the great improvement in conditions which is going on all over the country. To illustrate the great efforts of the voluntary hospitals to improve the conditions under which the nurses live, I need go no further than the Westminster Hospital, which is opening a great extension this very week within a few hundred yards from this House. There, undoubtedly, the nurses' home represents a very great advance on the conditions under which the nurses were living previously, and, indeed, represents almost model accommodation for nurses, or indeed for any class of the community at work in London to-day.

There are, however, further steps which need to be taken. We are prepared to accept the view expressed by the Athlone and Alness Committees that the conditions of service of nurses so far as they affect discipline, leave, amenities, and so forth, should be based on the conception of a nurse as a reasonable adult, anxious to live up to the high traditions of service for which the nursing profession in this country is justly famous I was asked by several speakers whether I would bring that recommendation in some way to the notice of the hospital authorities. I am willing to undertake, on behalf of the Secretary of State for Scotland and myself, to issue a circular to local authorities, not in the form of a model set of rules which, I think, would be a rather meticulous sort of recommendation to bring to their notice, but a circular on the numerous administrative recommendations contained in the reports. I propose to ask the British Hospitals Association whether they would be willing to issue a circular in similar terms to the voluntary hospitals. In this way these important recommendations would be specifically brought to the notice of the governing body of every hospital, whether local authority or voluntary, throughout the land.

I was also asked to state the Government's attitude on the suggestion that some procedure of the nature of Whitley Council procedure should be established as regards nurses, between employers and employed. I can tell the House that the question of establishing Whitley Council procedure for nurses, to discuss conditions, is under consideration by the Ministry of Labour, and if the Ministry decides in favour of such a step, it will certainly take the initiative in giving it effect. Some procedure by which these matters can be considered, and indeed decided, apart from these commissions of inquiry, is most obviously desirable.

Questions of finance were naturally very much in the minds of hon. Members because many of the recommendations in these two reports involve finance. There, again, there is a divergence between the committees. The Athlone Committee recommends the setting up of Burnham Committees to explore the question of salaries. The Alness Committee find themselves able to go further. They make their own recommendations in specific terms on this subject. It would clearly be inappropriate for me to make any pronouncement now, but I am hopeful that it will be possible to say more about this problem at a reasonably early date, and I do not think the House will expect me on this occasion to go further than that. I think it desirable, however, to say something on an aspect of the nursing service which has been touched on by one or two hon. Members—

Sir F. Fremantle

On what kind of occasion is the right hon. Gentleman likely to be able to deal with that point which he has just mentioned? Will it be in connection with the Budget, or on the Ministry for Health Estimates?

Mr. Elliot

I would not like to say on what kind of an occasion it will be, but I would not attempt to shirk the matter, as soon as it is possible to make a statement I hope to do so, perhaps in answer to a question. The important thing from the point of view of the House is that a Government statement will be made on the matter.

Mr. Ede

Can the right hon. Gentleman give any idea of when it will be made? Will it be in the near future?

Mr. Elliot

I have said that it will be made at a reasonably early date, and it is impossible for me to go further than that at the present time. I want to speak for a little time about the effect on these matters of the danger of war. We have already dealt with the peace-time aspect of this question, but there is another and a very important aspect of it which none of us can ignore at the present time. I have already explained in the House and elsewhere the general plan of hospital bed expansion which will be brought into operation if war should happen to break out. The round figures, which have been given to the House more than once, are that 200,000 beds will be available in the first 24 hours. These are to be beds in existing hospitals for which nursing staff is for the most part already provided. But there will be 100,000 additional beds to be placed in existing hospitals and so forth, for which staff is not at present provided. To supplement those beds, we are arranging for a programme of hutted annexes attached to existing hospitals, etc. The first block of these hutted annexes has been arranged for already. It is a block of 26,000 beds—20,000 for England and Wales and 6,000 for Scotland— and 20 local authorities have already given consent to the use of the land surrounding their institutions. Surveys of the land are in progress and the lay-out of these annexes has been decided.

As I said in the Debate on the Second Reading of the Civil Defence Bill, this block of 26,000 beds is only a first step, and we are already working out the next stage in the programme with a view to putting it into effect at once. Even, however, taking these 26,000 beds, the House will see that the total number of beds in sight for which staff will have to be provided is something like 120,000. At the rate of one nurse to three patients, which is the usual formula, the staff required for this programme alone, is 40,000 nurses and nursing auxiliaries, and, as I have said, we are already working out further stages of the programme. Nor does that exhaust the need. Other aspects than the hospital aspect are indispensable, and indeed vital. Nurses and auxiliaries are needed for first-aid posts, for helping the health visitors and the district nurses and for helping to look after those millions of children and others who will be evacuated from the congested areas into the reception areas.

We are, therefore, asking, for the nursing and nursing auxiliary services, for 100,000 women now. We ask for 100,000 volunteers from Britain, and we ask for them to-day. We ask for them not only from the towns but from the country places wherever a few people can gather together for training. We ask for them not only from the country places but from large organised units of industry such as the big shops and stores. We want those units to give facilities to their staffs for training. The House knows that local authorities have the power to incur any reasonable expenditure on such training. No expense need fall upon the recruit. The cost of training for the hospital service will, of course, be paid for entirely by the Government.

I wanted to give this word of explanation to the House, because I rely on hon. and right hon. Members on all sides of the House, belonging to all parties, to assist in the effort which we are asking the nation to put forward. The national organisations through which training can be given are the St. John Ambulance Brigade, the St. Andrew's Ambulance Association, the British Red Cross Society, and the Women's Voluntary Service organisation. These are all set out in the National Service Handbook. Furthermore, we have the Central Emergency Nursing Committees for the Nursing Profession—one in England and Wales and another in Scotland. Locally we have the medical officers of health of the counties and county boroughs (counties and large burghs in Scotland), to whom application can also be made, and in a large number of areas local Emergency Committees have been established to assist them. I should also appeal to retired trained nurses to continue to come forward and register their names with the Central Emergency Committees, either through existing organisations such as the College of Nursing, with whom they have been accustomed to work in the past, or with one of the other organisations named.

This is of course the women's own service. We have already a substantial recruitment towards our needs. By arrangement with the War Office, to which I should like to pay a tribute for their most helpful attitude throughout, we have available the services of some 11,000 St. John's and St. Andrew's and Red Cross enrolled and trained personnel. We have some 12,000 women enrolled with the Central Emergency Committee, some 5,000 of them fully trained nurses, enrolled for the most part through the College of Nursing, and some 7,000 untrained enrolled through these other various organisations I have mentioned. These 7,000 young women are now beginning or carrying through their training, or in some cases have completed it, by means of those various bodies, and are working to a single unified scheme for qualification as nursing auxiliaries. But we shall require many more yet, and we appeal to the women to see that they are forthcoming. I wish to take this opportunity of appealing to my colleages in the House to do their utmost to help us in making this appeal. There is no need more important, and there is none that ought to make a more personal appeal to all of us.

I think I have dealt with most of the points which were raised in the Debate. The hon. Member for West Fulham (Dr. Summerskill) mentioned the need for the protection of the staffs of the hospitals, and I should like to make it clear that the Government's scheme applies to protection for the staffs as well as for patients. The Government's scheme, under which all the expenditure of a voluntary hospital over£1 per bed will be borne by the State, and all the expenditure of a local authority in excess of a rate of a tenth of a penny, applies to expenditure on general measures of protection at hospitals. That is the answer to the question why protection is not compulsory in the case of staffs of hospitals as it is in the case of staffs of industrial organisations.

The hon. Member for North Camber-well, in winding up the Debate, congratulated the House on the spirit of unity which we have been able to achieve during this Debate. I think he was right to congratulate the House and he was able to do so because of the nature of the subject which we have been discussing. This short review has shown us the medical profession as consisting not only of the doctors, but also of the nurses— an indispensable part, the other half, one might say, of the profession of medicine, taken in its widest aspect. None of us will quarrel as to which of us is to be placed in one class and which in the other. As the poet said: "One man in his time plays many parts," and this was no doubt in the minds of hon. Members opposite who claimed their right to be enrolled at least as assistant nurses, though they could not qualify on the State register as fully trained nurses. This is a calling which, not merely in war but in peace, is literally vital. Its interest and variety increase every day, and so does the demand for skill, which is becoming more and more indispensable. It offers a career which we hope will be in the future more adequately recognised, both in its conditions and in its rewards. It is true also that it is a vocation as well as an employment, and that it offers a career which already has achieved one of the touchstones of greatness; the knowledge that she who undertakes it can truly claim to be the servant of all.

Mr. Liddall

Before the right hon. Gentleman sits down, may I ask whether he has referred to any of the points raised by the hon. Member for Lincoln? If he did, I must apologise for not being in the House, but nature demanded that I should go and have some refreshment.

Mr. Elliot

Unfortunately, nature seems to have simultaneously put it in the heads of both of us to go and have some refreshment, and I am afraid that I was out of the House when the hon. Member was speaking. I think the points which he raised have been dealt with, but if not, I will read his speech with close interest, and if there are any points that have not been dealt with in my remarks, I will write to him in regard to them.

Mr. Liddall

That is not quite satisfactory to me. I should like—

Mr. Deputy-Speaker (Colonel Clifton Brown)

The hon. Member cannot make two speeches.

Mr. Liddall

On a point of Order. I merely asked a question of the right hon. Gentleman, and not being satisfied with the reply I ventured to put a further question, which might have been termed a supplementary question. May I ask the right hon. Gentleman whether the point that I raised in regard to women of a higher age than 30 being permitted to sit for a probationer's examination has been brought to his notice?

Mr. Elliot

Yes; there were several points raised by the hon. Member as to the whole system of examinations. His speech, as reported to me, dealt with the system of examinations. I was not able to answer it at the time, but I think it will be suitably dealt with by the procedure which I have suggested, namely, that I will write to him at length, a personal letter, on the matter, and if he cares, I shall be glad to meet him and discuss the matter with him.

Mr. Liddall

Thank you,

Sir F. Fremantle

I beg to ask leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Question again proposed, "That Mr. Speaker do now leave the Chair."