NURSING PROFESSION

HC Deb 27 January 1970 vol 794 cc1321-54

Mr. Speaker

I remind the House that this is the fifth of 25 debates that are to taken place during the night. Reasonably brief speeches will help.

9.20 p.m.

Mr. William Hamilton (Fife, West)

I will do my best, Mr. Speaker.

The House will recall that, on 2nd December last, I initiated a debate on precisely the question of the nursing profession, and that, in his reply, my hon. Friend the Joint Under-Secretary of State, who is also to reply to this debate, said that the pay and conditions of service for nurses were determined not by the Secretary of State but by the negotiating machinery between the two sides of the Nurses and Midwives' Whitley Council.

My hon. Friend pointed out that on the management side were represented the hospitals and the local authorities, plus representatives from the various Ministries, and that on the staff side were representatives of the professional associations and the various trade unions. He also pointed out, quite justly and clearly, that the last settlement, which comes to an end in April next, was worth over £37 million to the profession. He gave details of that agreement which I need not now repeat.

Despite the improvements, the dissatisfaction of the nursing profession with its lot has intensified. Morale has declined and militancy, if of a genteel character, has increased. The decline in morale is not caused solely by low pay. It is partly due to a lack of efficient organisation by the nurses themselves. Twelve different groups represent them on the Whitley Council—12 out of the 29 representations in all on the staff side in the Whitley Council.

Secondly, the career structure of the nursing profession is unsatisfactory and it seems that the implementation of the Salmon Committee proposals on this matter is proceeding very slowly. Thirdly, the administrative set-up of the hospital service is too diffuse, too fragmented. I hope that that situation will be remedied in due course by the reforms that are getting under way in local government.

I think that it is true to say that, since the beginning of the National Health Service, indeed before then, the nurses have been and were subsidising the hospital service with their cheap labour. Their service has been consistently and persistently underrated and underpaid by successive Governments and acquiesced in by an apathetic public. It is astounding that the standards of care have remained so high and that the recruitment figures have not been more calamitous. That these disasters have not occurred to any marked degree is a tribute to the dedication of these men and women and their weakness and meekness at the negotiating table.

This very day, in this period of time in the hospital service, the demand for nursing services is becoming greater. Patients tend to stay in hospital for shorter periods. This means that more patients are occupying the same number of beds over any given period. That, in turn, means intensified demand on the nursing staff. It also means, of course, when patients go out, as they are going out after much shorter periods, an increasing demand on the domiciliary nursing services. This brings in the local authority nurses and health services.

In 1968, the number of in-patients rose by 5 per cent., or roughly 250,000, over the figure for 1966, and I understand that, in the one year, 1967–68, maternity cases went up by 21 per cent. There is no problem of productivity there.

The new surgical and medical techniques are making greater demands on nursing personnel. For instance, the Royal College of Nursing quoted an example of an intensive care unit of eight beds which might well need 24 State-registered nurses to staff, plus the supporting enrolled nurses, students and others. This is some measure of the demands made on our nurses.

Recruitment has not and is not keeping pace with this increased demand. Over 50 per cent. of those currently nursing either are unqualified or are in training and, therefore, in need of supervision. Very often—alarmingly too often—patients are being nursed by trainee or unskilled personnel, that is, by unskilled labour. This is unfair to those doing the nursing and it is unfair and possibly even dangerous to the patient.

It is this disparity between supply and demand for nurses which is shown by the closure of wards, the delay in opening new units, restrictions on hospital admissions and the increasing length of waiting lists. It is no exaggeration to say that the Health Service is fast approaching a crisis of the utmost gravity. In the year 1967–68, there were 3,000 fewer student nurses in training than in the previous year. Over the next few years, the indications are that the number of young people reaching the age of 18 will be reducing and, therefore, there will be fewer available for the nursing profession.

What we are getting in the hospitals now to an alarming degree is a team of cheap, exploited—what we call, mistakenly, student—labour in the wards, backed up by an all-too-inadequate num- ber of highly trained and ill-paid nurses and sisters. The number of student nurses who leave during the course of their training is well over one-third and in some hospitals it is as high as four out of five. This outstripping of supply and demand has meant an intolerable increase in the pressures on the nursing staff, pressures arising from the need to provide a more highly skilled service for a greater number of people.

The physical and emotional strains are often further increased by having to work in old hospital buildings, very often in over-crowded wards inadequately equipped. All too frequently we get public disclosures of inadequacies, especially in psychiatric hospitals, where one might get as many as 80 patients to a ward—that is not uncommon—often being looked after by three or four nurses on day shift and perhaps only one at night. There was one ward recently which had 130 patients. In many wards, beds are so close together that there is no room to put even a locker between them, let alone for the nurses to walk between them.

I mention these facts to show that a vast improvement in pay is only the first step towards improving morale, though nevertheless an important and vital one. Nursing is a 24 hours a day, seven days a week, 52 weeks a year job, and this round-the-clock, round-the-year service ought to have a pay structure to reflect that uniqueness.

That brings me immediately to the Whitley Council's latest proposals. It proposes a 22 per cent. increase for nurses over two years. Percentages can be misleading. The offer sounds a lot. But the proposition is that the award shall be divided into two parts, with roughly 15 per cent. in the first year and 7 per cent. as from 1st April, 1971. I wonder how much of that will be swallowed up by price increases before it is granted. How much will be taken back in increased charges within the hospitals? Probably at least half. It is far too little spread over far too long.

Let us not forget—and the National Union of Public Employees has made this point—that the nurses suspect that other problems might be swept under the carpet during the two years. The 84-hour fortnight, for instance, might not be considered and it is very important to a profession which is not paid overtime, which is an important consideration.

Under these proposals, a staff nurse in a general hospital would get a maximum salary of £1,197 by April, 1971. That is £23 a week gross and take-home pay would be much less than that. This is for key personnel, the nursing staff in any hospital, highly trained, a highly experienced, intelligent girl doing this kind of work—£23 gross and considerably less than that net. I looked up the average earnings of male manual workers over 21 in manufacturing industry in 1969. The figure was £24 12s. So by April, 1971, this staff nurse will be more than 30s. a week worse off than the average manual worker in manufacturing industry. By April, 1971, that £24 12s. could well be £30.

The gap between the staff nurse, the key worker in the hospital, and the average manual manufacturing worker could be widened. Many manual workers get a little more than that.

A ward sister will reach a maximum of £1,584 a year by April, 1971, I think that it is £100 more for a nursing sister in a psychiatric hospital. That is £30 a week for an educated, highly trained young woman, responsible for running a ward, responsible for the care of all the patients in the ward and for teaching and supervising students, pupils and other nursing staff.

I find these salary scales quite appalling and some measure of the neglect of the party opposite. When I recall that the right hon. Member for Wolverhampton, South-West (Mr. Powell), when he was Minister of Health in 1961, said to the nurses: Not more than 2½ per cent. for you people". at a time when their salaries were very much less than now, I believe that it is an absolute outrage that the country and the House tolerated that kind of thing.

Let us take the top of the scale, the chief nursing officer, responsible maybe for the administration of 20 hospitals. The maximum that she would get would be £3,927 which is over £1,000 less than the molt junior Minister in Government —over £1,000 less than the junior fellow making the tea across at Whitehall. Our values are quite wrong and outrageous. At the other end of the scale, a student nurse aged 18 in a general hospital will get a rise from £8 10s. 4d., including £1 a week meal allowance, to £9 7s. 6d. in April of this year and £9 18s. 5d. in April, 1971, which is less than £10 a week for a girl who could have five O levels, who could be qualified to go to teacher training college. This is cheaper than any labourer outside an Asiatic paddy field. The House and the country ought not to tolerate it any longer.

A student nurse starting training at the age of 21 or over will get £14 4s. 2d. gross in April of this year, £14 16s. 10d. in April, 1971, as against £11 17s. 4d. today. These girls are not students in the accepted sense. They are damned hard workers on the wards every day of the week. We should recognise that if accepted these scales are completely inadequate even if fully implemented this year.

It has just been reported on the tape that the Whitley Council talks today have broken down and are to be resumed in a fortnight. The Under-Secretary is turning round as if to question that statement, but it is on the tape. It is quite clear that at its meeting last week the Cabinet took a decision on this matter. Presumably the Ministry's representatives on the Whitley Council machinery have laid down that any award would be spread over two years. The House has an opportunity and a responsibility to put increased pressure on the Government before the next meeting of the Whitley Council.

If we fail in that duty, or Her Majesty's Government fail to respond to the pressures put upon them, then we shall get and deserve the censure of the nation. If there is one pay claim in which we can err on the side of generosity with complete impunity, it is this one. I hope that the Government and the House will rid themselves once and for all of this long-standing charge of meanness to a section of the community which has been for too long the silent, dedicated, impoverished service.

Several Hon. Members rose—

Mr. Speaker

I should like to make two observations. This is the fifth of 25 debates throughout the night. I appeal from time to time for reasonably brief speeches. I notice hon. Members rising who have not indicated that they wish to take part in this particular debate on the Consolidated Fund Bill. It would help me if they were so to indicate.

9.36 p.m.

Mrs. Jill Knight (Birmingham, Edgbaston)

I am most grateful for the opportunity to intervene in this debate. As a tribute to your generosity, Mr. Speaker, my speech will be one of extreme brevity.

I found myself an astonishing number of times this evening in agreement with the hon. Member for Fife, West (Mr. William Hamilton), which is a rare occurence indeed. But I wish briefly to take up one or two points which he did not appear to mention, or mentioned only briefly, and which are important.

The hon. Gentleman was right in saying that it is not only the matter of pay which worries nurses at present. A point which was brought up several times by nurses in their visit to the House last week was the number of times they are engaged in duties other than nursing. This happens a great deal, particularly after 5 o'clock on a Friday evening and continues throughout the weekend. Nurses have to undertake these duties simply because they are the only available people to carry them out. The duties do not involve nursing sick people, but are almost office duties, some porters' duties, some even involve making up medicines. This is quite wrong.

Another point which the hon. Gentleman raised briefly was the need for a complete restructuring of the nurses' pay system. Nurses have admitted to me that, although they have been engaged in nursing only a short time in comparison with the sister in charge of the ward, that sister receives only £200 a year more than the junior nurse, although, of course, her value and ability is far and away above that of the other category of nurse.

I should like to mention some of the bones of contention. One involves the number of times in which nurses have to drop in pay when they train for another grade of nursing. If a girl is a staff nurse on general nursing and wishes to train for midwifery, she must suffer a drop in salary of quite severe propertions. Some of these young nurses have taken on hire purchase agreements or have certain commitments which they must meet. I have spoken to several nurses who have found themselves quite unable to continue with their training when they wish to go on to another branch of their profession.

This applies not only to midwifery, but also to psychiatric nursing or to the category of nursing which involves looking after people in their own homes. Any nurse who wishes to broaden her experience to embrace other categories of nursing by training for them must face this drop in salary. The strain imposed, for example, upon a male nurse with a wife and children to support is particularly marked in the financial sense.

Other professions do not suffer a similar penalty. Once a teacher, for example, has a degree or diploma, his rate of pay goes up commensurate to the distinction he has gained. If that teacher then decides to take a geographical course or some other course he does not drop pay, but quite rightly continues to be paid the same amount of money.

A nurse who decides to take the midwifery course does not simply sit in a lecture hall writing in a notebook. She is on the wards, nursing. Surely she is infinitely more valuable than a completely raw recruit. This point must be taken into consideration, for it is a serious matter. I am sure that the Minister will bear it in mind and will mention it in his reply.

There has been a very severe nursing shortage in Birmingham. Throughout the recent influenza epidemic it is not stating the case too strongly to say that some deaths have occurred because of the shortage in the nursing profession. High salaries are being paid outside the National Health Service to lure a girl away from nursing in the hospitals. These are paid in jobs in the industrial world involving nursing in a factory in which the girl concerned will be paid a very much higher salary. This will certainly provide an incentive to her to go to that sort of job.

The awards made recently should not be spread over two years. It is a little hard that there should be two bites at a rather withered cherry. The awards should all be in the one year. We all admire enormously the patience of the nursing profession over many years. When Members of Parliament were lobbied by nurses last week, I could not help noticing that they had not taken the day off and left their wards unattended. They made the journey to London in their free time. Earlier, the teachers simply left their classes, but the nurses did not desert their wards, and they deserve our sympathy and consideration for the way in which they look after the patients in their care.

9.43 p.m.

Mr. Frederick Willey (Sunderland, North)

It is very important on occasions to demonstrate that the House is united in its opinions. When we are thinking of the House discussing 25 subjects throughout the night, perhaps no one is more important than this. That is my reason for intervening in the debate, because all that I am concerned with is the broad justice of their case.

In common with other hon. Members, I met a delegation of my own nurses last week, and I was so impressed by their moderation and persuasion that I thought it right to support my hon. Friend the Member for Fife, West (Mr. William Hamilton).

We owe a public responsibility to people like nurses who, after all, are in public service and in a weak position. Of all wage and salary earners, they are probably in the weakest position. The nature of their occupation weakens their position. A nurse serves as a nurse in many capacities, and those capacities are divided in themselves.

The nurses are also in a weak position because they are isolated. Recently, I took part in an inquiry into student unrest. By the nature of their work, nurses are very much divorced from students. As a result of this debate, I hope that the National Union of Students will pay more attention to those of their members who are training to be nurses. They are isolated equally because they are subject to a very cloistered discipline which, again, makes it more difficult for them to express their opinions. My hon. Friend and the hon. Member for Birmingham, Edgbaston (Mrs. Knight) are to be congratulated on taking this opportunity to see that we discuss the subject.

Nowadays, we judge claims by productivity. My hon. Friend has given some figures. I apologise for the jargon, but the figure which impressed me was that patient throughput has been doubled in the last 20 years. That is a remarkable achievement. Whether it is so or not, I know that nurses today are subject to far greater tension and pressure than they were years ago. Their life is more intense than it was.

Another figure which impresses me is the very serious one which reveals that 35 per cent. of nurses going into training drop out before the end of their courses. I wish that there was a better comparison between nurses and other students. That is a fantastic rate of drop out and must reflect conditions in our hospitals.

Hon. Members in all parts of the House clearly share the view that our nurses are in an exceptional position. Back-bench hon. Members have always felt this to be the case. My hon. Friend the Under-Secretary may say that he has no direct responsibility, but let him use his good offices and tell us tonight that he thinks that our nurses have a fair claim to receive the whole increase, because that will give them the fillip that they require.

Not only have we to improve conditions and provisions for the training of nurses; we have to do it at a faster rate than we have been doing for the past few years. We cannot congratulate ourselves for making things better. They have to be much better if nurses are to be recruited and retained in the hospital service. I hope that my hon. Friend can give some solace and comfort to those of us who are concerned about the situation.

9.48 p.m.

Dr. N. P. Winstanley (Cheadle)

I join the right hon. Member for Sunderland, North (Mr. Willey) and the hon. Member for Birmingham, Edgbaston (Mrs. Knight) in thanking the hon. Member for Fife, West (Mr. William Hamilton) for giving us an opportunity once again to debate this very important subject. We know that the hon. Gentleman has been indefatigable in his support for nurses and has gone on raising this issue over the years—I regret to say, too many years. Indeed, I recall that my hon. Friend the Member for Orpington (Mr. Lubbock) made his maiden speech on the subject of nurses' pay in 1962. It is regrettable that we are still in this situation.

I am glad of an opportunity to say a few words on this subject. As a doctor who has worked and lived in hospitals for many years, I have had an opportunity of seeing their work at close quarters and the rapid way in which it has changed over the last decade or two. It is no longer a matter of placing a shawl round the poor wounded soldier or laying a cool hand on a fevered brow. Our nurses carry out a highly technical job. They have the kind of work which warrants a reward and career structure very different from the one which it now attracts. The job is quite different. Tonight, in all our hospitals, even relatively untrained nurses are carrying out procedures which were unheard of when I was a medical student. They are procedures upon which a great deal depends; procedures upon which patients' lives depend. I am glad of the opportunity to say this as a doctor.

I am glad, too, that the medical profession has from time to time come out publicly in favour of improvements in the pay and conditions of nurses. But recently there have been signs that the profession has been concentrating on its own problems and has perhaps been a little jealous of the changes in the career which nursing has become. I hope that we shall soon hear the medical profession as a whole coming out strongly in favour of a new deal for nurses.

We must get away from the old idea of arrangements under which we in this country were prepared to exploit people's sense of vocation. We must provide the right kind of inducements and structure. Sometimes this kind of attitude is blamed on Florence Nightingale. But if we go back to her words we will find that she campaigned for recognition of nursing as a real job entitling it to a proper salary.

I accept that the nursing profession is, in part, responsible for delay in its case being met. There is a tendency for those who have suffered under the old regime, as it were, not to be quite as sympathetic to the new case as others might be. I find this as a doctor. I recall that when I qualified the pay of a house surgeon at the Manchester Royal Infirmary was 19s. 2d. a week. When I hear resident hospital doctors complaining about their conditions I am inclined to compare them with my conditions. I am quite wrong to do that. I should compare their conditions with those of other people here and now. This is what the nursing profession has at last started to do. I salute the leaders of the nursing profession on having at last changed their attitude and realised that they are in a different kind of occupation which has to be recognised in a different way.

Let us also acknowledge that nurses are peculiarly handicapped in this sphere. They do an essential job in the uttermost sense of the word. They are not in a position to withdraw their labour in any circumstances. Indeed, they would not be nurses were they to contemplate that kind of action. They are not people of that kind. So, first, they are handicapped in that way from a negotiating point of view.

Secondly, they have a monopoly employer. This is never a happy situation for any worker. A nurse cannot say, "I will not work any longer for this National Health Service. I will work for this other National Health Service." I know that there is private medicine here and there; but, in essence, there is only one employer—the Government.

That brings me to the third handicap; namely, that they are also civil servants. Sometimes the Government have to take certain actions over the economy; they have to try to control wages in one way or another. They are right to do so. But the tools at their disposal are rather limited, and any action that they can take over wages outside sometimes takes a long time. However, the Government can take immediate action over the people that they employ. Unhappily, they have done this from time to time. That is why we have recollections of the Geddes Axe, and so on. But people in State employment, although they may be privileged in certain ways, are handicapped in that way.

Because, from a negotiating point of view, the nurses are handicapped, in these three important ways, Parliament has a special responsibility to ensure that they are not exploited. We have that responsibility towards nurses as citizens. We also have that responsibility towards the National Health Service.

The National Health Service is in difficulties because of acute staff shortages. We talk about a rearrangement of the way that we run matters. But in the long term the efficiency of the National Health Service depends on the number and quality of people who do the work. Therefore, we must be conscious of any problems in recruitment. The Minister will understand that a nursing shortage snowballs. If a hospital is short of nurses, it soon becomes even more short of nurses.

If there is a bad hospital, with bad circumstances, and bad conditions, very soon the nurses find that they cannot work in those conditions. Some of them leave; those who remain find the conditions intolerable, and they, too, leave. This is why there is this disproportion in the distribution of nurses, and why certain hospitals are fairly well staffed, while others are badly staffed. This is something which, clearly, we must watch.

We must keep a close watch on the extraordinary conditions in which nurses have to work. Last night I dined at the House of Commons with a guest, the daughter of a friend of mine, who until two days ago was a nurse at one of our London hospitals. She has left after three and a half years. She has worked on every Christmas Day for four years. In her three and a half years as a nurse she has never had a weekend off, save when she was ill or on holiday. Like many other nurses working in this city, she has been doing what, in another context, one would call moonlighting for almost the whole period of her service. She has been doing little bits of jobs, waiting in restaurants, cleaning taxis, and so on. At last she said to herself, "I shall do it no more." She will start again after a rest, when perhaps conditions have improved. But I wonder how many other girls are in that situation? How many girls have we lost to nursing because of the intolerable conditions? How many girls have we discouraged from taking up this very important career?

I come, now, to the arguments which are constantly used about why it is impossible to make changes. The Government have a responsibility here, and they and the Treasury must realise that this automatic argument about inflation, exports, and things of that kind does not apply to this kind of occupation. Nobody thinks that if nurses are given an immediate substantial rise they will go out and buy two cars, or in some way put a great strain on our export industries. They will merely eat more, or perhaps wear better clothes, or perhaps stop moonlighting and doing other jobs which they have to do now to provide themselves with any kind of standard of living.

Those arguments do not apply. There is not the smallest reason—and I honestly believe that hon. Members of all parties accept this—why the Minister did not immediately pay nurses a proper salary and give them a proper career structure. If that were done, it would not have any effect on the economy. It would not lead to other consequential changes. The public would understand it, and there is no reason why it could not be done.

Mr. Leslie Spriggs (St. Helens)

Is the hon. Gentleman aware that it is possible that the Whitley Council has some confidential terms of reference which tie its hands behind its back when negotiating?

Dr. Winstanley

That may or may not be so. It is not for me to comment on what goes on in the negotiations, save that I comment on the fact that the negotiations have broken down. This is deplorable. They should be resumed.

The Joint Under-Secretary of State, Department of Health and Social Security (Dr. John Dunwoody)

This is the second time that the phrase "broken down" has been used, and I think that I should say now that there is no question of negotiations having broken down. Today's negotiations have been completed, and will be continued on 10th February. Negotiations are continuing.

Dr. Winstanley

I am delighted to hear that. I hope that before the end of the debate we shall hear even more in the same vein from the hon. Gentleman.

I know the hon. Gentleman's opinion. I know that he agrees with me. He knows what kind of work the nurses do, and what kind of responsibilities they have to bear. He knows the sacrifices which they make, and the sacrifices which, quite often, their families make.

The hon. Gentleman knows, too, that the automatic arguments which the Treasury trots out to deal with matters of this kind are wholly irrelevant, and there is not the smallest reason why he should not say here and now that the Government will do what is necessary to give nurses a proper wage and career structure which recognises the vast change which has taken place in that occupation in recent years. There is no reason why the matter should not be settled here and now.

9.59 p.m.

Mr. S. O. Davies (Merthyr Tydvil)

I shall be as brief as my hon. Friends have been. I thank my hon. Friend the Member for Fife, West (Mr. William Hamilton) for raising this extremely important matter, and for supporting his case with such overwhelming facts.

Last year, though the reason for it was not very serious, I had to spend a little time in one of our local hospitals. In my own life and in the experience of my family and relatives, the medical and nursing professions have been fairly prominent over the years, but what I heard when I succeeded in gaining the confidence of some of the most experienced sisters and nurses at that hospital really shocked me. I thought that the Government were either miserably ill-informed or equally miserably mean in a matter of this kind.

For example, I was told by a man whom I consider to be a first-class physician, "We will have that put right when you go home". He is a great personal friend of mine, and I asked him how it would be arranged. He said, "Sister So-and-so will call". I asked, "Why Sister So-and-so and not my medical attendant?" He did not then give me the proper answer to that question, but I soon found out. The nursing profession is almost the pillar of the medical profession.

What I learned during the time I spent in hospital and afterwards made me disgusted with myself that I had been so silent on this matter and so concerned about the well-being of people in industry. So, again, I give my thanks to my hon. Friend the Member for Fife, West.

I warn my hon. Friend the Under-Secretary of State that the Government had better be careful on this matter. I am speaking with some experience. I know of no other problem which can so easily reduce this or any other Government to contempt. It is a growing problem, and the public—I can speak for my constituents—have become more aware of the treatment meted out to nurses. I am certain that in time this will bring the Government down to sheer contempt unless they do what is obviously needed to improve the conditions of employment in this essential service.

Why should the 22 per cent. increase be spread over two years? My hon. Friend has given figures which demonstrate that, if it were granted immediately, the increase in actual salary to the nurses would be miserable, having regard to their service.

I have told my friends in the medical profession that I consider that they have been mean themselves in not raising their voices far more strongly than they have in the interests of the nursing profession. I know from experience and from information given to me by others that the nursing profession is the pillar of a great deal of the medical profession.

I hope that my hon. Friend the Under-Secretary of State will give us a good reply. I do not envy him unless he is prepared to approach the question head-on, basing himself on his personal experience and saying what he thinks should be done. I hope that he will not be mean and that he will give us tonight information which will save the Government from being referred to contemptuously by all who know the conditions in which nurses work and who want them to have an immediate substantial improvement.

10.6 p.m.

Mr. Michael McNair-Wilson (Walthamstow, East)

I make no apology for repeating many of the arguments already heard in the debate, for it is necessary to emphasise that nursing has historically been a badly-paid profession. It sprang out of charity and the Poor Law, and only when Florence Nightingale gave it respectability, perhaps, was anyone prepared to treat it as the serious profession which it is.

It has been said that, in Florence Nightingale's day, the ladies who worked in the hospitals did not need the money, and the paupers who did were not worth it. It is that historical background—either ladies who did not need the money or paupers who were not worth it—which, I believe, has always made nursing a badly paid profession.

No Government can take much pride in the way that nurses have been treated in their salaries, but tonight something could be done to give them a new deal and a new basis upon which their future pay and conditions could be placed.

In Florence Nightingale's day, and up to the last war, the limitations on what a lady should do were, perhaps, one of the reasons why so many women of private means who had a vocation went into nursing, for they were not necessarily concerned about the financial return which they would earn. A senior nurse told me only today that as a probationer at the Middlesex Hospital in the 19303 she was being paid £20 a year, and a staff nurse in the same hospital was paid £60 a year.

Before the war, nursing was primarily a women's profession, and as today when women still do not receive their fair share of wages, they were poorly paid. The unending stream of devoted women who were apparently always available to staff the hospitals, made many hospitals neglect the high wastage rate among those good people, is no longer there. No one can assume that, simply because they have a vocation, nurses will come forward if their pay and conditions are not comparable with pay and conditions in other work for which their talents would qualify them to do.

Before the war, I believe, the wage structure depended simply on what a hospital would pay. There was no national wage structure. Not until the Athlone Committee in 1939 was any suggestion put forward that nurses should have a say in the negotiations about what they were paid, and it was not until 1943, with the Rushcliffe Committee, that any attempt was made to lay down a limit on the hours a nurse should work during the week. I think that the suggestion then was that 96 hours represented a reasonable week's work.

The National Health Service changed all that. In 1948, the Whitley Council was set up to keep an eye on nurses' pay and conditions. But, when the Health Service was set up, nurses were not given the right basic pay. Consequently, they have never had it since then. Thus, they have always been among the worst-paid members of our society. I believe that, in 1948, a staff nurse earned about £200 a year, which cannot be described as a good salary for the job.

If that basic figure was wrong, as I believe it was, everything which has fol- lowed has maintained a distortion in the return that a nurse gets for her work and the tremendous responsibility she carries. She is a highly-trained person working very long hours, many weekends and Christmas Days. She has tremendous responsibility amounting to a question of life and death, and there is a very unlovely side to her work which many of us would dislike doing.

Nursing is a vocation: we cannot imagine anyone wanting to do it without that feeling. But this is no reason why those who want to help humanity should be penalised, as nurses have been for far too long. It is the failure of successive Governments to appreciate the work which nurses do, and the fact that their wages have been out of line virtually always, which has meant that nurses have gradually begun to feel a genuine grievance. This has created today a disgruntled profession.

I have received so many petitions from the hospitals in my constituency that I should be failing in my duty if I did not make their voices heard. The "raise the roof" campaign of the nurses is the right way to focus attention on their genuine grievance. I hope that the Under-Secretary, who is also a physician, will be able to show more sympathy to what the nurses want than has been given hitherto. He has a real chance to make a start and correct the nurses' basic level now, so that future increases will continue to give them the right level of remuneration for this onerous job.

After all, a nurse has to be a person of high calibre, the same sort of person who could pick up a job at £1,000 a year with no difficulty. Only recently, I took on a new secretary, aged 20, who would not look at the job under £1,000 a year, yet what training has she had, what responsibility does she carry, compared with a nurse? Also, she will have every weekend and her evenings free. She will not work extraordinary hours or have the sheer hard physical labour which goes into nursing.

The nurse of today is not being paid enough, and it comes down to a question of our priorities. It has been said that when one is ill and in hospital the nurse is worth her weight in gold, but that when one is well, one forgets that she ever existed. I hope that the Government will not forget that she exists, but will reconsider this award. Of course, a 22 per cent. award is nice to hear about, but why does it have to be split in this way? What we are really debating is a 15 per cent. award. Instead of two instalments it should be paid in one here and now. Better even than that, I suggest that the Government reconsider what the staff side of the Whitley Council asked for rather than what their representatives feel that they could dole out.

With this rise in pay a ward sister, having had many years' training, will get £1,095, while, as I have said, a secretary aged 19 or 20 can today get £1,000, with virtually no training. A highly skilled ward sister, who will probably be 26 or 27 years old, will receive just over £1,000. We should not forget that 20 per cent. of our nurses are male, with the result that I may be speaking of a married man aged 26 or 27 with a couple of children. Nobody would pretend that £1,095 is much of a salary for him.

A ward sister is responsible for the total administration of a ward, dealing with consultants and relatives, training student nurses and handling valuable equipment. Her responsibility adds up to deciding perhaps whether someone should be resuscitated. It is a question of life and death, yet we consider that such a person is worth no more than £1,095 a year. When the staff side of the Whitley Council asked for £1,400 a year for a ward sister it did not place her salary at a high enough level. I hope, therefore, that the Minister will give a reassurance that the Government will think again on this issue.

As the hon. Member for Fife, West said, to talk about 22 per cent.—or 40 per cent. as the staff side sought—may seem fantastic, but the percentage is insignificant. It is the take-home salary that matters and it still seems to be pitifully small. This is a penny-pinching approach to a real problem of priorities. We must go on attracting nurses to our hospitals, including male nurses, and we must make them realise that their vocation will be properly rewarded because we appreciate the tremendous service they give.

In considering the question of nurses pay, we must not forget those higher up the scale. The recent rise has shown, if it comes about, that the Government want to do something, but I suggest that what has been proposed is wretchedly insignificant compared with what should be proposed. We are now getting into a dangerous imbalance in the nursing profession. Matrons, assistant matrons and nursing tutors are not getting sufficiently high salaries compared with what is being paid lower down the scale.

A 15 per cent. increase this year means that a chief nursing officer, who is responsible for several hospitals, could be earning up to £3,927 a year. She has enoromous responsibility, and there are not many of these people. An ordinary matron with a 500-bed hospital will still be earning less than £2,000 a year, but her responsibility is enormous. We must, therefore, consider whether we can do something to get the whole structure and scale of nursing on the right basis.

I understand that a nurse can retire from the profession at the age of 55 and will receive a pension. If she then decides to return to nursing she will be paid only her pension plus a percentage of wage to bring her total up to what she was earning when she retired. This is an obvious disincentive to a highly skilled nurse to return to the profession, remembering that if she goes into, for example, the hotel industry she will draw a pension and a full salary. Therefore, I ask the Under-Secretary: are we so well off for nurses that we do not need some incentive to be given to encourage older people to come back to nursing when they probably have another 10 years of active service which they can give to hospitals?

Why cannot the Government implement the whole of the award this April? Why cannot they give the nurses what they have asked for rather than what the Government think they should have? Are the Government to suggest that £1,400 a year is too low a salary for a ward sister? Could the Government look at the whole structure of the nursing profession to make sure that those carrying the greatest responsibility get much higher rewards than they have at present so that the whole structure has an incentive about it and fair play for all?

Mr. Speaker

I remind the House, with the coldness which is part of my duty in the Chair, that this is the fifth of 25 debates we shall have during the night and early morning. Reasonably brief speeches will help.

10.21 p.m.

Dame Irene Ward (Tynemouth)

I will, of course, fall in with your very wise Ruling, Mr. Speaker, but if Ministers had dealt with all the problems, particularly the nurses' problem which has been so admirably outlined by my hon. Friend the Member for Walthamstow, East (Mr. Michael McNair-Wilson), we would not need to have this debate at all. That would have alleviated the tremendous strain which is put on the whole House of Commons, particularly the officials and the police, and we would have more justice than we have at present.

I am sorry that I was not present at the beginning of this debate but it is extremely difficult to know when individual debates are to come on. Although I have no intention of developing the argument, I could not resist putting in my word because for a very long time I have done everything I could to support the nurses' claim. If they are worth the 22 per cent. increase which the Minister of State is very pleased about, they must be worth that 22 per cent. increase now. Why have they to wait until next year? I suspect that the Government have not got the money to pay them, or else they are working on the honour and vocational attitude of nurses because they know that they are not likely to make as much funs as some other sections of the community would make.

I want to know exactly why this is. I am sure the Ministers concerned are pleased at the final result, but I do not know any more than my hon. Friend knows what has gone on behind the scenes. It may be that the Secretary of State, the Under-Secretaries or the Ministers of State, or the whole caboodle, have argued for the 22 per cent. to be paid now. I could not get at that this afternoon when I had a go at the Chancellor of the Exchequer. I do not know whether the block comes from the Chancellor. I cannot believe that it comes from the Department of Health and Social Security for I imagine that those who rule the destinies of nurses in that Department must know that they are being very mean to fragment the award.

I should like to see a few more Ministers being a little more independent instead of being so pleased that this is making the Chancellor feel uncomfortable. I should love to argue with the Chancellor, but I cannot do so. I think it perfectly ridiculous for Ministers to go on saying how much they want this done for the nurses and physiotherapists, in whom I am also interested, and teachers, while at the same time they instruct those on the management committee that they can go only so far in negotiations because Ministers have to kow-tow to the Chancellor of the Exchequer. That is why the whole thing is a farce.

I should like proper negotiations on a proper basis so that we could know the truth. We do not know the truth. I do not know what has gone on behind the scenes. It has taken a long time for the nurses to make an impact. If the Minister wants to do justice and to shorten the debate, so that we can get on to debate other injustices which need remedying, he should say that he will go back to the Chancellor and ask him to say that at least the whole 22 per cent. will be paid on 1st April.

10.25 p.m.

Mr. Maurice Macmillan (Farnham)

I wish to declare an interest in a technical sense, even if a slightly remote one. I am the publisher of the Nursing Times, which has campaigned in this cause. It is for that reason that I am glad that my hon. Friend the Member for Walthamstow, East (Mr. Michael McNair-Wilson) and the hon. Member for Fife, West (Mr. William Hamilton) have raised this subject—because of its importance to the structure and the future of the Health Service as well as in common justice to the nurses who serve it so loyally and devotedly.

I echo the tribute paid by the hon. Gentleman to the devotion of the nurses. All hon. Members would give unstinting praise to the courageous and self-sacrificing service of nurses. I hope that the Government realise the importance of this, and that the country and the nurses will recognise that this is a matter which has been raised and supported by all the three political parties with a degree of unanimity seldom seen in the Chamber.

The Joint Under-Secretary intervened and said that negotiations had not broken down but were to be resumed in a fortnight. I am glad to hear that. I get the impression, as do others, that there has been some hitch—that was my impression on listening to the news on the wireless—and that the points of dispute were relatively small.

The first point of difference is that the total involved in any disparity between the claim of the profession and what the management side is offering is the difference between £80 million and £65½ million—that is, about £14½ million, a derisory sum in this context. The second point of difference is the question of the whole 22 per cent. being paid in April, 1970, or split as to 15 per cent. now and 7 per cent. later. Other points of difference are, for example, the question of there being no fresh claim before February, 1972, and the question of the 84-hour fortnight, both of which are causing difficulty.

I ask the Joint Under-Secretary to tell the House whether that judgment of what has happened is more or less correct. If it is, and if there is any doubt or difficulty about the nurses' claim, how much is this due to the fact that 22½ per cent. or 22 per cent., whatever be the exact figure, seems a very large percentage in the context of the norm which the Government have imposed on themselves but which they have singularly failed to keep in all cases of trades and professions which are able to put on pressure by strike action, which the nurses are not? To what extent does the difficulty arise because it is relatively easier to hold down claims such as this one rather than because the claim represents too much in absolute as opposed to percentage terms?

I gather that part of the claim of the staff side was that a staff nurse—that is, a fully qualified nurse on first taking up a staff appointment, a key position, in any hospital—should start at £1,000 a year and that a chief nursing officer should rise to £4,500 a year. The question is: to what extent is it the Government's policy that is causing the difficulty, and to what extent is it the demand of the nurses for a little jam as well as the prospect of some jam tomorrow?

The percentage, for what it is worth, starts on a pretty low base. About 80 per cent. of the total nursing professional employees of the N.H.S. receive wages and salaries below the national average —that is, on the assumption that the ward sister earns the national average or above, and that is certainly not true at the moment. So 80 per cent. on that rather generous assumption are below the national average.

The right hon. Member for Sunderland, North (Mr. Willey) referred to the position of student nurses. Although, as the Secretary of State said some time ago, they are paid not a wage but a training allowance, they are used as labourers and not as students. The only additional point I want to make now—we have raised this before—it that any future settlement must decide whether student nurses are cheap labour or students. If they are going to be used as labour, they should be paid as such. This point has caused a great deal of difficulty.

At the moment, the maximum on the scales which can be earned in the nursing profession as a top chief nursing officer or matron in charge of a large group of hospitals is £2,950. The latest offer would raise this to £3,927 a year. The profession would like a further £573, making it £4,500. This is only barely commensurate with what can be earned by women in jobs of comparable responsibility and importance elsewhere.

A staff nurse can earn from £785 up to £985 as of now. The new offer would make this scale from £945 to £1,197. But even if the nurses' claim of a starting base of £1,000 a year and equivalent increases after three years were fully met, a fully qualified staff nurse after three years would barely reach the present national average, let alone what that average will be in three years' time.

Assuming, as the Secretary of State did recently in the case of pensions, a national average of about £24 a week, a ward sister does not now reach that level for about seven years, an deven the new offer will bring his or her salary only up to the national average after about two years. The maximum will remain extremely low.

My hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) and others have referred to the concertina effect of the present structure and the need to raise the differential, not only to increase the earnings of a staff nurse on first qualification but also to broaden the whole range of salary structure right through from the sister-tutors to the top level of all.

There is an increasing need to improve the career structure in other ways, although I am not blaming the Under-Secretary or the Department for any failures in those spheres, because so much of the need for improvement derives from relatively recent changes in the needs and demands made on the profession. There is a great need for nurses to be able to continue to earn increasing salaries in nursing, without being promoted into administration. There is a tendency for a fairly low block on the salary rise while they are doing a full-time nursing job, in contact with patients.

There is also a great need to consider the new managerial and technical skills required in nursing, such as those of not only the chief nursing officer but the theatre superintendent, in a large 800 bedroom hospital, as well as the earnings and relative status of sister tutors who can get equivalent jobs outside the Health Service for higher remuneration. It is not difficult to see that the problem is that the £80 million extra required, at the minimum, for increases in nurses' salaries must, under the present system, come virtually entirely from taxation. It is perhaps a little ironic that we have a shortage of nurses.

If we paid a market price we might find that shortage remedied. We will not be able to continue getting either the number or the standard required if we continue to try to pay nurses on the cheap. I would like the Minister to refer to some of the other false economies, in connection with the nursing profession, which are practised in the Health Service. How many hospitals, for example, are being held below their proper establishment of nurses for the sake of economy? To what extent are hospital authorities taking on, in emergencies, agency nurses at a considerably higher total cost to the taxpayer? We have heard that there is to be an intensified situation, with modern conditions and practices, making more and more demands on the nurse, and increasing the strain on her.

Mr. Spriggs

Can the hon. Gentleman assure the House that agency nurses who are supplied to hospitals receive more remuneration than other nurses?

Mr. Macmillan

I understand that the fee that would have to be paid to the agency results in a greater cost to the hospital authority employing agency nurses than the equivalent salary of normal nurses who would otherwise be employed. In other words, the nurses get their salary from the agency, and anyone using the agency pays the agency. This costs more. Despite all the demands that have been made from both sides of the House on behalf of the nurses for improvements, not only in salary but career structure and conditions—there is a great deal to be done here, and always will be—we should expect the Under-Secretary to admit that the real problem is how to get more money into nursing.

This is part of the wider problem of how to get more money into the Health Service. I would be out of order if I pursued that, and the Minister would be out of order in following me, but I hope that he will admit that the nub of this problem of pay and conditions of the nursing profession within the Health Service is the same as the problem besetting the Health Service—particularly the hospital service—throughout its structure, a shortage of money and resources which we must overcome if we are to do justice to the people who work in the Health Service and continue to provide the service required, rightly, by our people.

10.40 p.m.

The Joint Under-Secretary of State, Department of Health and Social Security (Dr. John Dunwoody)

In raising the subject of nurses' pay my hon. Friend the hon. Member for Fife, West (Mr. William Hamilton) and the hon. Member for Walthamstow, East (Mr. Michael McNair-Wilson) have raised an issue of very considerable importance. It is also the most topical issue of the 25 debates before us tonight.

Before trying to answer the points that have been raised I would like to make some general comments and deal with the position as I see it at the moment. As hon. Members will know, the pay and conditions of nurses employed in the National Health Service are determined not by Secretaries of State, but by a process of negotiation between the two sides of the Nurses and Midwives Whitley Council; the management side representing the Departments, hospital management and, let us not forget, local authorities as well, and the staff side, comprising professional organisations and unions representing all the grades of staff concerned.

As I have said in the House on a previous occasion, there is no suggestion that the negotiation of salaries on the Whitley Council relieves the Health Ministers of all responsibility for nurses' pay. Representatives of the three Health Departments, my own Department and the Welsh and Scottish Offices, serve on the management side and play their full part in negotiation. When any of the National Health Service Whitley Councils has reached an agreement the statutory approval of the Secretary of State is required before it is put into operation.

The Whitley Council still has under negotiation the staff side's recent claim and the offer made by the management side. The council has, in fact, been meeting today, the negotiations are continuing and the next meeting will take place on 10th February. While this certainly adds to the topicality of the subject, it makes it difficult for me to comment since it would be quite wrong for me to appear to prejudge the outcome of these vitally important negotiations or to prejudice them in any way.

Hon. Members will recall that the current salary scales for nurses flow from recommendations of the National Board for Prices and Incomes. The board carried out a comprehensive review from July, 1967, to March, 1968, and as a result of its recommendations and the subsequent negotiations in the Whitley Council, nurses received further increases of between 9 per cent. and 14 per cent. The latter increases were paid in two stages, the first stage being paid from 1st October, 1967; the second from 1st January, 1969.

With other major improvements, including improved and extended special duty payments for night and weekend work—a very demanding part of the nurses' occupation—an increase to £100 in the lead paid to staff in mental hospitals and the introduction of a similar lead—I think that this is important—for staff of geriatric and chronic sick hospitals, the total estimated cost of the board's main proposals on pay and conditions of service was over £37 million a year. The board recommended that this comprehensive settlement should run until 31st March, 1970, and the Whitley Council is now engaged on a review in readiness for a new settlement to operate from 1st April, 1970.

At the time of the last settlement both the National Board for Prices and Incomes and the Government recognised that exceptional treatment for nurses was called for within the terms of current incomes policy. While it is always possible to criticise pay agreements, a major settlement costing over £37 million a year was a definite and major step forward.

The staff side have now submitted a major claim for very large increases for all nursing staff and for new scales for the senior grades in the new nursing management structure which is being introduced following the recommendations of the Salmon Committee.

At the meeting of the Whitley Council on 13th January the management side made a substantial offer; indeed, it was by far the largest offer made in the history of the Whitley Council. The offer was for a two year settlement with new rates of pay to operate from 1st April, 1970, giving an overall increase of nearly 15 per cent. and a further set of scales to operate from 1st April, 1971, giving further increases averaging rather more than 7 per cent. In addition, the management side made an offer of salary scales for the new chief nursing officer posts in the new nursing management structure for which there have hitherto been no negotiated salary scales.

The management side, in making the offer, and the Government, in endorsing it as being consistent with incomes policy, both clearly recognised that nurses' pay was a very special case justifying exceptional increases beyond the normal range of 2½ to 4½ per cent. The White Paper on Productivity, Prices and Incomes contains ample provision for dealing with exceptional cases requiring special action. Many nurses are low-paid workers by any standards. Quite apart from this, there is a strong case for special treatment on recruitment grounds.

Nursing is subject to onerous requirements not found in the generality of occupations—working at night and weekends. Some of us will be working all night here, but none of us work the amount of night work many quite young nurses have to work. Their work is often undertaken under exacting conditions, with human lives at stake and subject to the continually increasing demands of modern technology. There is the unique combination of increasing technological demands in an occupation which also makes physical demands and involves work which, as one of my hon. Friends said, many people would find offensive and repugnant.

Present rates of pay are quite inadequate to maintain recruitment in these circumstances, and increases well above the normal range are necessary for the purpose. The White Paper specifically mentions future recruitment in skilled occupations as a relevant factor.

It would be quite unjustifiable for other workers to try to justify percentage claims of a similar size by reference to the offer to nurses. The nurses' case is quite exceptional. The Government recognise that the pay issue is not everything and are considering what further measures can be taken to clarify the rôle and function of nurses in the Health Service and improve their recruitment and deployment.

There is one feature of the offer to which I would like to draw attention. It is the proposal that, for student nurses in general hospitals, pay should be related to age from 18 to 21 with two further increments for the second and third year for those starting at age 21 or over. This is a major improvement and brings the pattern of student nurses' pay in general hospitals into line with that in psychiatric hospitals. Previously, there was a difference between student nurses under 25 and those over 25, with two different rates being paid.

Mr. Spriggs

May we have some information about these proposals?

Dr. Dunwoody

I will go on to tell the House what is the effect of the proposals. However, before I do that, I should remind hon. Members that this not only brings nurses into line with those in psychiatric hospitals but provides this important difference of improvement for girls between 21 and 25. Student nurses in psychiatric hospitals, of course, will continue to retain their "mental lead".

The effect of this proposal would mean that a student nurse joining at 19 would receive £540 from April, 1970, and £567 from April, 1971, instead of the present figure of £395 plus £48 meals allowance. I think this proposal is important because it could be very helpful in attracting to nursing those girls who, having started in some other occupation first, think of training as a nurse at the age of 19 or 20 but might have been deterred in years past by having to drop to the 18-year old rate of training allowance.

As I have said, the offer was for a two year settlement, and there has been considerable pressure, supported by some hon. Members, for a one year settlement giving the rates proposed for 1971 in 1970. To some extent, this may have been based on a misunderstanding of the nature of the offer. Under previous phases of incomes policy, it has been a requirement that, if an increase of more than a certain size was agreed to be necessary, it should be staged, only part being paid immediately and the balance a year later.

The offer on nurses' pay is not a case of staging in this sense. It would have been possible to have made an offer for a single year only, but this would necessarily have been lower than that which has been made. By making an offer for two years, the management side of the Whitley Council was able not only to propose substantial increases for this year but a further sizeable increase next year, thus giving some assurance for the future. This is important. We do not want to look at this on just a year-to-year basis.

Turning to some of the important points raised in the debate, although it will not be possible to answer them all, in introducing the subject my hon. Friend the Member for Fife, West made the very important point that this takes us further than just the question of nurses' pay. He talked about the morale amongst nurses and the importance of developing a career structure. This is a matter to which the Government are alive, and I would not altogether agree with my hon. Friend when he says that the implementation of the Salmon reorganisation is going slowly.

As I travel around I find that it is being implemented increasingly rapidly throughout the country. But I agree when my hon. Friend underlines the rôle that administrative reorganisation may be able to play. Here, I must ask him to wait for the second Green Paper which will be published shortly. This, again, will help us to see the future of the nursing profession more clearly in the same way as it will in other parts of the Health Service.

I fully accept that the salary structure —I am not just talking about the pay levels—needs to be reformed to remove anomalies in the traditional pay structure —anomalies that were mentioned by other hon. Members as well during the debate—and to provide agreed salary scales for the new pattern of nursing management which is being introduced throughout the hospital service. The need for such a reform is reflected both in the staff side's claim and the management side's counter proposals. Beyond this I do not think that I can comment at this juncture, when so much needs to be discussed by the negotiating body.

A similar reform of the structure of nursing management in the local authority nursing services has recently been recommended by a joint working party of the local authority associations and the Health Departments. For this to be implemented there will need to be a new salary structure appropriate to the new form of organisation.

My hon. Friend has already touched on the status of the nursing profession. Status is partly a question of public esteem. There is not the slightest doubt about the high regard in which the nursing profession is held in the country. Indeed, the way that the debate has gone tonight is one indication. But status is also partly reflected in pay, and the rates of pay now being offered make their contribution. Certainly, the rates of pay proposed by the management side for the chief nursing officers place them high in the hierarchy of principal officers of hospital authorities.

It is important that nurses should play their full part in the management of the hospital services. This has not only been acknowledged, but repeatedly stressed by my right hon. Friend and his predecessor. Under the traditional pattern of nursing administration, this was often difficult to achieve, particularly in those groups which had more than one hospital and where there was no single head of nursing services. The new nursing management structures recommended by the Salmon Committee do much to remedy this by the appointment of a single head of nursing services and by providing a proper management structure.

At first sight, this management structure may be divorced from the care at the bedside, which is the more traditional aspect of a nurse's work. The hon. Member for Farnham (Mr. Maurice Macmillan) implied this to a certain extent when he made the distinction between the administrative rôle of the more senior nurses and the day-to-day more traditional work of other nurses. But effective management, with good two-way communication between the senior and junior nurses, is an essential factor in improving the lot of the ordinary nurse, and it can have an important bearing on the standards of patient care as well.

I am well aware that pay and management are not the only factors which need to be tackled. I appreciate that nurses have other grievances, some of which have been touched on during the debate. The hon. Member for Birmingham, Edgbaston (Mrs. Knight) talked about the other duties that nurses sometimes have to perform. This is an example. The hon. Member for Cheadle (Dr. Winstanley) talked about the technical skills which are increasingly demanded of nurses.

My right hon. Friend is considering what other action might be called for to improve the nursing situation. I will certainly draw his attention to all the points which have been made in the debate.

I must take up one point made by the hon. Member for Edgbaston. The hon. Lady referred to the management side's offer of a 22 per cent. increase staged over two years, costing about £65 million, as a shrivelled cherry. In my view, this is a luscious, ripe fruit compared with anything which came from her right hon. and hon. Friends when they were in a position to do something to solve what admittedly we all realise is a long-standing problem, because when they were in power all that the nurses got was the pip.

I have listened with great interest to all the various points that have been made throughout the debate, but important negotiations are still proceeding and it would not be appropriate for me to comment further just now. I hope, nevertheless, that what I have said will have helped to explain the background to the current negotiations and it will have helped to convey the Government's understanding of the need for unusual measures to deal with unusual problems.