§ 12.2 a.m.
§ Motion made, and Question proposed, That this House do now adjourn.—[Sir H. Harrison.]
§ Mr. Percy Browne (Torrington)
My pleasure at having the opportunity of raising this question is somewhat tempered by the lateness of the hour, and I should like to apologise to my hon. Friend the Parliamentary Secretary to the Ministry of Health for keeping her out of her bed.
I am glad to have the chance of discussing this very real problem of the shortage of district nurses in various parts of the country. It is impossible to discuss this problem without also mentioning the shortage of midwives. I know that that shortage is appreciated by the Ministry, which issued a memorandum to authorities which stated:The need for action by hospital authorities to secure the improvement in staffing and organisation of midwifery departments gives guidance on the kind of action to be taken…etc. At the present time, out of 70,000 registered midwives only 50,000 are practising. Within this general shortage there is a particular shortage, and a very high percentage, among district nurses. I mention this particularly because in the country districts the nurse is also the midwife.
I believe that this shortage is likely to increase. In Devon we are 12 short, but the average age of midwives in the county is well into the 50s. I know one district nurse who will be compulsorily retired next year who has continued working because there was no one to take her place. I wish to discuss the reasons for this shortage and to suggest to my hon. Friend what should be done about it.
The main reason for the shortage is the conditions and pay of the service. I appreciate that the conditions and pay of the service are negotiated between the Whitley Council and the local authorities. Because the rate of pay has gone up since 1956 from £560 to £814, it can be said, I suppose, that the improvement has been good, but not all district nurses are on maximum salaries, nor have many of the conditions 1132 of service been carried out for various reasons. Much of the increase in pay has been vitiated by an increase in rents.
Here are the complaints. First, that the 5 per cent. increase made last December in the rates of pay has been cancelled out by the agreement which was entered into at the same time as the last pay award that the tied house rents should be increased. I give two examples from letters I have received for district nurses in Devon. The first says:I am about to be charged 55 per cent more for rent and rates, an extra £31 per annum after the 5 per cent. increase.Another says:My rent was £4 17s. 6d. a month plus rates. Now it will be £8 17s. 6d. a month plus rates.That is getting on for 100 per cent. While no rent and rates can be more than an eighth of the salary of a district nurse, and while I appreciate that the authorities have responsibility to their ratepayers, and county councils have difficult decisions to make, nevertheless these increases have already had an aggravating effect in increasing the shortage of district nurses.
The second complaint is that district nurses are not getting the time off to which they are entitled. This again is partly due to the general shortage. There are no relief nurses. Again I quote from a letter from a district nurse in Devon:In spite of a 44 hour week Devon nurses are still having one 24 hour day off call in seven with a two day week end every sixth week and, this is the bone of contention. Young nurses just will not tolerate these conditions.I think that last sentence of the letter is the crux of the matter. The extra hours, the added expense of living on one's own and the lack of regular hours are the reasons why young nurses are not now coming forward.
Finally, and interrelated with these other problems, is that of their loneliness as compared with nurses in hospitals who can take part in the community life of the hospital. With these irregular hours, just as irregular as those of a doctor or a Member of Parliament, it is understandable that district nurses cannot take part in the local community activities. I believe that district nurses play a vital part in the maintenance of the health of the nation. We in the countryside know of their worth. They 1133 are tireless, selfless and always ready to come to our aid. If this vital service is to flourish, I believe the Minister must take a hand, hence my reason for raising this matter tonight.
I am sure that my hon. Friend will say that it is up to the local authorities and the Whitley Council to negotiate conditions and rates of pay and that therefore the Minister cannot intervene. That, of course, is technically correct, but I do not believe that the Minister can stand aside if this service is not to break down. The cost in cash, if it does break down, will be considerable, let alone the cost in unhappiness.
The after-care of mothers, the time that mothers are in hospital being nursed, is often reduced now to forty-eight hours after confinement. If they have not the care of a district nurse afterwards, they will have to stay longer in hospital and the log-jam will increase. The chronically sick and the aged who are now cared for at home will have to go into homes or hospitals, at a probable cost of at least £14 per bed per week. That is why I say that it is up to the Minister to take a lead in ensuring that these dedicated people get better pay and conditions, for if he does not do so I do not believe that young nurses will come forward. At the same time, the cost to the country, in both money and unhappiness, will be considerable.
I hope, therefore, that my hon. Friend will consider what I have said and, if nothing else, endeavour to persuade both local authorities and the Whitley Council that it is high time that better conditions were available for district nurses.
§ 12.11 a.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
The hon. Member for Torrington (Mr. P. Browne) has raised a very important subject tonight and has described a problem which is by no means confined to his own county of Devon. We all recognise that within the particularly devoted and hard-working profession of nursing the district nurse certainly works as hard and as devotedly as any. I believe that the situation in many parts of this country is disturbing, to say the least. I hope that the hon. Lady in the course of her reply will try to indicate how far the situation described by her hon. Friend is common to other country areas and, indeed, to the 1134 country as a whole. We in London are perhaps not quite so dependent upon the district nurse as people in remote country districts. Nevertheless, we could certainly not get on without her.
I should also like to know whether the rent increases described by the hon. Gentleman are peculiar to his own country. It has always struck me as very unfortunate that, whenever nurses get an increase in pay, whether they are hospital nurses or district nurses, there always seems to be some counterbalancing factor in the form of a rent increase or an increase in deductions for board in nurses' homes attached to hospitals. This always seems to take the edge off the increase. I hope that now and again there is an increase which has not any strings of this kind attached to it.
Finally, perhaps the hon. Lady will say whether she feels that the terms and conditions under which district nurses now work are comparable to those of their sisters within the hospital service. They do a different job, and I know that some of them prefer the relative independence of district nursing. Nevertheless, it is important that the two sectors of nursing should be kept in balance. This can be done only by an intelligent appreciation of the differentials both in terms and in conditions of work.
§ 12.13 a.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)
I join with my hon. Friend the Member for Torrington (Mr. P. Browne) and the hon. Member for St. Pancras, North (Mr. K. Robinson) in paying tribute to the district nurse. I am grateful for the opportunity this Adjournment debate offers of acknowledging the valuable contribution of the district nurse in caring for the sick and disabled, and the wholehearted effort which local authorities have put into developing this service so efficiently.
There are two points which need to be made clear. First, the provision of a home nursing service, including the recruitment of enough nurses to staff it, is a duty which has been laid by Parliament on local authorities. Secondly, any shortcomings in this service must not be allowed to obscure the fact that local authorities, since they were given this duty about thirteen years ago, have done a magnificent job in developing, expanding and improving it. It is so important 1135 to get this into the right perspective that I should like to remind the House in a few words of what has been achieved.
Since 1948, under the National Health Service Act, every local health authority has been under an obligation to see that a home nursing service is provided, free to those who use it, in their area. Prior to 1948, their powers were very limited, and in many parts of the country the service available meant that it was only thinly covered. The Act did not put an end to voluntary effort, because it allowed the local authority to discharge its duty through the agency of the voluntary organisations, and we still have cause to be grateful for the help given in this work by the voluntary bodies.
The hon. Member for St. Pancras, North asked what the position was throughout the country. In 1948, there were 7,800 district nurses in England and Wales. Every year since then the numbers have increased, and at the end of 1960 there were 10,300 altogether. But this alone is not a true index of the development of the service; improved techniques, improvement in organisation and improvements in training have probably done as much as the increase in numbers to enhance the value of their work to the community.
The quality of the service naturally varies from authority to authority, but I can assure hon. Members that we rarely receive complaints about the efficiency either of the organisation or of the individual nurses, and it is fair to say that the standard generally is very high. Against this background we can look more closely at some of the points made by my hon. Friend.
First—shortage. As I have already said, at the end of 1960 over 10,000 district nurses were employed. Local health authorities, if they were able to recruit them, would like to employ about four hundred more district nurses. This is what local authorities think desirable, but I have no reason to think that the existing service with the present numbers is not proving adequate. Compared with the shortages in some other professions both inside and outside the National Health Service this overall picture is a reasonably satisfactory one, especially as we see the total numbers employed rising steadily year by year.
1136 In any case, the total figures do not give a clear enough picture. In most parts of the country the service is fully, or practically fully staffed. The shortage tends to be concentrated in some of the more remote rural areas, and in certain industrial towns. The explanation for the shortage in the rural areas lies, in part, in the fact that this work attracts married women. There are large numbers of married women—and I am glad to note that—in the service, but that also means that there is no suitable work in the rural areas for their husbands. In the industrial towns, the problem is the variety of work outside nursing, and the fact that nursing in the industrial towns is often carried out in unattractive neighbourhoods. That cannot possibly apply today hon. Friend's constituency.
There is no lack of effort anywhere on the part of the local health authorities to fill the vacancies, and a great deal has been done to improve the working conditions by such measures as the provision of assisted-car-purchase schemes and allowances towards running costs and—a very important factor—good housing accommodation. Loans totalling £1¼ million were sanctioned by the Government in 1960 for the provision of houses and flats for home nurses and midwives, and this does not take into account those allocated to their nursing staff by county boroughs which are, of course, themselves housing authorities.
My hon. Friend spoke of rents, and the hon. Member for St. Pancras, North asked me to expound upon the subject. Many district nurses live in accommodation provided by their employing authority, for which they pay rent. Until fairly recently, the rents were controlled by the Whitley Council, which laid down the maximum charges that could be made. Following the comprehensive review of the salaries in 1959, however, the Whitley Council agreed that an imposed maximum charge for rent was no longer justified. In November, 1959, therefore, the Council decided to discontinue its control, and to leave it to the employing authorities to fix the rent at an appropriate level, but not exceeding the full economic rent for the acommodation provided. In deciding the appropriate rent, the employing authorities were required to take into account any disadvantages imposed on the nurse 1137 through having to occupy the accommodation, for instance, if a room had to be set aside for professional purposes or if the accommodation was clearly in excess of her needs.
These new arrangements, though agreed in November, 1959, were not, however, to come into effect until 1st December, 1960, a full year later. Moreover, the nurses had to be informed by 1st June, 1960, of the new rents they were to be charged from 1st December, 1960. Ample notice of the change, therefore, was provided for.
There seems to be an impression that these new arrangements for rent are linked in some way with the recent 5 per cent. increase in salaries, which my hon. Friend spoke of as being entered into at the same time and to which the hon. Member for St. Pancras, North referred when he spoke of strings being attached to the salary increase. In fact, there is no connection between them, and the fact that the changes in salaries and rents both took effect from 1st December, 1960, is purely a coincidence. The agreement about rents was reached in November, 1959, whereas the agreement on salary increases was not concluded until January, 1961. Where, as a result of the former agreement, rents have now been increased, it is likely that the nurse had previously been receiving the benefit of a low rent at a time when her salary was being substantially increased.
I have mentioned some of the things which have been done to make conditions more attractive to the district nurse, but there are some obstacles to recruitment which, with the best will in the world, it is difficult for local authorities to overcome.
§ Mr. K. Robinson
Is it a fact that there is no limitation as a fraction of a midwife's income such as the hon. Member for Torrington suggested?
§ Miss Pitt
With the best will in the world, it is difficult for local authorities to overcome all the obstacles. In country areas where the district nurse is often the district midwife a temporary shortage 1138 of staff may be felt acutely in the neighbourhood. I appreciate the point which my hon. Friend raised.
My hon. Friend is particularly interested in North Devon. At present, out of the Devon County Council's total establishment of 176 district nurses, there are eight vacancies, not 12, as my hon. Friend said. I know that he got that figure from me some time ago. Happily, the position has improved.
§ Miss Pitt
Since my information also comes from Devon, I think we must check the facts. I am informed that the present position is that there are eight vacancies, and these are being covered by temporary staff or by staff from neighbouring areas in such a way that a satisfactory service is being maintained throughout the county. This is a considerable improvement on the position at the end of April, when there were twelve vacancies. A nurse took up her duties in the Hartland area a week ago, filling the post about which my hon. Friend wrote to me in March. This had been vacant since 31st December, 1960.
My hon. Friend suggests that the average age is high. District nursing is a profession which appeals to the older woman, particularly the one who returns to nursing after her family has grown up and no longer need such close care. Therefore, I should expect the average age to be relatively high. This is why, when the local authority provides housing, it is frequently two or three bedroom houses which are needed, because the nurse is married with a family or has elderly relatives to be accommodated. My hon. Friend spoke of nurses who are due to be retired. In fact, the Whitley Council rules do not stipulate any retiring age. A local authority may apply its own retiring age, but a nurse may continue nursing after 60 if there is a shortage in the area.
§ Mr. Browne
In the case I quoted, the lady is nearing her seventies and is being compulsorily retired next year.
§ Miss Pitt
Probably she herself is willing to look forward to the prospect of retiring if she is getting to the seventies, but there is nothing to prevent local authorities employing women over 60.
1139 I should also like to explain that, following the Report in 1959 of the Advisory Committee on Training District Nurses a national standard of training has been established for this valuable member of the health team. A four-months' course has been introduced, which is reducible to three months for nurses with certain qualifications and experience, and it includes lectures on local authority services generally and practical work. There is an examination and a national certificate for successful candidates. The third examination was held in May of this year, and 220 out of 232 candidates were successful. The majority of the candidates were trained by the Queen's Institute of District Nursing. The Minister has also approved schemes provided by five local health authorities, and students from two of those participated.
I hope that more local authorities will commence training, and that the smaller ones will perhaps combine for this purpose in order to stimulate recruitment or add to the advantage of the nurse already in the service. If she passes the examination she qualifies for increased pay. Furthermore, she can be seconded on full pay by the employing authority to take this training, and I feel that that, because it enhances her status, is a stimulant to recruiting.
Salaries have been improved very considerably since the appointed day. In 1948 a district nurse with district training had a commencing salary of £300 with a maximum of £405. Now her commencing salary is £578 and her maximum £788. So the rate of pay has been almost doubled in the intervening period.
These increases are the result of salary reviews undertaken from time to time by the Whitley Council, the most recent being in March, 1959, and December, 1960. The salary of a district nurse with district training is now £53 a year higher at the minimum and £132 higher at the maximum than that of a staff nurse in a general hospital, which I think answers the point raised by the hon. Member for St. Pancras, North.
A district nurse who is appropriately qualified and who holds a combined post as a district nurse midwife or a district nurse midwife/health visitor is paid at a higher level. The relative salary scales, all for nurses with district 1140 training, are: district nurse, £578 rising to £788; district nurse midwife, £630 rising to £814; district nurse midwife/health visitor, £688 rising to £872.
My hon. Friend pressed very hard that the Minister should intervene in negotions for pay, but he really answered himself. There is the separate Whitley machinery. It is its responsibility. I could not agree that it would be right for my right hon. Friend to intervene or endeavour to persuade—as I think the hon. Member for St. Pancras, North said—the Whitley Council to take action. It is its duty.
On relief nursing, the position at present is that the district nurse should have one consecutive period of 24 hours a week when she should be free from duty not on call, and this minimum Whitley provision is under review. Further, some authorities are able also to give one long weekend a month. To cover this relief—again, the pattern varies district by district, and I appreciate that Devon may not be in as happy a position as other areas—in some districts nurses from adjoining areas cover each other, and for annual leave and sickness some authorities have a pool of relief nurses. I would also explain that the district nurse is on call but it is most unusual for her to be called other than during ordinary duty hours. Again, in order to make an exception, if she is doing midwifery as well there may be difficulties.
I should like to add something about the work which is being done by the district nurses in the years since 1948. The number of visits to old people has steadily increased year by year to 14 million in 1960 because there are more old people and because we all realise how vital it is to try to help them remain in their own homes and not be uprooted and taken away.
Old people owe a great deal to the district nurse, as also do the children. It is equally important for the child to be nursed at home by its own mother wherever this is medically possible, under the care of the family doctor, assisted by the district nurse. The number of visits paid to young children by district nurses is falling, and this is probably due to the improved health of the younger generation.
1141 The adaptability of the district nurse, helped by refresher courses which keep her up to date in new techniques, means that there has been a steadily increasing demand for her services. It is because local authorities are convinced of her value that they have made such successful efforts to meet this demand and to establish the home nurse firmly as an integral part of the Health Service. It is an impressive fact that, in this nation of just over 50 million people, something like 23 million home visits are made by district nurses every year, and there is no doubt that they will have an increasingly important part to play in the future.
1142 The district nurse has made herself indispensable. Through her, the family doctor is able to play his part more fully. She is part of the health education team, helping to teach families the principles of health and hygiene. Above all, a strong home nursing service is essential to enable patients not needing hospital treatment to be cared for at home. We will continue to do all we can to support and strengthen this service.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes to One o'clock.