NURSES BILL

HC Deb 24 March 1943 vol 387 cc1636-87

Order for Second Reading read.

The Minister of Health (Mr. Ernest Brown)

I beg to move, "That the Bill be now read a Second time."

In rising to move the Second Reading of this Bill, I do not think that it will be necessary for me to detain the House long, not because the Bill is unimportant, but because I think that Members who have read it will agree that the subject with which it deals has been discussed very fully in official and unofficial reports over a long period of time. Indeed, there are hon. Members in the House who were members of that very strong Committee who sat under the Earl of Athlone, and they will remember that most of the items which are dealt with in this Bill were the subject of recommendations by that Committee; and I hope that Members will agree that the terms of the Bill itself are reasonably clear to the lay mind.

The main objects of the Bill are three—to secure that assistant nurses should be given a recognised status and placed on a roll under the control of the General Nursing Council; to secure also that the public should be protected from unqualified persons representing themselves as nurses; and to this end it is proposed that agencies for the supply of nurses, commonly known as "Nurses' Co-operations," should be controlled by a system of licensing and inspection.

There are one or two subsidiary points to which I will come later, but it is true to say that the contents of the Bill are broadly in line with the Interim Report of the Athlone Committee. If Members who possess a copy of the Report will look at Part VI of the Report, beginning on page 64, they will find the whole case set out. I should also like to point out that the Bill is broadly, although not entirely, in line with the Report of the Nursing Reconstruction Committee of the Royal College of Nursing, over which Lord Horder is presiding.

And now a word or two about the present situation. All who know about it will agree with the reports that have dealt with it, namely, that the position is most unsatisfactory. There is nothing in the Nurses Registration Act, 1919, to prevent a person from calling herself a nurse or practising nursing without training or qualification. The result of that is that the public and the patients may be, and indeed are, misled. There are many thousands of nurses who are called assistant nurses at the present time, but the phrase "assistant nurse" has no accepted meaning whatever. It describes a great variety of people, some with training, some without, some capable, some not capable. At the moment there are about 16,000 assistant nurses in hospitals doing useful work, and in addition there are a great number doing private work, mainly through the agencies which are dealt with later in the Bill.

One word about the agencies. They differ. Many of them are of the highest repute, others not so high, and there is another section much less scrupulous, which employ a large number of assistant nurses with small qualifications and send them out to patients at high fees without any indication that they are not qualified to give expert attention. Some of them have actually circularised student nurses who have just passed or even failed to pass the examination, offering them high pay. That is the background against which I am entitled to say that the sick may find themselves treated at considerable expense by nurses with little or no qualification, and so the status of the profession may be undermined.

The Athlone Committee in the paragraphs to which I have drawn attention clearly gave two sides to the picture. On one side they called attention to the need for a certain class of nurses who might be admirable nurses under supervision, though not able to reach the high standard set up under the Nurses Registration Act, 1919, which is the foundation of the present State Register. On the other, they drew attention to the need to eliminate from the profession those who might have been dismissed from hospitals or who proved unsuitable or unwilling to continue training. I need not add that the danger of having such people sent out as nurses to attend people in their own homes is, in war-time, greatly increased.

Let me then call the attention of the House to the main points of the Bill. Part I contains six Clauses. It provides for the establishment of a Roll of assistant nurses for the sick to be kept by the General Nursing Council. The House will remember that the Council is responsible for all matters affecting the State register under the Act of 1919. It provides for the making of rules subject to the approval of the Minister of Health, and those rules will cover such matters as the training required, its duration and the institutions in which it can be given. They also provide a basis for removal from the register if necessary and for the conduct of the necessary examination. Provision will also be made for those engaged in bona fide practice before the Measure comes into force, if they have the necessary knowledge and experience. The provisions in this Bill thus broadly follow similar provisions in the Nurses Registration Act, 1919, making these additions to the duties of the General Nursing Council.

In Clause 3 we provide for the formation of a Committee of the General Nursing Council. It is to be composed—as hon. Members will see in the first Schedule to the Bill—of 11 members, six appointed by the General Nursing Council and five—since there is as yet no roll of assistant nurses—for the first period by the Minister of Health. That is to say, I am to appoint five of these members after consultation with the appropriate persons and bodies. All matters wholly or mainly concerning assistant nurses will be reported on by this Committee before the General Nursing Council takes action. I need not trouble the House with Clause 4, except to say that it deals with the necessary fees. Clause 5 provides an assurance of appeal to the High Court against removal from the Roll and to the Minister of Health against refusal to approve an institution.

Clause 6 is very important. It restricts the use of the title "nurse," and it does so in order to protect the public and the nursing profession against unqualified persons operating in this field. Now there is an important issue here which I have had to decide. Hon. Members who have followed the various reports on this subject will know that those representing the Royal College of Nursing would have liked a closed profession. But a definition of "nurse" is very hard to reach, and I have not found myself able to accept the view of the Royal College. I have taken the course proposed in Clause 6, which provides that no person other than a registered nurse or enrolled assistant nurse may use the name or title of nurse. There are certain exceptions to which I will come. The chief abuse at the present time, as I see it, consists in leading the general public to believe that a person is qualified for nursing, when, in fact, she has little or no qualifications, with consequent danger to health and even to life in cases in which, if fuller knowledge had been available to those concerned, such danger might have been avoided. The Clause will secure the object of making it clear to the general public that a person who calls herself a nurse has, in fact, certain nursing qualifications. If, then, private persons choose to employ someone else to look after them, they know that the risk is theirs and that there is no blame either on the profession or on Parliament.

There are certain exceptions to this provision. It is obvious that a children's nurse, the traditional "nannie," has a traditional right to the use of the name "nurse," and I propose to retain it for her provided that she does not use it in circumstances such as to suggest that she is something other than a children's nurse, that is to say, use it in a form which might lead people to believe that she is a sick nurse as well as a children's nurse.

Mr. Graham White (Birkenhead, East)

Will my right hon. Friend forgive me if I venture to interrupt him? This Clause 6 raises the only point about which I have had any representations, having taken the precaution or rather rendered the service of submitting the Bill to interested people in my area. The inquiry which comes to me is whether the security given by this Clause is real. Is it not still open to agencies to employ people who are not nurses under some other designation? There seems to be doubt on that point.

Mr. Brown

I think the doubt can be resolved when I take action in making the regulations, for which proviso (b) to sub-section (1) arranges. It is clear to all those familiar with this problem, and there are many such in this House, that I must take steps to safeguard the rights of mental nurses, tuberculosis nurses, and other nurses of that kind but I want to make it clear that it is my intention to keep exceptions to the minimum. Unless I do so, the restriction of the title would be quite useless, but I have taken power to deal with the matter by regulation because we shall need to consider with all concerned just how far we ought to go to safeguard the rights of those whose rights ought to be safeguarded. I did think, however, that the term "children's nurse" was of such universal application that it ought to be mentioned specifically in the Bill.

Mr. Craik Henderson (Leeds, North-East)

The question which has just been raised is one which worries a certain number of hon. Members, namely, whether this definition of "nurse" is not too narrow and whether it will not be possible to get round it by the use of such terms as "nursing sister" or something like that. One remembers the difficulty about the use of "dental practitioner" instead of "dentist" and so on. Is the Minister satisfied that this Clause really meets the case?

Mr. Brown

My hon. and learned Friend may take it for granted that if I had not thought this was necessary, I would not have introduced it, but, naturally, before the Committee stage of the Bill I will have a very close look, with my advisers, at the point which has been raised to see whether we can make it any clearer and secure that what we intend to do is actually done.

Colonel Sandeman Allen (Birkenhead, West)

Will the right hon. Gentleman bear in mind, when he is looking into this question, which is a very serious one, the position of Roman Catholic sisters—nuns engaged in nursing—who are gravely concerned, and will he see that they are not excluded?

Mr. Brown

I am much obliged to my hon. and gallant Friend for reminding me of that point.

The next thing to which I call the attention of the House is Part II of the Bill, which concerns the control of agencies. I need hardly say that the different factors in this question hang closely together. Without the control of agencies for the supply of nurses, it would be useless to restrict the title of "nurse" or to provide a roll of assistant nurses. The Bill provides that anyone who carries on an agency for the supply of nurses shall supply only registered nurses, and enrolled assistant nurses, certified mid-wives and such other classes of persons as may be prescribed. This will mean, in practice, that these agencies will no longer be able to supply unqualified persons. The Bill lays down that the agency which supplies the nurse should inform the patient of the qualifications of the nurse supplied and I understand this is already the practice of the most reputable agencies. The Bill also provides that in each case the selection of the persons to be supplied by the agency to a patient must be made by, or under the supervision of, a registered nurse or a registered medical practitioner in order to secure that a properly qualified person should be in charge of the arrangements on the nursing side. The Bill proposes to make all these agencies subject to licence and inspection by the councils of counties and county boroughs, or, in the City of London, by the Common Council, and it deals with licensing procedure and enforcement, in common form.

In addition, I have taken advantage of the opportunity to do two other things. Clause 13 gives the General Nursing Council what it has not now power to do, namely to make rules governing the training and qualification of sister tutors employed by training schools for the training of student nurses. There is no power to do that now, and I am asking for that power. At present in the training institutions there is a course for training sister tutors, but no standard is laid down, and all those concerned in this matter are agreed that there ought to be such a standard.

In Clause 15 provision is made for the establishment of a new list of nurses by the General Nursing Council. That will be open to nurses who could have applied for admission as existing nurses under the Nurses' Registration Act, 1919, but did not do so for various reasons. Some were abroad, some expected to get married and not to continue nursing, and others were advised by the matron of the day not to register, there being at that time not the same unanimity about registration as there is now. These people are doing invaluable work, and we are proposing to set up a list.

I hope I have made clear the main purposes and outline of the Bill and that the House will give it a Second Reading.

Mr. Ammon (Camberwell, North)

May I congratulate the Minister on his clear exposition of the Bill and on taking another step to clear up certain matters connected with the medical and nursing professions which have wanted clearing up for a long time? I rise to give the Bill, which is the final blow at Sairey Gamp, more or less general support and to make one or two suggestions of a critical nature into which the Minister may look later. The first thing that I think is worth noting is that local authorities have been consulted with the draft of this Bill and have approved it in principle, as has, also, the Royal College of Nurses, to which most nurses belong. I think it is well that that point should be made clear, so that it may be realised that this Bill has not suddenly come "out of the blue," without those intimately connected having an opportunity of considering its provisions. The Bill gives recognition to an excellent and deserving body of people who up to now have had to do the disagreeable part of nursing, who have been most concerned with the chronic cases, have done all the drudgery, and have had little or no recognition. It also clears a bottleneck in that it enables a better flow of nurses to come forward and, by no means least, ensures a better scale of remuneration. I would like to quote a brief passage from the Athlone Report, which has been copied in the Rushcliffe Report: It is essential, however, to make it clear that we contemplate that, whatever scales of salaries may be ultimately established, they should show a marked improvement over the scales at present in operation, and should approximate to those in force in other comparable spheres of employment. What is puzzling to many of us is that callings like nursing, concerned with the highest duties of life, have been paid below what is a decent living wage.

Mr. Speaker

I do not think the general scale of the remuneration of the nursing profession comes within the scope of this Bill.

Mr. Ammon

I am only referring to assistant nurses, who are among the worst paid and treated. However, I understand that because of the heavy demands being made upon the nursing profession just now—and we hope they will not be heavier, but they may be—the need for raising the standard of assistant nurses will be realised. It is incorrect to say that this Bill means lowering the standard of nurses. Let us look at the definition of "assistant nurses" as given in the Report. It states: Category A.—Those possessing a certificate of two years' training as an assistant nurse given by a local authority, e.g., that given by the Essex County Council. The Essex County Council has probably done more in the way of training assistant nurses than any other local authority. Others have followed their example, but I think Essex deserves the chief credit. The definition goes on: Category B.—Those in training for such a certificate. Category C.—Those who have had at least two years' training in a training school approved by the General Nursing Council. Category D.—Those who have worked two years on nursing duties at a hospital under the supervision of trained nursing staff. Category E.—Others employed in nursing in a hospital or an institution. I think that is what the Minister means when he talks about assistant nurses. The Royal College of Nurses would make it a closed profession. The point was put to me that this Bill purported to do that. It does not. What it does do is to restrict the use of the term "nurse" so that those people who go about in various kinds of uniform and are engaged at high prices which are not at all commensurate with their qualifications will not find things so easy in the future. People who come on the list will have to satisfy certain authorities that they are competent to carry out nursing which will be helpful and efficient. The Bill also breaks down to a great extent a good deal of the snobbery which has pervaded the profession. More than that I will not say now, as I see that you, Mr. Speaker, are rising in your Chair. But that in itself is well worth while.

The Minister indicates that a Committee will be set up, as stated in the First Schedule as follows: The Committee shall consist of six persons appointed by the Council and five representatives of assistant nurses. I think there is a danger here that the assistant nurses may get a raw deal from the General Nursing Council, and I hope the Minister will look into this point again, as they are placed in a minority. I do not put this point of view forward solely on my own initiative; I have also had the advice of people intimately connected with the profession, who see possible dangers here. The other important thing which the Bill does is to place the licensing on a national basis, apart from the conditions which apply in localities at the present time. That in itself is a good thing. Moreover the Bill will prevent unqualified persons from calling themselves nurses. I wonder whether the Minister would think it worth while considering if something can be done to guard against extortionate charges. That is a danger that obtains now. For instance, would it be possible to have a fixed tariff and to have it deposited with the local authorities, so as to prevent charges from going up to fancy levels?

With regard to an agency that has its licence revoked, what is to prevent that agency from going over the border into the area of another local authority and setting up a business there? I think the Minister ought to look into the question whether steps can be taken to safeguard against this. In the case of agencies wanting to set up a business, perhaps there could be some provision regarding the giving of assurances that they have not been in business somewhere else or, if they have been, the reasons they went out of business and want to start afresh. Probably this could be done if the Minister were himself more or less the central agent, so that everything would be reported to him and he would have available the reasons agencies have closed down. I mention this because in other connections and in other organisations that sort of thing is happening at the present time, and bodies which have fallen out of favour because they have broken the rules established by one local authority move from London to Essex, or vice versa, and again carry on practices that have been found undesirable.

Having made those remarks, I have great pleasure in congratulating the right hon. Gentleman on the introduction of the Bill, which is a step in the right direction and which comes at a time when it looks as if we may very much need the assistance of these people. What must be re- membered is that examinations do not always tell everything. The difficulty which assistant nurses very often have in obtaining higher certificates arises from the fact of their having left school at a very much earlier age; but they possess qualities which are very essential in nursing and which are brought out in the practice of if. No doubt the precautions provided in the Bill will lead to a certain weeding out, but at the same time there are provisions to safeguard those who have some vested rights and who have proved themselves efficient in the calling. I think one may feel that all necessary precautions are taken in the Bill, subject to a review of the one or two points I have raised, and that the House may well give the Bill a welcome.

Mr. Linstead (Putney)

I expect we shall not want to give a great deal of time to the discussion of this Bill, because probably it will get fairly general support, but I think there are one or two observations that may usefully be offered. First of all, the Minister is to be congratulated on having implemented the Report of the Royal College of Nursing so very rapidly. It is rather a custom in this country to favour the unqualified practitioner. I do not know whether it is our natural proclivity for betting which encourages people to go to quacks rather than to registered and well known men, but undoubtedly, particularly in the health services, there is every reason why trained and qualified practitioners should be recognised by the State, so that ordinary people may know whether they are dealing with properly qualified men. In this Bill the Minister has gone a very long way to close the nursing profession, in fact if not in actual words in the Bill, but I hope he will watch the situation and that if he finds that a prohibition upon the use of titles is not sufficient, he will be prepared later on to come to the House with additional suggestions.

There has been rather substantial opposition to the proposals of the Royal College of Nursing, although that opposition, perhaps because the time was not sufficient, has not come out into the open against the Second Reading of the Bill. The opposition seems to be based mainly upon fears of dilution. It would seem that fears on that ground are more or less baseless. First of all, there is an enormous demand for nurses. The assist- ant nurses are in fact there, and no new set of people is being brought into the calling. There is also the probability of a universal medical service coming into being in the course of months, let us hope—[Interruption]—and that will undoubtedly increase the demand for nurses and assistant nurses. I say months, but it is open to other hon. Members to put their own time on it. There is also, of course, the third fact that it is not unknown for a nurse to get married and it is highly probable that gradually a large number of these assistant nurses will get married. Consequently, I do not think the fear of dilution need be very great.

I have received and possibly other hon. Members have also, a memorandum from the British College of Nurses, Ltd., which contains some very detailed criticisms of the Report of Lord Horder's Committee. I need, I think, refer only to two paragraphs in that memorandum. In one paragraph they say that the suggestions for the education of semi-trained assistant nurses would degrade the standards of nursing education and could only result in depreciating nursing as a profession for educated women. I should imagine the result would be entirely opposite to what is suggested in that criticism. Later on in the memorandum it is stated that the proposal that the assistant nurse should have all the economic privileges of the registered nurse could only have the result of eliminating the registered nurse from the body politic as it would prevent educated women from entering the nurses' training schools. I am sure that criticism is based entirely on a misapprehension. So long as there are higher educational qualifications available, so long will the great bulk of the women do their very best to achieve them. I think that probably the best answer to this series of criticisms is that of the 22 recommendations which Lord Horder's Committee made, the British College of Nurses, Ltd., has disagreed with 21 of them and agreed with one only. That probably is a fair measure of the value of those criticisms.

There will probably be some Amendments which some of us may wish to put down on the Committee stage. I would like to make only two observations on the details of the Bill at the present time. One is that I think it a great pity that the fee annually for assistant nurses should be only 2s. 6d. I know it is the fee for a registered nurse, but in this world we tend to value things according to what we pay for them, and I should have thought that some higher fee would give a better sense of the value of registration than a mere half-crown. Another point is with regard to the disciplinary control of assistant nurses. I have some experience of the working of a domestic disciplinary committee, and I hope it will be found possible for some legal advice, possibly a legal chairman or assessor, to be placed at the disposal of the Committee. I can imagine some difficult question arising where such help would be useful.

I believe the Bill will go a long way towards putting the nursing profession in a very sound position, and it should be implemented by all those who employ nurses seeing that they get the best possible conditions of service. I hope the General Nursing Council will not keep these assistant nurses in a sort of concentration camp. They ought to be encouraged by every possible means to take the training and to pass the examinations which will put them on the full register as registered nurses, and one hopes that the new grade will be received by the General Nursing Council in that spirit so that the whole profession can be welded together.

Mr. Messer (Tottenham, South)

I am sure everyone who is interested in the question of health and the care of the sick will welcome anything that tends to make the service one that can be reliable. One fact that we have to face is that we have assistant nurses. They are here, and, if it were not for them, the problem with regard to nursing man-power would be just that degree more serious that it is. There are those who say we ought not to have assistant nurses at all. We have not got assistant doctors; why should be have assistant nurses? Are there any sick people who should be cared for by those not having the highest qualifications? As one intimately connected with administration, I have to admit that we owe a great deal to the Cinderella of the nursing profession, the assistant nurse. Let us examine her as we find her. The nurse who has failed in her examination often becomes an assistant nurse. There is the nurse who started training and did not get on with it, probably broke off with it and came back as assistant nurse. There is still the V.A.D. of the last war, and there are those who just found themselves in a hospital or institution where they could be made assistant nurses. We have those varied types, and up to now nothing has been done to lay down any minimum standard that the assistant nurse should have, so that all those who are seriously interested must welcome the opportunity of controlling them. I also think that one must pay some attention to the criticism of the State registered nurse and the suggestion in the Bill of putting these assistant nurses on the roll. You can give them what title you like, but, if you put them on the roll, which of course is only another name for a register, under the General Nursing Council they will be State registered nurses. There are some people who favour placing them on a register directly compiled by the Ministry of Health or the Ministry of Labour.

I do not know that I would favour anything that would attempt to stigmatise a section of people, and I believe the qualities of nursing are not necessarily found in the intellectual capacity to pass an examination. Something more than intellect is wanted in nursing and something more than physical strength. There are human qualities. Nurses would not remain nurses unless they had a deep sympathy and interest in their work. Patience, perseverance and care are wanted and the tenderness of dealing with difficult subjects. This is the profession that we praise. We call them angels and treat them like menials. I am deeply interested in the nurses but more interested in the patients, and I want to be assured that, when the Minister's regulations come to be considered, assistant nurses are to be given a specific type of work to do. In the main, assistant nurses are employed by local authorities—not many of them by private hospitals—and in the main they are employed on what is called chronic work. The chronic case is very much misunderstood. It is a comprehensive term in which there are the aged and the senile, as well as cases of real sickness of long duration which require careful nursing, such as rheumatoid and other arthritis, etc. I want to be assured that the position of assistant nurse may be covered by regulation. I do not want to see a section of the sick nursed through varying phases by nurses who are not qualified to do it, so that the qualification of the assistant nurse should be sufficient to justify a nurse doing specific types of work. I think the community owes it to the nurse to secure her against the possibility of the grave situation in which she has found herself up to now, and it is a healthy sign that the Government themselves are turning their attention to the economic position of the nursing profession.

There are one or two other matters in the Bill which are long overdue and upon which every congratulation ought to be given to the Government. Those not familiar with the question will be very interested to know what has happened in regard to nursing agencies. Some of them call themselves co-operationists, but they are a long way from being anything in the nature of co-operative. They are merely employment agencies, and what they do is to farm out nurses. We have had nurses in a hospital with which I am connected, and as soon as they have gone on to the State register they have gone into the co-operative because they have been able to get higher wages. These agencies have held local authorities to ransom. Quite recently the London County Council called into conference representatives of the whole of the Home Counties health authorities to deal with the claims that were being made by these agencies for, I will not say too high salaries, but such salaries as made it almost impossible for us to compare them with our ordinary staffs. I am very pleased that the Bill proposes to control them, and, in controlling them, it will give the health authorities of the local councils the right of inspection and licensing, so that in the event of anything happening which would justify their removal they would not be able to continue. I hope the Minister will give some consideration to the point that, if they are removed in one county, they will not be able to set up in another.

Another point is the indiscriminate use of the title "nurse." Anyone can call herself a nurse at present; it does not matter whether she has had any training or experience. This applies to men as well as to women. The loose and indiscriminate use of the title "nurse" means that the public can be deceived, and the importance of the work done by nurses is such that such a deception is worse than a material one. We ought to take steps to see that the public cannot be imposed upon by someone not qualified to do the job.

I put a question to the Minister a few weeks ago and was disappointed with the answer, but I find that my question is answered in the Bill. I have always had very deep sympathy for nurses who have been through their training, passed their theoretical and practical examinations and actually got their training school certificates but are not on the register because they did not apply in time when the register was first formed. The Minister has done a generous thing which will not injure anybody. It will not injure the rest of the State registered nurses, but it will help these nurses to get on the register. They have exactly the same qualifications, they have their training school certificates and they have done all that has been required of them except the technical matter of having their names put on the State register. This Bill will make them State registered nurses, and to that extent the Minister has done a useful piece of work.

My last point is in connection with male nurses. Why should we secure the patient against the untrained nurse when the untrained nurse is a woman and not secure the patient against the untrained nurse who is a man? The male nurse can be trained. He can reach the standard which is required and pass every examination which is set, but he can never become a State registered nurse. There is no place on the general register for him. Why not? The argument that is advanced is that a man cannot be put on the register because male nurses do not study certain subjects which are taken by female nurses. There is no reason why he should not study these subjects. There are, however, different qualifications in the nursing profession. There are nurses who get their training school certificates and others who get their midwifery certificates. There are others, too, who get their "T.B." and those who get their "fever." All nurses are not exactly the same standard. Why should we not, therefore, say to the man that, provided he reaches the standard which is required for the particular type of work he does, he will be put on the register? I would ask the Minister to reconsider his attitude on this point. The number is not large, but there is a special type of work which can be done by male nurses.

The Bill in general is a good Bill. What we can do to tidy up what has been a very untidy profession in the past deserves the encouragement and support of all right-thinking people. I would like to see the nursing profession a real profession. The difficulties of nursing, because of the complexity of medical treatment, become more and more varied. We have a type of woman now nursing who is doing work much more difficult than the work that was done 20 years ago. We have nurses taking risks that were unthought of years ago. We have such an advance in medicine, which depends so largely on the nurse, that I am glad that steps are being taken to bring her to her rightful place in this co-operative service. One may have the cleverest surgeon to perform an operation and a good medical man to make the diagnosis, but the patient relies on one who is doing not only the day-to-day work but the hour-to-hour work in the ward. The sisters and nurses who are doing that work are deserving not only of protection but of recognition, so that they can have their rightful place in the most humane service to which we can put our hands.

Mr. Jewson (Great Yarmouth)

The hon. Member for South Tottenham (Mr. Messer) has given us, as he always does, the benefit of a wide experience in these matters to which I can lay no sort of claim. The subject of this Bill, however, is one in which every one of us must take a real personal interest. I suppose that we owe our very survival in the first instance to nurses, and I imagine that there are few of us who reach any considerable age without adding to the debt which we owe to the nursing profession. Certainly great strides have been made in our consideration of it in the last 100 years. Reference has been made to Sairey Gamp, who flourished about 100 years ago. Since her day we have had, fortunately for us, the Lady of the Lamp, and from that time the public have always been willing to accord some sort of halo to the nursing profession. But even ministering angels want something more solid than a halo as a basis for life, and I welcome this Bill because it goes a good way to provide that something. It means a real advance in status for a great number of nurses, and from the public point of view, which is even more important, it assures the qualifications which nurses shall possess. About 100 years ago Praed told us that among his many preoccupations he wrote "Hints to Noble Lords—and Nurses," though I always suspected he put in "Nurses" merely for the sake of a convenient rhyme. That shows in what a desultory manner nurses were expected to pick up their education in those days. This Bill will put them on a better basis while providing for proper examinations to be passed. That will be an excellent thing for the nursing profession. A Bill of this sort, however we look at it, must mean a certain restriction of liberty. For that reason it should be carefully and closely scrutinised by this House. My opinion is that the Bill will stand up to such a scrutiny. In a Bill of this sort we have to safeguard the rights of existing practitioners, as has been done in charters granted to other professions. Here again I think that the Bill stands well up to examination.

I should like to ask for enlightenment on one or two small points. I take it that all voluntary hospitals are included in the description in Clause 11, Sub-section (1), but I should like to know what is the position of cottage hospitals under this Clause. In Clause 14 it is indicated that the approval of Parliament has to be sought for the rules and regulations made. In war-time delay is dangerous and must be avoided, but this is really a peacetime Measure, and I do not think there is any great hurry about it. Therefore, I should be much happier if the rules made did not come into force until after the 40 days during which Parliament may express its opinion had expired. I wonder whether the Minister will consider an Amendment on those lines. In the First Schedule it is laid down that the first members of the Committee are to hold office for three years or such longer period as the Minister may from time to time determine. Should there not be a maximum time? It may not be considered necessary, but I should have thought that a maximum of five years might be desirable. With these small criticisms I welcome the Bill and hope that the House will give it a Second Reading.

Mr. Burden (Sheffield, Park)

May I join with those who have offered congratulations to the Minister upon sub- mitting this Bill to the House? The nursing profession is one which calls for many and varied attainments from its members. On the one hand, there may be required highly skilled and technical knowledge. On the other hand, what may be required from nurses is a kindly, sympathetic attendant with some training but with few if any paper qualifications. The Inter-Departmental Committee of 1939, the Athlone Committee, for the first time formally recognised the second grade of assistant nurse—less highly trained than the State registered nurse, but at the same time undertaking important and necessary nursing duties. The Bill gives recognition to the assistant nurse and for that reason is to be warmly welcomed. I agree that just as the General Nursing Council is the appropriate body for the register of duly qualified nurses, so it should keep the roll—that is the distinction—of the assistant nurses. I do not consider, however, that the General Nursing Council is the appropriate body to prescribe the training, its duration, the institutions at which training should be given, and the conduct of examinations. My alarm at that provision in the Bill is enhanced by the Minister's suggestion that the profession wish to keep it a closed one.

The problems associated with assistant nurses are those affecting public hospitals and institutions under the control of county councils and county borough councils. In the main it is a problem of providing for the nursing of the chronic sick. If I may, I will quote from the admirable summary of the P.E.P. Report dealing with the Health Services issued in 1939: To-day the public hospitals provide nearly three-quarters of the available hospital beds, including most of those for infectious diseases, tuberculosis and maternity, and they deal with the bulk of the chronic cases. I am aware that the Hospital Year Book gives a list of hospitals which admit chronic cases, but most of those hospitals are small, and some of them are restrictive as to the type of cases they will take. Some indicate that they will not accept chronic cases of cancer, or senile cases. These voluntary institutions cannot in any way be compared with an institution like Fir Vale, administered by the county borough of Sheffield, where there are more than 1,000 bed-ridden or, to use an expressive North-country term, "bed- fast," cases. Fir Vale has 250 assistant nurses, and they have to deal with men and women suffering from rheumatoid arthritis, diabetes and acute carcinoma and senile cases. That is typical of conditions in many other large public hospitals under the control of county councils or county boroughs. Voluntary hospitals will not keep the chronic cases. That is not a matter of reproach to the voluntary hospitals, whose job is a curative one, but the chronic cases turned out from voluntary hospitals have to go somewhere and they find their way to the municipal hospitals, and assistant nurses are administering to their needs.

I submit with respect that the General Nursing Council have no knowledge of these problems. As far as I can gather from the scanty published information, all the nurse members are retired matrons or matrons actively associated with voluntary hospitals. While official recognition is given in the Bill to assistant nurses, I submit that it is vitally important that the training and other conditions for assistant nurses should be prescribed by those who have some knowledge of the problems of nursing the chronic sick. I wish I were able to give to the. House some picture of the conditions in an incurable cancer ward—the sloughings from the wounds, the horrible stench, the problems of looking after the doubly incontinent, and so on. I am glad that at long last some official recognition is given to those men and women who so cheerfully undertake those very unpleasant duties, but I am more than anxious that their conditions should not be worsened by having on the proposed assistant nurses' committee a majority of people who have absolutely no knowledge at all or practical experience of the problem of the public hospitals. May I therefore respectfully submit to the Minister that he should consider withdrawing the Clauses placing responsibility on the General Nursing Council and take power under a new Clause himself to appoint six members, and see that he appoints women who have had some practical experience of the work of a chronic hospital?

In regard to the Clauses designed to bring what are known as Nurses' Co-operations under a system of licensing and inspection, while I readily acknowledge that the proposals in the Bill may have the effect of preventing one of the most glaring evils, the supplying of a person as a nurse whose only qualifications are that she has a birth certificate and has been vaccinated, I am sorry to say that the proposals fall far short of what is really required. I have here an advertisement which appeared in the "Nursing Mirror" of 20th March. I am not going to discuss salaries, in view of the Ruling of Mr. Speaker. The advertisement says: Vacancies regularly occur in London, Middlesex and provincial county hospitals and nursing homes at these weekly salaries: Assistant Nurses £2 9s. to £2 12. 6d. per week——.

Mr. Deputy-Speaker (Mr. Charles Williams)

By reading out a list of salaries the hon. Member is obviously opening the Debate very wide to a discussion of salaries.

Mr. Burden

With respect, the point I was going to make is a simple one. It is that these relatively high salaries as compared with the salaries paid in the hospitals attract nurses from the hospitals to the "co-ops," to the detriment of the public hospitals. What happens is that a matron of a hospital which is short of staff——

Mr. Deputy-Speaker

I think the hon. member really must leave this point, because if under the procedure we are not allowed to discuss salaries and we begin discussing the attracting of people from one part of a profession to another by means of salaries, it opens the whole subject of salaries.

Mr. Burden

I bow to your Ruling, Sir, and will only say in a general way that partly-trained or trained nurses are supplied by the "co-ops" to hospitals and at rates far higher than those which the hospitals pay, and the difference between what the nurse gets and what is paid by the hospital is a rake-off for the nursing "co-ops." The Bill provides for the inspection of the "co-ops" by the local authorities. In many cases the place consists of one room with one person and a telephone. While I admit there is some improvement, in effect this Bill legalises a racket. I suggest to the Minister that he should withdraw these Clauses and place upon the medical officers of health in county boroughs and counties the responsibility for keeping a register of nurses or midwives available for relief work or for private practice. I would com- pare the methods of the "co-ops" with the truly noble work performed, often under miserable conditions, by district nursing associations, both in the towns and in the rural areas. How can we ever have a comprehensive medical and nursing service while the nursing "co-ops" remain exploiting the needs of the suffering? I hope the hon. Lady the Parliamentary Secretary to the Minister, with her wide knowledge and sympathetic understanding of these difficult questions, will appreciate that I have tried to help, and I should again like to express my thanks to the Minister for his speech and for the Bill. The Minister has the opportunity of producing a real charter for assistant nurses, but in all seriousness, and speaking from my experience first as an appointed Poor Law guardian in 1929–30 and as chairman until recently of a public assistance committee under a county borough council, I would warn him that if the General Nursing Council dominates by a majority the assistant nurses committee, restrictive conditions may be prescribed which will hamper recruitment and may make more difficult the task of those who have to administer institutions providing for the care of the unfortunate suffering men and women who are the chronic sick of this country.

Mr. Storey (Sunderland)

The speech of the hon. Member for the Park Division (Mr. Burden) is one which leaves me in some little difficulty, because while he warmly welcomed the Bill, he first asked the Minister to withdraw the whole of Part I and substitute something different and then asked him to withdraw the whole of Part II and put something entirely different there.

Mr. Burden

The opportunity arises for doing that.

Mr. Storey

Apart from that, I think he is undoubtedly in general agreement with the principles of the Bill. I do not share his fears arising from the General Nursing Council being the body responsible for the enrolment of assistant nurses. I recognise that he has made a good case for his contention that the work done by many of the assistant nurses is completely different from that of the State registered nurses, but, on the other hand, much of the work is interlocked with the work of the State registered nurses, and therefore I feel that it is in the interests of both sec- tions of the profession that one body should be the registering authority.

Mr. Burden

I have admitted that and agreed to that.

Mr. Storey

I particularly think that is desirable, because I hope that the enrolled nurses will in many instances advance to be State registered nurses, and if there is one body in control of registration it is more likely we shall achieve that end. I, too, want to join in the welcome which has been given to the Bill, because I feel that it is an essential preliminary step in the creation of a national health service that can be safely undertaken even in a time of war. I am surprised that any body of nurses should oppose the provisions of the Bill. I believe it can only improve the status, both of the State registered nurse and of the enrolled assistant nurse.

Let us recognise the facts. The first is that there is work for the assistant nurse to do, and the second is that our health and hospital services could not carry on without her assistance. If that is so, it follows that we should take steps to ensure that the assistant nurse is properly trained for her own special work and that, when she is properly trained, she shall be confined to that work. That is not to say that the assistant nurse should be prevented from undertaking additional training which will enable her to become State registered. Indeed, the work that has been done in Essex shows that, under a proper scheme of training of assistant nurses, many recruits to the State Register may emerge. I believe that the development of the Essex plan should prove a useful ladder by which assistant nurses may advance to the highest ranks of the profession.

I am glad that the provisions of Part II for the control of the ages of supply nurses have received such a general welcome, because I believe they will go a long way, not only to stop the drain upon student nurses who are liable to succumb to the financial inducements which the agencies can offer to partially trained nurses but also that it will provide that the public, when engaging the services of a nurse, will be safeguarded in that people will know that the qualifications of the nurse supplied are such as will enable her to perform the particular task for which she is engaged. There is one point, however, on which I am not quite clear, and that is whether these proposals fully cover the position of the enrolled assistant nurse who is practising on her own. I feel that she should be under the same obligation as an agency to disclose her qualifications to the person who engages her services. I hope that the Minister, in drawing up his Regulations, will consider this point and will make it incumbent upon the enrolled assistant nurse to make it quite clear that that is her capacity.

I think the Bill does all that is reasonably practical to improve the status of the nursing profession. I have sympathy with the view of the Royal College of Nursing that nursing should be made a closed profession, but how we can achieve that aim in a more practical manner than is at present proposed I have yet to be convinced. I only hope that the Minister will carefully watch the working of the Bill when it becomes law, and that if any loopholes are driven through it he will take steps to close them, as I feel sure it is his intention to do, so that there may be no loopholes by which those who are not qualified can attempt to nurse for gain. In conclusion, I repeat that I believe the Bill is an essential step in the creation of a national health service. I hope that the Minister will be helped to place it quickly upon the Statute Book and that he will go on with these preliminary steps so that we may, at an early date—although I shall not express the optimism of the hon. Gentleman who thought one could be created in the space of a few months—build up a national health service that is worthy of the people of this country.

Mr. Frankel (Mile End)

Like other hon. Members, I rise to support the Second Reading of the Bill, but I wish to offer one or two criticisms at the same time or to emphasise one or two that have already been made. I do not agree with the hon. Member who has just spoken that this Bill could not have been stronger or more complete in its protection of the nursing profession than it is in its present form. Where the Minister stands on the question of a State service is rather dubious at the present time. Speaking as a member of a local authority very much concerned in this matter, I am doubtful—and I do not say this offensively—about which way the cat is jumping, whether still supporting to a great extent the voluntary hospitals or willing to do the sensible thing and recognise that the future must lie with the services of local authorities and in State hands—not that I want to run down the voluntary hospitals. They have done valuable work in the past, and a good many of them are still doing so. As I have said before in this House, I believe it was necessary for the voluntary hospitals to do their great work. Local authorities with powers in the matter did not exercise those powers for a great many years. I hope that we shall continue to move in the direction of a real State medical service.

The Bill is good, but more timid than it need be. It could go further. The hon. Member who preceded me described this as the preliminary step to a State medical service.

Mr. Storey

A national service.

Mr. Frankel

A national service. I beg the hon. Member's pardon. It is a preliminary step, but it is too timid a step. It could have been a much greater step. I entirely agree with the hon. Member that even during the war great strides can be made along the line to a national service. One provision of the Bill allows special exemption from restrictions in favour of children's nurses. It may be made also in other cases, but I do not know about this. Children's nurses are apparently still to be allowed to be called nurses. A great deal of misconception is met with in regard to these people whom the Minister described as nannies and who are often thought of as nurses fully qualified to do almost anything in the nursing profession. I urge upon the Minister the importance of finding some other term to describe these people. It must be chosen so that people will be less confused than they are on this subject. I have not thought much about such a term, but I will coin a phrase. Perhaps they could be called "children's nurses" instead of the generic term "nurses," which apparently is still to be allowed. I shall not be very critical about the other exceptions until I hear what they are. We are not at all certain about this matter.

Mr. Messer

The hon. Member must permit student nurses still to be called nurses.

Mr. Frankel

I entirely agree with that suggestion. "Student nurse" describes them. I do not want anybody to be called a nurse who is not a fully qualified person.

Mr. Messer

The student nurse is not fully qualified.

Mr. Frankel

The word "student" qualifies it, and I think that is sufficient. The hon. Member for North Camberwell (Mr. Ammon), who spoke earlier on this matter, mentioned a point which I would like to stress. He talked about what are called the nurses' agencies. The hon. Member for the Park Division of Sheffield (Mr. Burden) described another term which is very familiar to me, namely, the "co-ops." He mentioned that when a person who is not allowed by one authority to practise within its area may still be able to practise in the area of some other authority. There ought to be one central place where it is possible to know whether a person has been disqualified from practising in some other place before that person is allowed to start up in a new situation. I do not want to enter into the financial aspect of this matter, but a point occurs to me. If these persons are disqualified, they are probably almost bankrupt. I think bankrupts have to be notified everywhere. In this case it might be so too.

Another point mentioned by the same two hon. Members with regard to the "co-ops." requires to be stressed. It is that their charges should be published. The local authority should know what the "co-ops." propose to charge. It may be argued that this is a private matter between the patient, the nurse and the agency, but I do not think the present situation should be allowed to continue. We ought to know what it is permissible for the "co-ops." to charge and what they are legally entitled to charge, and everybody should be able to receive equal treatment for that charge. A further point which I want to emphasise was made about the nurse leaving voluntary or publicly-controlled hospitals to work for these "co-ops.," presumably for a bigger amount. I do not think it always works out that the nurse gets paid as well or treated as well after the change. In the expressive phrase used by the hon. Member for the Park Division, a phrase which is being used all over the world now, it is a racket and a most undesirable racket, with profits for those who organise and run these places to the great detriment, in the long run, of the nurses involved.

Although I think that assistant nurses have not been treated in the Rushcliffe Report as they deserved to be treated, I welcome the Bill, and I hope that the Minister and his advisers will go a little further on the Committee stage and make the Bill a much quicker step towards a national service.

Sir Francis Fremantle (St. Albans)

So much has been said about the Bill, about which there is really so little to be said in opposition, that I do not wish to take up too much time. But at the same time, having been a member of the Athlone Committee, which presented at the beginning of 1939 an Interim Report—I am afraid the only Report it will have made—I am bound to say on behalf of that Committee how much we must welcome the fact that the Minister of Health and his predecessor have taken up that Interim Report and have brought this measure of actual legislation before the House. It is a very difficult job to deal with. Certainly it is an enormous subject, requiring, as it does, treatment in so many ways of the nursing profession. I think none of us are divided about the tremendous gap there was between the actual conditions of nursing and what was required in the way of the decencies of nursing. At the same time the demands on the services of the nurses were being increased day by day, year by year, and it was almost impossible to fulfil the demands that were required—quite impossible to fill the demands required—by the existing numbers of nurses on the register.

Let me just run over the reasons for the increased demands. It was not simply that the nurses were already overworked, that the hospitals were already understaffed, but there were six factors in addition to that to account for the increased demand. First of all, the voluntary hospitals had increased for some time past by 1,500 beds a year. That meant to say that so many extra nurses were required every year in order to staff them. Secondly, after the Local Government Act, 1929, which was the main factor in transferring hospitals and infirmaries of the guardians to county and county borough councils, the nursing staff for these had to be tremendously increased. In the last 10 years it had increased from 9,000 to nearly 14,000. That is a great strain on the other requirements of the nursing profession; yet it did not fully meet the needs of these vastly improved municipal hospitals. Thirdly, there was an increased public demand for hospital treatment of acute sickness. That requires extra nurses if anything does. Fourthly, there was the increased public demand for domiciliary nursing. I was glad to hear the hon. Member for the Park Division of Sheffield (Mr. Burden) mention the wonderful work, the extraordinarily valuable work, done even in the villages by nurses of the nursing associations, not simply in nursing but in the widest sense by entering into every house and family, becoming a personal friend of the family and the neighbourhood—an immense factor in all cases of sickness, and a great deal of other troubles as well, and to a large extent helping to fill in now, in war-time, gaps made by the depletion of the medical service.

I find over and over again in the country, where the ordinary panel patients, for instance, cannot get hold of their doctor who lives five miles off, and is doing or trying to do the work of two other doctors as well, they run round to the nurse, who manages to hold the fort until two or three days afterwards, when the doctor can come and look after the patient. Meantime it may be that they have got well, which is a very good thing for the humiliation of the medical profession and for the benefit of the patients themselves. Then there is the constant need for fresh development. The new treatment of heart cases requires, say, three nurses for a single case. The X-ray and deep therapy treatments require extra care. Then there are the recent efforts in the hospitals to reduce the nurses' hours of work to a decent figure. What is proposed is a 96-hour fortnight; but to bring that in means an increase of some 20 to 30 per cent. in the establishment of many hospitals. All this means that on the whole, whereas 9,000 a year applicants have been sitting for the final examination, requiring 12,000 entrants for training (allowing for those who cannot get through their courses), another 8,000 a year are required—20,000 entrants instead of 12,000 as at present.

Where are you to get your increase? We should all like to fill up these demands and extra demands by fully trained State registered nurses. That is the ideal of what we might call the diehards of the nursing profession, people who have the highest possible ideals for their profession and desire to see nothing else. But it is impossible to get that number. It is hoped that the general influence of the present movement for youth will help in getting nursing understood more and more, as I think it is being understood more and more in the schools, especially in the secondary schools, as offering a future for those who decide to follow that profession. All of us regard the work of the volunteer aid detachments of the Nursing Reserve in this war as invaluable, not only in bringing home to the public generally the very great value of these half-trained, if I may so describe them, or partly-trained nurses, even in the great exigencies of war, but also in bringing home to the public the fact that nursing is a fine profession for women to go into, one that gives them a value in the event of our being able to carry out all the different proposals which are now made.

In order to fill the gap, what can we do? We must make use of the assistant nurses. I think it was the hon. Member for the Park Division who explored the possibility of other names for the assistant nurse. We were constantly doing it on the Athlone Committee. I personally suggested that they should be called aids, as being quite distinct from nursing. That would have passed the highbrows of the nursing profession, but I am afraid the public would not have called them that, as they are called nurses and are nurses for ordinary purposes. These partly-trained people are doing good work in the chronic wards of the municipal institutions. I think it is a very good thing that they should be called nurses. Perhaps we could add some kind of adjective to show that there is a difference. It is not enough simply to have a name. They will be enrolled instead of being registered. We shall have so many registered nurses and so many enrolled nurses, and I believe the public will realise the difference and when applying for a nurse will ask either for an enrolled nurse or a registered nurse. They will not say "full nurse" or "assistant nurse," but they will know what the distinction means.

I do not quite understand what the hon. Member for Mile End (Mr. Frankel) meant about children's nurses, because there is a definite provision in this Bill to allow children's nurses to carry on their work and title. People will shorten the title, and you cannot help it; but the official title is there, and I suppose they must put it on the brass plate outside the door, not that they are nurses, but children's nurses, though I have never seen a children's nurse put out a brass plate. If they apply for a post, they must do so in the proper form. I was particularly glad, therefore, that, in addition to the main part of the Bill bringing in the assistant nurses, provision is made by which they shall carry on their practice under the best auspices of the General Nursing Council, who I hope will rise to the great possibilities there of training these women and giving them such training as is possible and—a very important point—making a proper ladder by which they can, without undue demands upon them, proceed from the position of the assistant nurse to the fully trained State registered nurse. We do not want them to have to go through a very long ordeal. At the same time we want them to show that they are worthy to be considered fully trained State registered nurses. That will be left to the General Nursing Council.

As we found on the Athlone Committee, there are many women splendidly suited for nursing who can never get through examinations and never get through the higher training for the higher positions and consequently will never be able to aspire to the position of a State registered nurse. There are others who can get through perfectly well with proper training, and I hope that will be allowed and the way eased for them. There is a little tendency for these bodies when they have power assigned to them to introduce so many forms, ceremonies, courses, examinations, lectures in order to avoid any possible infraction or deterioration of their regulations that they make it really unduly hard for people to get into their profession or get up the ladder. I hope that will be avoided.

Mrs. Tate (Frome)

I am sorry to interrupt the hon. Member, but is he suggesting that wherever people cannot pass examinations things should be made easier for them? Is that to apply also to the medical profession?

Sir F. Fremantle

I am afraid you would rule me out of Order, Mr. Speaker, if I were to go into the hon. Member's point about the medical profession, but I know she only wants to have a dig at the medical profession as usual. On the subject of the nursing profession, what I would suggest is that the course or examination and the provisions required by the General Nursing Council shall not be confined to Latin and Greek, so to speak, and to what are called the higher requirements of paper work, but that they shall allow a great deal of latitude for assistant nurses to prove their qualification for the State register.

I am so glad that in this Bill the Minister has taken the opportunity to deal with the agencies. There is really a great deal of scandal attaching to the agencies. I am not going to infringe on your Ruling, Sir, in supplying the details, though there are many interesting details which one could supply on that subject. On the other hand here you are dealing with the question of distribution. It is just the same thing as the matter of the small traders. You have to have the distributing agencies. The ordinary nurse has no idea as to how if she wants to engage in private practice she is to get suitable employment. In that and in assisting her to choose between different employers, agencies are doing a very useful and necessary work. We have to see that they do that work properly and do not get undue reward for it at the expense of the individual members of the nursing profession. I think there is a good deal to be said for this Part II. I have not yet quite summed up in my head as to how it will work out.

What will be the powers as regards applications for the licence? The hon. Member for the Park Division was speaking on that subject. I have an idea that there is sufficient provision; the licensing authority may refuse to grant such a licence. I do not know what the grounds will be. It says something with regard to their being unsuitable. It seems to me this is on a par with regard to legislation which was passed eight years ago dealing with nursing homes. There was a similar scandal attaching to nursing homes, which otherwise did a great deal of good work. We put through a Bill requiring the supervision, registration and inspection of nursing homes, and giving powers to county and county borough councils. I presume that similar machinery will be used in the case of these agencies. Good work was done in improving the position of the nursing homes, and I am sure that similar improvement would result among these agencies. We may require some alteration or amendment later on.

Finally, we come to the sister tutors. I hope that some attention will be given to the very minor Amendment which has been suggested—I do not know whether it has been suggested yet in this Debate, but it has been suggested outside—that there should be male "brother tutors"—we had better call them teaching nurses. You will need proper rules for them. The matter was brought home to me recently by a distinguished colleague who has gone from this House to the upper House, Lord Keyes, and by a surgeon-commander, retired, of the Navy, in connection with sick berth stewards in the Navy and corresponding men in the Army. The point was whether arrangements could be made to admit them in the full role of State registered nurses. I do not think that the negotiations have completely terminated, but I expect the Admiralty think that their provision for sick berth stewards is sufficient to qualify such men to be registered, while the Ministry of Health do not think that it is sufficient, because these men have not had the training, especially in regard to women and children, that is required in civil life. These men who come from the Services, however, at the age of 45 or so, can do useful work in civil life.

As to whether nursing should be a closed profession or not, the medical profession is not, and we do not want it to be, closed. Anyone can practise the profession and take fees—and people do so—as long as he does not hold himself out to be qualified according to the law. But the two professions which we have dealt with recently, the midwifery profession and the dental profession, are closed.

Mr. Deputy-Speaker

I do not think we can go into those professions. This Bill deals with nursing. We are getting very wide if we go into the question of other professions.

Sir F. Fremantle

I bow to your Ruling, Sir. That might come up on an Amendment later on. I will only say that the nursing profession should be as free, as open, as liberal, and yet as precise, as conditions necessitate. Subject to those considerations, I think that this Bill will be a material help to the hospitals and to the country.

Mr. Rhys Davies (Westhoughton)

I would not have intervened but for the fact that I was a member of the Athlone Committee. After that Committee had sat for a considerable time I was amazed to find what was happening in our hospitals, in relation to the nursing profession. This Bill is a very necessary Measure, and every Member who has spoken to-day has supported it. But I feel, in spite of the provisions of the Bill, that the Government, the General Nursing Council and the hospital authorities will have to probe still deeper into the problem. This is the only profession that I know of for which a young person leaving school may have to work in an office as a clerk or in a factory as an artisan until she is 17 or 18 before she can start on her new career as a nurse. I would like to know of any other profession or occupation where that practice prevails. It seems to me that the Government and the General Nursing Council will not settle this problem until they find means of putting the girl on the road towards nursing straight from school. How that is to be done I do not know, but administration can do many things in spite of the law. I do not want to be too critical of the General Nursing Council, but they gave our Committee the impression that if they could have their way no girl would be allowed to enter the nursing profession unless she had passed through a secondary school. The Board of Education representative told them flatly that there were not enough girls passing through secondary schools to supply the requirements of nursing after meeting the demands of the teaching and other professions. I trust that the right hon. Gentleman will be very careful about this point. He will not secure the necessary number of nurses, even with this Bill, until he bends his mind to the question of enrolling girls from the elementary schools. That was clear to the Athlone Committee. A remarkable thing that transpires in this country—I do not know whether it is the case in any other country—is that the person who does the most humanitarian, the most necessary, and indeed the most dangerous task often gets the least remuneration for his labour. The competition of other vocations and the conditions of employment of this profession are such that you will not get the necessary number of nurses until something is done to alter those conditions for the better. Another point that arose—and I speak with a little knowledge of this— was, why on earth do they erect these huge buildings called nurses' homes? What sense is there in a girl being compelled to live in a nurses' home when her own home is within a mile or two of the hospital where she is in training? I studied this problem a little in America; they do not do those things there. Why should it be allowed here?

Mr. Messer

In many towns the nurses' home is used only for those student nurses who come from a long distance away, and the nurses live out.

Mr. Davies

Yes, but that is not the practice in every town. In the probationary period they are expected to live in the nurses' home even if their own homes are quite near. I hope that the right hon. Gentleman will bear in mind the very important fact that a girl should be allowed to go home, or, at any rate, to lodge with relations if she likes, instead of living in one of these big nurses' institutions. I come now to the problem of examinations. We found that the General Nursing Council in establishing a standard of examination never took note of the law of supply and demand. If, for instance, you require 30,000 doctors—I appeal to the hon. Member for St. Albans (Sir F. Fremantle) on this—what is the use of setting a standard of examination under which only 10,000 can ever hope to pass? The standard of examination must always relate itself to the law of supply and demand. When the last war ended it was very much easier for an ex-Service man to pass through a university than would have been the case if he had never been in the Services. I know the right hon. Gentleman does not take any notice of what I say. [Interruption.] He looks in that direction, and I suppose that where he looks he listens.

Mr. McLean Watson (Dunfermline)

The hon. Member should withdraw that.

Mr. Davies

Why should I? Nearly everybody else has thrown bouquets at the right hon. Gentleman. I want to raise another point with the right hon. Gentleman in connection with the General Nursing Council. I understand that he will draw up regulations for the Council from this time forward. I have reason for referring to this, because the General Nursing Council the other day passed an extraordinary and amazing regulation, in which they arrogated to themselves the right to determine when a girl was ready to sit for examination whether she should be allowed to do so. I called the attention of the right hon. Gentleman to this fact; he made representations to the Council, and then they modified it a little. I do not know much about the General Medical Council, but I do not think that, with all its power—and it is one of the most powerful trade unions in the country; it can even bring Coalition Governments to their knees—it lays it down whether a student shall sit for an examination. It can say whether he shall be registered when he has passed the examination——

Sir F. Fremantle

The hon. Member does not seem to know the difference between the British Medical Association and the General Medical Council. The General Medical Council is not a trade union.

Mr. Deputy-Speaker

I do not think we need argue the point as to which section of the medical profession is a trade union. We should keep to the Bill.

Sir F. Fremantle

I rose on the point that one is a statutory body and the other is not a statutory body.

Mr. Deputy-Speaker

I rose on the point that we should keep to the Bill. It is not relevant to the Bill which section is a trade union and which is not.

Mr. Davies

I am glad that it was not I who was out of Order.

Mr. Deputy-Speaker

I was saying that the discussion on both sides should keep to the Bill.

Mr. Davies

I ask the right hon. Gentleman to watch the point to which I referred. It seems a little unfair that these girls should study for examination and then be told that they cannot sit. We ought, however, to have this problem of nurses in proper perspective. It must not be assumed that, because there is a shortage of nurses, the number is decreasing. Inded, it is increasing. The flow of probationers into the profession is increasing annually. The point is that the demand is increasing more than the supply. I hope that the Bill will do a great deal to settle the problem of providing the hospitals with an adequate supply of nurses. After sitting on that Committee for 15 months, I was very impressed with the work done by these women. There is no sufficient tribute that we can pay to them for what they do in looking after the sick. In wishing this Bill well, I trust that the nurses may get a better deal because the Bill has passed into law, and I hope above all that, in dealing with hospitals, nurses and doctors, we shall not forget the patients in respect of whom everything we do must in the end apply.

The Parliamentary Secretary to the Ministry of Health (Miss Horsbrugh)

On this occasion we may congratulate ourselves that there is a Measure before the House which is agreeable to, and considered useful by, every hon. Member who has spoken here to-day. The subject of the assistant nurse has been discussed on many occasions. When the Civil Nursing Reserve was formed at the beginning of the present war there were three sections in that Reserve, and there are still—the trained nurse, that is, the State registered nurse with her full training, the assistant nurse and the nursing auxiliary. The assistant nurse is with us in hospitals and in the Civil Nursing Reserve; we hear of her work in various ways up and down the country, but never before has she been defined. Having had a good deal to do with the Civil Nursing Reserve and seen a good deal of work in the hospitals, I agree with many hon. Members that some assistant nurses are excellent nurses. They have a real aptitude for nursing. They may not have had the aptitude for the training in mathematics or chemistry or something else sufficient to pass examinations, but one cannot dispute their real gift for nursing, and they are doing this good work. But there may be others who may call themselves assistant nurses, because there is no regulation as to the name, but yet are not suitable persons and are entirely without any form of training at all. As the hon. Gentleman the Member for Westhoughton (Mr. Rhys Davies) said, we have to consider and defend the patient who may apply for someone to nurse him and find that it is someone entirely without any skill whatsoever. Therefore, the necessity which was put forward by the Athlone Committee of defining and enrolling assistant nurses has been in the minds of many of us for some time.

I would like to make it clear that it is not that at this moment we are going to recruit assistant nurses. I want to recruit, and we are doing it, many more girls who can come in and take the full training as State registered nurses, but we also want to organise assistant nurses who are working now and to find out which organisations ought to have a title under the new regulation and which ought not. I want to make that clear, because some people have thought that this Bill has been brought forward owing to the difficulty of staffing our hospitals and that we want to lower the standard of nursing and to have assistant nurses. It is nothing of the kind. I want to see the status kept up. It is a very proud thing that the standard of British State registered nurses is the highest in the whole world. Such a nurse can get appointments all over the world because she is known to have had that high standard of training. I do not want her to come down, but there are many people who could assist in hospitals and in sick nursing and who can help the highly trained State registered nurse and who are doing so at the present time. These are the assistant nurses we want to enrol and put under the new scheme, so that those who do not come up to that standard may no longer be employed for doing work for which they are not fitted.

The hon. Member for North Camberwell (Mr. Ammon), in welcoming the Bill, asked questions on some points about the machinery for the Nurses Co-operatives. These details have been worked out pretty successfully for nursing homes and other institutions of various kinds. If the hon. Member will look at the particular Clause in the Bill, he will see that it is drawn sufficiently widely in order that the local authorities may be able to satisfy themselves on the work that is being done and how it is being carried on by the agencies. We find, and I quote the words: Subject…to such conditions as they may think fit for securing the proper conduct of the agency. If there are further points—and the hon. Member for the Park Division of Sheffield (Mr. Burden) also spoke on arrangements for these co-operatives—no doubt when we come to the Committee stage we can make the position clear. The fact, as the hon. Member said, is that the co-operative might have to inform the licensing authority what its tariff was; any other schemes that it had would probably come under the licensing arrangements. These points are details, and any difficulty can probably be dealt with on the Committee stage.

Mr. Messer

The chief point about which I was concerned was, that if, for any reason, a licence is taken away by one authority, it would be possible to go over the border into another authority and set up business again at once.

Miss Horsbrugh

We have already noted that point. I had something to do with a similar case of licensing when piloting a Bill on child adoption through this House. We tried to guard against this particular idea. The hon. Member for Putney (Mr. Linstead), in welcoming the Bill, also asked whether the General Nursing Council had any legal advice. I am informed that the General Nursing Council has legal advice, so that that should also be available for dealing with the assistant nurses. I do not agree with the hon. Gentleman that the fee of 2s. 6d. is not sufficient. He pointed out that if the fee were larger, the enrolment would be more popular and that it would look as though it were something of greater importance. But it has been a good arrangement with regard to State registered nurses, and I think we ought to keep it the same. The General Nursing Council, in being asked to undertake this work in addition to the State registration, will have the weight of its influence, as the hon. Member for Sunderland (Mr. Storey) has pointed out, to urge whenever possible that a nurse should take her full training. Their desire is that as many nurses as possible should take that training, and by having the assistant nurses' roll and the State register of nurses under the same authority we shall get more cohesion. Personally, I do not want there to be any idea that the assistant nurse is outside the nursing profession. Suggestions were made that the enrolment should be under the authority of the Ministry of Labour or Ministry of Health. I want the assistant nurse to be what the title declares her to be—a nurse assisting the fully trained nurse, and I think that keeping the matter under the same authority of the General Nursing Council will give both the nurse and the public a clear idea of her duties.

In spite of the rather stern remarks that fell from the hon. Member for the Park Division of Sheffield on the subject of the General Nursing Council, we ought to give this scheme a fair trial. I do not think that there need be any grounds for the fear that he has for the appointment on the Assistant Nurses Committee of a certain number of members from the General Nursing Council. If he remembers how the General Nursing Council is appointed, perhaps some of his fear will be put at rest. He also feared that the examination might be too difficult and that there might be too many regulations for assistant nurses, but I do not think that that will be so. The idea is clear as to what work she should be asked to undertake, and it is not to be up to the full standard of the State-registered nurse. But the enrolment of the assistant nurse is important so that persons without any training at all should not be doing some of the work they are doing at this time.

The hon. Member for Mile End (Mr. Frankel) felt rather upset about the children's nurse being allowed to call herself a nurse. I do not believe that it will make the slightest difference, if the hon. Member for Mile End or anyone in this House or the Government said that a children's nurse was not to be called a nurse, because she would still be called a nurse. The old tradition and common sense would still remain, and no law or regulation would prevent a nurse looking after children being called a nurse. We want to stop anybody without training as a sick nurse from advertising herself as a nurse to obtain employment.

Mr. Messer

Is there not now a category of sick children's nurses?

Miss Horsbrugh

There is the category of sick children's nurses, and that really is a class of nurses.

Mr. Woodburn (Stirling and Clackmannan, Eastern)

Would it not be a mistake to suggest that children's nurses have no special skill? Apart altogether from the sicknesses of children, it has become a very specialised training to bring up children in the proper way, and many of these girls have taken such training.

Miss Horsbrugh

There are, of course, training and examinations for nursery nurses as well. There are some children's nurses who have not passed examinations and who have not been to college who are doing extremely good work, as we have found. The actual definition goes as far as possible in the Bill, although the hon. Member for Mile End thinks that my right hon. Friend was rather timid in not actually trying to get rid of the old-fashioned idea of the children's nurse. But I think most hon. Members will be glad that that description is to remain. The hon. Member for Westhoughton spoke of nurses' homes and of training and of various other things to do with the nursing profession. I was interested in his description of his work on the Athlone Committee, but these are subjects which it would not be in Order for me to go into at the moment. The enrolment of the assistant nurse, the necessity for the Nurses Co-operatives to be licensed and other minor points are what we have to deal with to-day.

Although there has been this criticism—and I agree with much of it—on the subject of the nurses' co-operatives, do not let us forget that there are a good many which are doing extremely good work and are very particular. Among these I believe that there will be a very warm welcome for this Bill. They have selected their nurses carefully and have told patients to whom they send nurses the standard of their training. I think that they will welcome this provision, which will give more knowledge to the person who receives into his or her home a nurse to look after any member of the family during illness. It will give a chance to more people to be enrolled definitely as part of the nursing profession, which we all hold as one of the finest professions for women, who have been doing a job during the years of war which may not be spectacular but which, I believe, is second to none.

Mr. Messer

Can the hon. Lady deal with the point as to whether the male nurse will continue to be known as a nurse, and will there be an opportunity of his being registered so that he can be a nurse?

Miss Horsbrugh

I am sorry I forgot that point. There is a supplementary register for male nurses, and in connection with that I would tell the hon. Member for St. Albans (Sir F. Fremantle) that there could be male "sister tutors"—brother tutors, perhaps! We only know of one, and we will look after his interests, and if he has any other brothers we will try to look after their interests, too.

Sir F. Fremantle

Does he act as male sister tutor?

Miss Horsbrugh

I think that in the Bill under the heading of "sister tutors" the word "persons" appears, and the word "sister" is not used in the terms of this Bill.

Question, "That the Bill be now read a Second time," put, and agreed to.

Bill read a Second time.

Bill committed to a Committee of the Whole House for the next Sitting Day.—[Captain McEwen.]