§ Amendments made: In page 4, line 11, leave out from beginning, to "expenditure," in line 12.
§ In line 14, leave out first "the," and insert "a hospital."
§ In line 15, leave out "the," and insert "a hospital."—[Mr. Blenkinsop.]
§ Mr. Diamond
I beg to move, in page 4, line 16, at the end, to insert:incurred in respect of an institution approved by the Council for the purposes of the training rules and.Clause 4 deals with the expenditure on nurse-training by hospital management committees and by boards of governors of teaching hospitals, which expenditure relates to the training of nurses and provides that it shall be defrayed by the nurse-training committee. I regard this Amendment, as often happens to those who put down Amendments, as of fundamental importance, and I hope that I shall satisfy the House that that is not an unreasonable statement having regard to the misapprehension which I find is widespread with regard to the essential working of the whole of the Bill.
It has been pointed out from the other side of the House in a most helpful way, and in other places, that the Bill will not achieve what every one desires it to achieve if the Council, whose primary function is the setting of standards, finds that it is embarrassed by a clash between its financial function of helping in a measure to provide the wherewithal for the standards being reached and its main function of improving training facilities and approving hospitals for the purposes of training once that standard has been reached.
It is therefore clear that the Council should not at any time be required to consider any estimate unless that estimate relates to a hospital which has already reached the necessary standards and has, therefore, already been approved by the Council for the purposes of nurse training. It is essential that that should be so, and I believe it to be the intention on all sides that that should be carried out when the Bill comes into operation, but I do not find in the Bill any Clause which makes it clear beyond doubt that 779 that is the way the machinery is intended to work.
I have therefore put forward my Amendment to make it clear that the expenditure to be considered under Clause 4 is only that expenditure which is incurred in respect of an institution approved by the Council for the purpose of the training rules. Until they are sure that the hospital is so approved, any expenditure which it may wish to incur and have approved by way of estimates cannot be obtained through the General Nursing Council but must be reimbursed and the estimate must be approved in some other form and by some other machinery.
I hope that I am right in saying that that is the understanding and the whole intention. If that intention is carried out it will relieve anxiety on both sides of the House about this duality of function, I hope, therefore, that it will be possible for my hon. Friend either to accept this Amendment or to show me somewhere or other in the Bill where it is made clear beyond all shadow of doubt that that is the way in which the Bill is intended to work.
§ Mrs. Leah Manning (Epping)
I beg to second the Amendment.
My hon. Friend the Member for Blackley (Mr. Diamond) has already shown in his clear statement that these apprehensions are bound to occur unless the Minister can, by accepting the Amendment, or in the statement he now makes, be quite certain that a clarification of the whole position is given to the House.
§ Mr. Blenkinsop
Again I fully appreciate the point which my hon. Friend the Member for Blackley (Mr. Diamond) has raised, and I am quite satisfied that I can give him the assurance which he desires. It is quite true that Clause 4 does not specifically refer to training which is in accordance with the Council's training rules, but if my hon. Friend will refer to Clause 6 he will see that it is there clearly stated:All expenses incurred by an area nurse-training committee with the approval of the Council shall be defrayed by the Council.We are quite satisfied that makes the position clear and that it would be entirely within the powers of the Council to decline to approve any expenditure 780 in training which is not in accordance with their rules. There can be no doubt about that. I imagine that there should be no risk of those responsible for other forms of training being misled as the Council will no doubt make its policy clear at the outset. With that assurance, which I give quite clearly to my hon. Friend, that the matter is fully covered under Clause 6, I trust that he will feel able to withdraw the Amendment.
§ Mr. Diamond
Is my hon. Friend equally quite satisfied that in the case of those hospitals which carry on nurse training of a different type which is not and can never in the present form be approved by the General Nursing Council, proper machinery exists for them to be reimbursed without going to the General Nursing Council? Is he, therefore, satisfied that the General Nursing Council will never be embarrassed by applications from that kind of hospital?
§ Mr. Blenkinsop
I can give that assurance. It is not the intention that such an application should go through the General Nursing Council.
§ Mr. Linstead
The point which has been raised by the hon. Member for Blackley (Mr. Diamond) illustrates the sort of difficulty which my hon. Friends and myself foresee. I do not think that this matter will in practice be so simple and clear-cut as the Parliamentary Secretary suggests. There are surely bound to be institutions which are on the border line and in respect of which the General Nursing Council cannot give unqualified approval then and there, but is bound to say, "If you do certain things in the next year or two years we are prepared to give you approval." In order that those things may be done, that training institution has to find the finance, and so far as I can see it can only obtain that finance through the area committee and ultimately through the General Nursing Council.
I was perturbed when the hon. Member for Blackley suggested that no finance would be forthcoming for nurse training except in respect of institutions already approved. That seems to me to crystalise and sterilise everything. We shall face the situation that those institutions which are approved on a particular day are the only ones which can through this channel 781 obtain money for nurse training. I am sure that that cannot be the intention of the General Nursing Council or the Ministry. New schools must surely be opened, and there will for two or three years be a fluid period during which experiments will be tried. So far as I can see, the Minister has no channel for financing those experiments other than through this machinery which the Bill is now creating.
I hope that the Minister can say a few words about that and help us to see how experimental training schemes, when they are being built up to the stage justifying approval, are to be financed. The managers of those schemes cannot finance them and the General Nursing Council is apparently not prepared to finance them. Are we crystalising matters today or are there some transitional provisions which would enable the development to take place? I hope that the Minister or the hon. Member for Blackley can give us some guidance on this point, which seems to be fundamental.
§ Sir H. Lucas-Tooth
I was worried about this point before the Second Reading of the Bill, and during the Parliamentary Secretary's speech on the Second Reading I interrupted him to ask:Could the hon. Gentleman take the matter a little further? Would it be possible for a hospital to incur expenditure on the training of nurses which was not approved by the standing committee? Is prior approval an essential to the recovery of such payments, and is it possible to recover money spent without prior approval?The Parliamentary Secretary replied:I take it that prior approval will be required, as I think it ought to be."—[OFFICIAL REPORT, 21st October, 1949; Vol. 468, c. 960–961.]So that the Parliamentary Secretary clearly had it in mind that prior approval by what is now the area committee will be required for any training expenditure before that expenditure can be undertaken.
He has now said that there will be cases when approval by the Council of expenditure undertaken by a hospital will not be necessary. There seems to me to be a gap somewhere here, and I do not see how that gap is to be filled. It is a real difficulty. There is no point at issue between the two sides of the House in this matter. It is merely that it occurs to us that something is missing in the 782 machinery, and neither the hon. Member for Blackley nor the Parliamentary Secretary has indicated how that hiatus is to be filled. I hope that before the Bill leaves the House we shall have that point clarified.
§ Mr. Speaker
That leave must be sought and granted before an hon. or right hon. Gentleman can speak a second time at this stage. Not even the Minister can speak a second time except by leave of the House.
§ Mr. Diamond
Perhaps I might commit that immodesty and ask leave of the House to speak again in view of the invitation extended to me by the hon. Member, in order to explain that this "gap" really does not exist. I hope that hon. Members will keep in their minds a clear distinction between experimental training and training in approved hospitals. If the hon. Gentleman has in mind the difficulty which may arise in the matter of a non-approved hospital becoming approved I can assure him that it is something which happens all the time and the machinery for that would be continued.
The hospital requiring approval would in the normal way in future—not quite in the old way—get in touch with the area nurse-training committee and submit its application to that committee. That will come before the Council and if the Council are carrying out their normal function and are satisfied in regard to the matter, they will express their approval and communicate with the area standing committee of the hospital concerned. Until that approval has been granted, no estimates referring to training carried on at the hospital would come before the General Nursing Council.
§ Mr. Linstead
Before approval can be given, such things as blackboards, desks, equipment and accommodation have to be taken into consideration. Where does, the finance for such things come from?
§ Mr. Diamond
It was that very point which I had in mind when I asked my right hon. Friend for his assurance that there would be proper machinery and a proper route to be followed for applications for money in cases where the 783 hospital had not yet been approved. I was very glad that he could give me that assurance. Therefore the Council will not be concerned with a hospital until it has actually been approved. Approval is sometimes granted when a hospital has practically reached the necessary standard and all that is required is for certain things to be done over the course of the next few months. In such a case the hospital is told that, provided these things are done during the course of the next year everything will be all right, and approval is granted. That was what the hon. Gentleman called a borderline case.
The other case is that in which the approved hospital is carrying out an experimental training system. If the hospital is approved, the estimate will go to the General Nursing Council in the ordinary way. I am satisfied that it is essential that there should be that clear definition in the point of time at which the estimate has to come before the General Nursing Council. I am grateful to the Minister for making it clear beyond all doubt that the intention and the wording of the Bill carry out that procedure.
§ Mr. Blenkinsop
if I may speak again with the leave of the House, I should like to say that the Bill leaves the General Nursing Council full discretion to deal with expenditure in the building up of training schools to the required standard, as indeed they always have had. This is a matter, as my hon. Friend the Member for Blackley (Mr. Diamond) has said, which has constantly come before the General Nursing Council in the past. It will continue to be within their discretion as to precisely at what point they give their approval to a scheme for work to be done over a period in which a particular school has to be built up to a certain standard. That would be generally acceptable. I have also in mind that there are certain forms of examination which are not generally approved by the General Nursing Council at the present time, expenses for which might quite properly be borne by the general hospital administration expenses. I was trying to make that point when I referred to the other channel for expenditure.
§ Mr. Linstead
I am awfully obtuse about these matters, but I am afraid I can see the hiatus still existing. The 784 hon. Member for Blackley (Mr. Diamond) said unequivocally this morning that no money will be made available through the channel of the General Nursing Council except to institutions which have already been approved. I wrote the words down as he said them. Money for the building up process cannot come under maintenance expenditure because it has nothing to do with the staffing of hospitals—
§ Mr. Speaker
Order. The hon. Member is speaking a second time without asking the leave of the House.
§ Mr. Linstead
I am sorry, Mr. Speaker. I trust that the House will give me leave to do so. In one sentence I will ask the Parliamentary Secretary to say from what source the management committee or board of governors can get money for the building of a school up to the standard required by the General Nursing Council, in view of the fact that the General Nursing Council are not prepared to supply that money until the standard is attained.
§ Mr. Blenkinsop
I beg to ask the leave of the House to speak again. I think there has been a little misunderstanding. It has been the practice in the past for money to be made available for building up to the standard required. I understand that the general practice has been that the General Nursing Council, subject to certain work being done, has given its approval in certain cases. We must leave responsibility for that approval in the hands of the General Nursing Council. Obviously one cannot say in advance, without knowing the particular circumstances of individual cases, whether that approval will be granted.
We are not making any real change here upon the past position. I am pointing out that there will not be the hiatus that is feared except, of course, that there may be cases which the General Nursing Council feel that they cannot approve even if certain work is done. Obviously that discretion must be in the hands of the General Nursing Council. I was trying also to deal with the point regarding particular examinations, which at the moment should not fall upon the General Nursing Council.
§ Lieut.-Colonel Elliot
We shall need to see how this matter works out. The Minister says that we are not making any 785 change, but a certain change has inevitably crept in. This body will have a good deal of financing power. As we all know, in the grading up of hospitals the standard of teaching institutions has been one of the cardinal points around which argument and discussion have gone on for years, as the hon. Member for Barking (Mr. Hastings) will know, and particularly in regard to the grading up of local government institutions to the point of being teaching institutions. That has often been a very sore point in the past. Other outside bodies had great command of finance and could give great help to institutions of local authorities and to the great voluntary hospitals. These hospitals now derive their funds from central sources.
There is a certain danger of rigidity creeping in here, with respect to an institution anxious to reach the standard. Such an institution and its backers may believe it can reach the standard. The General Medical Council may think that the institution will not be able to reach that standard. In those circumstances the Council would not be able to approve of the proposed scheme, and a promising development may be stultified. We cannot foresee all those circumstances, and so we must watch how this matter works out.
The point raised by my hon. Friend the Member for Putney (Mr. Linstead) is very real. I do not think that the hiatus has entirely disappeared, despite the assurances on that point by the hon. Member for Blackley (Mr. Diamond) whose knowledge of the subject we all recognise. The assurances are not borne out by the facts given or by the circumstances which might arise, as the hon. Member for Barking and myself know very well. There are many cases where development has gone on for a considerable time and where the enthusiastic advocates of such and such a hospital becoming a training school have often had very great difficulty in persuading the powers that be that the hospital was on the way to being all that it had already actually become, an institution fit to be recognised as a training school.
However, again the Minister gave assurances, and we take them in all good faith. The hon. Member for Blackley gave assurances that he does not think that the contingency feared by my hon. 786 Friend would arise. We are at the beginning of a developing process and we must see how these things work out. My hon. Friend has done great service in calling attention to this matter.
§ 12 noon.
§ Mr. Hastings
I should like to put to the Parliamentary Secretary a specific case. Suppose that a regional hospital board decides to build a 200-bed hospital. In order to make it a complete hospital and to secure nurses as well, it decides to have a nurse-training school which must involve a certain amount of building. A lecture room, practical class rooms and so on, will be needed for the nurses, and desks, skeletons and other equipment will be required. I should like the hon. Gentleman to tell us whether the regional hospital board can apply for finances for this purpose.
§ Amendment, by leave, withdrawn.
§ Mr. Howard
I beg to move, in page 4, line 19, to leave out "Minister may specify," and to insert:Council may specify and the Minister approve.This Amendment follows the same general line of argument as has been pursued on other points earlier today. It is designed to get a clear distinction between the professional duty of determining what is right and proper for the training of nurses and the political duty of determining what money can be apportioned from the Exchequer to make that purpose possible. This Clause states that moneys can be, and are to be, set aside:wholly or mainly for the purposes of, or in connection with, the training of nurses; and of such description as the Minister may specify for the purposes of this subsection;I submit that while the Minister should give his approval, it is not for him to specify what type of equipment or activity is desirable for the purpose of training nurses. It is for the professional body to specify and for the Minister subsequently to approve.
It is always rather dangerous to give either real or hypothetical examples, but I should like to quote one example which has occurred in the past and which will 787 continue to occur in future. Let us take any hospital ward where there are student nurses. It may come to the knowledge of those responsible for the training of student nurses in that ward that they are not getting sufficient attention and guidance to enable them to learn their job. They may, therefore, request that an additional trained nurse should be introduced into the ward specifically to look after that matter. It may be argued that that is not the real reason. It may be said that there are inadequate nurses in that ward to look after the patients and that the real reason for the request for an additional nurse is not to improve the training of students but to improve the standard of the nursing of the patients.
As I understand the matter, if a difficult point like that arises—and it will, and does, come up every day—it will be the Minister or his Department who will decide what is to be done, because only a certain amount of funds will be available and the Minister is bound to be influenced by the amount of funds which are available in pocket A or in pocket B. It is my firm conviction that a point of that sort should be decided by the professional body and not by the Departmental authority.
I hope that I have explained this Amendment clearly and that it is one which the Government will accept. I remind the Parliamentary Secretary that during the Committee stage the Minister of Health intervened to say:We are endeavouring to see to it that the academic side of medicine is kept entirely separate, and that the provision of apparatus on the secular side is the obligation of the Minister of Health."—[OFFICIAL REPORT, 28th October, 1949; Vol. 468, c. 1689.]He made clear the need for a distinction between the professional and the academic and financial side. I hope that the Government will be able to accept this Amendment, which would make the position more clear than it is at present.
§ Mr. Blenkinsop
I think that there must be a misunderstanding about the main point of this Clause which is designed to ensure that the general administrative expenditure of a hospital shall be divided into two sections—nursetraining expenditure and other expendi- 788 ture which can be more properly left to the hospital administrative side and which will continue to be dealt with through the channels established by the National Health Service. The decision how that general expenditure shall be divided is surely not the proper responsibility of the General Nursing Council. I am sure that it is not one which that Council would wish to accept.
What we visualised was that my right hon. Friend would issue for general guidance the specification of the categories of expenditure which he would regard as coming within this provision. In many cases it is obvious that there are classes of expenditure which are connected partly with nurse-training and partly with hospital administration. If we are to ensure that this scheme works smoothly, as we wish it to do, we do not want to be involved in a great deal of argument about, this particularisation of the different categories of expenditure. Therefore, the duty is laid upon the Minister to specify the categories.
For example, he would not specify a new training school, but he would specify in general that that was one of the categories of expenditure that he would consider even though that type of expenditure might also involve other hospital administration work. It might be used for many other purposes. It might be decided finally that the other purposes for which it was used took it out of category A as being wholly or mainly for the purposes of training.
I suggest that this Amendment would give to the general Nursing Council a responsibility for splitting up general expenditure which cannot be the responsibility of the Council and must be the responsibility of my right hon. Friend. The criterion which he will use in judging whether a certain form of expenditure should fall into nurse-training or should continue to be dealt with through the ordinary hospital accounts under the National Health Service must be decided partly by administrative convenience in order to avoid any difficulties which might otherwise arise. For example, we would suggest that the general payment for nurses in training should probably not fall upon this particular training part of the expenditure; otherwise, it would completely overwhelm the smaller items which we are anxious should not be sub- 789 merged and destroyed. That is the sort of issue which is bound to arise, and for that reason it is a matter which must be left to my right hon. Friend.
§ Sir H. Lucas-Tooth
I appreciate that there is a good deal in what the Parliamentary Secretary has said in regard to the responsibility for dividing up these expenditures, but I am not altogether certain that it will be as easy as he contemplates for the Minister to deal with this matter in the way that is proposed. I should have thought that a great deal of the expenditure might be regarded either as wholly for the administrative purposes of the hospital or wholly for training, according to the purposes for which the expenditure is incurred.
I do not see how, in advance, we can possibly give some general description of the expenditure which will cover not only the nature of the expenditure but the motive for which it is incurred. I do not see how that will be possible. I should have thought that in all cases of this kind it would at least be necessary for the Minister to have a good deal of consultation with the Council. As the Clause is now drafted, this appears to be the sole responsibility of the Minister, and I did not hear anything from the Parliamentary Secretary to suggest that, before he issues his general directive, as I think he is going to do, he will consult the Council.
§ Mr. Blenkinsop
On that point, I agree that my right hon. Friend would consult with the General Nursing Council, but the responsibility must, I am quite sure, rest with him.
§ Sir H. Lucas-Tooth
I am not certain that that is the case, but it is largely a matter of words. If the Minister gives a plain undertaking that he will consult them, it is merely a question of initiative—whether it lies with the Minister or with the Council—and I am not disposed to quarrel with the proposition that the ultimate responsibility must be that of the Minister. In view of that undertaking, I think the House may now be satisfied that the position will be more satisfactory.
§ Amendment negatived.
§ Amendments made: In page 4, line 22, leave out "standing," and insert "area."
§ In line 22, after "committee," insert "for the area."—[Mr. Blenkinsop.]