§ Mr. Blenkinsop
I beg to move, in page 4, line 14, to leave out "or," and to insert "and expenditure."
This Amendment and the proposed Amendment to line 15 are of a drafting nature. It might be possible to consider the Clause as referring to a hospital management committee appointed by the board of a teaching hospital, although that is very unlikely.
§ Amendment agreed to.1676
§ Further Amendment made: In page 4, line 15, after "being," insert "in each case."—[Mr. Blenkinsop.]
§ Sir H. Lucas-Tooth
I beg to move, in page 4, line 25, to leave out subsection (2).
This is an important Amendment, and indeed I think it is the most substantial on the Amendment paper. I assure the Parliamentary Secretary that I do not move it dogmatically. I regard the Amendment as little more than drafting if the effect of the Clause is such as I imagine it to be, but I think it true to say that there is a great deal of doubt, not only among hon. Members but on the part of those who will have to operate the Bill, as to how it is intended that this Clause shall work. The purpose of the Bill as a whole is really centred on this Clause and is to separate the responsibility for the training of nurses from the employment of nurses.
It is quite clear from what was said on Second Reading that that purpose is completely agreed in all parts of the Committee; but we did not on Second Reading discuss the question of how that purpose was to be carried out. I invited the Parliamentary Secretary at that stage to give some indication of the way in which he contemplated that the machinery outlined in this Clause would work when it came to be put into operation. He, perhaps wisely, declined at that stage to go into the matter. We must now, however, on the Committee stage really ask the Government to tell us clearly what they think will be the way this scheme will actually work, not only for the purpose of considering amending this Bill but also to be some sort of guidance to those outside the House who are following these matters, and who will in due course have to try to give effect to the intentions of the House in passing this legislation.
The nurse-training committees are given the power and the obligation to do two things. The first is to lay down a training programme for nurses for the hospitals within their area. The second is to pay for the carrying out of that programme by funds which are ultimately derived from the Government through the Council. There are two questions which I wish to put to the Parliamentary Secretary on that matter, because they are extremely relevant to the general question 1677 of the application of this Clause. The first is whether a hospital can do any training of nurses which has not previously been approved of by the nurse-training committee? I think that the Parliamentary Secretary indicated on Second Reading that a hospital could not do so. If that is the position, I am rather apprehensive that there may be some tendency to find that this scheme is what the Minister of Health would describe as muscle-bound.
The other question that I wish to ask the Parliamentary Secretary is whether all disbursements which fall to be made in respect of training will be made by the hospitals themselves or whether the nurse-training committee will be able to carry out the scheme within the walls of a hospitals? It is extremely important that the actual training should be carried out completely by the hospitals and that the only financial transaction should be the recoupment to the hospital of a total sum through the nurse-training committee.
The practical difficulty is due to the fact that there must be a large area of overlap between the training and employment of nurses; that is necessarily so from the nature of the problem. There will be a great deal of expenditure which is partly for training and partly for employment purposes. Where that overlap occurs and there are two different bodies responsible for policy and payment, there is obviously a danger of a real conflict. It is that which we should by this legislation seek to avoid and make as improbable as possible. The kind of question which occurs to me—here I cannot speak with the same knowledge as some of my hon. Friends or some hon. Members opposite who have experience of this matter otherwise than that as a governor of a hospital, which is all I have—is that a hospital might require 50 nurses in training for purposes of employment and the nurse-training committee might decide that for purposes of training only 30 nurses should be in training in that hospital. That is quite a possible circumstance. Both the hospital authority and the nurse-training committee might be right. In such a situation there will be a conflict which has somehow or other to be reconciled.
Supposing the nurse-training committee is able to say "You should not employ 1678 more than 30 nurses in that hospital because you have not the proper facilities for training more than that number," and the hospital really cannot do its work properly unless it has more women and can only get them as nurses for training, what is to happen? That is a question which will crop up when the scheme comes into operation. I should like to hear from the Government how they think that that sort of question will be reconciled in practice.
The scheme of the Bill, as I understand it, is that each hospital will formulate its own estimates for expenditure on nurse training, it may be for the next year or for a period of years. After the formulation of those estimates, there will be discussion between the hospital and the nurse-training committee, and in due course the estimates will be approved. Each nurse-training committee, when it has its own completed set of estimates for the hospitals within its area, will no doubt compile a consolidated estimate which it will in turn have to discuss with the Council. In due course the Council will have a complete set of estimates for the country which will go to the Ministry of Health for approval. That is a reasonable enough procedure and it is one that is desirable.
After the approval of the estimates by the Minister of Health I should hope that there will be nothing in the nature of interference from above; in other words, that once the estimates are approved all that will remain to be done as between these various organisations will comprise general supervision on the part of the Council over the training of nurses and general supervision by the nurse-training committees over the hospitals within their areas. That seems to me to be a desirable set-up at which we should aim. I believe it is the set-up which the Government have in mind, although I believe it is not the set-up provided for in this Bill as now drafted.
I ask the Committee to look at the phraseology in this Clause, because I shall try to show that it would be impossible to work out a scheme on those lines in accordance with this phraseology. The part of the Clause which I wish to quote, stripped of the drafting phraseology, reads: 1679… expenditure by a Hospital Management Committee … being expenditure—The point to which I draw the attention of the Committee is that under subsection (1) of this Clause, which I have read, we are concerned only with expenditure which has already been specified by the Minister as expenditure which can properly be incurred for the purpose of training nurses. That is the effect of subsection (2).
shall, so far as it is incurred in accordance with estimates approved by the … nurse-training committee, … be defrayed by that committee.
- (a) for the purposes of … training … nurses; and
- (b) of such description as the Minister may specify …;
§ 12 noon
§ Mr. Blenkinsop
Perhaps I should explain that paragraph (b) does say "of such description." That is the general description of the type or category of expenditure rather than the precise detail.
§ Sir H. Lucas-Tooth
I appreciate what the Parliamentary Secretary has said, and I am grateful to him. I only wish he had said this on Second Reading, because we have been in very great difficulty. I asked him for an explanation then and he did not give one, with the result that we must thresh out the matter in Committee.
As I understand the interjection of the Parliamentary Secretary, it is that the Minister intends to give some general description of the kind of expenditure which may be approved by the training committees for the purpose of training nurses. At this stage I might ask him whether that is to be something in the nature of an instruction given privately—I do not mean without the knowledge of those concerned, but by circular letter or otherwise to individual training committees—or is it to be done by some general order which will come up for discussion in the House? I imagine that it will be a specification of a fairly general and wide kind.
§ Mr. Blenkinsop
It would be the intention to issue first of all a general indication of the categories of expenditure which my right hon. Friend would regard as coming within paragraph (b)—the types of expenditure that he would regard as coming within the nurse training fund. 1680 It would be possible technically to separate it from the general administrative expenses of the hospital, because that is really the point. There are many expenses which may be regarded as connected with nurse training which it would be impracticable and unreasonable to separate from general administration expenses. Therefore, the purpose would be to set out in general terms the categories of expenditure which the Minister would regard as being separable and properly chargeable for this purpose. That would be the first step.
§ Sir H. Lucas-Tooth
I am obliged to the Parliamentary Secretary. Now we come to this point, that there will be some general indication given both to the nurse-training committees and to the hospitals as to the kind of expenditure which might be included in a scheme and might be included in payments to be defrayed through the training line of payment, if I may so call it. That must be available before any payments are submitted. It would be impossible to frame them without such information. After the information is given, there will be the question presumably of working out the estimates on the kind of lines indicated in my speech; so that there will be a second opportunity, so far as expenditure is concerned, for the estimates to be considered by the Ministry of Health. There is no question therefore of financial control. The financial control exists by the ordinary machinery of payment. The difficulty I have is in seeing why it is necessary to put in some provision for specially referring a question of expenditure under subsection (1) to the Minister.
§ Mr. Blenkinsop
Perhaps I can explain that now. A point might very well arise—this is merely where there is a difference of opinion which is to be—
§ The Deputy-Chairman
I think it would be better if the hon. Member for South Hendon (Sir H. Lucas-Tooth) moved his Amendment and then the Parliamentary Secretary replied, rather than that the Parliamentary Secretary should intervene now.
§ Sir H. Lucas-Tooth
I must apologise if I invited the Minister to join in a somewhat irregular Debate. The difficulty we are in is that we have not had previous information from the Government. I do not complain, because this is a difficult 1681 matter with which to deal except in Committee. My objection to subsection (2) is that it contemplates the reference of two questions to the Minister which should have been resolved either by the general instruction given in advance of the payments or at the time of the formulation of the estimates. I cannot see why it should be necessary to have this special provision in the Clause as it stands.
Subsection (2) of this Clause appears to be in conflict with Section 7 of the Bill. Subsection (2) provides that any question arising with regard to expenditure shall be determined by the Minister, but Clause 7 of the Bill provides that any question arising between a nurse-training committee and a hospital relating, as the Bill is now drafted, to the exercise of the nurse-training committee's function under the Act:shall, in default of agreement, be determined by the council.It is true that subsection (2) of Clause 4 relates to questions of expenditure, whereas Clause 7 is entirely general; but I think that in the case of this sort of machinery there could be no question which does not involve expenditure, and obviously far and away the most important will be questions of expenditure. I consider that there is a serious conflict between these two parts of the Bill. It may be that there is something which I have overlooked, but I know there are doubts felt outside this House as to the way in which these questions will be dealt with. They obviously cannot be dealt with both by the Minister and the Council, and I should like to have an explanation from the Government of how they contemplate dealing with a mixed question involving policy of training and expenditure, having regard to the two different provisions of these two parts of the Bill.
§ Mr. Blenkinsop
I am grateful to the hon. Member for raising this matter. We would not wish that there should be any doubts about the operation of this Clause, and I am grateful for the opportunity to deal with it. It is essentially a matter which we can discuss most usefully in Committee.
As I mentioned earlier, it is the intention of my right hon. Friend first to issue general information as to the categories of expenditure that he would regard as coming within paragraph (b); not only, 1682 of course, the sister tutors, expenditure on lecturers and others who would be required and general categories of expenditure of that kind, but it might very well include certain types of building, such as provision for classrooms, and so on. The hospital management committees and boards of governors, in framing their budgets for nurse training, would have regard to these specified types of expenditure which will be open to variation from time to time. Obviously there will need to be variation after experience of the work.
On submission of this budget from the hospital management committees and boards of governors, the new regional committees, which would of course have representatives of the boards of governors and the regional hospital boards, will consider those estimates. Possibly there may be some disagreement both on points of expenditure and on other matters of general policy, but it will be our hope that naturally we will get agreement in the regional committee that has been set up. We do not expect matters to be continuously sent up for final decision to the General Nursing Council or the Minister. The type of point which we have provided for here, upon which the Minister is to give a decision, is the case where we might assume that a hospital management committee has included in its training budget an expenditure which is within the general category of expenses laid down in the circular sent out by the Minister; for example, some new teaching centre, which, in view of the facts in the particular case, may also be used for many other purposes of general hospital administration.
It is for that reason that the regional committee might feel that it was not a matter that should be included in the training budget but one that ought to be included in the general administrative expenses of the hospital. That is the type of matter that would go to the Minister to decide—whether it should fall within training expenses or within the general hospital administrative expenses. For that reason, we feel that subsection (2) is necessary, because it does carry out a function additional to the other powers of the Minister.
§ Sir H. Lucas-Tooth
May I interrupt the hon. Gentleman? Where there is expenditure which is clearly partly train- 1683 ing and partly administrative expenses of the hospital, does the Government contemplate that the Minister should be able to divide it up?
§ The Minister of Health (Mr. Aneurin Bevan)
Yes. It is perfectly clear what is intended here. In this Bill, as a matter of fact, we are providing what is available already in the National Health Service. 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. What has to be determined is where the expenditure should lie, and the Minister will decide it, while the General Nursing Council itself will decide matters relating to training.
§ Mr. Howard
The last words of the Minister are the most valuable and important, from my point of view, that I have so far heard in this Debate. I am regarding this purely as a rather difficult practical matter. There is no disagreement of any sort between any hon. Members of the Committee as to the importance of dividing, so far as they can be divided, the different functions of the employment of nurses and their training. We all welcome this Bill, and we hope it will be successful in achieving that difficult object, but there has been a good deal of difficulty in defining clearly the difference between the professional function of saying what is right and proper and the political function of determining how much money shall be made available for the carrying out of that purpose.
What the Parliamentary Secretary said frankly alarmed me, because he made it perfectly clear that the Minister was going to determine this question, and he made no reference in his reply to the fact—and, presumably, it is a fact—that, before making up his mind on a point of that character, he would consult the General Nursing Council. He never mentioned them, which shows, without being at all offensive, that there is a danger of the "administrative convenience" Departmental attitude creeping in. What the Minister said was quite a different thing. The General Nursing Council are the people who must decide what sort of functions apply or what sort of apparatus is in their view desirable for training. 1684 Having decided it, no one disputes the right and necessity for the Minister preserving the position in which he can say "We cannot, unfortunately, provide the money for this, desirable as it may be."
What I am anxious to get absolutely clear is that the authority which shall set out what is considered the best possible thing for nursing training shall be the General Nursing Council and not the Minister. I ask the Government to look at the Clause again, and to consider whether, between now and Report stage, they will not be able to make this point absolutely clear by an Amendment to subsection (1, b). The Minister has put down a new Amendment in the interpretation Clause dealing with the word "prescribed." It may seem irrelevant at the moment, though it is not, because the introduction of the word "prescribed" refers to the rules which may be made by the General Nursing Council and the way in which they are to be made. They have to be approved by the Minister and presented to Parliament, so that there is full control. I suggest to the Minister that he should consider altering subsection (1, b), and, instead of saying—of such description as the Minister may specifyshould sayof such description as may be prescribed.That would mean that the General Nursing Council would have the responsibility placed upon them of laying down what they think should be specified, but that cannot possibly come into operation until the Minister has approved these rules, which would still be subject to being laid on the Table of the House. That may be too complicated, however, and the Minister might well use the very general term "specified"; but it is most important that we should know what it means.
I repeat that it is vitally important to get into the Bill both the fact that the determination of what is desirable from a professional point of view, and the question of what is best for the training of nurses, shall be a matter for the General Nursing Council to decide, and that what the Minister should do is decide how much money he can make available for the purpose. It should not be a Departmental responsibility to decide a matter 1685 which should really be the responsibility of a proper professional authority.
§ Sir H. Lucas-Tooth
I listened carefully to what the Parliamentary Secretary said, and I certainly have no desire to press this Amendment, which in itself is not much more than a peg on which to hang the discussion. The Parliamentary Secretary has gone some way to clear our minds on this point, and, in seeking leave to withdraw this Amendment, I would say that we shall consider carefully what he has said, and, if necessary, put down Amendments at a later stage. We are grateful to him for his explanation, which has carried us some way. I hope the hon. Gentleman listened carefully to what was said by my hon. Friend the Member for Westminster, St. George's (Mr. Howard) and that he will give consideration to it before we reach another stage, in order to see whether it may be possible to put down further Amendments on the general lines which I have indicated. In those circumstances, I beg to ask leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Motion made, and Question proposed, "That the Clause, as amended, stand part of the Bill."
§ Mr. Howard
I want to say one word on the Question "That the Clause stand part," which I did not wish to introduce into the discussion on the Amendment for fear of making a rather involved position even more involved. There has been some discussion on the part that teaching hospitals should or should not play in the standing nurse training committees, and I want to make it clear, as one closely associated with all the teaching hospitals, that so far as I am concerned as well as those with whom I am in close contact there is no desire whatsoever to isolate them from these proposed new committees.
Everyone concerned with the teaching hospitals must know that it is of vital importance to them that they should be in the closest possible touch with every person and body connected with medicine and the nursing world. Having said that, I would point out this one great difficulty—there will only be a certain amount of money available for this nurse training purpose. It will be doled out through the General Nursing Council to the regional standing nurse 1686 training committees. That having happened there will be the inevitable danger of those regional committees trying to equalise the grants they have to make. It is a fact, of which I am sure the Minister and his Parliamentary Secretary will be aware, that there is bound to be a larger number of nursing staff in a hospital where there are medical students than in a hospital where there are none.
The trained nurses engaged there have not only the duty of looking after their patients and student nurses, but they have also some association with the medical students. Any medical man in the House would agree, so far as medical practice is concerned, that, as students, they learned as much in the approach to the patients from the ward sisters and trained nurses with whom they came in contact as they ever did from the most emminent of their professional colleagues. It is an indisputable fact that, if the work of the trained nurses in hospitals where there are under-graduate students in particular, and if the care of the patients and the supervision of the student nurses are to be carried out properly, there is bound to be a larger staff.
If we look up the figures in these circumstances it will be found that there is an apparent disproportion between the number of nursing personnel employed per ward, per bed, in a teaching hospital to the number in a non-teaching hospital. Before we pass from this Clause, I hope that the Minister or his Parliamentary Secretary will say in general terms that he recognises the truth of the facts which I have stated today, because that may help to get over a really great danger in the future, when there is not enough money available to satisfy everyone, of it being distributed on an equal basis instead of on the basis of making certain that necessary functions are carried out as far as possible.
§ Mr. Bevan
I could, without any difficulty at all, make a short statement about what the hon. Gentleman has just said. It would, of course, be quite silly for the hospital system as a whole to say that all hospitals, no matter where they are, no matter what kind of cases they are treating, would require the same number of skilled nurses. That is part of the difficulty of costing the hospital system. It would be quite easy if we could say that there were so many patients per bed, 1687 and as a hospital has so many beds its ration of nurses amounted to so many. In that event the costing and control of the hospital administration would be as simple as selling pounds of margarine across the counter. We all know that is not the case. It is very difficult to find comparable hospitals. We shall, of course, confine it as much as possible so that costing systems are subject to identification and will show where gross extravagances take place. However, we have to have regard to what a particular hospital is doing, the kind of patient population that it has, what are the specialist needs of the hospital, and, of course, in this regard a teaching hospital occupies a peculiar position.
§ Mr. Howard
I am most grateful for what the Minister has said. He obviously sees the point I made, and he has dealt with it as fully as one could expect in present conditions.
§ Question put, and agreed to.
§ Clause, as amended, ordered 10 stand part of the Bill.
§ Clauses 5 and 6 ordered to stand part of the Bill.