§ 10.10 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
I beg to move,That an humble Address be presented to Her Majesty, praying that the Nurses (Amendment) Rules, Approval Instrument, 1960 (S.I., 1960, No. 409), dated 11th March 1960, a copy of which was laid before this House on 17th March, be annulled.The purpose of this Instrument is to re-establish, in two years' time, a minimum educational qualification—a somewhat modest qualification; two passes at "O" level—for entry into the nursing profession, or into the greater part of that profession. I use the word "reestablish" because there was an educational qualification in existence up to 1939. It then went into abeyance, and has been in abeyance ever since. A change of this kind involves a change in the Nurses Rules, and that, in its turn, requires the approval of the Minister under Section 32 of the Nurses Act.
I say at the outset that I understand the motives of the General Nursing Council in seeking the Minister's approval for an Instrument of this kind. The Council is very naturally concerned— some of us might think that, on occasion, it is a little too concerned—about the status of the nursing profession. I believe that we are one of the comparatively few countries—at any rate, one of the comparatively few- advanced countries—that does not have an educational qualification for nurse entry.
That does, on occasion, place our nurses at some disadvantage in other countries, notably in the United States. On the other hand, it is true to say that the reputation of the training of nurses in Britain is such that there is very seldom any real difficulty in a British-trained nurse obtaining a job overseas appropriate to her qualifications and experience.
I gather that the Council has also been worried about the level of wastage amongst student nurses, particularly in the early months of their training—I agree that that has been and, indeed, is a serious thing—and it believes that the introduction of an educational qualification would tend to eliminate this wastage. In this belief, I believe that 1404 the Council is mistaken, because there are very many causes of this wastage.
It may occur because a girl finds herself temperamentally unsuited to nursing; she may not like the work; she may fall for the attraction of some other, more convenient, less arduous and perhaps better paid job. And, perhaps, more than for any other reason, she may decide to get married. Therefore, in my view, only a minority of nurses fall out of their training because of any inability to measure up to the intelligence required to pass the examinations.
There are some moderately stiff hurdles to be surmounted in the three-year course—indeed, I think that some are a little too stiff—but nearly all matrons when accepting student nurses in the first instance apply their own intelligence standard, either formally or informally, before actually accepting a girl for training. Therefore, it seems to us on this side that there is no compelling reason for the introduction of this Instrument at this time.
Paragraph 3 (2) of the Schedule to this Instrument says that an applicant shall not be admitted for training… for registered general nurses, or for registered sick children's nurses, or for registered fever nurses unless…she holds a General Certificate of Education…There is one very significant omission there. The Instrument does not mention mental nurses. There has been, for a very long time, a somewhat deplorable tendency within the nursing profession, at any rate among the higher echelons of it, to regard mental nurses as a class apart.
I do not wish to exaggerate, but in some quarters they are almost regarded as second-class nurses. Indeed, I know of general hospital matrons who refuse to allow their student nurses to be seconded for training in mental hospital work because they do not want their girls to come in contact with mental nurses. The Royal College of Nursing itself practises a kind of professional apartheid in this matter by refusing to admit psychiatric nurses to full membership of the College.
All this has been happening in face of the fact that the work of the mental nurse constitutes in theory and very often 1405 in practice a more positive part of the therapeutic process than the work of the general nurse. I imagine that it will be generally agreed that in mental hospitals the nurse-patient relationships which may be developed form an integral part of the treatment of the patient.
Many of us have for years fought this reprehensible attitude on the part of some sections of the profession. We have recently welcomed signs that this attitude has begun to change at last. It is common knowledge that the General Nursing Council, in putting forward its proposals to the Minister, wished the Instrument to cover all types of nurses.
The current number of the Nursing Times, the official journal of the Royal College of Nursing, in its editorial, says quite categorically:… it is unfortunate that those who are training to care for the mentally sick are not required to have the same standard of education as those caring for the physically ill.A little later, it says:This is a short-sighted policy which does not augur well for the future, for even if the mental training schools adopt the Council's entrance test on their own initiative (as the Minister suggests) patients and would-be candidates may think the training offered is second best.The Minister, in face of this rather striking change of attitude on the part of the College and the General Nursing Council, has made a decision which perpetuates all the old prejudices and appears, at any rate, to support the idea of a two-class nursing system. In any case, I should have thought that the exclusion was illogical since the requirements of the preliminary State examination are, I believe, the same for both types of nurse.
Why has the Minister gone against the advice of the General Nursing Council and excluded mental nurses? The answer is no secret. His advisers know full well that, despite recent improvements, recruitment in mental nursing is still proceeding at a far from adequate level. They know, also—no doubt, they have so advised the Minister—that it would be inviting disaster to erect, so to speak, an educational barrier which might exclude many potential recruits who would ultimately make admirable mental nurses.
There are many excellent mental nurses and, I believe, general nurses, too, who have the right sort of temperament, the 1406 energy, the understanding and the intelligence, to do the nurse's job admirably, but who lack the educational qualifications and, perhaps, even the kind of educational aptitude which would be required to obtain them.
I must confess that I agree with the Minister's reasons for excluding mental nurses. I agree that recruiting would suffer if the Instrument were made to apply throughout. It would be highly dangerous at this stage to limit in any way the intake of mental nursing students. But, of course, there is the other side of the picture. The status and prestige of the mental nurse within the profession will be further damaged by this new distinction which has been introduced, and this in itself will have a detrimental effect on recruitment. I do not myself believe that it will be as serious as it would have been if the educational qualifications had been insisted upon.
I take these two arguments together. The first is that it is quite deplorable that there should be this differentiation, and the second is that if mental nurses were covered by this Instrument it would, in fact, have a deplorable effect on recruitment. Taking these two arguments together, I can only come to the conclusion that it is quite wrong to introduce an educational standard, at any rate at present.
I would go further. I believe that there are strong arguments against the introduction of this standard even in general nursing. I believe that it will have a serious effect on recruitment there, too. Most of us who have had anything to do with the hospital world know that the nursing profession is led, some would say even dominated, by the views and attitudes of the London teaching hospital matrons. This is perhaps inevitable because those matrons are, naturally, at the head of their profession.
In the London teaching hospitals there is no recruiting problem and, as far as I know, there never has been a recruiting problem. Those matrons are in the happy position of having a long waiting list of girls who want to train and get the cachet of having been trained at a London teaching hospital. They are able to pick and choose and they pick and choose girls with the best education and 1407 sometimes from the best families. It is very natural that girls should wish to train at the great London teaching hospitals. The training schools have a first-class reputation, and the work there may not be as arduous as it is elsewhere because the patient-nurse ratio is about one to one in many of the hospitals, and there are many social and recreational advantages which they do not get elsewhere.
Indeed, some of the matrons of the London teaching hospitals are able to operate their own educational qualifications. I know that from the case of a young woman I know quite well who, some years ago, wanted to take up nursing. She tried to obtain an interview at a certain London teaching hospital, but because she had not taken the G.C.E., owing to the vicissitudes of her education during the war, when she was moved from one part of the country to another, she was not granted even an interview by that matron. Fortunately, she went to another hospital where the matron took a slightly different view and she came out top, or second to top, in her finals. This shows how these privileged hospitals are able to pick and choose their student nurses.
What happens in the hospitals of the industrial areas of the North? They have never been able to pick and choose. They are forced, if they are to have any student nurses, to take nearly all comers, provided that they show some aptitude for the profession of nursing. Having done so, they do their utmost to turn them into good nurses and I think that they have succeeded in doing so.
But not only in those areas have there been difficulties. In one Metropolitan area, in the comparatively privileged South of England, I have been making a few inquiries and I find that of the total students at present undergoing nurse training no fewer than 17½ per cent. are from colonial territories. Then there are others who come from the independent Commonwealth countries and from European countries such as Germany, Italy and Spain. On a conservative estimate, the number from abroad is probably between 20 and 25 per cent. of the total number of student nurses, and few of those would qualify for entry under the proposed rules.
1408 Yet the hospital service depends on them not only to provide the future trained nurses we need, but also currently to staff the hospitals. That is in one of the most favoured parts of the country. I ask the hon. Lady the Parliamentary Secretary how far the regional hospital boards have been consulted about these proposals and to what extent the views which they expressed have been taken into account in reaching a decision.
In short, I think that these rules will have a deterrent effect on recruiting for general nursing, but I have discovered that that is apparently the intention of the General Nursing Council. I quote again from the editorial which I mentioned earlier:The policy of the G.N.C. for the future is to train more nurses for the Roll and fewer for the Register.That is an extraordinary volte face on the part of the nursing profession, because for many years both the Royal College and the General Nursing Council had looked rather askance at the State enrolled assistant nurse and had even been at pains to emphasise that that grade arose simply out of wartime expedient. Certainly, there had not been any encouragement whatever to extend the roll in the past. They showed no wish to see any new intake of enrolled assistant nurses—rather the contrary. Now we have this very different attitude. I wonder whether this will work. I wonder whether it is possible now to revive confidence in this grade of enrolled assistant nurse. I wonder whether there will be anything like the adequate recruiting that they expect and hope for in this grade.
I am afraid that we may well be in the danger of finding ourselves at the end of the day with a small, highly trained elite in the nursing profession and a quite inadequate rank and file to back it up. We may be building up what we used to say about the old Spanish army—all generals and no troops—and that could lead to a quite dangerous staffing crisis in the hospital service.
It may be that, in the long run, these rules will lead to placing the interests of training before the needs of the patient. I have never believed that entry into any profession ought to be limited to those who could be expected or might 1409 be expected to reach the top. If I may use the military analogy, I do not think that it is necessary for someone to have a field marshal's baton in his knapsack in order to be accepted into the Army in the first place as a private. In the nursing profession, we need large numbers of nurses who will do their job admirably, but who might never be expected to become matrons of large hospitals.
Judging by the length of time that the Minister has been cogitating over these proposals since they were first put forward by the General Nursing Council, I can see that he has no great enthusiasm for them. In the end, he has put forward what I can describe only as a rather wretched compromise which is at best premature and ill-timed. I hope that, in view of what I have said, and in view of what I believe to be the opinion of many hospital authorities throughout the country, he will have second thoughts and will accede to this Prayer.
§ 10.29 p.m.
§ Dame Irene Ward (Tynemouth)
I find the opposition of the hon. Member for St. Pancras, North (Mr. K. Robinson) to this Instrument rather difficult to follow, partly because I understood that in our professional services generally we have recently been trying to concentrate on increasing the qualifications and the educational opportunities offered and that that has applied to almost every form of professional, industrial and commercial life. Without going into all the arguments in very great detail, I cannot help feeling that there must be something additional behind the hon. Gentleman's presentation of the case.
I want to take the hon. Member up on one point in his concluding remarks. He has rightly asked my hon. Friend whether the regional hospital boards have been consulted and whether there has been contact between those in the regions, particularly in the industrial regions. However, I understood him to say later that the hospital authorities were opposed to the Instrument. According to what he has said, the hon. Member appears to have received a great deal of representation against the proposals embodied in the Instrument.
In my region, which is a highly industrial one, I have always tried to keep closely in touch with these matters, 1410 and I have never failed to get representations over a very wide area on matters which affect both hospital and nursing administration. Over the years I have been very closely associated, though not in a professional capacity, with the nursing profession and all that goes with it. However, I am bound to say that I have not received any representations against this Instrument.
Therefore, I feel that I am on quite strong ground when I say that I think it would be a very retrograde step if the House assented to the Prayer. The educational qualification which is implicit in the Instrument has for a very long time been requested by the professional organisations serving the nursing profession, and I hope that the House will accede to the Instrument and reject the Prayer.
§ Dame Irene Ward
If the hon. Gentleman will allow me to develop my case, I will deal with that point. That is part of the reason why I am speaking. I would not dream of burking the issue which was put forward by the hon. Gentleman.
The General Nursing Council, the Royal College of Nurses and the Asso-tion of Hospital Matrons welcome the new Instrument and regret that for the first time in the nursing profession there has been a differentiation in the register. It is rather regrettable that in this professional service, which means so much to the hospital service and the country as a whole, it has taken from 1939 to 1960 to re-establish the position which obtained in 1939. The reason is that so many people accept the nursing profession as a vocation and do not always seek to take the trouble to ascertain what those who are concerned with nursing really want for themselves. Consequently, the responsible bodies in the nursing profession and those who speak for the profession very much regret the differentiation.
I have a plea and a proposal to make to my hon. Friend the Parliamentary Secretary. I want to make it clear that, as a first step, those speaking for the nursing profession want this Instrument put into operation. In addition, if I understand the position correctly—and 1411 it is very difficult to be quite sure of the position if one is not in the profession —those who were responsible for negotiating with the Ministry of Health were under the impression that mental nurses would be included in the provisions of the Instrument. The Instrument does not come into effective operation until 1st July, 1962, so that there is quite a considerable period between its presentation and its operation.
I therefore suggest, to clear up the position, that those of us who are interested—and I hope that the hon. Member for St. Pancras, North will agree with me—will be allowed to take the appropriate professional bodies to the Minister and the Parliamentary Secretary to discuss the possibility of including mental nurses. I listened carefully to the hon. Gentleman, and I am sure that those who are connected with the recruitment of mental nurses for the Health Service do not accept all that he said about educational qualifications being detrimental to recruiting.
I am not in a position to offer this as my own opinion. I only say that I have discussed this with those who are in a position to know, and they say that it has been an advantage in recruitment. Therefore, it seems to me that it might be a good idea if those who are interested in this matter were able to join together with those who represent the nurses professionally—and this includes mental and other nurses—and discuss with the Minister and the Parliamentary Secretary the possibility of bringing mental nurses within the ambit of this Instrument.
I always believe that in matters of this kind, involving negotiations affecting many people—not only those in the profession, but patients as well—the negotiations should be conducted at the top. I think that it has been a source of regret to those who have been conducting these negotiations, and who feel very strongly on this matter of mental nurses, that it has not been possible to conduct the negotiations at the highest possible level.
I have had quite a lot to do with the Minister of Health and with the Ministry of Health, and it has seemed to me from time to time—and in a way I say this with regret—that it is much more difficult 1412 to get to the top people in this Department than it is in some other Departments. I do not want to be unduly critical, but I notice that in many fields, when I am discussing matters of importance to those connected with the national work of this country, some Ministers always seem to be able to have a word with one about what is going on.
I am bound to say to my hon. Friend the Parliamentary Secretary that I have gone into this matter as carefully as a non-professional can. I rang up my right hon. Friend the Minister and expressed some views on the matter, but I got not a line, not a word, not a comment, not an interview and not a telephone message. I think that that is rather sad and regrettable.
Like everyone else, I am proud of the nursing profession. I am proud of the work done and the services given by its members, and in the efforts made by the House and by those who represent them to meet their needs we ought always to have the very top advice and the top interest from the Minister and the Parliamentary Secretary.
As I say, I do not want to go into the detail of this matter any more. I merely wish to say that I support the Instrument. I am, I think, empowered to say that the General Nursing Council, the General College of Nursing and the Association of Hospital Matrons support the rules, and I hope that the Instrument will be confirmed by the House. At any rate, I think that these bodies appreciate the point that has been made by the hon. Gentleman opposite about mental nurses.
I think that it would be a very good idea for the future of the profession, for the future of the standards that it wants to continue and for the improvement that it wants made in the whole of the nursing services for the benefit of the patients and of the hospital service that as soon as may be those interested should seek to see the Minister and the Parliamentary Secretary to find out whether it is possible to make any progress in the direction of covering mental nurses in the same way as other nurses and to make them feel that they are covered. That matter, of course, is rather worrying those who represent the nursing profession. It is feared that this differentiation may be detrimental to those whom we want to recruit to the mental nursing service.
1413 I hope that we shall be able to find some way of making the profession one body. This, I am sure, would help the profession, the nurses themselves, and would help to staff the hospitals for the benefit of the nation, and all those who are willing and able to do so much to make our nursing service so valuable to the country.
§ 10.43 p.m.
§ Mr. G. A. Pargiter (Southall)
I agree with the hon. Lady the Member for Tynemouth (Dame Irene Ward) that we want the nursing profession to be treated as a whole and treated with equal esteem. The hon. Lady welcomes the Nurses Rules. I cannot welcome them in the same context, because it seems to me that they will tend to do precisely the opposite to what we want.
Whether or not these are the correct educational qualifications is a matter into which I do not want to go. There would probably be a controversy on what are peculiarly the right educational qualifications for nurses. That nurses must have a certain standard of education is obvious if they are to take the examinations, which are not easy and which are essential for the profession.
My early experience of mental hospitals and of hospital management goes back to the 1930s. I have seen considerable changes since that time, and although I am not now so actively concerned in the matter I have watched those changes with considerable interest. I have seen mental hospitals change from gaol-like places to places for curative purposes. What alarms me is the failure of these rules to recognise those changes.
In those days that I remember, back in the 1930s, mental nurses were little more than janitors. The knowledge of modern drugs and things of that kind which have been developed, some of them as a result of the war and some of which have been enormously developed since the war, has brought mental illness into precisely the same category as physical illness. It is essential that this should be recognised. I do not think that the General Nursing Council recognises it. I am not at all sure that it is so forward in the feeling with regard to mental health, otherwise I do not see how it could have put forward this Instrument or persuaded the Minister to accept it.
1414 Only last year, we had the Mental Health Act, which was to be the great lift forward of proper treatment of mental health. How will we get it if we create a second-class nursing profession for the mental health services? It is no good saying that we will have this method to start with, because everything else will go down the drain while we are building it up. The Minister should take back this Instrument and seriously reconsider it.
It may be that a lack of educational qualifications is a cause of wastage in nursing. I hope that we may have the figures of the extent to which that is true. What my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) has said is much more likely. All sorts of factors come into the question of wastage in the profession rather more, probably, than the educational qualification. It might become rather better in some respects in the great London teaching hospitals, and so on, which have no recruitment problem, if, perhaps, there were an educational qualification.
I have an idea that some people can get by in the London teaching hospitals, not necessarily because they have qualified, but because of the school which they have attended, or because a girl's father happened to train or be at that hospital, and all the things that go as part of the background by which certain people can get into certain hospitals. It may well be that the educational qualification might prevent some of them from getting in so easily. I should not be at all surprised if some of the failures we get in those hospitals might be those very people.
§ Mr. John Diamond (Gloucester)
Surely my hon. Friend is not suggesting that nurses come on to the register by these methods, or that the question of a nurse being the daughter of a particular father would have the slightest relevance to passing the examination laid down by the General Nursing Council.
§ Mr. Pargiter
I am talking not of the qualification of the nurse, but the qualification for entry into the profession, which is entirely different to the qualification which she must have. Whether 1415 this is the right standard or not, my view would be that it is desirable that there should be a general idea that they will have sufficient educational knowledge and background to be able to absorb the material which they must absorb and to pass the examinations. To that extent, I am not at all sure that this is the right Instrument.
To return to the question of mental nurses in the light of modern developments, in spite of what the hon. Lady the Member for Tynemouth has said there is considerable alarm already in the management of mental hospitals. Many of them are not yet aware of these rules. I am sure that when they become aware of them, the Minister will get a flood of protests about their exclusion. I hope that the Parliamentary Secretary will ask her right hon. and learned Friend the Minister to reconsider this aspect.
It would be a grave mistake for the Instrument to go through and for it to be left to be thought, as it will be, that mental nursing is second grade and is not regarded as being the equal of general nursing. To that extent, I am not able to support the Instrument in its present form.
§ 10.50 p.m.
§ Mr. Forbes Hendry (Aberdeenshire, West)
I think that every hon. Member of this House, in his or her inner heart, wants these rules to be approved. We all want to see the general level of education in this country raised. From that point of view there should be a high entrance level of education in this tremendously important profession. We ought to welcome this Instrument, and I hope that hon. Gentlemen will not press the matter to a Division, if for no other reason than that half a loaf is better than no bread.
We ought to welcome the higher qualification in the nursing profession. I ask my hon. Friend to consider carefully what has been said on both sides of the House about mental nursing. I feel strongly about this, because mental nursing is tremendously handicapped by being regarded as the poor relation, or a sort of second-grade profession. I have heard that opinion expressed time and again. The standard of men and women entering the mental nursing profession is lower than it would be if the 1416 feeling did not exist that mental health nursing is a sort of step-sister of the nursing profession.
The reverse should be the case because, while in medical and surgical nursing a nurse is trained to do something to or for the patient, in mental nursing a different attitude is required. One requires not a capacity for doing something physical, but a capacity for understanding the patient, and for living with the patient.
I should like to see an even higher qualification for mental nursing. We must get rid of the idea that a mental nurse is a sort of a drudge. She ought to be more skilled than the general nurse. I hope that my right hon. Friend will think very seriously about this.
I appeal to hon. Gentlemen opposite not to press the matter to a Division, but to allow the Instrument to go through in its present form, especially if my hon. Friend gives an undertaking to consider the position of mental nurses and to introduce another Instrument laying down more suitable educational qualifications for mental nurses.
§ 10.52 p.m.
§ Miss Margaret Herbison (Lanarkshire, North)
I can understand the fears that were expressed by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) about the difficulty of attracting nurses, but that is as far as I can go with him in his opposition to this Instrument.
Nurses, like any other professional body, have a right to be concerned about their status in this country, and I would give them all the backing I could in their fight for a proper status. I have the greatest admiration for the nursing profession in Britain, although it is those in Scotland whom I know best. I say to my hon. Friend who is afraid that this may lead to a shortage of nurses that the way to tackle the problem is not to say that we will ask for no educational qualifications at all, but to make it our job to ensure that the conditions and salaries are adequate to attract into this profession the type of woman we want.
The qualifications asked for are meagre indeed. Two passes are required at "O" level, one of them in English. 1417 I would not want any young woman who had been educated in this country who could not get that minimum qualification to be responsible for nursing in any hospital. It is for that reason that I support this educational qualification.
I have only one reservation, not about the young people who are attracted into the profession from this country, but about the numbers who come from abroad, about whom my hon. Friend spoke. It may be very difficult for some of them to attain this qualification, and in those circumstances the Minister should be ready to consider the question of students who come here from certain overseas countries. Before 1st July, 1962, he has time to do something about that.
My last point concerns the exclusion of nurses who are working in mental hospitals. That is very bad. It will make it more difficult to attract young women into this form of nursing when they realise that their status will be regarded as something very much less than that of those who go into general nursing. The hon. Member for Aber-deensihire, West (Mr. Hendry) and I are now very busy in the Committee stage of the Mental Health (Scotland) Bill. I agree with my hon. Friend the Member for St. Pancras, North; it seems to me that the great therapeutic value which patients in mental hospitals can get from their relationship with their nurses is of the greatest importance. We will have a much better chance of getting that deep understanding from someone who has been able at least to get two passes at "O" level.
I make the same plea as has been made by other speakers: I hope that the Minister will consider extending the qualification he is asking for in respect of general nurses to those who are going to do this most important work in the future—the work that has to be done in our mental hospitals.
§ 10.57 p.m.
§ Mr. Laurence Pavitt (Willesden, West)
There seems to be a wide measure of agreement among Members on both sides of the House on the question of the omission from the Instrument of those nurses who are engaged in nursing the mentally ill and the mentally defective. Indeed, the Instrument itself may be said to be mentally defective in that respect. 1418 The hon. Member for Tynemouth (Dame Irene Ward), in a very thoughtful speech, raised the question of the reactions of the regional hospital boards and hospital management committees to these proposals. I have three or four pages of their reactions, from which it is clear that although the boards have a number of criticisms to make of the proposals, especially in regard to the kind of establishment that shall qualify as a teaching hospital—whether the number of beds shall be 100 or 300—no objection is voiced against the educational qualifications required, and in the memorandum of the Association of Hospital Management Committees the same theme is evident throughout. They have no objection to the major provisions; they are concerned mainly with the way in which the system will work out.
I want to confine my remarks to the serious omission of the nurses who cater for mental defectives. I regret that we had to take the step of moving this Prayer, because the rest of the Instrument makes some desirable provisions in the direction of raising the status of this important profession. But the injustice done to these extremely worthy people, who are tackling the difficult task of nursing in mental hospitals, warrants our asking the Minister to withdraw the Instrument. The only difference between the two sides of the House is as to the best way to remedy this defect. We ask the Minister to allow us to annul the Instrument now, so that he can introduce something more complete later.
Incidentally, I wish we could change the clumsy title from mental nurses to something like psychiatric nurses, and so take some supposed stigma from a worthy profession. Since the war there has been a considerable amount of enlightenment in the attitude towards mental illness and deficiency. We have broken down the barriers between physical and mental illness not only from the point of view of the nurses, the doctors and the medical profession generally but also in the fact that in recent years great advance has been made in educating the general public to understand sympathetically mental illness and to appreciate the value of domiciliary help for those people who are unfortunately mentally ill.
This Instrument breaks that down and puts back the clock, making a division 1419 between ordinary general nursing and those nurses engaged in mental illness. Those nurses have a high sense of vocation and of devotion, and it is up to us to give them every possible encouragement rather than to put the clock back and to make it appear that they are a second-class type of nurse.
The position is even worse than in 1939. When this practice, which is being reinstituted, was waived in September, 1939, mental and ordinary nurses were pari passu; they were all graded exactly the same. Yet we are now reintroducing an educational qualification which will separate the sheep from the goats, as it were. This is the crux of the situation.
I suggest that at present the Ministry wastes a lot of money on training because of the withdrawal of students for a number of reasons. My hon. Friend the Member for St. Pancras. North (Mr. K. Robinson) made this point. Statistics showed that in 1957 there was a greater wastage among nurses dealing with mental deficiency than in general nursing. For example, those withdrawing after six months in the general female category amounted to 18.6 per cent., and in the male category 25.4 per cent., but in mental illness it was 30 per cent. and among those engaged in nursing mental deficiency it was 35.3 per cent. It appears that we have a larger wastage in mental categories, and I suggest that this Instrument will aggravate the position rather than assist to improve it.
Apart from the wastage, there is the effect on the service in general. The tutors do a certain amount of training and then are frustrated because they lose their students. The students who stay are perhaps held back because the initial standards on entry are such that they have fellow students who are not capable of absorbing the training being given. It is just as important for mental nurses as in general nursing that, as a starting point, there should be a satisfactory standard of education for entry to the profession.
The Report of the General Nursing Council up to 31st March, 1958, refers to a decrease in the number entering the mental categories. It says that the wastage during training remains excessive— 1,587 in mental nursing and 409 in mental 1420 deficiency nursing, making a 72 per cent. wastage. The Report continues,Such figures can allow for no complacency and again point to the need for careful selection of students; those training schools which have required a certain standard to be met have already proved that such a policy attracts more recruits of the right calibre.It is not good enough to say that an educational entrance test may be applied at the option of the hospital concerned, because that is the position at the moment; the General Nursing Council offers specimen papers for those hospitals which care to give a test. In practice, only 44 mental hospitals and 11 mental deficiency hospitals have taken advantage of the facilities offered.
I suggest that the question of status and public relations is involved in replacing the mental categories alongside the general standards of nursing. As my hon. Friend the Member for St. Pancras, North said, the Nursing Times wrote thatpatients and would-be candidates may think the training offered is second best.The Minister will probably agree that this is a long-term aim and that there should be parity eventually, but he may be reluctant to introduce it at this time. I suggest that this is the time, when the climate of opinion is conditioned by last year's Mental Health Act and when interest is going in this direction, to give this parity to the mental nurses and those nursing mental deficiency. If the Instrument is passed tonight, we shall only have to come back later with an amendment.
Why not introduce a completely new Instrument straight away, as my hon. Friends and I desire? The differentiation may lead to many anomalies later on in post-registration training, integrated training for admission to different parts of the Register and other experimental schemes, which the Parliamentary Secretary will know have already been passed by the Minister. These plans would be complicated as a result of this Instrument.
My plea is that the Instrument should be annulled. The Government should seek to introduce a Measure which gives credit to the devoted people who serve mental illness, as devotedly as the general nursing people serve physical illness.
§ 11.6 p.m.
§ Mr. Charles A. Howell (Birmingham, Perry Barr)
I hope that the Parliamentary Secretary will tell us what the object of the Instrument is. Is it to get more nurses? If that is the object, I hope that, if it is eventually found to be a failure, either the hon. Lady or her right hon. and learned Friend will have the courage to come to the House and say that it has been proved to be a failure and that it is desired to amend or withdraw it.
Irrespective of what any hon. Member on either side of the House says, I am not interested in the qualifications of recruits. I am interested in the qualifications of trained nurses. I have tabled Questions from time to time asking about recruitment. On every occasion I have been told that recruitment has decreased. Where is the evidence that the Instrument will result in an increase?
§ The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)
§ Mr. Howell
If the hon. Lady reads the Official Report, she will find that I am right. The possession of the G.C.E. will not enable a girl to qualify as a nurse. She must have far more about her than ability to pass these educational tests.
§ Mr. Howell
I am glad that my hon. Friend the Member for Lanarkshire, North (Miss Herbison) agrees with me. I have some knowledge of the nursing profession. I want to declare my interest. Since the National Health Service Act, 1948, I have been the chairman of a training hospital. We were a fever and T.B. training hospital. We are losing our status on both counts, due to the Ministry's idea that a hospital must have 200 patients per day before it can qualify to be a teaching hospital.
§ Mr. Howell
My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) tells me that it is 300. In any event, it is a high figure. I am convinced from my own knowledge, meagre as it may be, that only about four hospitals in England will fall into that category. As a result, nurses will be faced with the prospect of travelling so far that 1422 they will not come forward. The number of recruits will fall, and continue to fall.
My hospital has been designated as a pupil training hospital. We have any amount of vacancies. The Parliamentary Secretary and I represent divisions of Birmingham. We have a very excellent teaching hospital there. I will guarantee that it has a waiting list today.
§ Mr. Howell
It has a waiting list. The matron of a hospital in the group which I serve was a trainee at the North Middlesex Hospital. The hospital is very proud of that. The trouble with these rules is that they are made by matrons of hospitals which have waiting lists. They have not the faintest idea of the struggles of their fellow matrons in other hospitals which cannot get nurses.
There must be many hon. Members who live in localities where there are empty beds, and even wards which have been closed, in hospitals. This is due entirely to the shortage of nurses. Of course, there is a wastage of trainees. Where is there not such a shortage? There is a wastage in the police force. All recruits do not finish the 13 weeks at the training colleges. Even if they do, as soon as they get on to beats and shift work, due to pressure from their wives because it is shift work or a seven day a week job, they leave. It is an expensive job to train a policeman today. It is an expensive job to train a nurse, but that is one of the costs which we must bear.
As I say, I am not concerned with the standard of the qualification when a girl enters a pupil training school; my concern is to get fully-qualified girls at the end of the course. Every matron sets her own standard, and the law of supply and demand comes into it. I hate to say so, but I believe that many matrons turn their hospitals into snob training schools. I know of many cases where the daughters of, aldermen, councillors, doctors and the like have been able to get into these snob training schools while the working man's daughter, with a G.C.E. qualification, has been refused and has had to go elsewhere for her training.
I spoke to a matron who has now left the service for a better-paid job somewhere else. She raised the question of 1423 the interim period between the school-leaving age and the age for entry to the training school. Girls leave school at 16, but they cannot enter the training school until they are 18. When they leave school, where do they go? They go into offices, where there is the 5-day week, music while they work, canteen facilities, and other amenities that are not available in hospitals. As a result, they get accustomed to higher earnings and more congenial conditions, and we do not get them recruiting at age 18—
§ Mr. Kenneth Lewis (Rutland and Stamford)
This is one of the things that, had I spoken in the debate, I should have mentioned, but the fact that the hon. Gentleman has just referred to it gives me an opportunity. In recent years, the General Nursing Council has encouraged the setting up of cadet nursing schemes—
§ Mr. Lewis
Very well, it is developing in spite of the Council. I hope that my right hon. Friend will get the Council to come right behind the setting up of cadet nursing schools, because it is very important that the gap between leaving school and entering the training school should be bridged. If it is not bridged then, as the hon. Gentleman says, we shall not get the recruits.
§ Mr. Howell
That was a very enjoyable, if somewhat lengthy intervention, but the hon. Member made a point that I was obviously going to make, which is how the Ministry could bridge that gap.
I am seriously perturbed by the lack of recruits. It does not matter if 50 per cent. of the recruits fall by the wayside before they qualify as long as there ire enough in the other 50 per cent. If 100 start and 50 per cent. drop away, there are still 50 trained nurses at the end of the training, but if the qualifications we require are such that we get only 50 entrants in the first place, and there is that amount of wastage, we will not get our wards and our hospitals staffed.
Anyone who, as I do, goes round the hospitals every week will be told by matrons that there is a shortage of domestic staff. As a result, that work also falls on the nurses. That is the 1424 cause of some of the wastage; to learn to be nurses these girls have to become domestics. If we do not make the work interesting and congenial, they will give up.
Again, I say that my concern is with recruitment. My hon. Friends may well be right in saying that before girls enter this wonderful profession—and I give it every credit—they should have a high standard of qualification, but if we find that that is not successful, I hope that the hon. Lady and her right hon. Friend will look again at this matter and say that it is not only the highly-educated person who can come into the profession.
I am reminded of the story—I have read it several times in different forms— of the man who left school when he was about nine years old. He started selling things, became a barrow boy, went into business, and eventually became a millionaire. He could not even sign his name to a cheque. Someone said to him, "Just imagine what you might have done if you had been educated!".
Frankly, I do not have these qualifications. Having left school, an elementary school, at the age of 13, I could not possibly have them. There might be a few vacancies, at least on this side of the House, if hon. Members had to have these qualifications. However, I do not believe that the mere fact that one does not have a certificate means that one does not have an agile brain and ability to learn sufficient about teaching, provided that one has a good sister-tutor, to become a State-registered nurse. There is such a shortage of nurses that nothing should be put in the way of recruiting suitable girls, irrespective of educational qualifications.
§ 11.16 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)
First, I must tell the hon. Member for St. Pancras, North (Mr. K. Robinson) that I thought that he moved the Prayer with great sincerity and in a very reasonable way, showing his undoubted experience of this subject and interest in not only nurses, but those who receive the services of nurses. The hon. Member for Birmingham, Perry Barr (Mr. Howell)—after a series of speeches on the subject—asked me what these rules were all about and I will try briefly to explain.
1425 The Nurses (Amendment) Rules, Approval Instrument, 1960, which is the subject of the debate, approves rules made by the General Nursing Council for England and Wales in exercise of the powers conferred on it by Section 3 of the Nurses Act, 1957. The effect of these rules is to amend by substitution Rule 10 of the Nurses Rules, 1951.
The object of the change is to ensure that as from 1st July, 1962, an applicant shall not be admitted to a preliminary training school course of an approved training institution for registered general nurses, or for registered sick children's nurses, or for registered fever nurses unless she holds the stated minimum educational qualification — expressed generally in terms of the General Certificate of Education subjects at Ordinary Level—or has passed an educational entrance test set by the Council.
The General Nursing Council is the authority charged by Statute—the same Nurses Act, 1957—to make rules for regulating the admission to the Register of Nurses. Under the Act, these rules must contain provisions requiring that persons admitted to the register shall have undergone the training in nursing which is prescribed by the Council.
The rules of the General Nursing Council do not come into operation unless and until they are approved by my right hon. and learned Friend the Minister of Health, who is thus able to consider them in all their aspects and to consult other interests about them as may appear to him to be necessary before he gives his approval.
I have been asked about consultations and I can say that in the present instance the Minister's consultations extended over a period of a year and that the bodies who were consulted included all the regional hospital boards, the Teaching Hospitals Association and the Association of Hospital Management Committees.
The hon. Member for St. Pancras, North suggested that these decisions were largely based on the experience of London matrons, but, in fact, the elected members of the General Nursing Council are representative of all parts of the country, as he will see if he refreshes his memory by looking at the Schedule to the Nurses Act.
1426 It is generally felt that re-introduction of minimum educational standards for nursing is desirable. We are able now to consider this change because of the improvement in recruiting. I have with me an enormous statistical note, but I doubt whether time will permit me to give to the House. I have answered Questions recently and have shown the improvement in all branches of the nursing profession. That is one of the reasons why we are able to bring these rules forward now.
Another is the need to cut down wastage. The hon. Member for St. Pancras, North and the hon. Member for Southall (Mr. Pargiter) queried this wastage and asked me whether I could say how much of it was due to girls not having the necessary educational background. A recent inquiry indicated that in students with an educational qualification the wastage was substantially less than in students without. I cannot give completely accurate figures, because I doubt whether wastage is analysed in this way, and I know from my own experience and from talking with matrons that very often wastage can only be described under the one heading "personal reasons".
That is what the girls say when they leave the job, and it is not until long afterwards that somebody, perhaps by chance, finds out what those personal reasons really were. However, in many instances it is, in fact, the case that they have not an adequate educational background.
Another of the reasons why we can bring forward the change is that there are more 18-year-olds available. We are feeling the effects of the "bulge"—that inelegant word—in the nursing profession; more girls are available. Also, the assistant nurse grade and the auxiliary grades are available for those who wish to work in this sphere but perhaps have not the ability to undertake the full responsibilities of the State-registered nurse.
As the hon. Gentleman said in opening, the educational standard is not a new measure. We seek to re-establish it. There was a minimum educational qualification before the war, but it was abolished on the outbreak of war in 1939.
1427 Thus, the new rules do not break fresh ground, but are aimed at recovering lost ground.
By no stretch of imagination can the educational standard be regarded as unduly high, as the hon. Lady the Member for Lanarkshire, North (Miss Herbison) said. The General Nursing Council has, with expert advice, devised a special test to bring out whether a student is suitable for training. Perhaps, in parentheses, I may say that I have tried the practice test which I found among the papers in connection with the rules, and I am deligted to say that I passed. I did not take too long about it, which I think is fairly good, because the older one gets the slower one's reaction becomes to such psychological tests. I was happy that I passed the test. I should think that most girls with a background such as mine could pass it.
Exemption from this test can be secured in a variety of ways, including only two passes at O level in the G.C.E., one of which must be in English or the Welsh language, together with evidence of satisfactory study in at least five other subjects. The hon. Member for St. Pancras, North asked me about girls who come here from other countries and whose command of the English language may not be so good. The General Nursing Council is preparing a special test suitable for those students whose mother tongue is not English.
There is no question of this country going in advance of others with the rules we now put forward. One of the points made by the General Nursing Council in support of its new rules was that in 1957 of 35 member-countries of the International Council of Nurses only three had no minimum basic educational test for entry to training. The hon. Gentleman said we were one of the few advanced countries. I must disillusion him a little. The three countries which have no such test are Great Britain, Luxembourg and Northern Rhodesia.
One of the main avowed objects of the new rules and one that appeals forcibly to my right hon. and learned Friend is to cut down the wastage of students at a later stage by ensuring a better selection at the start. This is a much more 1428 sensible and less wasteful way of proceeding than allowing unsuitable students to embark on the course and then losing them later.
Those unable to qualify as student nurses will not necessarily be debarred from nursing if they have a vocation for it, for they may well be suited to become enrolled assistant nurses or nursing auxiliaries, of whom we need more to relieve trained nurses and midwives on jobs which do not require their full skill.
One part of the overall criticism, and a large part, which has come from both sides of the House tonight has been that the requirement has not been made to extend to the mental and mental deficiency parts of the register. It is, however, my right hon. and learned Friend's desire and policy to encourage any measure designed to improve standards of nurse training in all types of hospital. The reason for the restriction in the rule approved in the Statutory Instrument is that the staffing situation in the psychiatric hospitals is not yet sufficiently established to make it right for my right hon. and learned Friend to reach a decision, now, that the educational requirement shall become compulsory in them on 1st July, 1962, as it will in other hospitals. Where they are prepared to do so, it is open to psychiatric hospitals, like others, to apply the educational requirements to their student nurse entry straightaway, and the Minister would be very glad to see as many as possible do so.
The General Nursing Council has stated that it has reluctantly agreed to accept the Minister's decision, since it does not wish to delay introduction of a minimum educational standard to the other parts of the register, and it leaves no room for doubt as to its own views, as my hon. Friend the Member for Tyne-mouth (Dame Irene Ward) said. But in the interest of early publicity, it has confined its rule to applicants for admission as student nurses to an approved training institution for registered general nurses, or for registered sick children's nurses, or for registered fever nurses.
The staffing of mental and mental deficiency hospitals has given cause for concern from the beginning of the National Health Service, and although in the earlier years of the Service there was some increase in the total nursing 1429 staff in these hospitals there was also a corresponding increase in the degree of overcrowding of wards, so that the staff-patient ratio for the country as a whole remained almost unchanged. The numbers of trained nurses in mental and mental deficiency hospitals steadily declined from 1953 to 1958, and although there was a small increase in 1959, the total increase between 1949 and 1959 was only 1,204—under 9 per cent.— whereas the total number of trained nurses in other hospitals increased by 10,789—over 38 per cent.
My right hon. and learned Friend's view is that because of the still difficult, though gradually improving, staffing position in psychiatric hospitals it is prudent that for the mental part of the register the new conditions of entry to training should be tried out voluntarily before he can commit himself to their being mandatory. The General Nursing Council has expressed the hope that the Minister will be able, on the basis of experience provided by the hospitals, voluntarily to approve such an extension before the rule takes effect.
It is only on the practical ground of the staffing position that it has been considered necessary at the present time to distinguish between psychiatric and other hospitals; but the Minister has assured the Genera! Nursing Council and various correspondents that he intends to keep the matter under close review in the light of the experience gained by hospital authorities and the General Nursing Council of the way in which the new educational standard works in practice, including experience gained by psychiatric hosptials in applying the new standard on a voluntary basis. His review of the position will be continuous, and a 1430 fresh assessment of the position in the psychiatric hospitals will not necessarily be postponed until after 1st July, 1962.
My hon. Friend the Member for Tyne-mouth asked if she might bring the appropriate bodies to discuss this matter with the Minister and myself. My right hon. and learned Friend and I are always available to Members of the House and to deputations. Indeed, we seem to spend a large part of our time doing so. I am sure that my right hon. and learned Friend would be prepared to consider this request, though I would ask that it be made not too early. Let us have a little experience of the move that we are now making before we consider further these psychiatric hospitals.
I hope I have shown that this change has not been introduced without full consideration and consultation. I do not think that it is premature, as was suggested on the benches opposite. We are confident we can achieve this change by 1962 and that it will then be possible to apply compulsion in general hospitals without detriment to staffing. We do not yet feel the same degree of confidence about mental hospital staffing, which is the reason why it is not included in this rule, but we will keep it under review as I have promised.
In the meantime, I think that we should encourage all hospitals able to do so to use these guides in recruiting student nurses, and I am sure that this will help the profession.
§ It being half-past Eleven, Mr. SPEAKER put the Question, pursuant to Standing Order No. 95A (Statutory Instruments, &c. (procedure)).
§ Question negatived.