HC Deb 08 April 1968 vol 762 cc1035-46

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Harper.]

11.3 p.m.

Mr. Kenneth Lewis (Rutland and Stamford)

Obviously depending on which way one looks at it, we are either a little earlier with this Adjournment debate or a little late. At one stage of the evening, I began to think that we would reach the Adjournment at about 7 or 8 o'clock.

This debate which I am initiating on the modernisation of the training of nurses was put down before the Prices and Incomes Board reported on the pay and conditions of nurses. Therefore, I suppose, I may congratulate myself on foresight in putting it down. It is interesting to notice that some of the suggestions made by the Prices and Incomes Board have been made many times by hon. Members, both to the previous Government and, from time to time, to the present Government. Those suggestions have been by-passed by successive Ministers of Health.

I remember that during the 12 years when I served on a hospital management committee, when I was chairman of an establishment committee and, therefore, concerned with nurses, there were a number of improvements for which we were pressing there which, we thought, would improve the recruitment of nurses. Recruitment, and to a certain extent the rate of wastage, have improved during the last few years. Nevertheless, we are still deficient in recruitment and far too many nurses who join the hospital service leave to go into other jobs either during their training or just after it. I therefore want to suggest one or two improvements to this situation.

The late starting age of nurses has always been a problem and should have been dealt with many years ago; a somewhat high starting qualification is demanded from girls, particularly by the teaching hospitals. There is the difficulty of early marriage, which creates loss of trained staff; this applies not only to nurses but to many other professions, particularly to the teaching profession. In addition, too many out-dated rules and regulations still exist in discipline. There is also the problem of recruitment of qualified nurses away from the hospital service into industry and into the local authority services.

I will not take too much time on Fay, the principal question raised by the Prices and Incomes Board Report, save t a make two comments. First, no one would dissent from the suggestions made for increasing pay, and even for increasing pay beyond the norm of 3½ per cent., since it is justified in this case. Apart from straight increases, however, pay can be dealt with by looking at the starting point on a grade. I am not sure that the hospital service, in recruiting staff nurses and sisters, takes advantage of the possibility of putting more highly qualified people, or those who are specially required to fill certain posts, on a higher grading than may be justified by their actual years of service.

Secondly, a differential between rates paid to nurses by some local authorities as against rates paid by the hospital service should not be encouraged, and the Minister should look at this. It seems wrong that local authorities should be able to recruit from the hospital service nurses trained by the service at a rate of pay higher than is paid by the hospitals.

Finally, on pay, the Minister should take very seriously the use of nursing employment agencies. The Prices and Incomes Board suggests the creation of a new set-up called the Supply Nurse Service. This is a reasonable suggestion, but, of course, it would be of no avail if employment agencies for nurses were allowed to recruit and supply nurses to the hospital service on a rate of pay very much higher than that paid by the hospital management committees.

Most people with any knowledge of this subject would accept that the attraction of the nursing profession to young people is not dependent upon a marginal financial return. Many other things act as deterrents against recruitment into the profession. First, the qualifications demanded by some teaching hospitals are way above the qualifications demanded by many other nurse training hospitals. Teaching hospitals which have a social cachet to them could take on a great many more nurses for training if they were to reduce the high standard of, in some cases, two A-levels at present demanded.

The proposal by the Prices and Incomes Board Report that the starting age should come down from 18 to 17 is long overdue. It has been resisted at the top level in General Nursing Council circles, despite the pressure which has been brought to bear in this House. It should be brought down to 17, and I hope that the Minister will say whether he intends to act on this proposal.

The hierarchy of nursing organisations have also resisted the introduction of cadet schemes. I know that cadet schemes exist in many of our training hospitals, but they are not given great encouragement. They are somewhat frowned upon. At the same time as the age of entry for training as a nurse is lowered, there should be introduced cadet schemes throughout the service. Recruits should be able to come in at the age of 16, straight from school. If a girl, who wishes eventually to become a nurse, gets a stop gap job until she reaches the necessary age of entry she often settles into this job and does not want to make the change later.

The Report also suggests that the training of nurses should be concentrated in a limited number of large training hospitals. I think that this would prove impractical. Many of our training hospitals need trainee nurses for the care of patients. Part of a girl's training consists in taking care of patients, and if they had to leave their present hospitals and these hospitals were deprived of recruits, this would make a difficult situation much worse.

We should actively encourage the recruitment of enrolled nurses. There has been a lukewarm reaction by the nursing authorities to the wider use of enrolled nurses. There is danger of an apartheid situation developing within the profession on this. This is stupid, and does not help in the staffing of our hospitals. The Minister ought to make it clear that he intends to encourage an increased recruitment of enrolled nurses.

It is time that we ended the restrictive regulations which insist that a S.R.N. who goes on to take a maternity or other training course must suffer a drop in salary. This is undignified, apart from being financially damaging. A nurse who takes a course which will be not only to her advantage, but to the advantage of the service as a whole, should not have to suffer a loss of either status or salary.

Next, this is mentioned in the Prices and Incomes Board Report, and it has been dealt with by some of our hospitals, split duty shifts are a barrier to social life among the nurses. Young nurses are entitled to a social life, in the same way as is any one else. It is interesting to note that matrons and senior sisters do not work split duty shifts. The work of nurses should be organised on a rota system, so that those who have time off do not have to take it in the middle of the day. It is very difficult for a young nurse to go out with her boy friend if she is off during the middle of the day and he is working. This problem ought to be appreciated by those who organise shift working.

The Report has a good deal to say about the lack of staff at night and at weekends in hospitals. I think we should appreciate, however, that we cannot have it both ways. We cannot expect nurses to be given time off at hours that are socially advantageous if at the same time we call for full staffing in the hospitals during the night and at hours when perhaps there is not quite so much to do.

The sixth point I want to make concerns the living in of nurses, and this again is mentioned in the Report. I would think it reasonable that nurses in their first year should live in. It should be within the competence of the matron of a hospital to decide whether second year nurses should live in, but I am quite certain that third year nurses should be allowed—and indeed encouraged—to live out. Obviously apart from every- thing else this cuts down the cost to the service of having to provide the accommodation.

The Report suggests that nurses in order that they may have more money for themselves they should pay for meals as they go, rather than pay a board fee which is taken from them. I have some doubt about this. I think it is important that the first year nurse who is working very hard—she is young and has just come out of school—should have her meals. She should not be encouraged to do what some university students do, to save money and not buy proper meals. Therefore, so far as the first year nurse is concerned, it seems to me that meals should either be provided free, or at least it should remain that limited board be taken off so as to ensure that the girl does get sufficient food to enable her to do her job.

Finally, there is the general attitude of the nursing hierarchy to the whole question of the treatment of nurses who are under training. This is still old-fashioned in certain places. We have got rid of the barrack square technique in the services, but nursing is still overlaid with a stiff-cuffed approach to training.

This is an irritant. The decision of a nurse as to whether she carries on her profession after she is qualified, I would say, takes place in the first year. If, therefore, the nurse becomes disenchanted in the first year she may well decide that she is going to grin and bear it. She is going to carry on with her course; come what may, she is going to complete it. Then she is going to get out.

The hospital service has got to recognise that in the training of a nurse it is important that there should be a modern outlook in both the spirit and the techniques of training. The modernisation of this system, which is pin-pointed in the Prices and Incomes Report, is something that has been pressed, as I said at the beginning, over many years, and the hospital service will get great advantage from any improvements the Minister can either impose or persuade.

If he takes the view that he ought to try to persuade, I would remind him that various Ministers have been trying to persuade the Royal College, the Nursing Council and others to improve their general attitudes towards training. It may be, therefore, that we have now reached the position where action is needed by the Ministry direct. I hope that the Minister will not hesitate to take any such action in order to improve the situation for those who are already in the service, retain more of those who are going out of it, and recruit more of those who are looking forward to joining it.

11.20 p.m.

The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)

I am not quite certain what the hon. Member for Rutland and Stamford (Mr. Kenneth Lewis) meant when he talked about direct action, because the statutory authority for nurse training rests on the General Nursing Council, which lays down the syllabus of training for each part of the register and the roll of nurses. My Department pays £4¼ million a year direct to the Council to help it to carry Out its responsibilities.

Training must be related to the patients' needs and must then reflect the changes in the organisation of care and the methods of treatment. I agree, therefore, that nurse training needs to be kept constantly under review. At no time since the National Health Service started has nurse training been so constantly to the fore. The syllabus which is the responsibility of the General Nursing Council was revised by what is known as the 1962 syllabus, based on greater integration between theoretical teaching and practical experience.

It might be thought that by 1968 the results of a syllabus introduced in 1962 should be settled, but training takes three years and involves the running of two systems for a time together and causes some dislocation of the organisation for allocating staff to wards. Therefore, constant review is desirable, but constant change is highly undesirable. Many of the suggestions put forward for improving nurse training involve the separation of schools of nursing from the hospital service, either to form independent entities or to be linked with the general educational system. I think that the implications of such proposals are not always realised.

Much is often made of the conflict between service and teaching requirements. However, much can be done within the existing framework to mini- mise the effect of the conflict between service requirements and training needs, and many of the hospitals with the best training records have achieved a great deal in this respect. Guidance based on their experience was given in the memorandum on improving nurse education which was issued by my Department some six months ago. The measures suggested, which included a review of off-duty restrictions imposed on nurses, were endorsed by the National Board for Prices and Incomes, which thought that they should be followed up vigorously. I very much hope that hospital authorities will take these suggestions most seriously.

The reason I queried the hon. Gentleman's talk of direct action was that he will know that we must act through that statutory authority, the General Nursing Council. If we were to seek to follow the lines suggested by the Platt Committee, for example, as a means of completely eliminating all risk of conflict between training needs and service requirements it would involve making student nurses supernumerary to a very large extent in their first year and to some extent in their second year. Not only would this be very costly—and money spent on this would be at the expense of other developments in the hospital service—but it would also be expensive in manpower. Even accepting that replacement by equivalent numbers would not be required, it is likely that between 15,000 and 20,000 additional nursing staff would be required over and above those already needed to make good existing shortages and for the general expansion of hospital and community nursing services. I think it most unlikely that additional staff could be found to the extent required over the next few years.

It is quite possible to secure much revision and modernisation of nurse training within the existing framework of the syllabus; the key to this continuing revision and adaptation lies, I think, in close co-operation between teaching staff and those providing the service to the patient. We hope that the introduction of the Salmon proposals will clarify nursing management and, by fostering more efficient administration, will release ward sisters and nurses of assistant matron level particularly from non-nursing duties. It is important to remember that we have a great shortage of qualified nursing tutors. We shall closely examine the proposals in the Report with a view to alleviating this discrepancy.

The hon. Gentleman referred to State enrolled nurses. It is, of course, essential that we have an adequate and settled qualified staff, including this category of nurses. Publicity has been aimed at recruiting more enrolled nurses, and the Report to which I referred drew attention to the fact that their contribution, relative to that of other qualified nurses, is increasing. A sub-committee of the Minister's Standing Nursing Advisory Committee is now considering the function in the National Health Service of State enrolled nurses.

We fully accept that it is necessary to watch continually to see if there is a need for changes in methods of teaching and for major changes in the content of the courses which would require changes in the syllabus. Section 12 of the Nurses Act, 1957, gives the General Nursing Council power to approve, with the Minister's agreement, experimental courses of training. Indeed, my Department recognises the need to encourage the trial of new types of training.

My Department gave information to hospital authorities and in September of last year my right hon. Friend announced that he would be prepared to give limited financial help to foster some experiments which the General Nursing Council thought worthy of trial. Some of these are already under way and they include some combining university degrees with training for registration and others using facilities at colleges of further education. Some are aimed at widening the nurses' background or to help them to obtain, in addition to their registrable qualification, a Diploma in Nursing or additional experience in management. The hon. Gentleman referred to the status of educational qualifications. I do not see much harm in what he suggested, as long as we get the nurses who are wanted; in any event, we should achieve as high a degree of educational level as possible.

In this connection, experiments in psychiatry will give students registration as nurses for the mentally subnormal and a qualification in the teaching of the mentally handicapped, or the qualification of Registered Mental Nurse with a diploma in community nursing in the psychiatric sphere. This is an important matter because in the view of most people there should be a lead in pay for nurses specialising in this type of nursing.

There is a danger in too much experimenting without having a sense of direction and purpose. We must guard against this. My right hon. Friend offered the General Nursing Council finance to establish a small research section at the Council's office, where, in the course of the day-to-day administration of nurse training, the Council have material which would provide a sound basis for research. This offer was accepted by the Council. A research officer has been appointed and work has been progressing well. A joint steering committee, including members and officers of the Council and officers of my Department, has been set up to advise on the programme of work of the Council's new research unit. The General Nursing Council is not limiting itself to immediate needs. It has established a special sub-committee to consider long-term policy on nurse training.

The Report of the National Board for Prices and Incomes also drew attention to the desirability of making some changes in nurse training and of speeding up other changes, such as the grouping of schools. One specific proposal it made was the reduction of the age of entry to 17 and a complementary reduction in the training of cadet nurses, who are paid and employed under conditions laid down by the Ministry. In our view, the reduction of age to 17 is, and has been in the past, fully supported by my right hon. Friend. Unfortunately we have not yet convinced the Council, although we intend to try to do so again.

Mr. Lewis

That is the nub of the whole question. The hon. Member said that I should realise that he and his right hon. Friend did not have power over many of these matters. He has repeated that he has to convince the General Nursing Council. That is the difficulty, and he must do something about it.

Mr. Snow

The hon. Member is suggesting carrying out a fundamental change in the responsibility of the G.N.C. from a professional point of view. That is a fundamental question which cannot be discussed in such a short debate as this. We will examine any proposals that the hon. Gentleman puts forward, but there is a professional reticence and a professional attitude in this matter which it would take a great deal to change. I do not say that reform is not necessary, but we should have to establish a much deeper investigation of the relationship of the profession with the political direction of nursing.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes to Twelve o'clock.