§ As amended (in the Standing Committee), considered.
§ 11.7 a.m.
§ Mr. Alan Brown (Tottenham)
I beg to move, That the Bill be now read the Third time.
The purpose of the Bill is to permit the Minister to make regulations governing the conduct of nursing homes and to remove the present exemption from registration, and consequently inspection, of non-profit-making nursing homes. Before I explain the Clauses and subsections of the Bill, I would crave your 780 indulgence, Mr. Speaker, and that of right hon. and hon. Members while I endeavour to make known to the House the precise reasons, however unwelcome, which together have served to convince me that the measures contained in the Bill represent legislation which is long overdue. I seek this indulgence because, unlike the vast majority of Bills intimately affecting the public, which invariably and rightly are made the subject of a full measure of learned speeches and searching questions on Second Reading, such was not the case in relation to this Bill.
The Bill was given an unopposed Second Reading by the House on Friday, 7th December, 1962, and such an event, as far as a Private Member's Bill is concerned, provided what may reasonably be called a fairly unique Parliamentary occasion. I describe it thus because one hon. Member who accusted me in the Members' Cafeteria some ten minutes after that memorable event said, "This is the first one in nearly 200 Bills that a private Member has tried to slip through on the nod to which I have not objected." Clearly the hon. Member concerned was in the category of being a professional sinker of Private Members' Bills. Certainly he was a man with a mission.
At the same time I could not but sympathise with the phobia to which he so willingly confessed. I also take the view, which I think is fully shared by hon. Members on both sides of the House, that it is altogether right and proper and wholly in keeping with the long-established tradition of the House that every piece of legislation, whether its implementation be desired by the Government of the day or by a humble back bencher, should never be allowed to pass into law quietly, like a thief in the night. We must, as did our illustrious predecessors in Parliament, ever have it in our minds that each and every law which will affect the lives of the people must be brought openly to the floor of this great democratic institution; and here in this place, which is the forum for discussion by the people, should the proposed law be fully dissected, debated and made subject to the full glare of publicity. Such is the democratic right of the British people. It is one which I would at all times be prepared to defend, for it is a necessary safeguard 781 to freedom. To me and to most of us, the freedom of the individual member of our society is his birthright.
It was on 16th November, 1962, that the national newspapers first mentioned that a document produced by a dedicated and brilliant young man, a sociologist by the name of Peter Townsend, had just been published. It so happens that once in a while the public conscience receives a severe jolt. Once in a while, some unwelcome and quite unexpected feature of our national life becomes revealed for all the world to see. Caught in the brilliant glare of Press publicity, an astonishing defect somehow stands starkly revealed in the midst of this Welfare State in which we all take just pride.
One such rare example was brought home vividly to the public in the report by Mr. Townsend to which I have referred. He reported on the plight of old folk in institutions. His book was entitled "The Last Refuge" and it was based on the result of a four-year survey of institutions and—
§ Mr. Speaker
Order. I do not know anything about that report, but this is Third Reading, an occasion on which we discuss the contents of the Bill. Discussion cannot be as wide as we have on Second Reading.
§ Mr. Brown
I will say no more about that report, Mr. Speaker. I did, however, think that with your indulgence it might be brought in as it in some way affects the subject which is before the House.
I mention it, however, for this reason. Many of the newspapers, not unexpectedly, were shocked at certain revelations. Knowing full well that a Private Member's Bill was before this House calling for an end to be put to certain scandalous aspects of the treatment of our old and infirm folk, they not unnaturally connected the two stories. The effect was beneficial because it resulted in my receiving a large number of letters asking me what Parliament was doing about this shameful state of affairs. So far as that question has been posed, it is for hon. Members themselves to say.
I am hopeful, Mr. Speaker, by virtue of your indulgence, which, I assure you, I will not attempt to abuse, that the debate which takes place here today will, per- 782 haps, be wide enough and will contain sufficient information. I am well aware that my right hon. Friend the Minister of Health is very conscious that for reasons I have already mentioned relative to Second Reading, a gap exists in the public mind which can only be adequately filled by imparting to the public, not only full details of the defects which have been brought to light, but also the remedial action which, if the House passes the Bill, the Minister will be empowered to take.
I now wish to lay before the House some evidence both by way of named cases of persons who have complained and whose next of kin have written to me exposing the scandalous treatment which has been meted out to deceased relatives, and I shall recount examples of treatment of a nature which, I think hon. Members would agree, is so pitiless to old folk that many hon. Members here today may find it difficult to believe that such things could happen in England in this day and age.
It so happens that the first letter was given to me last November by the late Hugh Gaitskell, whom I never saw again. He stopped me in one of the corridors of the House and told me how glad he was that this Nursing Homes Bill was to be introduced.
§ Mr. Speaker
Order. The hon. Member asks for my indulgence, but however indulgent I may be I am bound by the rules of the House. The rules of the House relating to Third Reading are that we then discuss the contents of the Bill. We cannot have as wide a debate as on Second Reading.
§ Mr. Brown
Of course, I accept your Ruling, Mr. Speaker.
I turn now to the contents of the Bill. Its purpose is to permit the Minister to make regulations governing the conduct of nursing homes—I ask him at this stage whether they may be roughly similar to the regulations already made in respect of homes for disabled and old persons—and to remove the present exemption from registration and, consequently, inspection of non-profit-making nursing homes. In that connection, perhaps my hon. Friend the Joint Parliamentary Secretary would care to make a statement.
783 Clause 1(1,a) empowers the Minister of Health to make regulations as to the conduct of nursing homes which may, in particular, specify the facilities and services provided in such nursing homes as defined in Part VI of the Public Health Act, 1936, or where a home is in London, the Public Health (London) Act, 1936, which include maternity homes. The regulations may also, under subsection (1,b), empower the local authority responsible for the registration of the home under those Acts—normally the county council or the county borough council—to specify the maximum number of persons, or 'the number of persons of any description, who may be received in the home as patients. Thus it would be possible for the registration authority to ensure both that a home was not overcrowded and that it did not receive patients of types for which it did not have the staff, accommodation or facilities to cater. A home could, for example, be registered "for twenty-five geriatric or chronic sick patients only". The regulations I am asking for may also provide that contraventions of or failure to comply with any specified provision of the regulations shall be an offence. Clause 1(1,d) empowers registration authorities to institute proceedings in respect of an offence. I think it will be thought these are normal enforcement provisions.
Clause 1 (2) prescribes maximum penalties on conviction before a magistrates court of £5 for the first offence and £20 for subsequent' offences. These penalties are the same as those prescribed for similar offences in respect of mental nursing homes under Section 16 of the Mental Health Act, 1959, and in respect of homes for the disabled or old people under Sections 40 of the National Assistance Act, 1948. The subsection also enables the registration authorities to cancel the registration of a person in respect of a nursing home on the ground that he or she has been convicted of an offence against the regulations. This power supplements the powers to cancel nursing home registration in the existing provisions of the Public Health Acts and gives the registration authority the effective sanction in reserve for particularly frequent or serious contraventions of the regulations, as well as having what, we hope, will be a deterrent effect.
784 Clause 1 (3) provides that where an offence against the regulations has been committed by a body corporate and the offence can be shown to have been committed with the consent or connivance by or can be attributed to the neglect by any director, manager, secretary, or similar person of that body, that officer as well as the body itself is to be guilty of the offence. Slightly different versions of this provision which place the onus of proof more on the officers of the company or body to show that the offence was committed without their knowledge or consent are in the existing Public Health Acts and in the National Assistance Act provisions for the registration of homes for disabled or old people, but the formula used here is that used under all recent enactments in which offences by companies or bodies corporate are dealt with.
Clause 1 (4) provides that regulations made under the Bill shall be subject to the negative procedure in Parliament in the same way as are regulations made under the corresponding provisions of the National Assistance Act and the Mental Health Act.
Clause 2 repeals 12 months after this Bill becomes law, if it pleases the House today that it should, the existing provisions in Section 192 of the Public Health Act, 1936, and the corresponding Section 246 of the Public Health (London) Act, 1936, which enable registration authorities to exempt any hospital or institution not carried on for profit from the operation of the provisions of those Acts relating to the registration and inspection of nursing homes. The original intention of those Sections seems to have been to exempt voluntary hospitals from registration and, of course, from inspection, but nowadays, since the coming into force of the National Health Service Act, 1946, their main effect is to exempt nursing homes run by voluntary organisations and charities. In the interests of their patients it seems desirable that the distinction between profit making and non-profit making nursing homes which does not exist under the National Assistance Act, 1948, nor under the Mental Health Act, 1959, should cease, and that the same standards and the same requirements should apply to voluntary as to privately run nursing homes.
785 I should like to stress, if I may for one moment, while mentioning standards, voluntary organisations, and so on, that in so far as voluntary organisations or voluntary nursing homes are concerned the vast majority of them are well up to the agreed standard. We are really trying to cope with those which I would have mentioned had I been able to, those which do not maintain such standards and have no intention of maintaining such standards, but purely and simply take old, infirm and other people into the homes where it is purported that nursing and medical attention is given, but where in fact it is not given and where the standards are very bad.
Clause 2 would apply the provisions of the Public Health Acts as to registration and inspection to some 114 voluntary nursing homes and organisations running them. They will be given a year to arrange for registration and to make any structural alterations or other alterations which my right hon. Friend in his wisdom deems they should so do.
Clause 3 gives the short title of the Bill and its extent. Like the Public Health Acts whose provisions it supplements the Bill is to extend only to England and Wales.
I would, with your permission, Mr. Speaker, ask the Minister to deal with the subsection which was added to the Bill in Committee. I would also ask him to give the House when he replies some idea of the regulations he will make affecting the standards of skill and attention which are so important for nursing homes.
Finally, I would ask the House to be kind enough to pass this Bill, which I believe to be—as I am sure hon. Members would also believe had I been able to complete a part of my speech—possibly one of the most important pieces of legislation to come before the House for a long time.
§ 11.28 a.m.
§ Mr. Kenneth Robinson (St.Pancras, North)
The House will have gathered from the unusually smooth passage which this Bill has had so far, as described by the hon. Member for Tottenham (Mr. A. Brown), that it has the support of my hon. and right hon. Friends. We welcome it as a distinct but certainly a limited advance in the care of the sick and the aged. In Com- 786 mittee, whose proceedings were quite brief, a number of questions were asked of the Joint Parliamentary Secretary. Most of them he answered, but one or two, quite understandably, he sidestepped and avoided answering. A certain amount of time has elapsed since then, and I wonder if he could today enlighten us on a couple of the points which were raised then.
The definition of nursing home is something which seems to many of us not satisfactory today. Leaving aside the statutory definition, the phrase "nursing home" in everyday parlance covers an enormously wide range of institutions, from a home for aged and infirm people, to what is in fact a private hospital clinic. They are all known as nursing homes.
This is not something that statutory definition can do much about. It seems to some of us that there are establishments which are in fact nursing homes for old people, containing mainly and sometimes wholly aged and infirm people, which escape all legislation covering nursing homes because they purport to be boarding establishments or boarding houses. I ask the Parliamentary Secretary whether his Department has given any thought to this, and whether he feels that it is necessary or that it will be desirable in the future, to amend the statutory definition of a nursing home to ensure that places like this, most, if not all, of which are run for profit, come within the regulations which he is proposing to issue.
The other question which he did not say very much about was the capacity of local authorities to do the job which the regulations which he will make under the Bill will impose upon them. The effectiveness of this Measure, as of other Measures covering mental nursing homes, depends entirely on the quality and the number of personnel that local health authorities have at their disposal to inspect nursing homes in their areas, to inspect them with reasonable frequency and to ensure that proper standards are maintained. I think that most of us will agree that in many areas this job is not being effectively tackled today. I hope that we shall be able to have at any rate some encouraging remarks from the hon. Gentleman on that score.
Lastly, there is the question of sanctions. It was said, I believe, in Com- 787 mittee that one of the difficulties about the existing legislation is that a local authority has only one sanction, that is to refuse or to withdraw registration of the home. Many local authorities are reluctant to do this because they know that they will be faced, as the local health authority or the local welfare authority, with finding accommodation for the people, probably old people, who are at present being looked after in the home. It seems to me that, even under this Bill, this will be the only sanction, although the regulations will lay down certain standards that will have to be maintained. In the last resort there is only one sanction, and that is refusal of registration, and the same difficulties will apply. Perhaps the Parliamentary Secretary will let us have his observations on that point.
I regret to say that I do not know when the Minister intends to speak, but I have to leave the House at about 12 o'clock to catch a train to a longstanding engagement in the Midlands, and if it happens that he has not met my points by that time, I hope that he will acquit me of any discourtesy. I shall certainly read his replies with great care.
We welcome this Bill and we wish it well through its passage in another place, which we hope will be as uneventful and uncontroversial as its passage has been through this House.
§ 11.33 a.m.
§ Mr. Charles Doughty (Surrey, East)
In my humble opinion it is right that the House should consider this Bill a little more fully now because it had, as we have heard, an unopposed Second Reading when there was no opportunity for discussion, questions, criticism, if necessary, or praise, if that is the right word to use about the Bill. Let me say at once, before I deal with the actual details of the Bill, that if I should by any means be thought to have raised any points of doubt or criticism, it is not for the purpose of opposing the Bill, which has my support, but for drawing the attention of the House to one or two matters which should, in my view, be fully considered before we give the Bill its Third Reading.
The hon. Member for St. Pancras, North (Mr. K. Robinson) referred to the 788 definition of a nursing home. It is just as well to know what the article is that we are discussing. A nursing home is defined in the Public Health Act, 1936, Section 199:'Nursing home' means any premises used or intended to be used for the reception of, and the providing of nursing for, persons suffering from any sickness, injury, or infirmity, and includes a maternity home, but does not include—(i) any hospital or other premises maintained or controlled by a Government department, county council (including the London County Council), local authority …I shall not read the whole list of public authorities which ran hospitals in those days—… any institution, house or home certified or approved by the Board of control under the Mental Deficiency Acts, 1913 to 1927.and, of course, the definition was carried on in the Public Health (London) Act, also of the same year.
One has to remember that in the days when these two Acts were passed their consideration must have taken the House a considerable time, because there are hundreds of Sections in them, and the Committee stage on the two Bills cannot have been a very happy experience for those who had to consider them. In those days, before the days of the National Health Acts under which the hospitals are run by the Minister and so forth, we were dealing with public hospitals run by private boards, by charities, and, of course, the county council hospitals and institutions of that kind. It is important to remember that.
Nursing homes, which, of course, include hospitals under this definition, are now run under the National Health Acts, but I wonder if the House realises the cost per week per patient in those hospitals. This is important when we are considering this Bill, because it bears relation to the cost of private patients, or patients whether private or public, in these nursing homes, and the charges that have to be made. It is important, when we consider that, that we should be careful not to put on these nursing homes additional costs that have to be passed on to the patients.
The cost varies from hospital to hospital. Again, I am talking of hospitals, which means nursing homes under the National Health Service, and I am excluding altogether the medical costs, surgical costs, cost of operating theatres 789 and matters of that kind and considering only what might be called boarding and lodging costs. Does the House realise that I should not be exaggerating if I said that the average cost in the hospitals in and around the big cities is approximately £40 a week per patient? That is extremely high. If that is the cost of these institutions—and I do not criticise the running of them—what is the cost in smaller establishments run, it is said, for profit—under the description in this Bill—and how can they make a profit if they have to charge private patients in relation to the figures that I have mentioned? If we put additional regulations, additional burdens and additional restrictions on these nursing homes the people who suffer will be those who go into them for treatment and who receive their account at the end of their stay or at the end of each week.
I appreciate that the Bill gives the Minister powers only to make regulations, but if the Bill becomes law, as I hope it will, I hope that the regulations will be of such a kind that additional costs and charges which have to be passed on to the patients, will not be put upon the nursing homes. We can, of course, make regulations and make these places in every circumstance most up to date and clean and with plenty of bed space, but it all adds to the cost, and the cost of the treatment must also be considered.
I want to deal with some of the Clauses a little more fully. We are repealing part of the Public Health Act, 1936, and part of the Public Health (London) Act, 1936. I have dealt already with the conduct of nursing homes. Under Clause 1 of the Bill the Minister has power tomake provision as to the facilities and services to be provided in such homes".The words are short, but they are extremely extensive. "Facilities and services" means everything. The Bill will give the Minister power to regulate every single matter which occurs in a nursing home.
I would remind the House that under both 1936 Acts the Minister already has very wide powers indeed. I will not weary the House with the powers in respect of appeals and registrations and other matters dealing with the conduct of nursing homes. If any hon. Member is interested, he will find the information 790 in Sections 187–195 of the Public Health Act, 1936, and there are approximately the same number of Sections in the London Act. Ever since that date—probably before then, for all I know—such nursing homes have had to be registered, and, under those Acts, they can be inspected and must have a very high standard before they are allowed to continue their registration and their business.
Under Clause 1(1,b) the local authority—it is the local authority which is responsible for registration of nursing homes—would have the duty of enforcing any regulations the Minister saw fit to make under the provisions of the Bill. It could limit the number of persons who could be admitted to a nursing home at one time or the description of persons who might be received into the home. It could limit the registration to such numbers.
We have not heard, partly because the Bill was not discussed on Second Reading, and apparently it went through the Committee stage extremely shortly, whether there has been proved to be any necessity for the very wide power which was given to the local authorities and to the Minister. Is there any evidence of overcrowding in nursing homes other than mental nursing homes—which I shall deal with in a minute because they are exempted from the Bill? Is there any evidence that any of these institutions are run in such a way that too many patients are accepted at any one time? There may be, but I do not know; I have not been able to find out because there was no Second Reading discussion. Also, we have not heard the Parliamentary Secretary on the subject, and it will be interesting to hear from him whether there is any necessity for this part. Maybe there is; but I am against—I am sure most hon. Members are—passing legislation for the sake of passing legislation and anticipating overcrowding when overcrowding does not exist. If there are nursing homes which are crowding patients in and putting beds close together and the patients cannot have proper attention, it is right that this provision should be passed. If there is such evidence, the Clause will have my support.
§ Mr. K. Robinson
Surely the hon. and learned Member must know that it is not only a question of crowding too many 791 people into a given space. It is a question of having too many people in a home for the skilled staff available to look after.
§ Mr. Speaker
Order. We are a little outside the rules of order here. The fact that the Second Reading was unopposed does not affect the matter that the Bill has had a Second Reading. The House has already decided upon the principle of the Bill, and I had to stop even the promoter of the Bill from seeking to discuss now instances of evidence of the mischief which the Bill was designed to meet—because we are past that stage. I am fettered by the rules of the House in the matter.
§ Mr. Doughty
Perhaps, Mr. Speaker, I may put what I want to say in a slightly different way and thus say the same thing again in a form which I hope will be in order.
The Bill states that the regulations mayempower the local authority responsible for the registration of any such home under the said enactments to limit the number of persons, or persons of any description, who may be received into the home.That may be by reason of overcrowding or, as the hon. Member for St. Pancras, North has just said, by reason of the fact that the nursing home does not have sufficient staff. That is a matter which is mentioned in the Bill, and I should certainly like the Parliamentary Secretary to deal with it. Then there are the usual provisions providing for what takes place in the event of any contravention.
It is upon the repealing of the earlier Sections that I should like to say a few words. Section 192 of the Public Health Act, 1936, which is to be repealed by Clause 2, says that the appropriate authoritymay grant exemption from the operation of the provisions of this Part of this Act relating to nursing homes in respect of any hospital or institution not carried on for profit, and may attach conditions to any exemption granted by them.So the Section deals with the exemption of that type of nursing home.
Why is it that we are withdrawing the exemption which was given to nursing homes not run for profit? It is 792 a little difficult to understand why that should be and why it is necessary to repeal that Section. Is it because some charitable body runs a nursing home without complying with the requirements applying to other nursing homes and is to be allowed to get away with it? That would be the effect of repealing the Section. It may well be that an Amendment might be tabled in another place after this question has been particularly considered. The same thing applies to Section 246 of the Public Health (London) Act, 1936, in which the same exemption was granted.
Why we should not extend the Bill to Scotland or Northern Ireland I do not know. Looking round the House, I see no Scottish Members present. I am wrong; the hon. Member for Glasgow, Provan (Mr. W. Reid) is here. I do not see why the Scots should not have the same obligation put upon them. If there are—I do not know whether there are, and I do not for a moment think that there are—persons who run for a profit nursing homes which are badly conducted in order that they may make more money out of them, will they be able to cross the border into Scotland or go to Northern Ireland and carry on in the way in which they will not be able to carry on in England and Wales after the Bill becomes law? I think we are a little too sensitive about the feelings of the Scots in these circumstances, and I feel that in another place subsection (2) of Clause 3 might well be deleted. But distances are short nowadays, and some people might want to go to Scotland to be nursed. In case I am criticised for what I say, I had better add that so far as I know Scottish nurses are extremely capable and gentle and very efficient.
§ Mr. Doughty
I am so sorry if I woke up the hon. Member. At any rate, I am glad to see that he agrees with me. Perhaps he will agree with me later on, if he catches your eye, Mr. Speaker, that the Bill should be extended to Scotland. Perhaps we could jointly agree that the benefits—
§ Mr. Speaker
This is very difficult. One cannot propose on Third Reading Amendments that should be made to the text of the Bill in another place. That 793 cannot be fitted in with the rules of order.
§ Mr. Doughty
I appreciate my difficulty and yours as well, Mr. Speaker. But I am drawing attention to particular Clauses so that the House may consider them. If I went too far and said that Amendments might be made in another place, I willingly withdraw. However, these are the matters to which I draw the attention of hon. Members so that when and if they catch your eye they may consider it worth while to give their views.
I have expressed my own views only, such as they are, and having given them I shall listen with interest to what my hon. Friend the Joint Parliamentary Secretary has to say. Subject to that, and to an assurance that it will not make the cost of nursing homes to patients unduly high, the Bill will have my support.
§ 11.50 a.m.
§ Mr. Eric Fletcher (Islington, East)
I support this Bill, and I want to urge several reasons why it should be supported which have not yet been put before the House and which are of some importance. A great deal has been said about the patients in nursing homes and about staffs. We are all anxious, of course, for their welfare. But there is another class of person affected, and very often vitally affected, by what goes on in private nursing homes. These are the relatives of patients. It is on their behalf that I draw the attention of the House to certain circumstances which now exist, sometimes giving rise to scandals which I hope can be obviated in future if the appropriate regulations are made by the Minister as he will be empowered to make them under Clause 1.
At present there is no redress, as I understand it, on the part of any relative of a patient in a nursing home who wants to visit that patient and who is refused admission by the matron or whoever is in charge. There is no redress, no appeal from her fiat. The Minister cannot intervene, nor can the medical officer for health for the local authority.
It sometimes happens—I hope not too often—that very serious injustice is done and very great pain is caused by unfortunate decisions on the part of those in charge of a nursing home as to 794 whether or not certain close relatives of patients will be admitted.
§ Mr. Doughty
Such decisions, distressing as they may be to close relatives sometimes, are genuinely made, if not in the interest of the nursing home or hospital, then certainly in the interest of the patients themselves, who will be better left alone and should not be worried.
§ Mr. A. Brown rose—
§ Mr. Fletcher
Perhaps the hon. Memfor Tottenham (Mr. A. Brown) will let me reply to the hon. and learned Member for Surrey, East (Mr. Doughty) first. What the hon. and learned Member says should be the principle, and one would hope that the principle was generally accepted that decisions about the admission of relatives should be taken in the interest of the patients. But it does not follow that this principle is always observed. Occasions arise when there is a departure from that principle; nor is it always easy for the matron as distinct from the doctor, to determine what is in the real interest of the patient.
I can best illustrate the point by giving an example which recently came to my notice and about which I have had correspondence with the Minister. I refer to the case of Mrs. Dorothy C. Brown—no relation, I hasten to add, of the promoter of the Bill.
Mrs. Brown was an epileptic. She was seriously ill, and after being well looked after in a nursing home in Torquay she was eventually taken to the Dawlish Nursing Home. There she was visited on a number of occasions by her only relative, her brother, the Rev. E. F. Tozer, who was for forty years vicar of Emmanuel, Exeter, and his wife.
White in the Dawlish Nursing Home, Mrs. Brown inherited from a cousin a large sum of money. Whether it was a coincidence or not I do not know, but from that moment onwards the matron refused to allow Mr. Tozer or his wife to visit this lady. Other persons were admitted. On what ground these decisions were made or applied I know not. But I do know that when a few weeks later Mrs. Brown died it was found that she had left a will in circumstances which, to say the least, gave cause for very grievous suspicion. A number of 795 complications have subsequently arisen into which I need not go at this moment.
On the face of it, it seems very odd that during the last few weeks of this lady's life her only brother, a respected clergyman in Exeter, should have been debarred by the matron admission to see her, although other persons were allowed to visit her. This not unnaturally caused very great pain and distress to this elderly, respected clergyman and his wife.
For a long time past I have been trying to ascertain what was the cause of it. It may well be that the matron had some good reason. Many people think that she had not good reason. Here we have a situation which certainly calls for some explanation. it so happens that there has been very considerable dispute about how Mrs. Brown's estate should go, because she apparently left some instructions which appear to be inconsistent with the precise testamentary provisions of her will. I do not need to go into that, however.
I hope that this is a rare occurrence, but it is the kind of occurrence which occasionally produces, and is thought to produce, serious scandal in the administration of private nursing homes. In such a case, as I have said, the injured relatives, or relatives who think themselves affronted, are caused great suffering through being refused permission by a matron to visit a dying patient.
I would like to know the grounds on which such decisions are made. As the law stands, relatives in that position have no redress. They cannot ask the Minister to intervene. I wrote to the Minister and had a very sympathetic reply from the then Joint Parliamentary Secretary, the hon. Lady the Member for Birmingham, Edgbaston (Dame Edith Pitt), who pointed out that the Minister was powerless to inquire into the case because private nursing homes are outside the National Health Service and he has no jurisdiction over them.
I asked whether the right hon. Gentleman could suggest anything so that I could try to clear up a situation that seemed to me disturbing and something which ought to be inquired into. The hon. Lady pointed out that I might be able to bring the matter to the attention of the medical officer of health of the 796 registering authority. He had no power to investigate, no power to inquire into it, no power to see whether there was any justification for this refusal.
§ Mr. Dudley Smith (Brentford and Chiswick)
Would it not have been possible for the local authority or the medical officer to order a special inspection of the premises under the provisions of the present law?
§ Mr. Fletcher
I dare say, but an inspection of the premises would not have revealed anything. I wanted not an inspection of the premises, but an inquiry into whether there was any possible justification for the matron of his hospital having refused the Rev. E. F. Tozer permission to go to the nursing home during the last few weeks of his sister's life, although he had been a regular visitor and closest friend of his sister for many years. He told me a few weeks before his own death, which was a few weeks ago, that not only was he not allowed to see her, but was not allowed to write to her.
§ Mr. Fletcher
No, Sir. There is no litigation. I do not think that there is any prospect of litigation. A set of circumstances came to my notice and produced the most unfortunate and undesirable consequences which could not have resulted if this lady had been in a hospital under the jurisdiction of the Minister of Health, or in a private nursing home over which a local authority had jurisdiction.
§ Mr. Charles Curran (Uxbridge)
I am following the hon. Member with interest. Is he satisfied that this state of affairs could not recur when the Bill becomes law?
§ Mr. Fletcher
That is precisely the question I am raising. I want to try to satisfy myself that it may be prevented in future, and I hope that the Minister will be able to satisfy the House to that effect.
Mr. Tozer wrote to me to say that he felt it a ghastly business that in this modern age someone could be shut up in a private nursing home and her only relation excluded from visiting her. He said:This could happen to anyone, as the present law stands …797It cannot matter to me, now, as my sister is dead, but / wish to he instrumental in safeguarding others from a similar fate—at the hands of those who scheme for what the dying person has to leave.He said that he would be greatly obliged to me if, through Parliamentary channels, I could publicly rectify this scandal. This seems to be the opportunity to try to do something about it.
§ Dr. Donald Johnson (Carlisle)
Is the hon. Member quite satisfied that there is no remedy at law in a case like this which seems to be almost a case for habeas corpus or false imprisonment?
§ Mr. Fletcher
I do not know. All I am saying is that it seems that the matron of a private hospital can decide in her own discretion whether to refuse the only or nearest relative permission to visit the patient.
§ Dr. Johnson
The hon. Member has not answered my question. I am asking whether he knows how the law stands as regards habeas corpus in matters like this and whether it is not false imprisonment for which there is a perfectly good remedy at common law. I think he should inform us of that fact before he brings forward an instance like this.
§ Mr. Fletcher
I will certainly answer the question. It does not seem that habeas corpus or false imprisonment has anything to do with it, because this patient was quite properly an inmate in the nursing home and was no doubt being well looked after there. One could not have obtained habeas corpus to remove her from the nursing home. I am complaining about the refusal of the authorities to enable third persons to visit her or write to her or otherwise communicate with her. No proceedings for habeas corpus or false imprisonment could be taken on behalf of the close relative of the patient of a nursing home. There is no injury to the patient, except perhaps, indirectly. It is an injury to her brother and his wife, her only relative, who were prevented from seeing her. It may well be that there was some medical justification, but I cannot believe that there was because I understand other persons were allowed to visit her.
All I am saying is that as the law stands it is a most undesirable state of affairs that the discretion should be vested in the matron of a hospital, with- 798 out any possibility of her discretion being investigated by someone, by the Minister of Health, or the local authority, or someone else.
It is because of this scandal which has come to my notice that I intervene in this Third Reading debate to ask the Minister to assure us that when he makes regulations under Clause 1 he will bear this in mind, in addition to all the others which have been brought to his notice. I was afraid that unless I made the point explicitly and ventilated it in public today as an example of what could occur, however infrequently, it might well be overlooked in the regulations which I hope will be subsequently made. It is for those reasons that I have intervened, and I hope that note will be taken of what I have said. Because of what I have said, I support the Third Reading of the Bill.
§ 12.7 p.m.
§ Dr. Alan Glyn (Clapham)
I hope that the hon. Member for Islington, East (Mr. Fletcher) will not take it amiss if I do not follow him except to say that I would have thought that the words "conduct of nursing homes" in Clause 1(1) would cover the type of case which he has detailed.
I have to be rather careful, Mr. Speaker, because already two hon. Members have been called to order for not discussing what is actually in the Bill in a Third Reading debate, and I hope that I shall be able to confine my remarks to the Third Reading.
We are here discussing a Bill whose ramifications are very great. One of the country's greatest social problems is looking after the semi-infirm, particularly the elderly semi-infirm. Nobody in any walk of life can be unaware of the great difficulties encountered by relatives and medical people in securing adequate places for patients of this kind. The choice is between homes which are run by local authorities and those which are run by private individuals. The Bill deals with the privately run side of this social service. Although many of these homes are run purely for profit, there is an element of social service in many of them.
The Bill quite rightly attempts to strike at those people who do not obey a 799 reasonable system of conduct in the manner in which they operate these homes. My hon. and learned Friend the Member for Surrey, East (Mr. Doughty) stressed an important point with which the Bill will deal. He said quite rightly that the present cost of looking after a patient in a public hospital is about £40 a week. It would not be right to go into that matter at this stage. What we have to consider is how much it costs in a private home, how many private homes there are and how many people this Bill will affect, because these are matters of considerable importance.
The hon. Member for Islington, East also touched on an important point when he asked what would be the effect of the Minister making regulations and a local authority deciding to impose sanctions. As I see it, there are only two sanctions which my right hon. Friend can impose under the Bill. First, the radical one of striking the nursing home off the books—in other words, refusing to renew its licence—secondly, to use persuasion and tell the home in question that the beds are too close together, that it has not provided sufficient sanitation; and so on. These are the sanctions which we are proposing to allow the Minister to use under this Bill.
The question is how these sanctions will be interpreted, and the hon. Member for Islington, East, was very fair when he put forward this point because he appreciated the difficulty with which we are faced. If a local authority imposes the ultimate sanction, it will be faced with the responsibility of finding accommodation for those who have lost it in the home which has been closed. The Minister will have to be very careful because he may be in an extremely difficult position. He will make the regulations, but it will be the responsibility of the local authority to interpret them.
If a nursing home, or an old people's home—and I gather that this second category is covered by the Bill—is ordered to close, can it appeal to the Minister? I am not trying to defend bad nursing homes. I am trying to look at the problem from a practical point of view. I think that it is important to ensure that a nursing home has the right to appeal against a decision of a local authority, and I hope that my hon. Friend 800 will deal with this point, which, as my hon. and learned Friend the Member for Surrey, East said, is of considerable importance.
We would of course like to see all those who need it to be looked after in the most delightful circumstances, but with this enormous backlog in the lack of facilities and beds for the two categories of people to whom I referred, we have to face the real practical problem of cost. The cost of staying in many of these homes compares favourably with that in a home provided by a local authority, though it is fair to say that the standards are not comparable, but there are many people who are able to pay a lower scale of fees to remain in a private home. The accommodation available under the National Health Service, or any other local authority service, is limited and promises to remain so for a long time, and there are many people with small incomes who, helped by pensions and National Assistance, are able to avail themselves of the facilities offered by this type of private nursing home or private old people's home.
As I read the Bill, it appears to apply not only to those in nursing homes, but to those who are infirm, because the distinction between the two categories is very fine indeed. At what point does one say that an old person is an ill patient, and not merely an old patient? If the Bill became law, any regulations made by my right hon. Friend could cover both the ill and the elderly, and I hope that my hon. Friend will also deal with this problem.
With great respect to my hon. Friend the Member for Tottenham (Mr. A. Brown), the important thing here is not so much the Bill itself, but the regulations which will be made under it, because this is an omnibus Measure which will give the Minister considerable powers to regulate the conduct of nursing homes and old people's homes, and it will be the responsibility of my right hon. Friend and his Department to ensure that the regulations are reasonable and flexible.
I hold no brief for the bad nursing home, or for the badly run old people's home. I am not talking now about whether the beds are too close together, whether the motive is profit, whether there are no facilities whatsoever for the patients, or inmates, or whatever one calls 801 them, and so on, but I appeal to my hon. Friend to make sure that those who are struggling to keep down the costs of these homes, many of which are not entirely profit making—and here I am not referring specifically to the charitable organisations but to some homes which are run not only to try to make a small profit but to be of benefit to the community—are not prevented from doing so.
I hope that the regulations will take account of these important facts: First, that we must preserve the number of privately run homes to take up the slack for which the national and local authorities are unable to cater. Secondly, that we must stamp out the really bad cases, because I believe that in the bad cases we should adopt the ultimate sanction and get rid of them.
Many of these homes are run without qualified nurses. In some cases qualified nurses are not necessary because the people with whom they are dealing are not really sick. I hope, therefore, that this Bill will strike at the bad institutions. I hope that by this Measure we may be able to help those people who are genuinely trying to provide a good service. I hope that the regulations will not be so tough or unreasonable that the really good home, which perhaps has more beds than we would really like, is forced out of business. I hope that we shall not force the good homes to close by increasing their overhead costs to such an extent that they are unable to continue to provide the great social service which at present they provide throughout the country.
§ 12.20 p.m.
§ Dr. Donald Johnson (Carlisle)
I am also happy to support the Third Reading of a Bill which has enjoyed universal approbation among hon. Members—even to the extent of not being objected to by my hon. Friend the Member for Exeter (Mr. Dudley Williams) because it happens to be dealt with on a Friday. We can all feel happy about its provisions. I shall follow the remarks of my hon. Friend the Member for Clapham (Dr. Alan Glyn), and in order to keep within the rules of order I shall speak mainly to Clause 1(1)(a) concerning the Minister's powers in connection with the provision of facilities and services.
We must now consider the question of the provision of these services from a 802 positive rather than a negative point of view. When I interrupted the speech of the hon. Member for Islington, East (Mr. Fletcher) I did not mean to express disapproval of what he was saying, but we have heard so much about the undesirable features of private nursing homes, and have read about them in the Press, because such matters make news. What does not make news is the quiet, honest service which is provided in many well-regulated nursing homes. We must consider the facts of the situation and realise that in this part of our social services there is a vast gap.
Hardly one local authority is satisfied that it is making proper provision of residential accommodation for its elderly citizens—largely for financial reasons. The provision of private nursing home facilities can be of immense benefit to certain people who, from no sense of social snobbery or superiority but simply because they are busy people, find it convenient to be able to arrange their own stay in a nursing home or hospital rather than have to fit their arrangements into the more complex machinery of a local authority hospital.
This supplementation of our social services by qualified nurses who happen to have a small amount of capital and start up these nursing homes—ordinary nursing homes or elderly persons' homes—is a welcome feature. These homes are started up as private ventures with a view to obtaining a quite legitimate form of livelihood.
Trouble arises from the fact that in most cases the capital available is insufficient to provide the proper service which society demands in these days. From now on we must turn our thoughts in the direction of helping people who start nursing homes, as a supplementation of our social services, instead of blasting them all round, as seems to be the present policy both in this House and also at local government level.
The Bill, by way of the regulations and the powers it provides, will help to give local authorities more confidence in the situation. Many local authorities, while admitting that they have a problem in finding residential accommodation for the elderly people on their hands, are still not willing to provide help—and often put up every possible resistance in their power—to those who seek to establish private nursing homes. Very 803 often this is because they feel that they lack the proper power to provide adequate supervision, in order to see that such homes reach required standards.
Now that they are to be given these powers, I hope that local authorities will adopt a different and less ideological point of view towards this kind of supplementation to our social services. Nevertheless, I agree with my hon. Friend the Member for Clapham that if the regulations are applied too fiercely there is some danger that we shall regulate private nursing homes out of existence. The only effect of that will be to put a still greater load upon our already overloaded National Health Service, by making it even more difficult to cope with the immense load created by the situation of elderly people at the moment. I hope that the Government will bear that point in mind in applying the regulations.
I have one small interest in the matter. I admit to a feeling of gratitude that I have been fortunate enough, during my stay in the House, to have needed medical attention of this kind only for two days. It was then entirely thanks to the existence of a private nursing home in south London—where I was able to arrange my own times—that in the last Parliament, when majorities were somewhat tighter than they are now, I was able to finish my week in the House and be fit enough to return to the House on the following Tuesday in response to a three-line Whip. This would have been quite difficult to arrange with ordinary hospital machinery, which does not allow a person to pick and choose his times.
Furthermore, I was agreeably surprised at being provided with an excellent service at a cost almost 50 per cent. lower than I would have had to pay for a private bed in a hospital. It is possible for these homes to provide a good service at a much lower price than is charged for a private bed in a National Health Service hospital. As far as I know, this nursing home has now gone out of existence. It happened to be sited on valuable property, and nobody could blame the owners for selling it. I do not think that it has been replaced.
These private nursing homes can provide facilities which are of great benefit to busy people who, when suffering from minor illnesses, find it important to be 804 able to receive treatment without the ordinary tenor of their lives being interrupted. Such people view with some apprehension the future of these nursing homes. That is why I ask my hon. Friend if he will look at the powers in the Bill in this way, as well as in the more negative ways as he has been urged to do. The only other thing I wish to do is to echo the request which has been made that if he can my hon. Friend should in the remarks he makes give us a clearer definition of a nursing home.
§ 12.30 p.m.
§ Mr. Dudley Smith (Brentford and Chiswick)
I hesitate, in some ways, to follow two of my hon. Friends who are both medical men, but I should like to give a welcome to the Bill. I consider it a valuable step forward. I should also like to congratulate my hon. Friend the Member for Tottenham (Mr. A. Brown), who is not in his place at the moment, on his good fortune in the Ballot and on having had an unchequered path so far in the progress of the Bill. My hon. Friend has had the unique experience of having sat on both sides of the Chamber during the present Parliament, but I think it pretty obvious that on both sides of the House there is unanimous support for the Bill. We all welcome it, irrespective of our politics.
Many local authorities carrying out their work extremely well in respect of the administration of the registration of nursing homes. They do their work conscientiously. I know something of the work of the Middlesex County Council, which is, the second largest local authority in the country. I know that the team of its Medical Officer of Health devotes a good deal of time to the inspection of nursing homes and to seeing that they are properly and effectively run as far as legislation permits. I think, therefore, that the Bill will do a good deal to strengthen their hands and that its introduction will prove to be very useful.
I know, on the other hand, that there are some local authorities which are not quite as efficient as some of the large county councils in the administration of the registration of nursing homes, and I wonder whether in some ways the Bill, admirable as it is, will be strong enough to enable them to tackle the 805 job more vigorously than they have been doing up to the present. I agree with my hon. Friend the Member for Carlisle (Dr. D. Johnson) that the Bill may well give them confidence, but had there been more teeth in it perhaps we could have looked forward to a more wholesale reappraisal of the nursing home situation.
There are something like 1,100 nursing homes in the country at the present time, many of which do an extremely good job. Some however, do not do such a good job. I have not come here today, to use the words of my hon. Friend, "to blast them all the way round." They fulfil a most useful purpose in society. On the other hand, of course, there are the black spots. We have heard about some of them today. I was perturbed to hear the observations of the hon. Member for Islington, East (Mr. Fletcher). The case which he cited may be a particularly bad one, and I hope very much that the hon. Gentleman is going to pursue the matter in the future. I hope, too, that my hon. Friend the Parliamentary Secretary has taken due note of it. It reveals a very disquieting state of affairs. I personally have heard of cases where relatives have had extreme difficulty in visiting a patient. Sometimes, of course, it was unsuitable medically for them to do so. One cannot imagine the same state of affairs in hospitals.
The nursing home service provides a very valuable adjunct to the hospital service, particularly in maternity cases. This relieves the hospitals very largely. The service is extremely valuable, too, in cases where it is very difficult for a prospective mother to get into hospital, unless there are special medical circumstances, after the birth of her first child. Many expectant mothers, therefore, go into a nursing home to have their second and subsequent children. In these circumstances, it is right that there should be adequate inspection of nursing homes which provide maternity services.
I was interested in the remarks of my hon. Friend the Parliamentary Secretary during the Committee stage. He said:… there is one nursing home bed to every twelve hospital beds. It is clear therefore, that nursing homes are making a substantial contribution to the care of the sick. Of the total beds in these nursing homes, 1,558 were for 806 maternity and the remainder for acute, chronic or geriatric cases. About 85 per cent. of the patients were of pensionable age and the majority were over 80. This indicates how important it is that there should be effective control by the registration authorities over the conditions and conduct of these homes."—[OFFICIAL REPORT, Standing Committee C, 23rd January, 1963; c. 6.]I welcome very much those words of my hon. Friend. I think that they add particularly to the comments made by the hon. Member for Islington, East.
Quite obviously, nursing homes cater, to a large extent, for the elderly, and we must always bear that fact in mind. How often we have heard that nursing homes have a general air of sadness about them because the older people who inhabit them are often those who have been left without relatives or who are unwanted. They have a little money and, therefore, do not go to the old people's homes run by the State or by the local authorities. They go instead into a private nursing home. They may be in failing health but still in control of their faculties. This is sometimes a very sad thing indeed. Often, they are in the position of having no one to keep an eye on them and so they go into a nursing home. If they have a little money they are able to pay for their keep, or sometimes relatives meet the cost. In the majority of cases these people are well and kindly treated, but, unfortunately, in other cases—I have had instances of this brought to my attention—these old people are shamelessly exploited. This is a scandal in this day and age, and I hope very much that the Bill will do something to correct that trend.
I should like to ask my hon. Friend the Parliamentary Secretary whether he is aware of the practice which has developed in the last year or two, and whether or not it is covered by the Bill, whereby people start nursing homes and then find after a while that most of their patients are old people. They then change over to becoming private welfare homes catering exclusively for the elderly and the chronic sick. As a result, they are sometimes able to charge £30 or more a week, and make a fat profit. I do not say that many of these homes are badly conducted. They seem to be forming a new stream in this section of health administration. I wonder whether my hon. Friend realises that this is going on 807 and whether he feels that these private welfare homes are also covered by the Bill.
I think that the limitation of numbers referred to in Clause 1(1,b) is particularly valuable, because it prevents gross overcrowding and provides that there should be proper sanitary facilities and adequate room for beds in nursing homes. I think that nothing but good will accrue from this provision.
Unlike my hon. Friend the Member for Carlisle, I have been unfortunate enough to have two stays in hospital during the time that I have been a Member of the House. From my experiences, I would always prefer to go into a hospital rather than into a nursing home either as a National Health patient or as a private patient. It is absolutely essential that the nursing home system should be preserved in order to take some of the burden off the National Health Service.
Looking at the penalties provided in subsection (2), I wonder if they are heavy enough. I wonder if fora first offence … a fine not exceeding five poundsis really going to deter anyone set on the course of running a nursing home in order to exploit the public. I suppose that, in the long run, the best deterrent to such a practice is the resultant publicity from court proceedings as in so many criminal cases. Perhaps, therefore, the fine even though I do not think it is enough, will have something of a deterrent effect.
I believe that the Bill will provide useful facilities for the local authorities. It will give them that added strength which they need to make their system of registration effective and to carry out regular inspections. I think that it will do a good deal to preserve what is, despite the black spots, a very valuable service. Again I commend the Bill, as so many of my hon. Friends have done, and also thank my hon. Friend the Member for Tottenham for introducing it.
§ 12.40 p.m.
§ Mr. Charles Curran (Uxbridge)
The purpose of the Bill is to prevent the exploitation of old age. It is for that reason that I and my colleagues have been happy to support my hon. Friend the promoter of the Bill and do all that 808 we can to turn it into law. The fact is that this country is now facing a problem for which, I fancy, we have not made adequate provision. It is the problem caused by the rising age level of our population and the presence in our society of a larger and larger number of people who are past working age.
This problem is accentuated by the changing family pattern. The Victorian family was a three-generation structure. The Victorian family tended to take for granted that it was the business of that stratum of the family which was in active working life to look after that stratum which had become too old for work. This family pattern has now changed. We now have the two-storey family in this country.
This is a change which has been accentuated and speeded up by the change in the housing pattern. We have followed ever since the war a policy of building houses which are big enough to hold two generations only. It is physically not possible for the average British family to make provision for the grand-parents, and some other provision has to be made for them. Victorian England tended to take it for granted that it was the business of married couples to look after the parents. Welfare-State England on the whole does not do that, partly because it very often does not want to, and partly because it cannot do so.
Short of some radical change in our housing policy, short of some expansion of what is regarded as a normal house so that it will be possible for the ordinary family to make provision for, and to undertake care of, that generation which has got past working age, it is necessary for the State to step in, and it is also necessary for private nursing homes to step in.
The purpose of the private nursing home is primarily to provide a shelter, a refuge, for people who are too old to work and who are financially able to take advantage of them or whose relations are able to to make some provision for them. When the Bill was in Standing Committee my hon. Friend the Joint Parliamentary Secretary to the Ministry of Health mentioned a figure which has already been quoted in the debate and which I propose to repeat. At the end of 1961 there were, in round figures, 18,000 beds in nursing homes. No fewer than 85 per cent. of the people occupying 809 those beds were people of pensionable age, people too old to work. The majority of the people in nursing homes were over 80 years of age. I suggest that these figures make what we are doing abundantly plain. We are seeking to provide protection for these people, most of whom are too old to work, and the great majority of whom are over the age of 80 and who, without the protection which the Bill will give when it becomes law, are liable to exploitation.
I am not asserting—nobody in the House would assert—that nursing homes in general are open to attack. I do not believe that anyone would assert that. I have no doubt—nor, I fancy, has anyone who has spoken in the debate—that the great majority of nursing homes are well conducted. It is a fact, nevertheless, that it is possible, as previous speakers have shown, for the occasional nursing home to exploit the old people who go there in a fashion for which at present there is no redress. The Bill therefore closes a gap which needs to be closed in the interests of people who are too old to look after themselves.
So far from supposing that the need for the provisions of the Bill will diminish, we must take it for granted that the need for them will increase. One of the most remarkable and enduring facts about England nowadays is the steady and continuous rise in the age level of the population. I think I am accurate in saying that at present roughly one-sixth of all the voters in this country are people who have passed working age. The proportion and the numbers keep on rising. This is a process which creates in our society a larger and larger number of people who are too old to look after themselves. The business of looking after them has been disrespectfully described by one member of the medical profession as a process of medicated survival. It is a process which necessarily continues and is extending all over the country.
I do not believe that the Welfare State has applied its mind as it ought to do to the problem that is presented by this steadily increasing number of elderly people. I do not believe that our housing policy has been shaped with this fact in mind. I do not believe that our welfare services have been organised so as to cope with this steadily multiplying number. It 810 is quite clear from what we have heard in the debate that the job which is now being done by nursing homes which take elderly people is a job which needs to be done by them, because it will not be done by anybody else.
I therefore welcome the Bill. I congratulate my hon. Friend the promoter. I recognise, as we all do, that he is closing a gap which needs to be closed if elderly people are to be protected. I hope that the Bill will become law as soon as possible.
§ 12.46 p.m.
§ Lord Balniel (Hertford)
I, like my hon. Friend the Member for Uxbridge (Mr. Curran), am a sponsor of the Bill, one of the six Members on this side who have sponsored it. However, I am most anxious, for obvious reasons, to turn the debate as soon as possible to another Bill which I am promoting which is, alas, rapidly disappearing over the horizon of Parliamentary life. My remarks will therefore be brief indeed.
As a sponsor of the Bill, I feel that the great mass of us fully support my hon. Friend the Member for Uxbridge's statement that the overwhelming majority of nursing homes are conducted with the very highest standards by people who have dedicated much of their life's work to helping old people. Equally, anyone who has read "The Last Refuge", by Mr. Peter Townsend, will realise that there is a great deal still which ought to be done to improve standards. I should also like to join in the congratulations to my hon. Friend the Member for Tottenham (Mr. A. Brown) on introducing the Bill and carrying it through the House.
§ 12.48 p.m.
§ The Joint Parliamentary Secretary to the Ministry of Health (Mr. Bernard Braine)
We have had a most interesting and constructive debate. I, too, should like to join with hon. Members on both sides who have congratulated my hon. Friend the Member for Tottenham (Mr. A. Brown) on putting through thus far this very useful Measure. I must confess that I had some sympathy with him during the course of his speech, in that it is a disadvantage of our procedure that if a Bill is not debated on its Second Reading there may be a lack of understanding as to what it seeks to do when it reaches Standing Committee or even 811 when it is returned to the House. It is very important indeed to avoid any such misunderstanding about a Bill which, as is the case here, gives Ministers the power to make regulations. I know that my right hon. Friend the Minister of Health holds that view very strongly.
Thanks to my hon. Friend the Member for Tottenham and to the hon. Member for St. Pancras, North (Mr. K. Robinson), who made such a useful contribution to the debate earlier today, the Bill had a swift and smooth passage in Committee. I am sure that the whole House is grateful for the very full explanation my hon. Friend the Member for Tottenham gave this morning in moving the Third Reading.
My right hon. Friend welcomes this Bill. It is quite an important Bill in its way. It is, of course, designed primarily not to help the nursing home but to help the patient. If my hon. Friend had not had the good fortune in the Ballot and had not selected this Bill or been assisted in the way in which he has been assisted by hon. Members on both sides of the House in facilitating its passage, it would have been the Government's intention to take action in this field.
My right hon. Friend welcomes the Bill because it enables him in respect of nursing homes to do what he already has power to do in respect of mental nursing homes and residential homes for the elderly and also for the disabled. That is to make regulations referring to their conduct, the standards of care they provide and the standards of staff whom they employ. I am very glad to know that there is broad agreement on both sides of the House that my right hon. Friend should have this power in respect of ordinary nursing homes.
§ Dr. Alan Glyn
Will my hon. Friend clear up this point? Is the reason for subsection (5) of Clause 1 being in the Bill that the Minister has powers in other directions so to inspect?
§ Mr. Braine
Yes. I shall later explain how the whole field is covered. In reply to the specific point raised by my hon. Friend the Member for Clapham (Dr. Alan Glyn), the effect of subsection (5) is twofold. It is, first, to exempt from the regulations which my right hon. Friend will make under the Bill, if it 812 becomes law, mental homes which are already covered by the equivalent provisions, partly in the Mental Health Act itself and partly under regulations already made under it—the Conduct of Mental Homes Regulations, 1962.
The second effect of the subsection is to ensure that regulations to be made under the Bill will not apply to Christian Science nursing homes. These, as some hon. Members know, are already exempt from legislation by virtue of Section 193 of the Public Health Act and Section 247 of the Public Health (London) Act. It is clearly unreasonable to expect a registration authority or my right hon. Friend to take any responsibility for the conduct of homes run on Christian Science principles. Provision for the exemption of those homes by the Minister has existed since nursing homes were first registered. We feel—I am sure the House would agree—that it is wholly inappropriate for regulations made under this Bill to apply to those homes.
I should say in passing that exemption is given on the advice of a special Christian Science committee, which requires applicants for exemption to undertake that only persons over 16 who wish to rely on Christian Science principles should be in those homes. I think tht there are adequate safeguards there for the individual.
My hon. Friend the Member for Clapham asked how many nursing homes were likely to be caught by this Bill. I confirm the figures which have been given by other hon. Members. There are 1,100 nursing home in England and Wales, providing over 18,000 beds. There is one nursing home bed for every 12 hospital beds, apart from the provision for the mentally disordered. That is a very substantial contribution. It underlines what so many speeches this morning have made clear, that the private nursing homes are making a very substantial contribution to the care of the sick.
However, as I believe my hon. Friend the Member for Uxbridge (Mr. Curran) said in his striking speech, of the total number of beds in those nursing homes between 1,500 and 1,600 are for maternity and the remainder for acute, chronic or geriatric cases. In them 85 per cent. of the patients are of pensionable age and the majority are over 80 813 years of age. It is quite clear that my hon. Friend was putting his finger on a major purpose of the Bill when he said that it is to prevent the exploitation of old age. We are concerned here with a particularly vulnerable group of people. On that account it is especially necessary that there should be effective control by the registration authorities in regard to the care and treatment of these patients.
The Bill fills a gap. As the House knows, and as we have been reminded many times this morning, the Public Health Act, 1936, requires the registration with local authorities of nursing homes run for profit. It is an offence under existing law to run such a home without registration. My hon. and learned Friend the Member for Surrey, East (Mr. Doughty) asked if there was any justification for Clause 1(1,b). That goes to the whole root of the matter. I shall not stray outside the rules of order, Mr. Speaker, in view of your earlier Ruling. Suffice it to say that powers given to county councils and county borough councils and the provision for delegation to district councils for registration and inspection exempt nursing homes not run for profit, of which about 114 were exempted from these provisions.
Incidentally, the Bill remedies that and brings them within its scope, allowing them a reasonable time before registration. All these nursing homes vary very much in size and type of case for which they provide. They range from quite small establishments, with a retired nurse caring for three or four elderly patients, to quite large institutions run on hospital lines. Whatever their size, and whatever the scope of their provision, they should be brought under effective control. In a moment I shall say why.
My hon. and learned Friend asked why the Bill repeals Section 192 of the Public Health Act. There is no reason why non-profit-making nursing homes should be exempt from registration and inspection, especially as the best of them—and there are some very good ones—have elected voluntarily to become registered over the years. The less satisfactory compare unfavourably with a good many of the better nursing homes run for profit. The Bill will now end this anomalous situation.
814 The answer to my hon. and learned Friend is that as things stand my right hon. Friend has no jurisdiction over any nursing homes whatsoever. If a complaint is made to him, all he can do is to refer it to the registration authority. If the nursing home is well run, as the vast majority of them are, it matters not at all. If there are some not so well run, he still has no jurisdiction. For some time past the County Councils Association, the Association of Municipal Corporations, the Society of Medical Officers of Health and individual medical officers of health have been pressing my Department on the ground that local authorities have been finding increasing difficulty in securing the maintenance of reasonable standards in certain homes and that they need additional powers.
The position was such that two county councils, Hertfordshire County Council and Devon County Council, were so concerned that they included provisions in local Bills. The House will find those provisions in the Hertfordshire County Council Act, 1960, and the Devon County Council Act, 1961. The Hertfordshire County Council Act includes provisions for taking power to register the proprietors of nursing homes, as to the numbers of patients, the suitability of nurses and medical staff, suitable care, suitable catering, and the keeping of records. These are regulations of a kind which my right hon. Friend will seek no doubt to introduce once this Bill becomes law.
It may be asked why these difficulties have arisen. The answer came out very clearly in some of the speeches that we have heard this morning. There is a shortage of this type of accommodation. There is a great need for nursing home provision. True, in a glaring instance of inadequate provision, a registration authority can refuse to register or it can cancel a registration. That is a very drastic step to take. But the existing law does not provide any lesser sanction which would enable the proprietor to put his house in order before being put out of business. For this reason, local authorities have been reluctant in many cases to take enforcement action. The refusal of registration, or cancellation, penalises not merely the proprietor but, far worse, the patient who has been looking for a bed in the nursing home.
§ Mr. L. M. Lever (Manchester, Ardwick)
The Minister was saying that local authorities have no power to give a proprietor an opportunity to put his house in order. May I say that in Manchester invariably in such a case before we make a final decision to refuse registration, we adjourn the application in order to give the person concerned an opportunity to put his house in order. We may give an adjournment of one, two or three months according to the exigencies of the situation. Therefore, although we can refuse to register, we have always been constructive in Manchester in trying to get the best out of these people before deciding whether to refuse registration. I thought that I should make that point clear.
§ Mr. Braine
That was a most helpful intervention. I am sure that it is the practice of all enlightened local authorities to conduct their affairs in such a way—and who am I to say that Manchester is not in the front rank of such authorities? Nevertheless, the fact remains that the local authority associations and the medical officers of health, who after all are most closely concerned in seeing that proper standards are maintained, have been pressing the Ministry of Health for some time for the kind of regulations which this Bill will for the first time enable my right hon. Friend to make.
§ Mr. L. M. Lever
I support the Bill and I am in favour of the regulations which this Bill will enable to be made, but without prejudice to what we have been doing so successfully in Manchester.
§ Mr. Braine
I always admire the way in which the hon. Gentleman succeeds in striking a blow for his great city. I have no doubt that these things are very well organised in Manchester. But, as has been adduced in the course of the debate, there are glaring instances of local authorities which have felt unable, for one reason or another, to take appropriate action, and this is something which this Measure will remedy.
In any event, the action by the registration authority is subject to an appeal to the magistrates' court. There has been, not unnaturally, a reluctance on the part of magistrates to deprive a proprietor of his livelihood. These factors 816 taken together indicate how necessary it is for my right hon. Friend to take the powers which this Bill will confer upon him. I am not saying—I do not think anyone has said in this debate—that there is widespread abuse, but clearly this is an unsatisfactory state of affairs and my hon. Friend's Bill will, as I say, provide a remedy. In short, it will close a loophole.
My right hon. Friend already has adequate powers in respect of residential homes for the elderly and the handicapped under the National Assistance Act, and for the mentally disordered under the Mental Health Act. For example, my hon. Friend the Member for Brentford and Chiswick (Mr. D. Smith) raised a very important point about a marginal type of home which I think he described as a residential home, and I should like to say straight away that this would be caught by the regulations laid down under the National Assistance Act.
It might be helpful at this stage if I were to attempt to answer some of the questions which have been put in the course of the debate. I am exceedingly sorry that the hon. Member for St. Pancras, North is not with us. I fully understand, as we all do, why he had to leave early in the debate. He has taken an interest in this matter for some time past. He contributed notably to our short but very interesting debate in Standing Committee and he has spoken this morning. I am, therefore, anxious to give him a reply to his questions. He asked for a definition of a nursing home. I think I can best answer that question by saying that nursing homes are covered at the moment under three Acts. A nursing home is defined in the Public Health Act, 1936, or in the corresponding Public Health (London) Act, as:any premises used or intended to be used for the reception of, and the providing of nursing for, persons suffering from any sickness, injury, or infirmity, and includes a maternity home"—which is also defined in the Act—but does not include … any hospital or other premises maintained or controlled by a Government department, county council … local authority … or any other authority or body constituted by special Act of Parliament or incorporated by Royal Charter.These are the nursing homes that we are seeking to cover by regulation under this Bill.
817 There are mental nursing homes already covered, subject to regulations, by the existing law. The Mental Health Act, 1959 provides for the registration of mental nursing homes under the Public Health Act. These are defined as:any premises used or intended to be used for the reception of, and the provision of nursing or other medical treatment for, one or more mentally disordered patients (whether exclusively or in common with other persons)subject to the exclusion of hospitals, and any other premises managed by a Government Department or provided by a local authority. The regulation-making power in this instance is contained in the Mental Health Act, 1959. Mental nursing homes, therefore, are already covered by adequate regulations which have been made by order by my right hon. Friend.
Then we come to disabled or old persons' homes—the kind of establishment to which several of my hon. Friends, notably my hon. Friend the Member for Clapham, referred earlier. The National Assistance Act, 1948, as extended by the Mental Health Act, 1959, provides for the registration of disabled persons' or old persons' homes which are defined as:any establishment the sole or main object of which is, or is held out to be, the provision of accommodation, whether for reward or not, for persons to whom Section twenty-nine of this Act applies …"——that is a disabled person—or for the aged, or for both.It also provides for the registration of residential homes for mentally disordered persons designated as:an establishment the sole or main object of which is, or is held out to be, the provision of accommodation, whether for reward or not, for persons suffering from mental disorder.…This category of home is covered by regulations made by my right hon. Friend; so the effect of the passage of this Bill will be to give my right hon. Friend the power to make regulations covering the whole range of these establishments. The answer to those who were doubtful about what would happen to a welfare home is it would be covered, if it would not provide nursing care, by the regulations made under the National Assistance Act.
The hon. Member for St. Pancras, North asked whether I was satisfied that there is no serious gap. He expressed 818 the hope that, if there was, then at some future stage the definition of a nursing home might be amended to include all establishments where old people who are frail, confused or disabled in any way, are cared for. I have explained that there are three statutory codes for the registration of nursing and residential homes, each code defining the type of home to which it applies. I hope, therefore, that I have answered the hon. Gentleman's question.
I understand the hon. Gentleman's fears. They are that there may be premises which ought to be registered and inspected, but which fall along the borderline between the three definitions and are not caught by any of them—rest homes; convalescent homes, not providing nursing service; nature cure homes, which do not provide conventional nursing service or treatment; guest houses; and boarding houses—where the guests are mostly infirm or bedridden but who may not be receiving nursing care.
The hon. Gentleman's suggestion that any problem which there may be over these borderline premises might be met by having a single definition and a single system of registration for all the establishments which need to be registered, is similar to a suggestion made by the local authority associations in discussions with us over the last two years. The associations pointed out that there is increasingly an indeterminate borderline between old people's homes with a high proportion of very infirm or bedridden residents, and nursing homes with a high proportion of patients of the same kind. The associations suggested that new legislation on registration might well cover both nursing homes and residential homes.
A similar point was made in the Report published in 1961 by Caroline Woodruffe and Peter Townsend—"Nursing homes in England and Wales. A study of public responsibility"—and in Mr. Townsend's recent book, "The Last Refuge". It is not clear that amalgamation of the systems of registration for nursing homes and residential homes would ensure that borderline homes not at present registered would become subject to that registration. The possibility of overlapping between residential homes, homes with a high proportion of bedridden residents and nursing homes with a high proportion of infirm rather 819 than sick patients is of limited practical consequence as long as registration is effected under the Public Health, National Assistance or Mental Health Acts.
The home run for profit claiming to be a home for old people is almost certain to be registerable under the National Assistance Act or, if it employs nursing care, it would be caught under the Public Health Act and therefore under the regulations to be made under this Bill. I have gone into that in some detail because I recognise that there is a genuine anxiety in the minds of the hon. Member for St. Pancras and other hon. Members who have contributed to the debate.
We have no evidence, however, that there is any serious gap between the present definitions which would allow homes which ought to be registered to escape registration. Moreover, it would be difficult, I am advised, to amend the present definitions with the object of widening them to catch more convalescent homes, or boarding houses which specialise in taking in elderly and infirm people, without there being a danger of making the definition far too wide. In short, my right hon. Friend is well aware of this point. But he does not feel that there is any present need to seek to extend the area covered by the effect of the various definitions under the present statutory codes. The object of the present Bill is to strengthen the hands of the local authorities in relation to nursing homes which are already subject to registration by enabling my right hon. Friend to confer on them by regulation powers similar to those which they already enjoy in relation to other types of homes. I hope that I have made that clear.
I turn now to the second question asked by the hon. Member for St. Pancras, North, whether local authorities have adequate staffs for their functions of registration and inspection. The hon. Gentleman wanted to know whether existing staffs were adequate in number, qualifications and experience, and he asked for an assurance that, unless my right hon. Friend was satisfied that inspections are being properly carried out, he will see that the authorities obtain the necessary personnel to carry out inspections.
820 We have no reason to think that local authorities are unable properly to discharge the functions of inspection already laid on them by the Public Health Acts. Their wish to have their hands strengthened by powers such as are proposed to be conferred on them by regulations to be made under this Bill arises from the judgment of their officers who inspect at present that conditions in every case are not satisfactory. I think that this is a clear indication that the authorities have the staff which they are using to the best effect, short of the regulations which will give them more effective powers.
I was asked by my hon. Friend the Member for Tottenham what form the regulations would take and how they will be used. A good deal of anxiety has been expressed about this, and rightly so, by a number of hon. Members. I will do my best to answer the question, I am sure, however, that the House will appreciate that it will not be possible at this stage for me to give any detailed list of matters which my right hon. Friend hopes to cover in the regulations he expects to make under the powers in Clause 1 of the Bill, for a very simple reason. It is the intention of my right hon. Friend, as the House will expect, to ascertain the views of the local authority associations and interested professional organisations, once the powers have been given to him. It is likely that the regulations will follow, in general, the lines of the National Assistance Conduct of Homes Regulations, 1962, and the Conduct of Mental Nursing Homes Regulations, 1962, and this enables me to give some sort of indication of what my right hon. Friend would probably like to see in the regulations.
First, they will probably provide that each patient should have efficient nursing care, and for this purpose the nursing home will have to employ by day and night suitable qualified and competent staff in adequate numbers having regard to the size of the home and the number and condition of the patients received there. The regulations will probably be required to provide for each patient in the home by day and night reasonable accommodation and space having regard to the patient's age and sex and the nature and degree of the illness or disability from which he or she is suffering. They are also likely to cover the 821 provision of adequate and suitable furniture, bedding, curtains and, where necessary, screens and floor coverings in rooms occupied and used by patients. Appropriate and suitable medical and nursing equipment should be provided, having regard to the condition of the patients. There should be provision too for the use of patients of a sufficient number of wash-basins and baths, hot and cold water supplies, water closets, and the necessary sluicing facilities.
The regulations would be expected to lay down certain standards of adequate light, heating and ventilation in all parts of the home occupied by the patients. There would be a requirement that all parts of the home occupied and used by the patients should be in good structural repair and should be clean and reasonably decorated. Inevitably there would be included provisions for adequate precautions against the risk of fire and accident, having regard in particular to the age and condition of the patients. This is very important when we consider the high proportion of very elderly patients one often finds in so many nursing homes.
We should expect to see regulations to provide for efficient and suitable kitchen equipment, crockery and cutlery, together with adequate facilities for the preparation and storage of food. We should also expect provision for the supply of suitable and properly prepared food for the patients and for the regular laundering of linen and articles of clothing. It would also be expected that there would be some reference to the provision for any patient of medical and dental services under the appropriate statutes.
One could think probably of a number of other provisions, and the hon. Member for Islington, East (Mr. Fletcher) raised a most interesting question about visiting. I think that I can say that my right hon. Friend will look at that point when he comes to make his regulations, although it may be that it can be met by means other than by inclusion in the regulations.
§ Mr. Fletcher
The hon. Gentleman is giving us a long catalogue of all the regulations which he will expect to find. I certainly shall expect to find some regulations dealing with facilities for visitors to patients in nursing homes.
§ Mr. Braine
Provision on that point does not exist in the regulations for the conduct of mental nursing homes where, after all, relatives also have an interest in the welfare and well-being of patients. Nor is provision for this made in respect of residential homes for the elderly and disabled. I am not saying that we will not look at the point. On the contrary, I undertake that we will. All I say is that there may be some other way of dealing with it. Normally, visiting is allowed in a nursing home in the same way as it is in a hospital but, as the hon. Member knows, there are difficulties. The governing factor must be the health of the patient and, as I think my hon. Surrey, East made clear, the decision rests not with the patient or his relatives but with the consultant, the doctor, the patient's medical advisers.
§ Mr. Fletcher
I do not mind it resting with the patient's consultant or medical adviser but I would object to it resting with a matron or those who run the nursing home.
§ Mr. Braine
I take the hon. Member's point. His argument this morning arose out of a particular case. Obviously I cannot comment on that case because I have not the facts at my finger tips. This is a matter which has occupied my right hon. Friend and my Department and I would not argue it on the basis of that case. I agree that there should be a definite rule about this. As the House knows, my right hon. Friend has taken the lead in trying to persuade the hospitals to provide more liberal visiting hours. This presents to even the best-run establishments some difficulty if large numbers of visitors come and stay for a long time.
§ Dr. Alan Glyn
This new practice in the London hospitals has been very much appreciated by patients, although I agree that it means considerable work for the staff who, I gather, are willing to undertake it in the very genuine interest of the patients.
§ Mr. Braine
I endorse what my hon. Friend has just said, and we all know that he is a medical man. I do not doubt that there is a therapeutic value to the patient in having visits from members of his family. This is a matter which must be seen in perspective. I think that all that the hon. Member for Islington, East would 823 expect me to do at the moment is to say that I have taken careful note of what he has said and will ask my right hon. Friend to consider the matter. I must make it plain that my right hon. Friend will not make his regulations in a vacuum. He will be taking advice from a wide variety of bodies, but this is clearly a matter which he could consider and which may well be put to him from other sources.
There would also probably be provision that if the registration authority considered that the regulations were not being applied, it could give notice to the managers of the nursing home to that effect, specifying what it considered should be done to satisfy the regulations. If after a period of notice the regulations were not complied with, the registration authority would be able to take proceedings against the managers for an offence under the regulations.
This brings me to the point where I was asked by several hon. Members how these powers will be used. We certainly have no reason to believe that they will be abused. Powerful testimony to that effect was given by the distinguished former Lord Mayor of Manchester, the hon. Member for Manchester, Ardwick (Mr. L. M. Lever). The registration authorities have used their existing powers fairly. I know of no case where it could be charged that they have done otherwise. My hon. Friend the Member for Clapham asked about the right of appeal. The real safeguard against abuse lies in the courts. The Bill makes appropriate provision. A proprietor of a nursing home or a maternity home has a right of appeal to the courts against the cancellation of registration.
If the regulations to be made under the Bill provide that contravention of the regulations shall be an offence, the issue of whether a local authority has acted unreasonably in insisting upon any particular standard of accommodation or staffing—to the extent to which standards are left to the discretion of local authorities under the regulations—would also need to be decided in the courts before whom proceedings were taken. In other words, the courts will have the power, as they should, to see whether what a nursing home proprietor is required to do is fair and reasonable in all the circumstances.
My hon. Friend the Member for Brentford and Chiswick considered that 824 the penalty of £5 was too low. He was referring to the provision in Clause 1 (2). But this subsection also provides that conviction for an offence against the regulations may be a cause for cancellation of registration. This is a fairly powerful sanction. It means the closing of the proprietor's business and the ending of his livelihood. The beauty of the powers which the Bill provides is that local authorities will have more than this one sanction. They will be enabled to talk to the proprietors and to help them over a period to see what can be done to raise their standards.
It is necessary to get this matter into perspective. My hon. Friend the Member for Carlisle (Dr. D. Johnson), who spoke with personal experience of a period spent in a nursing home, reminded us that the vast majority of nursing homes provide a good and efficient standard of care. They do not present a problem. It would not be necessary for the powers given under the Bill to be applied to them. They already provide adequate standards.
In Standing Committee, the hon. Member for St. Pancras, North referred to recent surveys of old people in nursing homes showing that on the whole the best care that is given, especially to older people, is given in voluntary homes. I agree with him. We are not, however, dealing with a static situation. What were acceptable standards a few years ago are not always acceptable today and what is acceptable today may be quite unacceptable in ten years' time. The public are becoming more aware of the need for improved standards of care. Everywhere, we see better provision for the elderly being made by local authorities, including accommodation which combines privacy with comfort and a degree of oversight by a residential warden, who often may be a trained nurse.
One cannot yet measure the effect of what is happening all over the country in the local authority welfare field. Because there is a degree of oversight, little illnesses among elderly people are prevented from becoming big illnesses. On the other hand, as my hon. Friend the Member for Uxbridge said, the numbers of elderly people are growing all the time and will grow substantially in the next decade. The numbers of the very old and frail will grow even 825 more sharply. Therefore, to some extent, improved residential care for the elderly, on the one hand, may be offset by increasing numbers, on the other hand.
The development of domiciliary services means increasing availability of nursing help to people living either in their own homes or in residential or nursing homes provided by voluntary agencies and local authorities. Here, again, is another development which is now getting under way and will lead to a higher standard of health and welfare in the community than we have hitherto had. It is not yet possible to measure what effect this will have upon nursing home provision. We are not dealing with a static situation and it is right, therefore, that local authorities, as the registration authorities, should have power to insist upon decent standards of care and staffing in nursing homes. This is what the Bill will enable them to do.
There was one last query which was raised by my hon. and learned Friend the Member for Surrey, East which I dare not pass over. He questioned the inclusion in Clause 3(2) of the reference to Scotland. He could, of course, have added Northern Ireland, but he showed no anxiety on that score. He could not understand why the provisions of the Bill should not be extended to Scotland. As an English Minister, I hesitate to say anything on that subject. Scotland has, of course, its separate code of Public Health Acts; it always has done and probably always will. It is not possible to forecast what action may be taken in relation to nursing homes in Scotland, which, in any event, are not covered by the English Acts to which the Bill refers. That is where we must leave the matter.
In England and Wales, however, we should seek a steady improvement in the existing standards of care in nursing homes. The Bill fills a gap and it enables us to move forward in the right direction. For these reasons, I commend it to the House.
The hon. Member can speak only by leave of the 826 House. I understood that I heard an objection.
§ Question put and agreed to.
§ Bill accordingly read the Third time and passed.