§ Order for Second Reading read.
§ 3.48 p.m.
§ Mr. David Price (Eastleigh)
On a point of order, Mr. Speaker. May I draw your attention to the fact that the House is in great difficulty over our discussion of the Bill, because it is based on the Briggs report, the "Report of the Committee on Nursing", Cmnd. 5115, published in October 1972 and reprinted in 1977?
Since the time of the Queen's Speech I and many other hon. Members have applied to the Vote Office for copies of the report. It is not available. I understand that the Library has three copies. It is unreasonable to expect it to photocopy the entire report. I believe I am not giving away trade secrets when I say that my hon. Friend the Member for Reading, South (Dr. Vaughan) has a copy.
Those of us who would be minded to take part in the debate do not feel that we can do so properly without having studied the report again. Therefore, I for one shall not seek to catch the eye of the Chair, although I should have liked to make a contribution to the debate. I have no hostility to the Bill, but I should like to make a sensible contribution, and hon. Members, particularly those not on the Front Bench, are in grave difficulties when important documents of this kind are not available. I am making no party point but a House of Commons point.
I appeal to you, Mr. Speaker. I think that this will be only the first of such situations. We are in grave difficulties, particularly those of us who wish to make constructive contributions to the debates on forthcoming legislation.
§ Sir Bernard Braine (Essex, South-East)
Further to that point of order, Mr. Speaker. May I reinforce the representations of my hon. Friend the Member for East leigh (Mr. Price)?
In the past few days some of us have received letters from professional organisations that will be most seriously affected by the Bill. Those letters make it clear that the Bill's provisions are unacceptable 36 to them and that they wish to see the Secretary of State. When we, naturally, look for the document upon which the legislation is based, we cannot obtain it. I suggest that this is a most serious matter for Parliament. We cannot give proper consideration to the Bill today for this reason. May I inquire through you, Sir, what can be done about it?
§ Mr. Laurie Pavitt (Brent, South)
Further to the point of Order, Mr. Speaker. If it will assist the hon. Member for East leigh (Mr. Price), he may borrow my copy of the report.
§ Mr. Speaker
May I say to the House that I know we have been in difficulty? It is due to the delay caused by a current printing dispute as a result of which deliveries of printed copies of the report have been held up. I think that it is very serious for anyone to try to hold up the work of the High Court of Parliament, and I should like that on the record.
§ Mr. David Price
Further to the point of order, Mr. Speaker. May I refer to the kind offer made by the hon. Member for Brent, South (Mr. Pavitt)? The plain fact is that on matters such as this—this is a very lengthy document—hon. Members need to have the report in their possession in order to test it against the text of the Bill. It is no good going in off the cuff. Most hon. Members take a Bill such as this extremely seriously. We wish to do our own homework in our own time. We cannot ask it of the Library, because it cannot produce it. The position is getting very serious. This is the first occasion, but I understand that it will continue. May I suggest that you take counsel with the Government about how they can assist the House?
§ Mr. Speaker
It would be a sorry day if we allowed anyone to hold up the work of this House, although we have to work under difficulties. I do not think that any group of people should have the satisfaction of knowing that they are strong enough to prevent the Mother of Parliaments functioning.
§ Dr. Gerard Vaughan (Reading, South)
Further to the point of order, Mr. Speaker. I wonder whether the Secretary of State could undertake to provide copies at least for those hon. Members who will serve on the Standing Committee.
§ 3.52 p.m.
§ The Secretary of State for Social Services (Mr. David Ennals)
If I may refer to the matter just raised by the hon. Member for Reading, South (Dr. Vaughan), I shall of course make inquiries. I understand the difficulties in which hon. Members find themselves. If it is possible for me to be of any assistance, I shall do so.
I beg to move, That the Bill be now read a Second Time.
The Bill is a relatively modest one; it consists of only 23 clauses and seven schedules. But to nurses, midwives and health visitors its introduction is an event of great significance, for which most of them have been pressing for a long time. I do not pretend that they all welcome it, as some hon. Members will know, although that is the reaction of the majority whose realistic attitude is probably well summed up in the editorial in this week's Nursing Times under the heading "The Work Starts Here". The editorial says:It is an historic moment for the nursing professions.The Nursing Mirror reports on the enthusiastic reception by the Royal College of Nursing and the Royal College of Midwives.
The purpose of the Bill is to replace the existing separate bodies responsible for the education, training and regulation of the professions by a single central United Kingdom council supported by powerful national boards in each of the four countries. It will for the first time bring the professions under one umbrella and for the first time bring together the nurses, midwives and health visitors of England and Wales, Scotland and Northern Ireland. The Bill does not of itself make any change in the substance of professional education and training, but it paves the way for the professions themselves to initiate a new system of integrated training on the lines recommended by the Briggs report when the substantial resources which such a change would require are available.
When Richard Crossman, in March 1970, announced in Parliament that he had invited Lord Briggs—then Professor Asa Briggs—to chair a committee whose terms of reference wereTo review the role of the nurse and the midwife in the hospital and the community 38 and the education and training required for that role, so that the best use is made of available manpower to meet present needs and the needs of an integrated health service",it was against the background that though there had been many other committees and many reports, both official and unofficial, during the previous 30 years, never before had the subject been looked at in the context of an integrated health service.
This emphasis on an integrated structure of health care, concerned with prevention as well as with cure, was the keynote of the report which Professor Briggs and his colleagues presented to the right hon. Member for Leeds. North-East (Sir K. Joseph) and his fellow Ministers then in office in October 1972. However, it was not until after the General Election and a change of Administration that my right hon. Friend the Member for Blackburn (Mrs. Castle), in May 1974, announced on behalf of the incoming Government the acceptance of the main recommendations of the Briggs report. Certainly it has been a long time coming. I can assure hon. Members that we have no intention of rushing the Committee stage of the Bill, but they will understand that we now want to see it on the statute book as soon as possible.
As the House will know, recently the Royal College of Nursing presented to me its report, "An Assessment of the State of Nursing in the NHS 1978", which highlights some of the worrying aspects of the current nursing scene. One of the most serious issues is the fall in nurse training recruitment during the last two years. I should like to say a few words about the current situation of nurse manpower and recruitment before dealing with the Bill itself.
The March 1978 figures, which are the latest available, show that the total number of nursing staff in the NHS is continuing to rise. The proportion of qualified nurses in the total work force has also increased slightly. These increases—and the RCN argued this strongly—have to be viewed in the context of the rising nurse work load caused by the increasing numbers of patients receiving treatment, reduced lengths of stay and the technological advances made in medical science. Nurses have been coping with an increasingly heavy burden of responsibility, in recent times added 39 to by industrial action. It is essential that we should train more nurses to meet the increasing demands.
There are shortages of nurses in some localities where recruitment is difficult and in some specialised areas of nursing such as theatre nursing and intensive care. There are also still shortages in priority areas, such as psychiatric and geriatric nursing. However, there is in the country a considerable reserve of trained nurses who have left the Service for domestic and other reasons. Together with the health authorities, I am examining ways of attracting some of them back to nursing.
§ Mr. Robert Hughes (Aberdeen, North)
Can my right hon. Friend tell the House about the attempts being made to re-recruit trained nurses, since it is my experience in different areas of the Health Service in Scotland that most of these attempts have failed totally? How can we get the nurses back?
§ Mr. Ennals
They have not failed totally. There are a considerable number of nurses who are able to come back into service, taking part-time appointments. I was about to say that I am now examining ways with the health authorities by which we can make a major drive to bring back into nursing some of those with experience who have left the profession.
More than 9,000 jobs—more than half of them for nurses and midwives—should be available as a result of the Government's injection of the additional £40 million into the NHS in England announced in the Budget.
There is a need for positive manpower planning at all levels in the Service. Work is being done on this in the Department and in the NHS, and I intend to issue to NHS authorities and to publish early next year a discussion document dealing with a wide range of issues affecting nurse manpower planning, including recruitment.
The fall in entrants to nurse training in the last two years has been very worrying. I have responded energetically to the downward trend and told regional health authority and area health authority chairmen that I attach great importance to increasing the number of 40 learners. I am pleased to announce that the latest figures are more encouraging. In the first half of the current year, April to September, numbers of new students increased by 40 per cent. over the same period last year. The fall in pupil entrants has also been arrested, and there was a marked increase in their numbers between July and September.
But two quarters' figures, encouraging though they are, are not enough to lead to any complacency. We must train more and more student nurses, encourage them to stay in the Service and attract back to the Service as many trained and experienced nurses as possible.
§ Dr. Vaughan
Does the Secretary of State agree that part of the fall in recruitment is due to the reduction in the number of courses in training schools which was part of the Government's policy? This is what has led to one part of the shortfall of nurses.
§ Mr. Ennals
It was not part of Government policy. This was action taken by a number of areas in reducing their intake. I have made it very clear this was an extremely dangerous policy to pursue, and most of the areas which have done this in fact have now established a larger figure. It is for this reason that the figures are substantially improved—and thank heavens for that. We cannot expect to have the nurses whom we will need in the future if we are not ready to recruit them and train them now.
I would like to make one other point. We should be reminded of the debt that we owe to members of the nursing profession for the way in which they are carrying on their crucial role in the whole health care task, faced with ever-increasing demands on their services. No one would wish to detract from the role of any others who work in the Service—doctors, ancillary workers, supervisors, ambulance drivers and others—but often it is with the nurse that the buck stops.
The Briggs report is an impressive document, running to well over 300 pages. Thank heavens I have a copy. Those who have read it will know that it goes far wider than making proposals for a new education system, which is what most people automatically think when the Briggs report is mentioned. Its proposals 41 included the recommendation that there should be one basic course of 18 months for all entrants to the three professions, leading to a common certificate of nursing practice enshrined in a radical review of the whole nursing situation when the concept of an integrated NHS, unifying hospital and community services, was beginning to take shape.
` The report contains 75 recommendations, five under the heading "statutory framework", 32 on education, 14 on manpower, 13 on conditions of work, 10 on organisation and career structures, and the remaining one on assimilation, which is the matching of positions and qualifications to the new recommended ones.
§ Mr. Robin Corbett (Hemel Hempstead)
Will my right hon. Friend understand that I say, more in sorrow than in anger, that he has been on his feet for 10 minutes and has not once mentioned the word "patient"? Before he concludes his speech, will he find time to put what he is now proposing into the context of what I think the National Health Service is about—patient care?
§ Mr. Ennals
If my hon. Friend looks at the record in Hansard, he will see that I was talking about patient care and the responsibilities which nurses have, as part of the Health Service, for work with patients. My hon. Friend is absolutely right. That is what it is about more than anything else. I have already made mention of this, but I am glad to have the opportunity of saying again that this is what the Health Service is about. All of us who are responsible for helping to provide it with resources and leadership and those who work within it need to be reminded of that.
I was talking about some of the recommendations that have been made. The Bill deals only with the first five, on statutory framework. Leaving aside the block of recommendations on education, the greater part of the rest of the Briggs report which did not require legislation has already been carried into effect in other ways, either as a result of recommendations contained in other reports or as a direct consequence of the continuing concern that the Government have for the well-being of nursing and its sister professions.
42 Examples of the former are the Salmon and Mayston reports, which introduced new management structures for the nursing, midwifery and health visiting services which were still in the process of being implemented when the Briggs committee reported. There was then the report of the committee chaired by the Earl of Halsbury, which was concerned with pay and conditions of service. We would have had a great deal of trouble if it had taken us as long to implement Halsbury as it has to legislate on Briggs.
As to the recommendations on education in the Briggs report, it is my hope and expectation that the new statutory bodies proposed to be set up under the Bill will study them carefully, together with other proposals for the reform of education and training which have been made elsewhere and will, in due course, present the Government with an up-to-date consensus. Very much has changed since the questionnaires on which the Briggs committee relied for a great deal of its information were sent out and completed. We have another generation of nurses and midwives, who must be given the opportunity to voice their opinions. Health visitors too, who received relatively scant attention in the report but who have since asserted their position, are entitled to have their say. That is what the Bill is all about.
§ Sir Bernard Braine
The Secretary of State says the Bill is all about these noble professions having their say. Is he aware that in the last few days some of us have received representations, for example from the Council for the Education and Training of Health Visitors, which says that it utterly rejects the Bill, and from the Central Midwives Board, which has serious reservations about it and says in its conclusion that its offer to meet the Minister to discuss its view, which was made in July, is still open? Where is the consultation? Where is the seeking of the views of the professions involved?
§ Mr. Ennals
I think that the hon. Gentleman knows there has been an enormous process of consultation—
§ Mr. Ennals
My hon. Friend says that it has taken six years, but in the last two years, almost to the day, since I established the working party on which 43 the organisations mentioned have been participating there has been a great deal of consultation. The question raised by the hon. Gentleman perhaps shows that I should not have given way, because I shall refer to some of those who have criticised the Bill and will deal with some of the issues. Perhaps the hon. Gentleman can wait until I come on to that.
I want to say a word about the financial implications. I have to make it clear that whatever recommendations on education and training finally emerge will have to be carefully examined by the Government of the time against the background of other competing claims on resources. That is the phrase that we have to use virtually every time a proposal is made. The finance available to back the Bill—about £2.5 million at 1978 survey prices—which is needed for the hand-over period before the new bodies take on the functions of the old, is proposed to be found by adjusting existing programmes.
The main purpose of the Bill is to establish a United Kingdom Central Council for Nursing, Midwifery and Health Visiting, and four national boards. The Central Council is to prepare and maintain a central register of qualified nurses, midwives and health visitors and to determine, by means of rules, education and training requirements and other conditions for admission to the register.
The new bodies will replace all the existing statutory training bodies—the General Nursing Council for England and Wales, the General Nursing Council for Scotland and the Northern Ireland Council for Nursing and Midwifery, the Central Midwives Board for England and Wales, the Central Midwives Board for Scotland and the Council for the Education and Training of Health Visitors—and will also take over the functions of the three non-statutory bodies—the Joint Board for Clinical Nursing Studies, the Committee for Clinical Nursing Studies, its Scottish equivalent, and the Panel of Assessors for District Nurse Training.
By the restructuring of the present training bodies, all those concerned with education and training for nurses, midwives and health visitors will be brought together so that the whole range of education and training issues can be looked at across the board and the concept of 44 education as a continuum throughout the individual's career can be fostered, having a single controlling body dealing with all aspects of it.
§ Mr. Leslie Spriggs (St. Helens)
Earlier in his speech my right hon. Friend made one statement and now he has gone on to say that the financing of this new central board will be by an adjustment to the present programme. Is he aware that the education of all these professional people suffers as a result of the area health authorities not having the resources to provide the education resources required? I hope that he will not take it out of the present allocation.
§ Mr. Ennals
Not at all. The responsibility for the provision of funds by the health authorities stays the same. What I am talking about is the additional funds which are required to bring into operation the bodies established by the Bill. I have said that I am not today asking for additional moneys. We have already made provision for this in the general financing. I can give an assurance that there will be no cut-back. I have been pressing area health authorities with some success to increase recruitment to training schools.
Fundamentally the Bill is concerned with the government of the professions by the requirement that nurses, midwives and health visitors should be registered for practice in their professions and by the enforcement of standards of professional conduct through a disciplinary process. These provisions are vital to the protection of the public and will ensure that those who care for us are in all respects qualified to do so.
In the new structure, nurses, midwives and health visitors will form the majority on national boards and on the Central Council. Indeed, the majority on the council will be directly nominated from the national boards. More importantly, after an initial term during which all members will be appointed by Ministers, the majority on each national board will be directly elected by the professions themselves, as soon as the necessary electoral arrangements can be worked out. This is not something new for nurses, but it is a major change for midwives and for health visitors and is an important extension of the democratic principle.
45 If the new bodies are to have such influence over an individual's life and career, including the right to take away his livelihood, through removal from the professional register, it must be right that the representatives of such an individual should be involved in setting the standards for the professions and in enforcing them.
If this Bill achieved nothing else, its reform in this respect would be a significant step forward. But it will achieve more than this. It is a first step towards changes in education and training for the professions. Of itself it does not make those changes, as the House will understand. It is not designed to do so. But, by bringing together and unifying the statutory basis for the professions and by removing the hindrance that exists in the wording of the present legislation, it makes it possible for changes to be introduced in the future without waiting for further primary legislation.
§ Dr. M. S. Miller (East Kilbride)
Will the Minister give an assurance on a matter which is disturbing to some midwives and health visitors? May we have an assurance that the new boards will be merely governing bodies? Hospital nurses are not exactly the same as midwives and health visitors, who require different forms of training.
May we have an undertaking that the form of training which is given to midwives and health visitors will continue and will not be usurped by the nursing profession?
§ Mr. Ennals
I can give that assurance in a general sense. I want to deal with the problems involved in training and some of the similarities that exist in the three professions. There is much common ground.
I do not propose to describe the contents of the Bill in detail, clause by clause, but I shall draw attention to the main provisions.
Clause 1 establishes the new United Kingdom Central Council. Its detailed membership will be prescribed by Ministers but the crucial feature is the high degree of cross-membership with the four national boards, each of which will nominate in equal numbers members of the council. Those nominated by national boards will form the majority on the 46 council and, as is right in a body that is concerned with nurses, midwives and health visitors, that majority will be members of the three professions.
Clause 3 deals with specialist standing committees of the council. They will be established by order. In particular, there is a requirement to constitute a midwifery committee, which the council is required to consult on all matters relating to midwifery and which may discharge such of the council's functions as are designated to it.
This is in recognition of the many unique features of midwifery which differentiate that profession from nursing. There is also power to establish other specialist committees, including those for district and mental nursing and for clinical nursing studies—that is, the whole range of post-basic specialities such as intensive care, renal nursing, operating theatre nursing and the care of the elderly.
Clause 4 establishes the national boards. Clause 5 deals with the functions of national boards in relation to training and investigating cases of alleged misconduct.
Clause 6 deals with standing committees of national boards. Clause 7 deals with joint standing committes which serve both the council and the boards.
§ Mr. Alexander W. Lyon (York)
Is my right hon. Friend aware that health visitors in my area have a general unease about the Bill because of the differences in treatment between them and the midwives? There is provision for a midwifery standing committee under clause 3, whereas under clause 7 the health visitors are treated in a different way. In order to allay their fears, will it be possible in Committee to amend the Bill so that health visitors are treated in the same way as midwives are under clause 3?
§ Mr. Ennals
Clause 7 deals with joint standing committees. There is a requirement to establish a health visiting joint committee which the council and the boards must consult on all matters relating to health visiting and which will discharge the functions that are assigned to it. I have not finished with the problem that is in the mind of my hon. Friend the Member for York (Mr. Lyon) and other hon. Members. I shall deal with that problem shortly.
47 Clause 9 is, in a sense, the practical kernel of the Bill. It requires the council to prepare and maintain a professional register of qualified nurses, midwives and health visitors, which will replace all the existing registers and rolls.
Clauses 10 and 11 deal with admissions to and removals from the register. Clauses 14 to 16 restate, in relation to the council and the boards, provisions for existing legislation on the practice of midwifery. In particular, they require the council to make rules governing midwifery practice and restate the provision for establishing local supervision of midwifery practice.
The presence of this group of clauses is a recognition of the separate characteristics of midwifery and the need, in order to protect the public, to have adequate control over the way in which midwives operate. Clauses 18 and 19 deal with the finance of the council and boards. The remaining clauses are of a technical nature.
The Bill has seven schedules. Schedules 1 and 2 deal with the constitution of the council and boards respectively and set out in detail their procedures and methods of working. Schedule 3 deals with disciplinary proceedings before the council and boards. Schedule 4 contains transitional provisions relating to the transfer of staff, property, and so on, from the existing to the new bodies.
Schedule 5 contains the adaptations required for Northern Ireland and its national board. The constitutional position in Northern Ireland is different from that elsewhere in the United Kingdom. It is necessary to adapt United Kingdom legislation to take account of that. Schedule 6 contains amendments of other Acts. Schedule 7 deals with Acts that are to be repealed by the Bill.
The proposals are the result of extensive consultation with the professions. I pay particular tribute to the work of the co-ordinating committee, which, in the last two years, has helped in the preparation of the legislation. It is right that the representatives of the professions should have had an opportunity to discuss with the Minister what they would like to see enacted to control their own professions. The substance of what is before us is a result of those discussions. 48 This democratic participation in the preparation of the Bill must be a favourable augury for the democratic involvement of the three professions in the running of the new statutory bodies.
Not all the organisations which participated have, at the end of the consultation period, given their support to the proposals in the Bill. The majority have done so, and all dissenters as well as supporters have given unstintingly of time and effort. I am grateful to them. If [...] mention only those who have reservations I am sure that the majority will forgive me, because it is only to the critics that at this moment we should give a special examination.
The Central Midwives Board for England and Wales has fears for the rights of the midwife, fears that those rights will be swallowed up in the interest of the numerically superior nursing profession. I understand those fears but I do not share them. Neither, may I say, do the Royal College of Midwives and the Central Midwives Board for Scotland.
The Council for Education and Training of Health Visitors has expressed similar anxieties on behalf of health visitors, fearing that the commendably high standards of education and training of health visitors achieved under the aegis of that council will suffer as a result of the changes proposed—the point about which my hon. Friend the Member for York was asking.
To these and other organisations which are uncertain of the future I say that they must seize the opportunity to make their voices heard. They should not let the opportunity pass. No one ever influenced an organisation by refusing to participate in its deliberations.
Throughout my speech I have emphasised that we are dealing with professions, not simply a profession. The Bill deals with three groups, and it is worth looking at the distinctive features of each and what they have in common. Each has a separate role within our Health Service, and each has different skills.
Though the three groups can be clearly differentiated and their roles can be seen as very distinctive, they still have an enormous amount in common. They are trying to help individuals to do things which, for whatever reasons, those individuals cannot do for themselves. The sick have 49 immediate physical needs, The mother-to-be has a need for practical advice and guidance to help her through her pregnancy. The health visitor, in advising those she visits, is also providing something for them which they might not otherwise be able to provide for themselves. It may be advice such as referral to other agencies which can give practical help. This common interest is also expressed in a common core within their training and education.
There is a great deal of overlap in the knowledge required by nurses, midwives and health visitors. Indeed, one of the prerequisites for health visiting is a qualification in nursing, and 95 per cent. of all midwives are also trained nurses. This indicates the tremendous interrelationship between the three groups. The Briggs report placed much store on this common grounding of knowledge. Each group has a different perspective on health, but I believe that each has much to learn from the others. I feel that it is right that they should be brought together as the Bill proposes, in a single statutory framework which, while providing adequate safeguard for their separate identities and those separate specialist interests which are unique to each profession, nevertheless allows for a wider debate on those large areas of common ground.
I should like to say something about other specialist groups which may also be concerned that their interests will not be safeguarded. These are the groups such as mental nurses and district nurses, who have publicly voiced their anxieties, as well as the growing number of nurses working in occupational health services, sick children's nurses and many more. Though none of these groups would deny that they are first and foremost nurses, they all have, to varying degrees, separate identities, require distinctive training and face distinctive problems in their work.
It is for that reason that the Bill contains powers for Ministers to set up further specialist standing committees to look after specialist interests, if that is felt to be necessary and desirable. Indeed, for some groups I am already well aware that this will be necessary, and the Bill cites district nursing, mental nursing and clinical nursing studies. I am sure that the new Central Council and national boards will wish to have a source of ex- 50 pertise in these fields and that committees will be established for these three areas.
My right hon. Friend the Minister of State has already said publicly that the provisions in the Bill will be used to establish these committees. I wish now to repeat that commitment, as I know that many district nurses and mental nurses in particular are still concerned that their interests will not be sufficiently safeguarded.
I hope that my assurances and the assurances that my right hon. Friend will give will set their minds at rest. As time passes, the need for other specialist committees may well emerge. I certainly do not rule out the possibility of their establishment.
It is clear, however, that from the beginning the new bodies will need specialist knowledge and expertise in district and mental nursing, and I shall ensure that this will be available to them through the establishment of standing committees.
I should like to pay tribute to the existing statutory and other bodies, which have done yeoman service over the years and may well feel sad, and perhaps a little hurt, at being supplanted by a new statutory framework. As the Briggs report said:It is in no sense because we fail to recognise the achievement of these bodies that we recommend that in the interests of the professions there should be one single central statutory organisation to supervise training and education to safeguard and when possible to raise professional standards.I certainly endorse fully those remarks and others in the report about the achievement of the present bodies. They have all done a splendid job over the years, and we are all deeply grateful for their work. The restructuring to be achieved by the Bill is not required because the present organisations have failed. It is required to strengthen and develop the organisation and prepare it for the future. It is required to give nursing, midwifery and health visiting that "authoritative voice" that the Briggs committee felt was essential.
To the staffs of these organisations I say that we are proposing in the Bill the fullest possible safeguards in the way of transfer of employment to the new bodies, 51 [Mr. Ennals.] guaranteed continuity of existing remuneration and other terms and conditions of employment. They have nothing to fear from the Bill.
§ Mr. Spriggs
My right hon. Friend will be aware of the importance that we attach to the Second Reading of a Bill. Clause 16 states that a person other than a registered midwife or registered medical practitioner shall not attend a woman in childbirth. What happens in the case of emergencies? Must a woman be left alone in an emergency when neither midwife nor doctor can be present? What will my right hon. Friend do about that?
§ Mr. Ennals
I can assure my hon. Friend that there will be no change in the present position. If he has any further point that he wishes to make, if he fails to catch Mr. Speaker's eye I shall certainly ask my right hon. Friend the Minister of State to fill in the gaps. There will, however, be no change in the handling of emergencies.
§ Mr. Alexander W. Lyon
My right hon. Friend still has not dealt with the central point. Three professions are involved. One of them—which has by far the most numerous membership—is given considerable priority in the arrangements. The midwives are given their separate committee. Why are the health visitors treated differently when they are one of the three professions that have come together in this organisation? Why can they not be given the same sort of committee as the midwives, rather than operate under the arrangements made for them in clause 7?
§ Mr. Ennals
This matter will be debated in the House and in Committee. I have already given an assurance that there will be a joint standing committee especially to look after the interests of the health visitors. We must, however, look at the numbers. We are talking about well over 400,000 nurses in the National Health Service. The health visitors number 7,000. That is not in any way to underestimate the role of the health visitors, but numerically they are small in the generality of the numbers that we are dealing with. I think that it will be accepted that the special interests of health visitors will be catered for by the joint committee which I have 52 assured my hon. Friend will be established.
§ Mrs. Renáe Short
My right hon. Friend has given way to two hon. Members twice. May I ask him to say a word about the training of midwives? He has rather glossed over that in the description of what appears to be a somewhat massive network of bureaucratic committees. My right hon. Friend will understand, will he not, that the training of midwives is a very sensitive subject now, especially when people are concerned about perinatal mortality rates, a subject which the Expenditure Committee is about to examine?
Will my right hon. Friend comment on the proposal in the Briggs report to reduce the period of midwifery training, which is contrary to that of the Central Midwives Board, whose view is that the period of training of midwives should be increased? Will my right hon. Friend say something about the way in which that will be affected by the Bill?
§ Mr. Ennals
The Bill does not propose to change the period or the standard of training for midwives. It would be most unwise to do so, I believe. In fact, the provisions of the Bill and the establishment of the statutory bodies to which I have referred will enable the profession itself to come forward with such changes as it wishes to propose, based either on the Briggs report or on subsequent conclusions which it will have reached or which other professions may have reached.
As my hon. Friend will recognise, the purpose of the Bill is not in itself to make any changes in the education pattern. Such changes may well follow, but they will follow in the light of the decisions from the professions and the statutory bodies and standing committees set up for this purpose.
I wish to conclude now, so that the maximum possible number of hon. Members may have opportunity to catch the eye of the Chair. I have taken longer than I intended only because I have been generous in giving way to my hon. Friends 53 and hon. Members on the Opposition Benches.
The view of the Briggs committee was thatWhat the branches of a united profession have to give to each other is more significant and more fundamental than the respects in which they differ. We believe that a structure can be created in which essential differences are safeguarded within the overall unity.That is what I believe, too. I believe that the Bill creates that overall unity while safeguarding differences, and from that unity, I am sure, will come an authoritative voice from the professions, seeking higher standards in training and in professional conduct.
Higher standards in any of the health professions can only be to the benefit of standards of patient care, and that is what the Health Service is all about, as I said to my hon. Friend the Member for Hemel Hempstead (Mr. Corbett) when he intervened. That is what my Health Minister colleagues and I, and all those working in the National Health Service, are striving to achieve. I commend the Bill to the House.
§ 4.33 p.m.
§ Dr. Gerard Vaughan (Reading, South)
It is clear from the debate already that there is considerable anxiety about the Bill on both sides of the House. There is anxiety because there is a fear that the care of patients will suffer. The Secretary of State has told us that this anxiety is needless, but some of the bodies making representations to us are very worried, and I shall come back to that in a few minutes. There is also a fear, coming, in particular, from the health visitors but also from other professional groups, that their own special contributions and their identity will be lost as a result of the Bill.
I assure the Secretary of State that it is not a question of numbers. He is wrong to say in justification of his case that the numbers are small. The fact that the numbers are small for a special kind of nursing does not alter the needs of those nurses to have their own training and identity in the care of patients. I put that very strongly to the right hon. Gentleman.
The House as a whole recognises, as we on the Opposition Benches do, that the nurses generally want the Bill. For example, in her address to its annual gen- 54 eral meeting on 8th November, the president of the Royal College of Nursing said that history was being made for the nursing profession with the introduction of the Bill. In many ways, of course, she is right, and the nurses clearly welcome it.
The Bill will be of immense significance, but we should recognise, as comments from hon. Members have already shown, that we are being asked to set up a very complicated structure. In Committee we shall have to study these matters with close attention, since there are great problems in the nursing profession today. As we all know, standards of patient care are falling, and we certainly do not want to start changing the administration of the nursing profession in a way which will exacerbate problems which the nurses have already. As I say, we can look at that in Committee.
I have wondered how Florence Nightingale would feel about changes of this kind if she were here. Perhaps she would see the committee structure as necessary, because the role of nurses has, without doubt, changed a great deal and they are now highly technical and highly skilled people in their own right, and we have to recognise that.
The nurses have been waiting a very long time. The Briggs committee started its work in 1970. It reported in 1972. In 1974 the Royal College of Nursing began pressing the Government to bring forward legislation, and only today do we see it. Moreover, the nurses were deeply upset and disappointed that the doctors had their own General Medical Council reorganisation, following the Morrison report, ahead of them, and they felt that this was a mistake.
But that is all past history, and from the Opposition Benches we assure the nurses that we welcome the intention of the Bill and we shall do all we can to speed its passage through Committee. Indeed, we said earlier this year that we would welcome a Bill on Briggs, provided—this was our caution—that the nursing professions themselves, especially the midwives, health visitors, district nurses and psychiatric nurses, were reasonably agreed on what they wanted.
The sad fact is that the nursing professions are not agreed as at today. During the debate, for example, I have had a 55 telegram from the Association of Supervisors of Midwives saying that it is strongly opposed to the Bill and asking us, please, to stop it. That is from the supervisors of midwives, a very important group of people.
I listened with care and interest to what the Secretary of State said on this aspect of the matter. I hope that the Government will not curtail our proceedings in Committee. I put this most seriously to the right hon. Gentleman. It would not be of any benefit whatever to the Health Service and the nursing profession if the Bill, which has all-party support for its general intentions, had its consideration in Committee restricted by a guillotine. We hope that we shall be able to produce from Committee a Bill which will carry all the professional nursing groups with it.
Why is there so little of Briggs in the Bill? The Briggs report makes 75 recommendations. We have less than a handful of them in the Bill. The Bill is rather like the "Cheshire cat": it is all smiles, it is all head, perhaps it is all brains, but there is no body to it—and the body is the education proposals and changes which were intended.
The long title of the Bill tells us that one of the purposes isto make new provision with respect to the education, training, regulation and discipline of nurses".That is the only reference to education which I can find anywhere in the Bill. Once one moves away from the long title, there is no further mention of education.
In her address, the president of the Royal College of Nursing said:However, I would like to emphasise that the legislation is only the first step in implementing the main recommendations of the Briggs committee, which were"—I emphasise her words—primarily concerned with the introduction of a new system of nursing education.I think it right to query why, if that is the main intention, we should be dealing today only with a new committee structure. Are we to follow the same path as that set by the Medical Act reorganising the General Medical Council —that is, starting off with a Bill with no education in it and then in Committee 56 having whole new provisions on education transforming the Bill? That is one road that the Secretary of State may have in mind. If he has, he should tell us. If that is not what he has in mind, how are the educational proposals to be introduced? In discussions with the Minister of State, I understood from him that there was to be further legislation. I may have misunderstood the right hon. Gentleman, but that was my understanding.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
I am happy to assure the hon. Gentleman that he misunderstood me.
§ Dr. Vaughan
That is what I feared. If there is not to be further legislation. whole sections of immense importance to the nursing profession will be introduced by regulation. Are we being asked to open a back door through which anything that the Government would like to introduce may be passed? That is a sort of blank cheque. The House should know what it is being asked to do.
§ Sir Bernard Braine
That is what many of us have been complaining about. That applies to the Bill and so much else. Bills are brought before the House without adequate consultation or preparation. We shall be forced to spend a long time in Committee repairing the omissions of a Bill that is opposed in some measure by some of the parties that are being brought together. That is a most unsatisfactory way of dealing with parliamentary business.
§ Dr. Vaughan
My hon. Friend is right. That is a matter of concern. The House should be told of the Minister's intentions. If the Government intend to introduce regulations through the back door, as it were, we do not agree that that is a proper procedure. That is not a correct way of introducing changes that are so fundamental to the nursing profession. The nurses are one of the most essential parts of the Health Service and they form the largest professional group working within it. If we are to make major changes in their educational programme and procedure, we should know about them and deal with them in the House.
§ Mr. Tom Litterick (Birmingham, Selly Oak)
I have been listening to the hon. Gentleman carefully. I think that I 57 understand what he is against, but I do not think that the House can be sure what he is for. I have no familiarity with and very little knowledge of the professions that we are discussing. However, I have some knowledge of other professions. Surely we should easily be able to agree that it would not be possible for the State to legislate for the educational requirements of any one vocation. We should have the wit to allow the practitioners to legislate themselves and to determine their own training requirements. We should all be in favour of that, but is the hon. Gentleman so in favour?
§ Dr. Vaughan
If I may say so, that was an extremely good intervention. I am in favour of the professions concerned telling us and setting out how they feel that their training should be carried out. However, a major issue of this sort should come back to the House so that the House may have a say. It seems that the Government are leaving open the back door and everything that will happen without returning to the House.
The Secretary of State referred briefly to the nurse recruitment problem. Obviously it is extremely serious. However, he did not refer to any of the other problems of nursing. We know that nursing is in the most appalling state of chaos. The Bill will do nothing to put right the main problems facing nursing. It will do nothing immediately to put right morale. It will do nothing to put right the shortages, although the right hon. Gentleman talked about them. It will do nothing to put right the grossly inadequate pay. It will do nothing to put right the industrial unrest and, in some areas, unemployment among nurses.
We wonder why the Government should have gone for a change in administration but done nothing about the critical factors that are affecting nursing generally. For example, it is clear that the Whitley machinery needs changing. In our view, it is a disgrace that the nurses are refused the opportunity to consult other groups working in local hospitals and administration. The Secretary of State brushed that on one side only recently. It is wrong that the nurses should have to be seen separately from the other groups of workers within the Health Service.
58 Even in 1971 the Briggs committee made it clear that all was not well with the nursing profession. In the first chapter of the report it is made clear that all its recommendations are within the context of the general problems facing the nursing profession.
I was disappointed that the Secretary of state did not talk more about the problem facing nurses. It may be that he did not dare do so. It may be that he considered them to be irrelevant to the Bill. However, that was not the view of the Briggs committee. In the Briggs report it was made clear that the changes in the committee structure are relevant to what is going on generally.
§ Mr. W. R. Rees-Davies (Thanet, West)
I very much share the view that my hon. Friend has been expressing. As for recruitment, shortages and the regulations of nurses, the most serious problem in our hospitals on the nursing side is that about two-thirds of the nursing staff are agency nurses. Does my hon. Friend agree that the structure that is being set up by the Bill is irrelevant to being able to secure the regulation of the nurses and the necessary assurances and under-takings? Unless and until we can recruit nurses who carry out their duties as permanent nurses, we shall not be able to get anything right. What I have said about agency nurses is true even in the major teaching hospitals.
§ Dr. Vaughan
I am grateful to my hon. and learned Friend. He has raised a matter that we shall have to consider carefully in Committee.
The Opposition have constantly made clear that they are worried about the care of patients. We have constantly brought to the right hon. Gentleman's notice comments about deteriorating standards. Earlier this year I reminded him that the Royal College of Nursing had said that the care of patients was at risk. He brushed my question on one side and said that nurses were always asking for better conditions. That was a foolish way to approach an anxious situation. I hope that events at Harrogate taught him how strongly the nurses feel about falling standards of patient care.
It was a pity that the right hon. Gentleman did not respond to a question that was put to him during Question Time last 59 week, especially after all that he has said recently about industrial unrest. He was asked whether he would congratulate the Royal College of Nursing on saying that strike action was not action that it would take over its claim to be a special case under the pay code. He chose to ignore that part of the question and merely answered the latter part. I was surprised. I thought that it was foolish of the right hon. Gentleman to keep quiet on that issue.
§ Mr. Ennals
When representatives of the Royal College of Nursing came to see me, I congratulated them. If I did not make that clear during Question Time, it may be that that was through fear of giving too long an answer. I warmly congratulated them.
My task today was to introduce the Bill's Second Reading. If I had dealt with the whole problem of industrial relations in the Health Service—as the hon. Gentleman knows, I have been extremely busy dealing with proposals to improve district procedures and with how we can within the Whitley Council system avoid industrial disputes—it would have been an extremely long speech. Today was not the occasion for such a speech. When another occasion is found to debate the Health Service, especially the problems of nurses, I shall readily respond.
§ Dr. Vaughan
The Opposition will welcome a debate as soon as the right hon. Gentleman likes on the general nursing situation.
In Committee we shall want to examine the implications for Europe. That is in clause 10.
Most of our discussions are likely to centre on clauses 6 and 7 and the rights of the special groups to preserve their future. Several hon. Members have had representations already from a number of principal groups, and particularly from the health visitors, who are not at all happy. They do not think that their special position in relation to preventive work is sufficiently safeguarded. It would be very sad indeed if, as a result of the Bill, the health visitors—they have already indicated that this is a possibility—took themselves out of nursing and into the social services. That would be a tragedy for the National Health Service.
60 The health visitors say that the Minister of State has not followed up the assurances that he gave them on 4th November 1977. They also say that the chairman wrote to the Minister of State again on 18th October this year but that for some reason—certainly up to 7th November—he had not cared to reply. As a result, they are anxious and concerned and they feel themselves to be, as they put it, in a totally vulnerable position.
The health visitors understood from the Minister of State that the intention was to transfer the Council for the Education and Training of Health Visitors to the statutory committee, that this committee would have control of health visitor education and training and that it would have adequate representation on the Central Council. The health visitors are now asking whether the Minister, when he replies to the debate, will state what his views are on this and confirm the position.
The health visitors say that they are deeply concerned that the education and training of health visitors, which they have worked so hard to establish will not be safeguarded. There are further questions, which I will give the Minister of State after the debate, in which the health visitors ask him to clarify his intentions. Is it correct that the nurses, midwives and health visitors in the field have not had access to the proposals for the Bill? If that is so, it is a very strange kind of consultation. Is is correct that no opportunity was given for the coordinating committee to discuss alternative methods of achieving co-operation—for example, by forming a federation of the existing organisations and progressing by what they call evolution? Is it correct that no attempt has been made to assess the feasibility of the new structure and of ways in which the different parts will be interrelated?
The health visitors suggest that the paragraphs in the Bill dealing with finance and with manpower are incorrect. They suggest that the Bill will require much more in the way of resources of money and manpower to handle the work. They suggest that in its present form the Bill will lead to a lowering of the standards of patient care. These are very serious questions and I hope that the 61 Minister of State will address himself to them when he replies.
We are concerned generally about the size of the committee structure and about the numbers of boards. We are concerned about the explanatory and financial memorandum. It is extremely unsatisfactory that the penultimate paragraph starts with the words "In the first instance". We wonder what is to follow afterwards. I had understood from the Minister of State that it was likely that these matters would cost at least £1½million a year extra during the first year. That is a lot of money.
Concerning manpower, the memorandum states in the last paragraph thatIn the long term, the Bill will have no measurable effect".That is not what the special groups of nurses are saying. They say that there will be an increase in manpower needs.
We welcome the Bill. We respect the view of the nursing profession that a reorganisation is necessary. We shall help the Bill on its way, but we shall look very carefully at its provisions. We deplore the Government's lack of any other more immediate and positive suggestions for helping nursing and stemming the disastrous fall in the standard of care for patients. Although the Bill will probably do a good job for the nurses, it is no substitute at all for what we see as a lack of leadership right through the management of the National Health Service.
§ 4.55 p.m.
§ Mr. J. Enoch Powell (Down, South)
The right hon. Gentleman the Secretary of State, in introducing the Bill, indicated that it represented a number of firsts. One respect in which it represents a first is that for the first time it brings the professions in Northern Ireland under the same system and organisation as the rest of the United Kingdom, and sets up an all-United Kingdom organisation and legislation for the purposes which are detailed in the long title. It would be wrong if this were not recognised. It is welcomed not only by my hon. Friends and myself; our inquiries in the Province, so far as they have gone, indicate that the Bill in its general form—subject to any alterations that might commend themselves in Com- 62 mittee—meets with the approval of those working in these professions in Northern Ireland.
The Bill sets up for Northern Ireland one of the four national boards. We quite understand that during a Session in which the referendums on the Scotland Act and the Wales Act are to take place, the Government were anxious to introduce the word "nation" wherever possible, although that is not the formulation which we in Northern Ireland would have chosen. We believe that the correct expression is to be found in clause 21(3)(b,) which refers tothe National Boards for the parts of the United Kingdom ".We in Northern Ireland are a Province and an integral part of the United Kingdom, and as such we have been dovetailed into the Bill.
Any ruffled feathers, however, on the score of the terminology would be allayed by our observing the uncommonly generous way in which the representation of Northern Ireland in the structure set out in the Bill has been treated. If hon. Members will look at the first schedule, they will see that although Northern Ireland represents a very small fraction of the total population of the United Kingdom—and a small fraction, of course, of the professions in the United Kingdom as a whole—it is given equal representation and equal numerical representation on the Central Council. We regard that as very generous and as a welcome approach to bringing the professions of Northern Ireland into a much closer coordination with their colleagues on the mainland.
There are only two points to which I wish to draw attention at this stage. One of them may be able to be dealt with at greater length in Committee, although it is sufficiently important for the Minister of State, I hope, to be able to say a word on it in winding up. It relates to discipline. It appears from the Bill as it stands that disciplinary functions are exercised both by the boards, in clause 5(1)(e,) and also by the Central Council, in clause 11(2).
The boards are toinvestigate cases of alleged misconductwhile the Central Council is tohear and determine proceedings for a person's removal from …the register".63 The grounds of removal from the register may include misconduct. Will the Minister of State indicate how it is considered appropriate that one body should investigate alleged misconduct while another body should adjudicate upon whether that misconduct should be a ground for removal from the register? At first sight, there would seem to be something unsatisfactory in one body establishing the facts of misconduct and another body visiting the appropriate punishment or action arising out of that misconduct. I hope that, at any rate in general terms, that matter can be referred to.
The second point relates to schedule 5 —"Adaptations for Northern Ireland". The Secretary of State remarked that this schedule and these adaptations were required because of the special constitutional circumstances in Northern Ireland. It may come as a shock to hon. Members not normally concerning themselves in detail with the affairs of that Province to know that the provisions set out in the schedule will, for the most part, not come into force at all. An innocent hon. Member reading the Bill and schedule 5 would suppose that the schedule was, as it were, the application clause for Northern Ireland. He would look at the table on page 23 and assume that, for example, where the Treasury was mentioned, in the case of Northern Ireland we were to read" The Department of Finance for Northern Ireland." That is not the case.
The schedule refers to a non-existent constitution—the 1973 constitution. Whatever views may be held upon the constitutional future of Northern Ireland, I have yet to meet an individual who supposes that the 1973 constitution will be summoned back into existence. Therefore, grateful though we are that Northern Ireland is in the Bill, we are writing into it a series of provisions which will not come into effect because the Northern Ireland Act 1974 contains a provision which cancels all that out and provides that it is not to happen. Therefore, what we read here will have an entirely different meaning.
It is a pity that at a time when the House is legislating for the United Kingdom as a whole we should not legislate for Northern Ireland as circumstances are, and will continue for a considerable time, 64 but should persist instead on harking back to constitutional provisions which have gone out of effect and will not come back into effect. It may be possible to shorten and simplify the Bill if we let it take effect in Northern Ireland, subject to such adaptations as are required for things as they are, and go on from there in time to come.
I shall detain the House no longer, except to say that the progress of the Bill will be watched with equal interest in Northern Ireland. We are grateful to have been brought under what the Secretary of State described as the "umbrella" We believe that it will be to the benefit of the morale, education and training of the professions in Northern Ireland that they belong to a nation-wide structure. We wish the Bill well.
§ 5.4 p.m.
§ Mr. Stan Thorne (Preston, South)
I hope that it is not over-simplifying matters to suggest that Briggs in 1972 had the job of attempting to make sense out of a somewhat chaotic and fragmented training situation. I suggest that the main conclusion of Briggs was in the direction of a nursing council with general responsibility. Following from that, it seems that various professional sections became increasingly worried about possible loss of identity.
The midwives have certainly made their position clear on the establishment of a midwives' council to protect their interests. Indeed, from time to time we have heard statements from other professional bodies.
Now we face consideration of the Bill. I am particularly concerned about the part dealing with health visitors. The question that I pose to the Minister, to the House and to myself is: will the Bill give health visitors the kind of reassurance that they seek following Briggs and the events, or the lack of events, in recent years? That is very doubtful, for some of the reasons that have already been indicated in the debate.
The Royal Commission on the Health Service is still sitting. I mention that because I consider it to be relevant. That Royal Commission will clearly make recommendations which I suggest will be relevant to the subject covered by the Bill. Indeed, I hope that I shall be forgiven for wondering whether it might have 65 been better to leave the Bill until after the Royal Commission reported, because it seems that we can only speculate about its recommendations.
I know that the Royal Commission has already taken evidence from health visitors, and I shall deal with that matter. One problem is the absence of a real definition of the role of the health visitor. It is clear—I think that this is accepted by the Secretary of State and by the spokesman for the Opposition, the hon. Member for Reading, South (Dr. Vaughan)—that health visitors should not be lumped in with the curative services. Their role is primarily preventive, as can be seen from the evidence that has been given to the Royal Commission, because they specifically referred to health education, school health and occupational health.
The Secretary of State said that the training of health visitors was different from that of nurses and midwives. Nurses do not undergo training in social history, sociology and social psychology, but those areas are relevant to health visitors. Knowing something about conditions within a community will tell them a great deal about the experiences that mothers taking home new-horn children will have within that community.
Some people suggest that the local authority has such a connection with health visitors that it might be beneficial for it to be restored to a position within the local medical officer of health's staff. I want to deal with this point specifically, because it is one of the dilemmas that we face in the Bill. Certainly there are administrative and structural relationships between health promotional services and the necessary involvement of health visitors within the community in terms of a close relationship with general practice. A health visitor is a general practice preventive health worker. To some degree, that impinges on the role of the medical officer of health within a community.
There is an answer to those two ways of looking at the role of the health visitor —either as part of local authority services under the medical officer of health or within communities having a role in terms of primary care, which, in my view, is the most important role of all for health visitors. As I favour the latter, I think that it is essential that the training and 66 role of health visitors in health education and preventive involvement is not given a secondary place as is implied in certain parts of the Bill.
I want to be brief, in the interests of allowing other hon. Members to speak and because I should like to catch Mr. Speaker's eye at some future date, so I make one final point. When these councils have been established and when they are looking at the training of nurses, midwives and health visitors, I should like them to give some consideration to the way in which they can contribute to a position in which nurses and midwives who have served in hospitals and within the communities can be trained as doctors, in order to overcome the shortage of doctors in the NHS at present.
The hon. Member for Reading, South, being a learned member of the profession, probably frowns on the notion that such people should enter training as doctors. However, in my view, this is long overdue. If the Bill and the establishment of training within four general councils permitted us to make one step towards that objective, I would welcome its present clauses, with the addition, I hope, of some amendments in Committee that would draw attention to the comments that I have made in regard to the role of health visitors in the future.
§ 5.11 p.m.
§ Mr. Robin Hodgson (Walsall, North)
It is hard to argue with a measure whose primary purpose is to establish and improve standards of education, training and professional conduct for nurses, midwives and health visitors, because, obviously anything that this House can do to improve the standing of these joint professions, for which I think all hon. Members on both sides of the House have a great deal of respect, must be applauded. The question that I have in my mind is whether the slightly monolithic structure that seems to be proposed in this Bill is actually going to help in this way.
I know that Briggs himself had absolutely no doubt about the matter. I am also lucky enough to have a copy of his report. Paragraph 71 says thatThere is a strong feeling which has been conveyed to us by many witnesses, that too many bewildering distinctions exist within nursing and midwifery—too many avenues of entry, too many courses in too many places of study, too many qualifications, too many 67 grades, too many controlling or regulating bodies.The point which emerges from that is the point that was raised in questions during the Secretary of State's speech, particularly the question by the hon. Member for Hemel Hempstead (Mr. Corbett). Nowhere is the patient actually mentioned. The patient seems to me to be absolutely primary and most important of all.
People prefer to be ill at home. They feel more comfortable at home, they feel more relaxed and more reassured at home and they will probably make a speedier recovery at home. Not only will they be more relaxed and make a speedier recovery; they are probably cheaper to look after at home. The capital cost of our modern hospitals and all the ancillary functions that go with them is very great. Therefore, it seems to me that the role of community care, of the primary health team working in the community, is essential. This has not necessarily been fully appreciated in the way in which the Bill has been drawn up.
In the summer, we discussed the question of preventive health, and the Government's response to the Select Committee's report, and we had some very interesting observations from all sides of the House about the role of prevention. But the key to prevention must be the people who are actually going to work in the community—district nurses, health visitors, and, to a lesser extent, the midwife. Their role is important now and will certainly become more and more important because, as was pointed out in that debate—and it has been pointed out in subseqeunt debates—the number of elderly and, particularly, very elderly people will increase rapidly. I believe that I am right in saying that the number of people who are very elderly, that is, aged over 85, will rise by nearly 50 per cent. over the next 15 years. I suggest that those will require a tremendous input of community care and health visiting on the ground, in their homes, if we are to prevent their becoming sick and ill, and thereby clogging up—and I mean that in the nicest possible way—the hospital structure.
I fear that if the Bill is implemented precisely as it stands there could be a 68 step back and away from community care. I do not think that as it is presently drawn it gives enough protection or recognition to those nurses who are involved in extra-hospital care.
Why is this? The Secretary of State referred to the question of the structure of the profession. Briggs, I think, again talked about the relative balance between local authority health employees—as it was when he wrote his report—and the nursing staff. In the tables in the back of the report, Briggs points out that there are about 300,000 nursing staff—I know it is seven or eight years ago, so it is obviously well out of date now—and that the local authority health nursing staff was under 30,000. Therefore, there is obviously the fear that, as a smaller number of people, they will be squeezed out and that, indeed, their profession will not be adequately recognised.
Then there is the attitude amongst the nursing profession itself. I would not want it thought that in my questioning of the attitude of the nursing profession, I am implying that there is any malice amongst the nurses but, rather, that hospitals are relatively neat and well-organised packages, which nurses and the nursing administrators can handle. By contrast, community care is messy and fragmented. It does not allow the neat boxlike approach and structure that can be followed when one is bringing patients out of the community into a hospital where they are entirely under one's control.
Thirdly, there is the question of the differing needs of different areas. If one considers—and I do not want to dwell on this point for more than a moment—the different community health needs of an inner urban area, an outer suburb or a rural county, one finds it hard to see how this sort of structure—again, slightly monolithic is how I describe it—will be able to meet and have the flexibility to cover the needs of areas as different as those I have mentioned.
The Secretary of State says "Not to worry". He answered a number of interventions during his speech and said "I can assure you that it will all be all right and that the powers for joint councils contained in one of the clauses of the Bill will be sufficient to project the midwives and the health visitors." I am not 69 sure that that is entirely correct. Perhaps I may use an analogy. The right hon. Gentleman's colleague, sitting on the Bench beside him, the Minister of State, was good enough to receive colleagues from both sides of the House in an all party delegation on homoeopathy earlier in the summer. I am not a homoeopath and I have no particular interest in homoeopathy, apart from the fact that I believe that those who find homoeopathic treatment useful and effective in treating their illnesses should be able to get it under the National Health Service.
There seems to me to be little doubt that, as developments are going on at present, homoeopathic treatment is gradually being squeezed and squeezed. We put forward to the Minister a number of examples of where homoeopathic facilities and the number of beds at various hospitals in different parts of the country were gradually being removed from homoeopathic treatment and given over to general clinical treatment of the normal kind.
It is possible that that was because it was thought that there was no demand for homoeopathy. In fact, however, that was not the evidence that this all-party delegation had. It seems to me that there is a good analogy here between what could happen to district nurses and health visitors. One has a slightly specialised and small profession operating on its own outside the general structure, and, in that case, just as homoeopaths are getting squeezed out, it is not surprising, no matter what the Secretary of State says, that district nurses, midwives and health visitors have some concern that they may go down the same route.
§ Mr. Ennals
I noticed that the hon. Gentleman said "no matter what the Secretary of State says." I shall, nevertheless, say that, quite apart from the assurances that I gave in relation to the Bill, I think that the hon. Gentleman will know that in the priorities that we have set for the development of the Health Service we have envisaged a much faster rate of growth for health visitors than we have for nurses in general. Six per cent. a year is the growth rate towards which we are heading, and want to achieve, because we see the vital importance of the health visitor, particularly in 70 the field of primary health care, as has so rightly been said.
§ Mr. Hodgson
Again, I am grateful for that further assurance from the Secretary of State. None the less, it seems that there is a very easy solution here. Either the Secretary of State can follow the suggestion made by the hon. Member for Preston. South (Mr. Thorne) about bringing out the health visitor under the local authority and thereby creating a more autonomous local unit responsive to local needs, or following the suggestion of using one of the optional statutory units under clause 3 and paralleling the compulsory body that will have to be set up for midwifery with something to cover the community care side. If that were done it seems to me that in large measure it would meet the genuine fears which the community care nursing profession, in the broadest sense, may have.
Earlier, I quoted from Briggs, against myself. Perhaps I can quote once more in favour. I refer to paragraph 627, where Briggs underlined the difference between nursing and midwifery. He said:After careful consideration, we conclude that there are aspects of midwifery practice on which a body dealing also with all aspects of nursing could not rightly pronounce with the necessary degree of authority.If that is true of the midwifery profession, it is also surely true of people dealing with very different, very special and very localised requirements of community medicine. I would like to see clause 3 amended in such a way as to enable some special recognition to be given to the needs of community care.
One of the omissions, which I regretted, related to recommendation 8 of the Briggs report, about the setting up of colleges of education which would enable the nursing profession to have more contact with people outside their immediate professional interests. It is important that we should not create a nursing profession that is cloistered away from prevailing attitudes and educational influences. I shall be grateful if the Minister will say why recommendation 8, which I do not see anywhere in the Bill, has not been progressed further. Is there any intention of progressing it shortly?
I come next to the question of the national boards. This is where we come again to the monolithic question. The 71 House went over some of the arguments when, in the last Session, we discussed the Medical Bill which set up the national boards based on the Merrison committee recommendations. I wonder whether a national board is the right way of structuring the nursing profession in order to meet local needs, because the relative size of the constituencies, for nurses as well as for doctors, must be very disparate. I do not know what the numbers are, but I remember that in the case of doctors there were about 45,000 doctors in England and about 2,500 in Northern Ireland. If those sorts of ratios exist in the nursing profession, and I presume they do, it does not seem to fairly represent the aspirations, ambitions and wishes of the vast majority of nurses who are employed in England if we give such in-equal constituencies equal weight on the governing body.
Apart from what Briggs himself wrote in his report, I wonder whether there was any real demand from nurses at the grass roots for this sort of structure. When they said that they wanted some local autonomy or influence, did they not really mean "local" in terms of their area rather than "local" in terms of Scotland, England, Wales and Northern Ireland?
My hon. Friend the Member for Essex, South-East (Sir B. Braine) referred to enabling legislation and was rather cavalierly treated by the Government Front Bench. To start with, the Medical Bill last Session was a fairly slim volume, but by the time it had gone through all its stages, from Lord Hunt's amendments in the other place to Third Reading here, it had become a pretty fat volume. It is all very well for the Secretary of State or the Minister to say that my hon. Friend did not have a fair point, but on the record of what we saw with regard to the doctors' profession, and the reorganisation of the GMC, I believe that he had a very fair point.
One cannot argue with the overall aim of the Bill. However, is the proposed structure flexible enough to cater for local conditions? Is it balanced enough to meet the increasing need of community care? Many people have spoken of how Briggs began in 1970. The main period of his deliberations was between six and eight years ago. After six years there has been such a change in attitudes towards the relative merits of hospital and com- 72 munity care that I believe that we are in danger of bringing in a structure for the nursing profession which covers yesterday's needs rather than the needs of tomorrow.
§ Mr. Deputy Speaker (Mr. Oscar Murton)
Order. Before I call the next hon. Member, I should say that it may have occurred to the House that there is a little local difficulty, inasmuch as the present incumbent of the Chair is in the dark—some hon. Members will probably think not for the first time. What is more important, the digital clocks have gone off. They are off at the Table, too, and until further notice we shall take our time from the clocks at each end of the Chamber.
§ Mr. Corbett
On a point of order, Mr. Deputy Speaker. Can you assure us that although we cannot see you, you can see us?
§ 5.25 p.m.
§ Mr. Laurie Pavitt (Brent, South)
The hon. Member for Walsall, North (Mr. Hodgson) has echoed the cry which has gone through the NHS for the last 25 years about how one should concentrate attention upon the place where it really happens—in the community, in domiciliary care and prevention. Unfortunately, under all Governments, Back Benchers have these things to say, but when it comes to the balance of power—when one seeks to tranfer any resources into that area—there is tremendous resistance from all hon. Members if it means touching their local hospitals. As a result, we always have a problem of trying to concentrate our minds on domiciliary and community care and yet failing to give practicality to a general theory with which we would all agree.
This Bill is a thin Bill. It is a skeleton of a Bill. I had some sympathy with the hon. Member for Reading, South (Dr. Vaughan) when he listed most of the things that the Bill does not do. Unfortunately, no Bill does all the things that hon. Members want it to do. This Bill is only about a limited thing.
From time to time I share the hon. Gentleman's feelings, especially when I think that my attention to the health of 73 the individual and the community leads to a need to solve all the problems in the world, because frequently that brings us back to the question of how one organises the social and economic life of the country.
However, let us give a welcome to the Bill, thin and skeleton as it is, for at long last—after too long a delay—trying to tackle the problem of putting the right professional status into the nursing education and training schemes.
I also share the disappointment of the hon. Member for Reading, South at the way in which legislation seems to be increasingly distant from Back Benchers. The hon. Gentleman said this was not the proper way for legislation to take place, because things come in by the back door through statutory instruments. Unfortunately, this has been a habit of Governments since 1971. It is a change in the pattern of the House. Before that time, we used to have a Bill with most of the provisions already in it. It was the right hon. and learned Member for Surrey, East (Sir G. Howe) who found a new method of having a framework Bill—on the Common Market—into which everything was put after it had been passed. This Bill is a framework Bill. It does none of the things that Briggs is about, except establishing the framework upon which those things can be done. I therefore accept that all the consequential matters pertaining to the Bill are hardly before us in this Second Reading debate. All the matters that have so far been raised are mainly concerned with the contents, and that will happen after the framework has been put into operation.
The top floor is in the Bill, by establishing the Central Council and the national boards. We all accept that this is just the first step, because the real work will be done by the standing committees, which will be set up by orders which we may or may not discuss in this House. This will make it even more important that in Committee we get on the record all the things that we want to see eventually put into the Bill.
Even more important than our responsibility at our own Committee stage is the point that has already been made by various hon. Members, namely, that the standing committees provided in this Bill, when constituted, must have the full con- 74 sent, support and participation of the people it is supposed to be serving. For example, in the two cases most before the House today—health visitors and midwives—each standing committee must carry those bodies with it. That will be an essential part of the responsibility of my right hon. Friend.
I take seriously the misgivings expressed about the Bill. We have all received representations about it. I commend the points made by my hon. Friend the Member for Preston, South (Mr. Thorne) concerning the constitutional position and work of the health visitors. Representations about the Bill have been received from the Council for the Education and Training of Health Visitors, the Central Midwives Board and the Health Visitors Association. We have already dealt with the numbers-game point. As a minority man, I do not believe that we must always look only to the large battalions. However, my right hon. Friend has responsibility for dealing with the vast majority.
The fact that there are 405,817 nurses and only 15,358 midwives means that my right hon. Friend has to pay a great deal of attention to the training and education of nurses, whether in the community or hospital services. Nevertheless, there is a fear that the Royal College of Nursing, NUPE and COHSE may act in negotiations as a "Big Brother", or perhaps in this context I ought to say "Big Sister"? There is the fear that the small organisations will be oppressed by the larger bodies.
I understand those fears and am certain that they can be allayed. Meaningful discussions with all concerned should take place before the standing committees are established. This is one of the few Bills to come before the House in the drafting of which those with whom it deals have been involved. This was a breakthrough that came in November 1976 when a Briggs co-ordinating committee was established, comprising all those concerned with the negotiations arising from the original concept of the Bill. I hope that the fact that the Bill receives its Second Reading today will not mean that the work of that committee will cease. It should continue until all the arrangements have been concluded.
75 I hope that before the Bill goes to Committee there will be discussions with all involved and that the Government will be prepared to table amendments aimed at allaying fears. I have received an amendment from the health visitors in connection with clause 7. The health visitors wish to add something that will give them an extra safeguard. I would be prepared to move such an amendment in Committee but would prefer the Goverment themselves to do so, because I believe that it would improve the Bill.
One of my fears is that the establishment of this new organisation may lead to greater bureaucracy and administrative clumsiness. Like all other drawing board structures, it is frightening in its diagrammatic shape. My concern is that we should not have too many clinically qualified people carrying out committee chores. Nursing is concerned primarily with patients. It would be a tragedy if the bedside were emptied to fill the committee rooms. This fear is shared by others, following the costly restructuring carried out in 1973 by the right hon. Member for Leeds, North-East (Sir K. Joseph). Are we, through the Briggs structure, to return to another monstrosity of bureaucracy?
The Bill gives us the opportunity to look again at the implementation of the Salmon report. I have been contending for years that that report, implemented in 1966, needed the educational structure of Briggs to make sense of its career structure. We are now to carry out a few of the Briggs proposals. This is a step in the right direction. The educational and training structure must be seen to be geared to the structure of Salmon. Now, after 12 years, we have the opportunity of re-examining the Salmon structure and learning from experience.
It is difficult to get through the House of Commons Bills dealing with health matters. When we have dealt with this one it may be some time before we see another. I wonder whether we could not add something to deal with one of the basic problems arising from the present career structure for nurses in hospitals. In the last 10 years since the implementation of the Salmon report, the emphasis has been upon a management career for nurses. It is about time that the Govern- 76 ment introduced a proper career ladder for those nurses who wish to remain in clinical nursing.
The best nurses do not always want to become administrators. They may wish to remain nurses, using the nursing skills which they have so painstakingly acquired. However, the grade I sister has no way of advancing other than by moving to grade 6, grade 7, and so on. This takes her away from the bedside. It is possible that this problem could be dealt with by creating a new grade of clinical nurse consultant. We could then build up a structure which did not take nurses away from patients and also ensured that they continued to use their nursing skills.
Would such a scheme require new legislation, or is it possible within existing arrangements in the Department? If new legislation is needed, could we introduce a "piggy-back" clause into the Bill? Obviously we shall not have another Bill dealing with nurses for some time. If we want to do anything in this regard, we must do it now.
I am also concerned about the question of registration fees. We all know that nurses have been underpaid for years. This is despite the fact that the Labour Government implemented the Halsbury award, which gave nurses their biggest rise since the introduction of the National Health Service. If registration fees are to be required and increased in the various sectors, I hope that the Government will give an assurance that nurses will be compensated by pay awards.
I turn now to the question of domiciliary care. I hope that the district nurses will remain part of the primary care team. We have always spoken of the GP as the leader of such a team. Unfortunately, except for the district nurses, they have never been given the tools to do the job. Now 90 per cent. of district nurses have a direct attachment to general practitioners. I hope that nothing in the Bill will detract from that position, as this team work is now an integral part of the district nurse's job.
I welcome the Bill and wish it a speedy passage—even speedier than the recognition that I hope the Government will give shortly to the nurses as a special 77 case under the pay policy. In spite of our present financial difficulties, it is an incontrovertible fact that, for the morale, education and training of nurses and, most of all, so that they may feel that they can afford to live on the same standards as others in their age group, we must give their pay claim priority and that they should be included in the category, which covers so few groups of workers, of special cases. I hope that the Secretary of State will use all his muscle in Cabinet to persuade the Chancellor of the Exchequer to that end.
§ 5.41 p.m.
§ Mr. George Thompson (Galloway)
As usual, I have found a number of matters illuminated by the hon. Member for Brent, South (Mr. Pavitt)—even though we are in dimmer circumstances than usual. I was particularly taken by the hon. Gentleman's description of the Bill as a framework Bill for which the various orders provided for in the measure will provide the necessary filling. That description illuminated for me the connection between the Bill and the Briggs report and I am grateful to the hon. Gentleman.
I join the tributes to the existing statutory bodies, the General Nursing Council for Scotland, the Central Midwives Board for Scotland and the other bodies in the rest of the United Kingdom, but I wish to criticise strongly the indecent haste with which the Bill has gone from First to Second Reading. Ten days is much too short a period for the relevant professional bodies to have been able to meet and discuss this important Bill properly.
I accept that there was a great deal of consultation, but there is still the problem that the grass roots reaction has to pass up to the central bodies. The Government constantly talk about getting things right, and we do not do that by acting in haste. The Briggs report was published six years ago and I think that the Government should have allowed an extra week or two before Second Reading.
I understand that, for instance, the General Nursing Council for Scotland could not have held a council meeting specifically to discuss the Bill before Second Reading because its statutes do not permit that. That is not the way to treat a valued and devoted profes- 78 sion such as nursing. Can the Minister assure us that a proper length of time will be allowed between this debate and the start of the Committee stage so that we allow the professional bodies to put forward suggestions for amendments? That is the least that the Government could do to repair their blunder in the rush to Second Reading.
§ Mr. Thompson
There is no need for six years, or even six weeks. Four weeks would have been ample time between First and Second Reading.
The House would do well to give itself time for reflection on any reorganisation legislation these days, because when we legislate in haste it is those who are legislated for who often have to regret at leisure. The House rarely repents and, when it does, it usually tries to avoid admitting that it is doing so.
The 1960s and the early 1970s were lived under the "white heat of the technological revolution" and reorganisations of all sorts went forward. We had local government reform and the reorganisation of the National Health Service. In this House and in the Scottish Grand Committee, we find that right hon. and hon. Members behave as though these reforms had descended upon us Prom outer space—from Mars perhaps, although some people have suggested that they came from the moon when it was at its full.
We have proceeded to needless centralisation and to an extension of bureaucracy which has met with criticism. I hope that this reorganisation will not prove to be of a similar nature. I hope that we shall not be sitting here in five or 10 years' time trying to pretend that we had no hand in this legislation.
Turning to a specifically Scottish aspect, the Briggs committee reported in October 1972 and a year later the Kilbrandon Commission reported on devolution. We are bound to wonder whether the Briggs committee would have reported as it did if it had reported after Kilbrandon or especially if it had had to report after the passing of the Scotland Act.
Will the Minister state how he thinks that the Bill will fit into the new situation 79 that will arise when the Scottish Assembly takes over the running of the Scottish Health Service? An indication of this would be of assistance to nurses, midwives and health visitors in Scotland as they consider the effect of the Bill upon their professions.
§ Dr. M. S. Miller
Does the hon. Gentleman agree that the Health Service in Scotland is run very much better than the Service in England and Wales?
§ Mr. Thompson
I certainly agree with that. The hon. Gentleman and I have often been in complete agreement about the Health Service in Scotland vis-à-vis the Service in England. We share the same ideals about the commitment of the Service to all the people of Scotland. We have both paid tribute to it and do so again today. I am happy that the hon. Gentleman made that intervention.
It seems odd that we are centralising, in London I assume, functions which have previously been exercised in Scotland. Can this make sense when we are about to have devolution in related areas? I welcome the provision in clause 3—and the Secretary of State's reiteration of it—for the standing committees on, among other aspects, district nursing and mental nursing. I am sure that this provision will give satisfaction to the nurses in these areas who have made representations on the subect to hon. Members.
Since the Central Council is to be the kingpin of the structure, why should it not be at least partially directly elected rather than partially appointed and partially indirectly elected through the directly elected national boards? The General Teaching Council for Scotland is elected by the teaching profession. Why should nurses, midwives and health visitors not be treated in the same way? After all, it is likely that the Central Council will have the real power and will make the important decisions.
I join other hon. Members in pressing the Minister of State about the difference in treatment of midwives and health visitors. There are to be midwifery committees as standing committees of each national board, but there is to be only one joint committee of the health visitors' Central Council and national boards. 80 Will not the health visitors feel aggrieved about this difference in treatment? They may be in a minority compared with the other professions, but they deserve our respect and assistance.
Turning to the English Central Midwives Board's representations to hon. Members, may I ask the Minister to deal with the EEC connections? Can he tell us, for instance, whether there are moves afoot for what I suppose I must call in the usual jargon Euro-nurses, Euro-midwives and Euro-health visitors? If so, the Minister will need to assure us that the provisions of the Bill will fit in with subsequent EEC legislation. I hasten to add that I am asking for this not because I want any more Euro nonsense—I do not—but because we must not have a series of unsettling changes due to the Bill not providing a smooth change to European legislation. The English midwives have represented to us that the treatment of midwives in the Bill will put us in this country out of step with the mainstream of European tradition.
§ Mr. Litterick
I may be able to throw some light on the hon. Gentleman's darkness. In some aspects of nursing, the formal standards required of European practitioners are very much higher than in Great Britain, and if there were to be any harmonisation it amounts to revolutionising one or two of the nursing vocations we are talking about.
§ Mr. Thompson
I thank the hon. Gentleman for that information, and I hope that I shall have the chance to hear him expand upon it, because it is extremely interesting.
I am much puzzled about clause 17. It is perhaps because I am not a lawyer that I do not quite grasp why it should state:Practising midwives shall be exempt from serving on any jury in Scotland.Can we have an explanation for that provision?
I am also puzzled by clause 10(4), which refers to the registration of people trained outside the United Kingdom. For those trained both outside the United Kingdom and outside the EEC there is a provision that it shall be an additional condition of a person being registered thathe has the necessary knowledge of English.".81 The subsection goes on:but this does not apply in the case of a national of any member State of the European Communities, whose professional qualifications are designated as having Community equivalence.Is the termdesignated as having Community equivalencea guarantee that the people who become registered here with Community qualifications will have at least a reasonable command of English, Welsh or Gaelic?
§ Mr. Powell
I congratulate the hon. Gentleman, if I may say so, on observing that a circularity is embedded in subsection (4) and that it should really say that it does not apply in the case of a national of any other member State, that is to say, in a State other than this State of the EEC. Otherwise, perhaps a large number of persons to whom in similar circumstances the General Medical Council has decided a language test shall be applied will escape.
§ Mr. Thompson
I am grateful for that piece of information.
I will conclude now, because I fear that the absence of the digital clocks at present may have led me to get muddled in my Roman numerals when I look at the other clocks. I will simply say that at this stage of the Bill I have advised my right hon. and hon. Friends that we should not seek to divide the House on it so that discussion with the professions can go ahead between now and Committee stage and also during the Committee stage. But then we will want to take a long, hard look at the Bill on Third Reading.
§ 5.55 p.m.
§ Ms. Maureen Colquhoun (Northampton, North)
I have very severe reservations about the Bill, about perhaps creating another body, however good it may be thought to be in future, and dissolving the existing statutory training bodies with all the expertise, knowledge and know-how that they have built up over the years. I understand that there is a stark and dismal difference between what the Bill proposes and what has existed before, and the House ought to be convinced that what is being proposed specifically for health visitors and midwives is a workable and accountable alternative to what they have now. We must ask certain questions, 82 and I hope that they will be answered in the reply by the Government.
For example, will the new United Kingdom Central Council for Nursing, Midwifery and Health Visiting really constitute a balanced redistribution of power for those working in the professions and those who are their patients? Will the existing Central Midwives Board and the Council for the Education and Training of Health Visitors lose their status as independent practitioners in their own right?
The Bill is not a mere detail of administration, as attempts have been made to present it. It is seen by midwives and health visitors as destructive of what has gone before, and this House has a responsibility to put that situation right. Midwives say that it is an attempt by the Government to move outwards in a wrong way, concentrating power in a larger structure which will be costlier and counterproductive and which seeks—this is very important—to classify them as nurses, thus not only losing them their status but containing far-reaching implications for the future independent development of midwifery, and losing them harmonisation of qualifications within the EEC.
Even more important, it is claimed by radical midwives that the Bill contains interference for women at home who may want to exercise their right to home delivery of their babies. These are very serious reservations, and I hope that my right hon. Friend will say something about the fusion of nursing with midwifery and whether it is intended to standardise the professional identity of the midwife.
Does the Bill recognise the present statutory differences between the clinical responsibilities of the midwives and their greater degree of independence in the practice of their work? For example, why is it that the Community directives make it clear that throughout the Community midwifery is recognised as a separate profession under separate control from the nursing profession, yet the Bill, far from bringing us into line with Community practice, merely emphasises the main differences?
Again, the Council for the Education and Training of Health Visitors says that 83 the Bill as it stands leaves the health visitors in a totally vulnerable position as a minority group who offer a specialised form of preparation, with interest in preventive rather than curative medicine. The council has put foward both to me and to other hon. Members its genuine concerns about the Bill.
It is time that we in Parliament asked how it is that the Department and the draftsmen have got the Bill to the Floor of the House on Second Reading without the total support of those in the professions who will have to make it work and of those who are the consumers of their work. Instead of patting itself on the back about the extent of consultation that it is said to have had over a period of years, the Department should consider why the outcome is looking somewhat disastrous.
I had hoped that the disastrous restructuring of the National Health Service would at least have been used to strike caution in any proposals for any restructuring within the Health Service itself. It should at least have been used to moderate bureaucratic proposals and strengthen, not destroy, minority interests. At its simplest, it is weakening minority interests, and at its most wicked it is destroying them.
No lessons have been learnt. It is almost as if Governments can learn nothing from past follies. Many hon. Members have accepted that institutional and technological groupings have become out of control and that old-fashioned government, using traditional formulae—the belief that strength and effectiveness and cost control are a direct result of combining power and resources, making things bigger—wilfully travels along the road to a stage at which the British people no longer feel in control of their own lives. I hope that the Standing Committee will balance the appallingly retrogressive old-fashioned legislation that we constantly churn out.
The Bill does not have the consent of the midwives and health visitors, the consent that it needs if it is to be effective and workable. It must be changed to secure that consent. The criteria that have been applied to the Bill to date, the tradition that Government should clarify society's problems before decisions are taken, have been shown today to be 84 ineffective and bankrupt. The long-drawn-out intellectual preliminaries in the Department before the decision was made to produce the Bill have failed Parliament yet again.
There is an idea that politicians, civil servants, economists, academics, lawyers and other powerful people, observing the midwives and health visitors from their Olympian heights, can dispassionately calculate the pros and cons of all the possibilities, sometimes with the help of elaborate techniques, such as cost benefit analysis and technological assessment. The idea that one can then reach objective answers, that one can provide solutions that will be gratefully accepted as correct, is totally futile.
Once again, a great deal of time and money have been spent on holding investigations and reaching decisions that are contrary to the recommendations of those who work in the professions.
§ Mr. Litterick
Is my hon. Friend aware that no official studies have been made of the comparative costs of hospital confinements and domiciliary confinements? Those unofficial investigations that have been done clearly indicate that domiciliary confinements are much cheaper.
§ Ms. Colquhoun
I thank my hon. Friend for that intervention. I was aware that domiciliary confinements were much cheaper.
§ Ms. Colquhoun
Much better, but that would not concern a high-powered technological inquiry by the Department. That point would be too simplistic, too logical and too real.
Is it not time for more weight to be given to people's feelings about what is right and what is wrong for their groups, about what they stand for and what they will stand for, about what should be done and how it should be done? All those matters should carry more weight than the disembodied analysis that has produced the Bill.
§ Ms. Colquhoun
I thank my right hon. Friend for telling me about the Royal College of Midwives. But I talked earlier about the radical midwives, and I put great weight on the deliberations of the younger people in the profession, who have creative ideas to make it more workable.
The role of the midwife and the health visitor has always been of great importance to women. Everyone knows that midwifery and nursing are two entirely different professions, because midwives work essentially with healthy women, and nurses care for the sick.
Similarly, everyone knows that health visitors deal largely with preventive medicine. In this connection, I refer my right hon. Friend to the evidence to, and recommendations of, the Expenditure Committee in its report on preventive medicine produced in Session 1976–77.
The Government's proposals will need amendment and creative political thought before the Bill returns to the House on Third Reading. I hope that my right hon. Friend the Secretary of State will respond to that need. We shall have to vote against Third Reading should the Bill emerge from Committee unamended in some of the areas about which we have spoken today.
I should like also to make my usual point about the language of the Bill. All the way through, "he" means "she". I wish to put this point to my right hon. Friend and to parliamentary draftsmen. In an age of the Equal Opportunities Commission and equal opportunities for women, it is grossly offensive that in every Bill women are totally ignored because, according to the generalisations of the legal people who do the drafting, "he" means "she".
§ Ms. Colquhoun
I shall not give way. I am nearly on my last sentence.
I do not know what the nursing, midwifery and health visiting professions would do without the "shes". It is about time parliamentary legal language was changed.
§ 6.8 p.m.
§ Dr. M. S. Miller (East Kilbride)
I want to give an ungrudging but neverthe- 86 less somewhat cautious welcome to the Bill, which, after six years of deliberation and discussion, has managed to give birth to a few of the recommendations of the Briggs report.
The setting up of a central organisation is overdue, as is the proposal to establish and maintain a centralregister of qualified nurses, midwives and health visitors.I draw the attention of the House to the medical register. Any registered medical practitioner can write a prescription, and, as long as he adds his name, it will be honoured in any part of the country by a chemist, who merely looks up the medical register and finds that a bona fide doctor has written the prescription. I do not see why a similar register cannot be established for the nursing profession.
It is not surprising that the nursing associations are happy about the Bill. They are very much in the majority and perhaps see themselves in a dominant role. But, as several speakers have said. midwives and health visitors have genuine fears. I appreciate fully that no one likes to lose a little empire which she or he has built up—and I say that without meaning to be offensive. However, there are genuine fears on the part of midwives and health visitors. I cannot say that they disapprove totally of the Bill, but there are aspects of it which worry me.
May I add whatever weight I may have as a former general practitioner to what my hon. Friend the Member for Northampton, North (Ms Colquhoun) said about midwives? Midwives are in an entirely different category from the general run of nurses, and they are extremely important from the point of view of expectant mothers who wish to have their babies at home.
Three of my four children were born at home. It was an extremely valuable experience to all concerned. For a number of years, there has been tremendous pressure to have babies born in hospital. But I suggest that that was at a time when housing standards were so low that it was dangerous for children to be born at home. That is no longer so. I do not suggest that every baby should be born at home. I say merely that those mothers who want their children to be born at home and whose general practitioners are 87 satisfied that there are no complications should be permitted to have their children at home if housing conditions are good. Certainly, there is no danger at home of the cross-infection which very often occurs in hospital and which takes a considerable toll of babies' lives in hospitals.
It is in this sphere that the midwife plays a part which no other nurse can play. My right hon. and hon. Friends should listen carefully to what midwives say in this connection and should make sure that the training and the autonomy which they have at the moment are retained.
I make a similar plea on behalf of health visitors. When I was in general practice, the three most valuable people were the midwife, to whom I have referred already, and the medical adjuncts of the health visitor and the district nurse. The health visitor's training and education comprises very much more than just nursing training. There is much more involved, including sociology and knowing the background of the patient. There is also the fact that very often the health visitor is more involved in prevention than in cure.
My hon. Friend the Member for Preston, South (Mr. Thorne) dwelt at some length on the differences between the nurse and the health visitor. He pointed out the very important role of the health visitor because of her knowledge of the background of the patient. However, this is where the Bill is right. While we are stressing differences, as my right hon. Friend the Secretary of State said, we must also emphasise the important similarities that there are. I ask my hon. Friend the Member for Preston, South to compare, say, the general practitioner with the hospital pathologist. Their work is different, yet both have had to undergo the same basic training, both are on the medical register and both are subject to the discipline of the General Medical Council. However, no one can say that there is anything other than gross differences in what they do.
It has become a platitude to say that the National Health Service is about the patient. Nevertheless, it is true. In a 88 very thoughtful speech, the hon. Member for Walsall, North (Mr. Hodgson)—he makes excellent contributions to debates on the Health Service—regretted the pressure on homoeopathy and feared that the practice could disappear. I hope not. Unfortunately, homoeopathy has become a victim of the technological advance of medicine. Perhaps it even belongs to another century. But that does not mean that it does not still have a part to play. I think that it does, and I hope that it will not be discouraged.
I add my voice to those hon. Members on both sides of the House who have said that, although they welcome the Bill, changes must be made in Committee. At this stage, it is not for us to spell out what they should be. However, my hon. Friend the Member for Brent, South (Mr. Pavitt) pointed to one area in which we would be looking for change in respect of health visitors. I hope that my right hon. and hon. Friends will take note of what has been said in this respect. Certainly the promise made by my right hon. Friend that the Bill was a framework upon which other matters would be constructed will be for the benefit of the patient. There is no doubt that making a start with nursing education falls into this category.
§ 6.17 p.m.
§ Mr. Robert Hughes (Aberdeen, North)
I want first to place on the record my appreciation of the work which nurses give to their patients and to people who are not strictly speaking patients in the sense that nurses are involved in preventive medicine. It seems sometimes as though we pay lip service to the importance of nurses in the Health Service. Yet we all know that the NHS would not operate without the service of dedicated nurses. I am sure that this experience is shared by all other hon. Members.
From time to time, we get complaints about the behaviour of doctors, both general practitioners and surgeons. Very often we get complaints about the behaviour of administrators in the Health Service. But in my experience it is very rare to hear complaints from patients about nurses. In eight years, I have had only one such complaint and that was not so much about nursing care as about the 89 indiscretion of a nurse who went home and spoke to a friend about the condition of a patient, and it leaked out. It was unforgivable, and I do not condone it. However, that is the only complaint which I have received in eight and a half years, whereas I should not like to say how many complaints I have received about other branches of the NHS.
It is worth recalling, if only so that hon. Members may recognise how slowly legislation passes through this House, how slowly events move in the government of our country. The Briggs committee was appointed in March 1970 by the late Richard Crossman. It reported comparatively quickly. After all, two years for the job which the Briggs committee was set up to do is really a short time. But it is now eight and a half years later, and we have a Bill which deals with only a very small number of its recommendations. In that period, the Health Service has changed. We have had reorganisation of the Health Service in Scotland and in England and Wales. I am not sure about Northern Ireland, and I am thankful that the right hon. Member for Down, South (Mr. Powell) is no longer in the Chamber.
We have had reorganisations which, far from carrying out the ideas behind them, seem to have made matters worse. The idea of reorganisation of the Health Service was to marry the hospital service and the local authority health services, including home nursing and the preventive care work done by health visitors. It was hoped that by this integration of the Service we would see an integration of work of different branches of the Service in the clinical sense and in the patient care sense. There have been many complaints about that.
I think it is worth recalling that since Briggs was first published in November 1972, there has been a great deal of consultation. In fact, I sometimes think we never actually do anything about the problems that exist because we spend so much time consulting about them that by the time we have gathered all the threads together the whole condition which we set out to treat has changed. We then set out to set up a body and no sooner has it been set up than we say that things are different and we will have to look at the matter again.
90 I am in favour of consultation, but I sometimes think we have to accept that there has to be a point at which consultation has to stop. If one cannot get complete unanimity of view, an absolute consensus, one has to proceed or otherwise abandon the whole exercise. I understand that people have particular views which they feel strongly about, but at some time we have to call a halt. Whether it is time now to call a halt on Briggs or whether we should wait another five weeks or couple of years, I do not know.
I get the impression—I am only going by memory—that although there was almost universal approval for the propositions put forward in Briggs, some of the people who were wholeheartedly in favour of the report are now beginning to change their minds. I am not saying they are right to change their minds, but it looks as though people are having second thoughts. The disappointing thing about this Bill is that it does not really implement Briggs in any real sense at all, apart from setting up the statutory bodies.
As Briggs himself reported, the eventual cost of bringing all his propositions into being could be very great and he said it would take a considerable time before they could be carried out. They could not be carried out at one fell swoop because of the difficulties over finance. If anything, since the publication of the Briggs report, finance has become even more difficult to come by and the Health Service is suffering even more because of shortage of finance. Yet what we are now being told about Briggs is that all the recommendations about education will have to wait until the new statutory bodies have been set up. I think that the Secretary of State said that it will be the first duty of the new bodies to re-examine the propositions in the Briggs report in the light of current events.
How long will we have to wait before the other recommendations of the Briggs report come into effect? I think it is widely recognised, although perhaps not proper to say so, that there is a crisis within the Health Service because of a general nursing shortage. Within the global shortage of nurses, there are particular shortages in the disciplines—for example, in psychiatric nursing. Certainly, there is a shortage of nurses in the geriatric service.
91 Many of the area health boards, whether those in Scotland or their equivalents in England, are looking at the provision which has to be made for the geriatric service and looking at ways in which to reorganise the hospital provisions, but often what prevents them is not the availability of beds but he availability of nurses to staff particular wards.
This leads us to examine the proposition about the sort of training we should provide for nurses. There is the argument in Briggs that nurses ought to begin with a general training of 18 months and then move on to different modules. I wonder whether this idea of having general training is right or whether we should be moving over to a greater specialisation. This is the argument that has been going on for a long period, and not only in the National Health Service.
Those who recall the passing of the Social Work (Scotland) Act in the early days, and the removal from social work of the specialist probation officer, the specialist children's officer and the subsun[...]ng of all these into general social work training, found that, once that was done, the work of the specialists was just not being done. We found that people who had no basic training in these specialties, were unable to cope with this narrow field of work, which was very important.
Therefore, we have to look at how we train nurses. Should we train them as specialists or should we train them generally? How far are we going along the road suggested in Briggs and the evidence to Briggs that much more of the training of nurses in the NHS, on the hospital side, should be done off the wards and not on the wards?
It has been a scandal for generations, probably as long as there have been hospitals, that pupil nurses have been exploited as cheap labour to man the wards. One of the recommendations in Briggs was that no pupil nurse should be left on the ward at night without qualified staff. Yet we know that within the hospitals this often happens. If we move to much more off-the-ward training, where shall we find the manpower to carry out the work that the pupil nurses 92 are doing? We should consider the costs of this.
I hope that my friends in the nursing service will not be too angry when I say this, but I wonder how far we should be looking—I know that this is in slight contradiction to what I said about training—at the way in which the trend, confirmed by Briggs and the evidence of other bodies, has been towards exclusive groups. A midwife has her own exclusive group and does not want to be anything else, and does not want influence from outside. As a corollary, she may also he saying that she does not want influence on others.
What about the health visitors? Having been chairman of the health and welfare committee in Aberdeen, where the medical officer of health is Dr. Iain MacQueen, who did more than anyone in the United Kingdom to pioneer the system of health visitors, I would not dare say anything against them. I have the greatest respect for them.
I am not attacking those two professions, however. I am simply pointing out that a health visitor becomes exclusivs and has no thought of moving out of that area to a different form of nursing.
What strikes me about the problems of the Health Service is that particular areas of work require demanding nursing, with heavy emotional strain, yet because of the narrowing of the profession, once one becomes a geriatric nurse, for instance, one cannot get out of it again. Once one becomes a psychiatric nurse, the same applies. Perhaps we should look much more closely, in the management of nursing services, at ways of treating people more flexibly.
I sometimes think that people should spend more than—to choose an arbitrary figure—five years as a psychiatric nurse. This applies to the medical profession as well. If a nurse spends five years in a psychiatric hospital, where there can be tremendous emotional stress, strain and exhaustion, should we not be considering ways in which the profession can turn around more, so that people can spend so much time in medical wards, so much in geriatric wards, so much in psychiatric hospitals and so on? This is not done enough.
93 In considering the views of groups which are naturally concerned about their status and what they can put into the Health Service generally, I hope that we shall not forget that the real point of having nurses, of whatever training, is the patient. We are right to remind the Secretary of State and ourselves that the NHS is about patients, but we should also remind the nursing profession, and especially the medical profession, that the NHS is about the patient and not about the professions.
I turn to the question of recruitment. We must make nursing an attractive profession. Of course, we expect people who enter nursing to be dedicated, to care for the patients and to have a dedication to the job which is greater than the dedication of someone who uses a brush to sweep a factory floor. But we must not pay them less because of that. But that is what happens. Nurses do not get paid enough because the attitude is taken that they are really interested in their job and therefore the money is not important. We must emphasise to recruits that nursing can be materially beneficial. That means establishing proper pay scales.
Perhaps I was a little harsh earlier when I said that all attempts at encouraging nurses back into the profession had been a total failure. The truth is that those attempts were a dismal failure. The efforts did not fail totally, but the amount of effort put into encouraging married women to return, for example, was not of proper value.
Women often offer to return to nursing for four hours a week. Unfortunately, that is a difficult period of time to fit in. It is particularly difficult because part-time nurses are required mainly at weekends. But that is not a time that married women wish to work, because they have their families at home. We must look at that situation carefully. I am glad that the Secretary of State is going to examine how we can best encourage people to return to nursing.
I turn to the question of the membership of the boards. It is important that a profession should be able to oversee the discipline and character of its own profession. There is a strong need for lay participation. I wonder how many of those who are appointed to the boards will be lay people who are not directly concerned with the profession.
94 The Bill states that the majority of members of the boards must be professional people. The Bill states:The Secretary of State's direct appointments to a Board…shall be made from among persons who either are nurses, midwives or health visitors, or have such qualifications and experience in education, medicine or other fields as, in the Secretary of State's opinion, will be of value to the Board in the performance of its functions.I am a lay member of the General Medical Council. I have no connection with medicine or education. I represent "the public". There are only a few lay members on the General Medical Council and we are overworked. A lay representative must be a member of almost every committee. The situation will be much worse when we have the new General Medical Council. On each of the committees there are about seven doctors and one lay member.
It is strange that after a disciplinary body is established complaints tend to be made. I do not believe that a ratio of seven professionals to one layman is correct. I have no complaints about my treatment by the doctors. They listen to my point of view. But I hope that there will be a greater proportion of lay members on the boards that are to be established by the Bill. It is important to stress that the public have the right of access because the Service is provided for them. I hope that the public will be represented adequately and that not only the academics will sit on the boards.
The hon. Member for Galloway (Mr. Thompson) mentioned the question of a knowledge of English. How will the English language qualifications be determined? Are we to have a parallel system under which people must undergo an examination in English—the "TRAB test" as it is known to doctors? That part of the Bill should be spelt out in greater detail. We also need clarification about that part of the Bill dealing with equivalents in qualifications.
I am not satisfied that nurses' morale is as bad as it is made out to be. Of course, people are upset from time to time, but there is no evidence that morale generally has collapsed. It is wrong to say that nurses have lost their morale. However, it certainly needs boosting.
If we are to restore nurses' morale, we must act with resolution. The passage of 95 the Bill will not be enough. What we really need is a massive injection of funds into the Health Service. We must face that. Too often hon. Members and others say that we must have more money for various services without facing up to the central dilemma of our time.
Every person who visits me at my advice centre and everyone who writes to me about the various social services says that more money is needed for a particular part of the Service. Few of them are prepared to pay the price. It is not right to say that there must be an injection of funds without also saying that taxes might have to be increased to pay for them. We delude the public if we say that there can be improvements in our health and social services without having to pay the price.
I give the bill my qualified approval. I hope that the debate on the nursing service will not end here. I hope that it will not end with the setting up of these bodies. They have an important part to play but the public has an even greater part to play.
§ 6.38 p.m.
§ Mr. Nicholas Fairbairn (Kinross and West Perthshire)
I rise to record my profoundest suspicions of the Bill. Let us consider all the organisations which have been set up in the country by the long and expensive process of establishing a Royal Commission with the statutory philosopher kings sitting on it to distil the eternal wisdom and the eternal cure. Eventually a Bill is produced in Parliament which sets up some more Government-inspired organisations. Inevitably, as in this case, with the large amount of departmental control and departmental appointments, the burden and the weight of those organisations is the burden from which the people truly suffer.
If the hon. Member for Aberdeen, North (Mr. Hughes) wants nurses to nurse patients and doctors to tend patients rather than doctors and nurses in administrative posts, he shoud oppose this type of legislation. We have been through this process with the reorganisation of the Health Service. [An HON. MEMBER: "Yes."] An hon. Member says "Yes". I hope that he will oppose the same dismal repetition and echo of that process that this Bill proposes.
§ Mr. Fairbairn
There is nothing wrong with a sinner brought to repentance, but the hon. Member for Hemel Hempstead (Mr. Corbett) is saying that if we have sinned he is about to sin in our shadow. Let him not sin at all.
§ Mr. Litterick
We know that the hon. and learned Member knows that he is not going to vote against the Bill tonight, so please will he stop humbugging the House?
§ Mr. Fairbairn
I thought that I was indulging in honesty, not in humbuggery of any kind.
The Bill begins with the disastrous process of centralisation. We shall abolish some small and effective organisation and set up a plethora of new ones. For a start, we shall set up a Central Council which will be drawn from the four national boards which will be the same size, or, in the case of Northern Ireland, almost the same size, as the Central Council. I can already envisage the warrants that will be issued to the members of the national boards to come to the Central Council. I can see the amount of paper and waste, secretaries and offices that will be required to house this spurious enlargement of departmental authority.
It is departmental authority. The Secretary of State may have the responsibility for these matters, but it is essentially the suggestions of the Department and the enlargement of the Department behind him that will provide the inspiration for the advice that he is given.
Clause 1 begins by setting up the grand Central Council. With that council comes the right of the Secretary of State to appoint a large number of persons whom he will choose. In other words, he gives a job to a friend or to the friend of someone in the Department. This will again encourage the British disease, the State disease, by which the Secretary of State or his advisers have the right to give quango jobs to a large number of people who no doubt will give up nursing, midwifery or health visiting, just as so many doctors have given up practising, in order to secure administrative advancement.
§ Mr. Moyle
I should like to help the hon. and learned Gentleman with his speech. The body that is being set up can in no way be regarded as a quango. If the hon. and learned Gentleman is looking for an analogous body, perhaps he should turn his mind to something like the Bar Council. We are talking about the government of an independent profession. I pass the hon. and learned Gentleman that tip in the hope that it will help him with his speech.
§ Mr. Fairbairn
I regret that it does not help me. I am prompted to ask whether the method by which the Minister comes to his conclusions on this matter is as wide of the mark as his suggestion that this body is like the Bar Council. I should like to know whether the Minister of State knows how the Bar Council is constituted. I do not know why he should talk to me about it. It is relevant only in England. The Minister of State has not the slightest idea how the legal profession is regulated in Scotland. I am forbidden to practise in this country. Given all these factors, I find the Minister's intervention most unhelpful. The Bar Council membership, thank God, is not yet the subject of appointment by the Home Secretary in England. The members of the Faculty of Advocates, thank God, are not appointed by the Secretary of State for Scotland. It is that which I find initially objectionable.
If the nursing, midwives' and health visitors' professions were to run themselves, they would be much more efficient than if the Secretary of State appointed to them persons who in medicine, education or other spheres would be of value to the council in the performance of its functions.
I can envisage the list of the people who will be appointed. I can see all the retired local politicians. I can see the hon. Member for Aberdeen, North being a frightfully good person to appoint. I can see the old gravy train. All the people who have been on the new town corporations in Scotland, the people who have been lay observers to the Law Society, will all get on it some day. This process enlarges the circuit for the appointment of the national parasites.
I therefore wish to record a warning. It is too easy, as so often happens in this 98 country, for people to complain of the weight of bureaucracy and taxation, and of the proportion of non-medical people in the Health Service who administer fully qualified medical staff, but to do nothing about it. That proportion is vast and shameful.
This is the sort of legislation which creates administration and power building as a job in itself. I can see the Central Council having all sorts of powers. I have not the slightest doubt that, before we know where we are, the Secretary of State will be appointing to the various sub-committees, as he is entitled under clauses 6 and 7. He can provide for the constitution of training committees. I am prepared to bet that no sooner will the Central Council be set up, with the Scottish, English, Welsh and Irish boards also created, than they will be telling the Secretary of State that there should be training committees. Alternatively, the Department will be prodding them to set up training committees. They will say "Dr. Miller used to be a medical practitioner. We shall make him the chairman".
§ Mr. Fairbairn
These animals breed remorselessly and in a way that no other animal is allowed to breed. They breed under a guarantee that death will never interfere with their existence once they have been created.
The power given to the Secretary of State and to the committees to make a constant enlargement of the numbers of persons involved is most worrying. It is astonishing that the Labour Government appear to be committed to the concept of devolution as a great method of taking the decisions away from the centre and putting them out to the periphery yet in a large number of Bills, such as this, they operate the process in reverse.
There will be 45 people on the Central Council, 40 on the Scottish, Welsh and English boards, and 35 on the Irish council. In mitigation, let us look at the explanatory and financial memorandum, with its expression of pious unlikelihood: We are told that there will besome additional cost during the handover period…before the new bodies take on the functions of the old99 but at the beginning of that paragraph we read thatit is expected that the new bodies will operate at the same administrative cost as the existing training bodies (at present in the order of £4 million a year).If there is one fallacious pious hope here, that is it. I hope that the Minister of State and the Secretary of State will make a note of this on their pads so that they get the answer right when I ask the pertinent question in a year's time. Well—they will not be Ministers in a year's time, so I say only this. I am certain that what is proposed will vastly enlarge the cost of administering these things.
I believe that there will be a great sacrifice of the individual interests of the midwives and the health visitors in being lumped together with the nurses, and I am certain that once again we shall aggravate the shortage of money for the treating of patients in the Health Service by enlarging the size of the animal which, by administration, eats so much of the funds and diminishes what is or should be available for the purpose of the whole Service —that is, the care and cure of the sick.
§ 6.51 p.m.
§ Mr. Robin Corbett (Hemel Hempstead)
I gladly join in the tributes already paid to the nurses, midwives and health visitors. I do so for two reasons—first, because I am a user or consumer of their services and, second, because in my constituency, as my right hon. Friend the Minister of State is well aware, we ask especially the nurses to work in the most appalling and inadequate physical conditions.
I was able to intervene when my right hon. Friend the Secretary of State opened the debate, and I intervened, as I said at the time, more in sorrow than in anger, to remind him that in the first 10 minutes of his speech he had not once used the word "patient". This point cannot be stressed too often in our debate today. What we are talking about, or should be talking about, is patients and patient care. That is what anyone and everyone within the National Health Service—I am sure that they understand it as they do their work—is, and should properly be, concerned about.
100 What is before us may appear to be an abstruse exercise in, according to the Government, enabling people in these professions to be better able to administer their own affairs, but the real people outside, waiting for admission into hospital, waiting for operations or relying on a nurse to bring round medicine, a meal or bedpans, are at the sharp end of the Service, and we ought constantly to remind ourselves of that.
I know that my right hon. Friend is especially sensitive to the fears which have been expressed—rightly, I believe—that unless we proceed with care we may be in danger of creating yet another piece of bureaucracy within the National Health Service. I know that the hon. Member for Reading, South (Dr. Vaughan)—I have heard him say it—has had second thoughts about the wisdom of some parts of the National Health Service reorganisation. I say that in no critical way. I am glad of it, though, if I may say so, it might have been better if he and his colleagues had listened to criticisms which were made during the passage of the reorganisation Bill.
Be that as it may. It is universally recognised—this is why the Royal Commission was established—that the reorganisation took far too many people away from the actual business of patient care overloaded the National Health Service, already short of funds, with bureaucrats and administrators, so that almost within a matter of months of the reorganisation coming into operation various Ministers had to appeal and issue what directives they could to those responsible for spending this kind of money in administration to cut back on it and make the exercise much more efficient.
I am not knocking bureaucracy and administration—it is important that it is carried out, but it is more important that it be done efficiently and effectively and that the first call on money in the National Health Service should not be for that purpose. Every penny spent in that direction—I am sure that the majority of those involved in the administration know this—does not go into patient care.
It would be wrong of me to seek to comment on the area health authorities and regional health authorities, save to say this to my right hon. Friend, if I 101 may. He will be aware that in my own area any claim which either the Hertfordshire area health authority or the North-West Thames regional health authority had to speak on behalf of people in that area or to command their respect went out of the window as a result of their behaviour over our urgent case for a new hospital.
I say that not principally to pursue a constituency point but because I believe that we have to learn some lessons from what we have done in the past. Perhaps the biggest single criticism of both these bodies—the area health authorities and the regional health authorities—arises from the way the jobs were handed out to them on the back of ministerial patronage. If we put people in that position, however public-spirited they may be, it is inevitable that they will feel they are not as directly accountable as those of us who stand for membership of this House or for membership of district and other councils in local government.
I am extremely sorry to see, right at the start of the Bill, that this whole operation —should it reach the statute book—will start with another exercise in patronage. Are the Government saying that these professions, with which my right hon. Friend has been locked in a joint committee for two years, still need their hands held? Are they so new in this business that it would somehow upset them if we said to them "From the first day you will elect the people you want to lead your professions under the arrangements which we are proposing in the Bill"?
I find that an appallingly bad way to proceed. We are not here considering new bodies coming into existence to deal with the problems of microprocessing or whatever it might be. We are talking about well-established professions with years and years of experience, professions to which everybody properly pays tribute, yet at the start of the exercise we say to them "Yes, that is as may be, but, regrettably, we cannot trust you yet directly and democratically to run and control your own affairs".
I see a risk here—it worries me greatly —that this can be a case of democracy delayed turnings out to be democracy denied. There is power proposed in the Bill that the members of the Central 102 Council shall be appointed for a period of not less than three years and not more than five years. Many hon. Members will probably take the view that in practice it will be the longer rather than the shorter period.
Another provision in the Bill lays down the duty that the Central Council shall have two years within which it can put proposals to Ministers for a system of democratic election to these bodies. I believe that the time scale is too long. I am perfectly prepared to listen to him if, in winding up, my right hon. Friend says that he and those concerned have enough on their plate in the establishment of these bodies without at the same time having to devise every detail of the democratic structure. But, if that be the case, I must say that I regard the pace indicated in the Bill for the achievement of the election of members of the Central Council as far too leisurely. I firmly believe that.
It is not as though we were talking of some icing on top of the cake. This issue can be—in my view, it is—central to the contribution which that body in particular is supposed to make under the provisions of the Bill, in giving advice and, indeed, taking decisions on matters affecting training, education and the rest across the professions.
I urge my right hon. Friend to think again between Second Reading and Committee and to consider whether he can see a better prospect for an earlier date by which the Central Council can be elected. I ask him also to say something about the envisaged role of trade union representatives in the drawing up, application and overseeing of any proposed changes in training in these various professions. There need be no conflict. There is a legitimate interest at hospital and local levels for the fullest participation by all those involved in the Health Service. Participation should not be confined to isloated little compartments and blocks.
Secondly, I direct my remarks to home confinement. My right hon. Friends may be clear about what is intended, but it is not universally understood outside the House. Bodies such as the National Childbirth Trust, for example, let alone some of the midwifery bodies, fear that what is proposed could lead to greater 103 difficulties for mothers and fathers who wish to have second and subsequent babies delivered at home. I hope that my right hon. Friend will be able to say that it is no direct intention of the Bill and, from his knowledge, no intention of what will flow from it to put extra bars in front of mothers and fathers who wish to have home confinements where it is safe to do so and where housing and other conditions make that acceptable.
My third topic is health visitors. I was disappointed when earlier my right hon. Friend gave the impression, when replying to an intervention, of defending the proposition in the Bill for dissimilar treatment for health visitors, mainly on the ground of numbers. I suspect that there is some misunderstanding. I am sure that my right hon. Friend needs no lectures on the subject that numbers, especially in this area, do not by themselves establish the correctness of a case.
We all know of the invaluable contribution that health visitors make within our communities. I doubt whether there is one hon. Member who would not put up his hand to vote for extra money to enable more health visitors to he provided, as much for the preventive aspect of their work before a child's birth as for the preventive aspect following the arrival of a child. I am sure that neither my right hon. Friend the Secretary of State nor my right hon. Friend the Minister of State would need that said to him.
However, bearing in mind what is proposed in the Bill, it will be difficult for health visitors to understand why, apart from the numbers argument, they should receive less recognition than their sisters in other branches of these interrelated and interdependent professions. I hope that consideration will be given to meeting the understandable fears of health visitors before we examine the Bill in Committee. I hope that these fears can be overcome.
The Bill has been six years in gestation and it has now arrived with all-party support. However, it seems to be having a difficult birth. I hope that my right hon. Friends will understand that the view is taken on the Labour Benches, and generally shared on the Opposition Benches, that, critical as we may be of some of the details and questioning 104 as we may be about its overall intentions, we recognise that there is at least a case for its receiving detailed examination to try to ensure that it takes its place on the statute book.
§ 7.4 p.m.
§ Mr. Tom Litterick (Birmingham, Selly Oak)
I am not a nurse, midwife, health visitor or doctor, and I approach the Bill with a degree of caution, perhaps even humility. I recognise that all the activities with which we are concerned are to a greater or lesser degree highly professionalised. Each branch of the profession has a highly developed sense of its professional identity and preserves, especially the doctors.
I am encouraged to support the Bill because I am advised that the principal bodies concerned—namely, nurses engaged in general nursing, the midwives and the health visitors—support the principal purposes of the Bill. Therefore, it seems that the House should at least give the Bill qualified approval. I share the view that we shall want to have a more detailed examination of the Bill in Committee and make certain propositions for its amendment.
I have a lay interest in the extent to which the Bill's proposals will affect midwifery. It is my impression that midwives have a relationship with the medical profession that is different from that of nurses. When nurses carry out the functions of midwives they are subordinate to doctors, whereas when midwives carry out the functions of midwives they are subordinate to no one. They are free agents and they are formally recognised as such.
It seems that the Bill proposes that the profession of midwifery will, as a whole, be made subordinate to a national governing council that will not be dominated by midwives; it will be dominated by nurses. As I have said, when nurses operate in a professional capacity as midwives they are subordinate to doctors. The midwives may now suffer from the disability that their governing council is dominated by doctors. The result of the proposals in the Bill is that they will exchange one disability, namely, being dominated as a profession by doctors, for another, that of being dominated by general nurses.
105 I have used the word "disability" because it seems that midwifery is special. Midwives do not deal with the sick. They deal with healthy people, unlike all the other branches of medicine and nursing. There are special skills associated with the profession of midwifery. I am impressed, too, that the standards of training demanded by the general nursing profession are not as high in Britain as the standards of training currently demanded by midwives.
As the nurses will dominate the national council—their numbers will be hugely predominant, and presumably the representation will reflect that fact—the nurses will be reluctant to raise the training demands of a particular specialty. They will argue that that can be done only at the expense of other nursing specialties. In the general training of nurses it will be argued that the existing higher standards of training for midwives should be reduced to conform to the existing lower standards demanded by the general nursing profession. That would seem to lead to a dilution of the profession of midwifery.
I am sure that objections to my argument will come from those who are aware that most midwifery practice nowadays is carried out in hospitals. The team that surrounds the putative mother is made up of doctors and general nurses that one normally finds in a hospital. The hierarchical arrangement of authority that we find in a hospital is one in which the doctor is boss and the nurse willingly—indeed, she never thinks otherwise—submits herself to the authority of the doctor. With respect to the doctors who are present and any midwives who might be listening, they are turned into not midwives but maternity nurses.
The function of a maternity nurse in a well-equipped modern hospital is that of a machine minder and not that of a midwife. It is to be a machine minder and a dispenser of drugs of various sorts, the whole effect of which—I know this will sound unfair—is to remove from the experience of parturition all the natural sensations that I, as a prejudiced male, feel ought to be the prerogative of the woman who is having the baby. In that context she is surrounded by a group of well-meaning, highly trained people but people who have a powerful vested 106 interest in persuading the patient that she must have the analgesics, that she must have this complicated instrumentation, and that she must be monitored like a space capsule in order to have her baby. That seems to me to be rather an odd kind of balance of forces.
§ Dr. M. S. Miller
I think that my hon. Friend has his terminology wrong. There are, of course, maternity nurses in hospitals. When a nurse becomes a midwife she is acting on her own at the time, but let me assure my hon. Friend that she is still under the directive of the doctor, although not dominated by him. She can carry out everything on her own, but she is still under his directive and direction, and he must be available to be called out if anything goes wrong. I honestly think that my hon. Friend is putting up Aunt Sallies in order to put them down. I cannot envisage the situation developing that he has in mind. However, the point of view that he is putting forward is very interesting.
§ Mr. Litterick
I am glad that my hon. Friend is at least interested. I am quite impressed that I am able to hold his interest, remembering that he is a doctor.
I think it is inevitable, notwithstanding the remarks of my hon. Friend, that the dominance of the general nursing profession on the main council that is to be created will inevitably mean the universalising of the standards of the general nursing profession in relation to the other specialist groups. I am thinking particularly of midwives in this respect. I am, at least in lay terms, aware of the fact that the standards of midwifery in Britain are apparently relatively low. I say that because I am aware only in general terms of the incidence of perinatal mortality in this country compared with that in other countries. It is much higher—
§ Mr. Litterick
It may be, but it does not seem to compare very well with the figures in France, Holland and other West European countries.
§ Mr. Litterick
We can all check our figures and argue it out in Committee. This seems to me to be not unconnected 107 with the fact that hospital confinements are less frequent in those other countries than they are in this country. I think, in other words, that we would be wrong, as a legislative body, to persuade ourselves that we can in any way legislate for the educational training requirements for any profession or vocation. We have to bear this in mind before anything else. I was trying to suggest in the earlier part of my speech that we might accidentally be setting up a structure which will militate against the improvement of standards. I was using the practice of midwifery as the best example, because I know absolutely nothing about all the other specialties in the nursing field.
If we are setting out to establish a set of institutions that will be self-governing and will themselves lay down the training requirements for the various nursing professions, it seems to me that we are first of all kidding ourselves; secondly, we are being presumptuous; and, thirdly, we shall guarantee that the nation will have a lousy nursing service, because we are in no position to tell these people how they should be trained.
This leads me to the point made by my hon. Friend the Member for Hemel Hempstead (Mr. Corbett), with which I agree. I cannot understand why the Secretary of State should wish to appoint anyone to the governing bodies of these professions. We all know that from time to time Secretaries of State have some experience in this field, but generally they do not, and the majority of hon. Members have no experience of these things. I wonder, therefore, what it is that our Front Benchers think is lacking in the hundreds of thousands of people who follow these professions that disqualifies them from self-government. The Secretary of State shakes his head, but clause 4(4)(a) says that it is the Secretary of State who shall appoint members of the boards, and so on. To be sure, after the stated day the Secretary of State will not appoint them all, but he will still be insisting on appointing certain members of the councils.
§ Mr. Pavitt
Does my hon. Friend realise that neither the Department of Health and Social Security nor any of the other 108 Government Departments ever makes appointments without discussing the interests, as they call them? Is he aware that no Secretary of State in any Government has ever appointed anybody in connection with the medical profession without the British Medical Association having first said that it will accept that person? If the person is not acceptable to the BMA, that appointment is not made.
§ Mr. Litterick
I am sure that my hon. Friend is absolutely right, but in return perhaps I may ask him to consider this point. How does he think that the Institution of Mechanical Engineers would react if a Secretary of State decided to appoint five or six members of its governing body? As soon as one considers the question one understands how ridiculous and presumptuous it is. I do not believe that any politician would dream of trying to do such a thing. But it is interesting that not only this Secretary of State but his predecessors—he is merely following custom and practice—should want to appoint people to long-established professions of this kind. These are professions which have a high degree of awareness of their professional identity and of the kind of skills required of people such as themselves.
I should like to discuss this more fully in Committee. Why should we want to appoint people from the State? We know very well that there is a State involvement in the Health Service—indeed, the State created it—but mechanical engineers also work for the State. I am sure that they would not tolerate having on their governing body members appointed by a Secretary of State.
My hon. Friend may argue whether anyone from the same profession should be other than elected to office, but I think it is important that there should be a balanced representation, the majority being elected and a small number being appointed. But where people not of that profession are being appointed, such as educationists and lay members—as one of my hon. Friends argued earlier—it would be quite impossible, unless one instituted a system of popular election, to have educationists and lay people other than appointed, and this after very wide consultation.
§ Mr. Litterick
I take my right hon. Friend's point. I suppose that the effectiveness of that procedure will depend on the kind of network that the Secretary of State uses in obtaining his recommended people.
I repeat my mild disquiet—it is mild mainly because I know relatively little about these things—that the profession of midwifery may not be well served by these proposals, and that some amendments to them may be necessary. It seems to me, above all, that if the profession of midwifery is badly served by these recommendations, all of our women will be badly served by these recommendations.
§ 7.19 p.m.
§ Mr. Robert Boscawen (Wells)
This has been a very interesting and constructive debate. Despite being about a Bill which is really an enabling Bill to set up a single framework around which new standards and patterns of education for the nursing service will evolve, the debate has gone far wider and gone into more matters concerning this important and vital profession than are contained in the Bill.
I believe that is right, because we owe it to the nursing profession, to patients and to the public, on the rare occasions on which Bills to set up bodies to meet the needs of nurses, midwives and health visitors come before the House, to discuss these matters in detail and in as wide a context as possible.
The Bill is a milestone—I suggest only a milestone—in the process of improving the training and manpower of the nursing profession. In the long term, I hope that it will have some effect on the morale of nurses in the whole of the United Kingdom. Unfortunately, for it to have any immediate impact on today's deplorable situation within the National Health Service is more than we can expect. There is little or nothing that the Bill can do to improve the training of nurses and the manpower requirements until the early 1980s. We require urgent and effective measures today to put these matters right. My hon. Friend the Member for Reading, South (Dr. Vaughan) listed some of the vital requirements that we expect from the Secretary of State in this sphere as of today.
110 It is right, however, to set the Bill in the context of 1978, because the role of the nursing profession has continued to move rapidly in the past 10 years since the Briggs committee was set up. The sooner we are able to progress along the road towards improving training and education on the lines recommended in the Briggs report—recommendations which must be updated to account for the past 10 years since Briggs was set up—the better.
The changes envisaged in the Briggs report and in the Bill cannot come in. we are told, before the early 1980s-1982 or 1983 at the earliest. We are also told that the estimated cost of bringing in the education and training provisions is likely to be about £35 million.
The first question that I put to the Minister of State is: what commitment is he able to make that such an amount is likely to be available when the Central Council and the boards are set up and the recommendations are made for improving training and education in this great profession? I strongly suspect that he is unable to make any such commitment and that we shall have to wait until the next Conservative Government come in to make it available.
There is an important reason today for turning the spotlight on the nursing profession in the way outlined in the debate. The appalling deterioration of health care in hospitals, in geriatric hospitals and in long-term mentally sick hospitals is a matter for the greatest concern.
§ Mr. Boscawen
The right hon. Gentleman said that was not true, but he has only to read, as others have, the Royal College of Nursing's assessment of nursing in 1978 to see that it expresses deep concern about the increasing threat to patient care and about the additional pressures placed on nursing staff in the NHS. No one can be the least bit complacent about the present situation. A crisis exists in respect of manpower, money and morale in the NHS. The least that we could expect was that this long-awaited Bill to enact at least part of the Briggs report would be produced at an early stage.
§ Mr. Pavitt
I think that we all accept that many problems exist. However. 111 would the hon. Gentleman at the same time pay tribute to the tremendous effort made by devoted and skilled nurses who, despite the difficulties, still give a standard of care second to none throughout the world?
§ Mr. Boscawen
No one would disagree with the dedication of the nursing profession throughout the past 30 or 40 years. We owe an enormous debt to the dedicated people who have devoted their lives to nursing, often with little remuneration. I for one have been helped greatly by the kindness, care and common sense of nurses in the past. I pay my fullest tribute to that profession. I readily accept what the hon. Gentleman said.
Before turning to what has been the major argument in the debate, I want to mention some matters which have not been raised. One such matter was obliquely drawn to the attention of the House by the right hon. Member for Down, South (Mr. Powell), who pointed out that clause 1 provided uncommonly generous representation in the size of the board given to Northern Ireland. If uncommonly generous representation is given to Northern Ireland, it seems that uncommonly ungenerous representation is given to England, because each of the boards will send the same number of representatives to the Central Council. It seems that there is an overwhelming argument for considering whether the representation sent from England should be greater than it is.
Undoubtedly the main matter which has exercised the House has been the question of minority groups represented in the nursing profession—the health visitors and midwives. My hon. Friend the Member for Walsall, North (Mr. Hodgson) and the hon. Members for Preston, South (Mr. Thorne), Northampton, North (Ms Colquhoun) and Hemel Hempstead (Mr. Corbett) made powerful speeches drawing attention to the fact that the midwives—admittedly, not all midwives—and health visitors are concerned about the possible loss of professional identity which might result from these proposals. Some of these bodies have asserted their positions very strongly.
112 The letter from the representatives of the health visitors' training centres to the Minister of State pointed out that, where the interests of minority groups are concerned, intentions and realities do not always match. They feel that the preponderance of numbers in the larger profession and the larger representative organisations, such as the Royal College of Nursing and COHSE, could lead to their virtual extinction as professional bodies and that their standard of training, which they—and the House—believe is certainly needed in order to carry out their particular tasks, which are totally different from those of ordinary nurses, will suffer.
The health visitors, as a number of hon. Members have mentioned, form really a preventive service and one which is interested, above all, in family education. They see that the education provisions that might come out of the Central Council would be harmful to the standard of education which they have already achieved. They have also pointed out that within recent years they have done much to introduce new training methods and update their training in line with Briggs' recommendations. Therefore, there is a natural cause for concern on the part of that body, as there is, indeed, in some of the minority groups of midwives.
I was interested to hear the Minister of State say that the Royal College of Midwives was 100 per cent. in favour of the Bill. I was surprised, because I have in my hand a letter, which I have just received, which says that members of the Preston branch of the Royal College of Midwives have the very opposite view. They say:There is a fundamental difference between a midwife and a nurse which has been recognised for many years and we do not consider that a single statutory body could satisfactorily control both.Therefore, perhaps the Minister of State would withdraw, a little, his assertion about 100 per cent. support.
It remains to be seen whether the statutory committees proposed in the Bill for these minority groups can overcome their fears and concern about the Bill. In Committee we shall want to see whether there can be brought into the wording of the Bill a further measure of flexibility to do just that and to secure 113 more firmly the position of these minority groups. The fact that they are so small compared with other major nursing groups in the country really underlines their case. I hope that we shall be able to do that in Committee.
As I said earlier, we have been left in no doubt that there are now real problems concerning the question of nurse manpower, or womanpower, whichever way one wishes to put it. We have learned of the serious decline in the number of learner nurses in the NHS and the impossibility of filling posts, which in many cases has extended the waiting lists in some hospitals. I have particularly in mind the orthopaedic hospital in my area, the extension of whose waiting list has been directly due to that cause.
I wish to draw attention to the question whether learner nurses should be employees or whether they should have the status of students in hospitals and should not be, as I think the hon. Member for Aberdeen, North (Mr. Hughes) said, exploited in the way in which they have been in the past. This is a matter that we should all like to consider very seriously in Committee, because there is concern about it. Nevertheless, one has to bear in mind the reality of the situation. I wonder whether the NHS could exist at all if learner nurses were not often made to do the donkey work of their more senior colleagues.
I apologise for interrupting the hon. Gentleman again. Dos he agree with the point that COHSE has made—that students should retain their employee status and that their placement should be determined by their educational needs rather than the requirements of the NHS?
I have seen that view expressed by members of COHSE. It has some drawbacks. I should like to hear more about this very issue and discuss it further when it comes to Committee, because it concerns the public as well as Members of this House.
Above all today, what we urgently need is action to restore to those in the nursing profession their morale, their taste for the job, their sense of vocation and their feeling that it is essential that those who run our public affairs recognise that something concrete must be done to convince 114 nurses that their sense of vocation is not being taken for granted.
That is a very important question. The Bill itself cannot do that. It is concerned with the long-term future training of the nursing profession. It cannot overcome the shortcomings in nurses' morale at present. I am afraid that that comes down to two matters. First, in an era in which all are obsessed about maintaining real take-home pay, sticking to a 5 per cent. fixed limit norm for nurses would be straining their loyalty beyond breaking point.
Next, in order to restore their morale, nurses also wish to see the resources of the NHS being deployed more effectively for patient care rather than an administrator's dream. We shall now have to wait for the coming of the Royal Commission before we can see that put right.
Will the Bill, as we see it now, make for better morale? Will it help or hinder in the long run? Will it draw in the recruits? It is true that the nurses have been wanting this measure for a long time. Many nurses will welcome it. However, a new centralised and unified structure for nurses, midwives, and health visitors to replace a wide range of disparate bodies, statutory and non-statutory, concerned with nurses', midwives' and health visitors' education and training does not please everyone. As I have said, we shall have to face that in Committee and see whether we can make the Bill's provisions more flexible for dealing with the minorities.
It must be recalled, too—I am glad that the Secretary of State did so—that the Briggs report recognised that the existing bodies, to which many dedicated people have given such good service in the past, have well served the needs of the branches of the nursing profession and have safeguarded their training for their different roles. We have to recognise that. In doing so, we can realise the basis of some of the opposition to the Bill that exists among some of the minority groups.
Therefore, I shall be asking my hon. Friends to give the Bill one cheer only, so far, until we get into Committee, when we shall see how far we can go in improving and amending some of the provisions in the Bill. Perhaps we shall be able to give it more, but I ask my hon. Friends to let the Bill go to the Committee stage 115 on the principles that lie behind Briggs. Let us also remember that the passion of this age in which we live is for centralised, controlled bodies, for curing all local anomalies, and for ease of planning from the centre—particularly planning from the Department of Health and Social Security: centralised planning, so beloved of Socialist thinking.
From my experience, such planning has not been without some loss at the expense of the individual in the field. I was glad that my hon. and learned Friend the Member for Kinross and West Perthshire (Mr. Fairbairn) and the hon. Member for Northampton, North dwelt on these two particular points. We must be sure that by doing away with the old, rather disparate organisations and introducing one new central umbrella we are not throwing out the baby with the bathwater.
Over-centralisation has depersonalised so much in people's lives. It also tends to insist on conformity as a virtue among all its constituent members. I believe that is the basis of the fears of many of the minority groups affected by the Bill. Let not the nurses, midwives and health visitors in the local community say after the Bill leaves this House "No one listens to us. No one cares about the field workers in the front line, the overworked juniors in the hospitals and the hard-worked seniors in charge of the wards." The more remote control becomes the less the result is a good assumption to make when dealing with a Bill of this kind.
We should approach the Committee stage with suspicion and caution to ensure that this new centralised council for the nursing profession avoids this common experience of today so far as is humanly possible.
§ 7.42 p.m.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
I agree with the hon. Member for Wells (Mr. Boscawen) that we have had an interesting and informed debate. I appreciate the opportunity to wind up, because, although the Bill is to get an unopposed Second Reading—I am sure the great bulk of the nursing profession will be pleased about that—a number of misconceptions have to be cleared up. Perhaps I can throw some light on them, 116 and I am grateful for the opportunity to do so.
Perhaps the most spectacular misconception was that of the hon. and learned Member for Thanet, West (Mr. Rees-Davies)—who is no longer in his place—that two-thirds of the nurses in our hospitals were agency nurses. I am happy to say that out of about 400,000 nurses in the United Kingdom health services, about 3,500 agency nurses exist in England—most of them concentrated in London. Happily, most of the misconceptions were not of that order, and I hope that I shall be able to throw some light on some of them.
As chairman of the Briggs co-ordinating committee which was set up by my right hon. Friend, I should first like to place on official record my thanks for the work, support and interest of all the members of the committee who have worked with me for nearly two years in order to prepare the Bill. It was a pleasant re-entry of my family into the committee life of the nursing profession, because my father represented the TUC on the Rushcliffe committee on nurses' salaries and superannuation in 1944–45. He always found it a worthwhile experience, and I regard my chairmanship of the Briggs co-ordinating committee as an equally heartwarming experience to the one he had then.
I should also like to join all hon. Members who have paid tribute to the work of our nurses, midwives and health visitors, not only in hospitals but also in the community. In case there is any misunderstanding about the role of patient care in the Bill, I would like to say that nursing techniques are always developing either on their own account or in order to keep pace with the development of medical techniques. We must devise a system whereby all these changes are properly taken into account, and have our nurses properly trained in their mastery so that they can continue to give caring attention to the patients in their charge in accordance with all the latest developments in order that the return to health is hastened as rapidly as possible and, indeed, in order that people suffering from conditions that many years ago could not be cured will be cured in the future.
A number of points have to be dealt with. First, a number of themes ran through a number of speeches all of which 117 worried about the creation of some elaborate machinery. I should say that the machinery we are creating is not likely to be any more elaborate than the machinery which it is replacing. At the moment there are the General Nursing Councils, the Council for the Education and Training of Health Visitors and the Central Midwives Boards. All of them have their permanent staff and from time to time they set up committees. That is not unknown. What we are replacing them with is a co-ordinated Central Council with a national board for each of the four countries of the United Kingdom.
Therefore, there is no obvious case for saying that a fresh bureaucracy is being created. Indeed, to a large extent we are moving away from bureaucracy because we are moving towards a substantial element of democracy in the nursing profession. The eventual machinery which we are creating by this Bill will ensure that the vast majority of members of the four national boards, and of the Central Council, will be elected by the various members of the nursing profession.
My hon. Friend the Member for Hemel Hempstead (Mr. Corbett) had some reservations about the transitional period which would elapse before this took place. It is certainly not our desire that it should be any longer than necessary. But schemes of election will have to be worked out by the nursing profession itself in order to have confidence in the working of its own internal democracy. It is not our desire in any way to impose that machinery on the profession. Whether we have estimated the time accurately or correctly is, I suppose, a matter for judgment, but at the end of the day the profession will elect the great majority of the members of the four national boards, and then the great majority of representatives on the Central Council will come from the four national hoards and will be elected members.
Some worry was expressed by my hon. Friend the Member for Birmingham, Selly Oak (Mr. Litterick) as to why lay people should be on these bodies at all. He felt that other professional bodies would not put up with this. If that is the case, I can reassure my hon. Friend that this is something which the medical profession is willing to put up with. Both 118 the medical and nursing professions feel that it is useful to have educational people on their governing bodies. The nurses feel it is important to have some medical people on their governing bodies, because there is such a close working interface between the two professions. I do not need to make out the case for some lay representation on the bodies after the contribution of my hon. Friend the Member for Aberdeen, North (Mr. Hughes).
On the whole, we are not elaborating machinery to a greater extent than exists already. Indeed, we are injecting a measure of democracy into the government of health visiting and midwifery which up to now has been totally absent. In England the Central Midwives Board is totally appointed, as is the Council for the Education and Training of Health Visitors. In future, under this new machinery, they will be able to elect their representatives who will serve on the appropriate standing committees.
The hon. Member for Reading, South (Dr. Vaughan) raised another theme, which has been characteristic of the debate, when he asked why there was so little of Briggs in the Bill. I quite concede that there is not a great deal of the original Briggs report in the Bill. At the same time, his hon. Friend the Member for Essex, South-East (Sir B. Braine)—also missing from his place—said that there was not enough consultation. One or two other hon. Members made the same point. My right hon. Friend has dealt with this.
The Briggs committee reported in 1972. My right hon. Friend the Member for Blackburn (Mrs. Castle) accepted the report in 1974, in the first few weeks of this Government. From 1974 until the autumn of 1976 there was a great deal of consultation between the Department and the professions and almost two years ago today my right hon. Friend set up the Briggs co-ordinating committee, which met regularly under my chairmanship from the beginning of January 1977 until last summer.
The most valuable comment on the process of consultation was made during the course of our debate by my hon. Friend the Member for Aberdeen, North, who said that the important thing about consultation was that at some stage it had 119 to stop. Frankly, after six years I came to the conclusion that the time had arrived to make decisions. Apart from anything else, there is the question of getting a slot in the programme during a busy parliamentary Session. [Interruption.] I see that I have general support for that remark. I was afraid that, unless the chance was taken this autumn, the opportunity for introducing further legislation might not arise for a period of years. I admit that I took decisions on recommendations to put to my right hon. Friend and pressed ahead on that basis.
The theme of the debate has been the worry that hon. Members have expressed about the future position of health visitors and midwives. I shall deal with this, but before doing so I reassure the hon. Member for Reading, South that we do not intend to introduce further legislation. After a moment's reflection, he will agree that full-scale legislation, in terms of Acts of Parliament, for making modifying arrangements in the nursing profession is not the best way to go about things. Is he really arguing that it is better to have an Act of Parliament every time we want to modify the governing arrangements of the nursing profession? If so, he will find that the question of parliamentary time will be a substantial obstacle which could lock the profession into a form of organisation for years, without any ability to modify it. We think that acting by regulation is the best way of dealing with what are likely to prove subsidiary modifications.
I turn now to the question of the midwives and the health visitors. I accept that midwives argue that they are not nurses because they do not take care of sick people. They argue that childbirth is a perfectly natural function and that they are not, therefore, on the same footing as nurses who take care of sick people. The health visitors argue that they are more concerned with prevention than cure, which is the main concern of the great body of nurses, although not exclusively. There is a large number of nurses involved in preventive work.
It is asked: why have the three professions in one body? Apart from the element of democracy which will now be introduced into the government of the health visitors and midwives, all three 120 bodies, general nurses and their various permutations of district nurses, mental health nurses and so on, health visitors and midwives, make use of the basic general nurse training for three years. In England and Wales, 95 per cent. of midwives go through the general nurse training before topping it up with a final specialised course in midwifery. In Scotland, all midwives go through the general nurse training before becoming midwives. Broadly speaking, the same is true of health visitors.
All three groups have a keen interest in the fundamental construction of the basic nurse training course. For that reason alone, it is important that the influence of midwives and health visitors is brought to bear upon nurse training at the earliest opportunity so that they can ensure that such training does not diverge from paths which they would wish it to follow. That, basically, is the philosophy which Lord Briggs and his committee put forward on this point.
Nevertheless, the House will readily appreciate, given that brief description of the attitudes of health visitors and midwives, that I realise they are minority bodies within a large general nursing profession, even though that profession has other manifestations in terms of district nurses, mental health nurses and so on. It was my concern throughout to ensure that the interests of health visitors and midwives would not be swamped in the general arrangements for the nursing professions. That is why we have written into the Bill a provision which can be amended only by Act of Parliament, namely, the existence of statutory committees for midwifery and health visiting. We have not put the details of membership and the terms of reference into the Bill. Those matters will be dealt with by regulation. That is the first protection afforded to midwives and health visitors. They have those two invaluable statutory committees within the Briggs set-up.
The ultimate responsibility for all decisions by all the committees of the Central Council will rest with that council. If we are to have some form of unity covering the nursing professions, that is an essential reservation to the Central Council. I can understand that some midwives and the bodies representing most of the health visitors have worries. 121 It is important to remember that the Royal College of Midwives, representing 20,000 midwives in a professional capacity, is in support of the Bill. These worries of which I have spoken are largely without foundation. Given the existence of the two statutory committees, the Central Council will have to refer matters concerning the education and training of health visitors and midwives to those committees in the first place. The council will then have to receive recommendations from the committees. That will start from the point we are now at with regard to the independence of those two groups.
One of the things which the Central Council will have to do before agreeing to a new scheme of education and training, or any matter concerning professional standards, or indeed any other matter of importance, is to consult all appropriate bodies before making recommendations to the Secretary of State. If either the midwives or the health visitors through the statutory committees recommend that certain people be consulted, and the Central Council does not consult them, there will be an issue between the two bodies from the outset, apart from any issue which there may be concerning the content of the training.
When that stage is completed, the Central Council will have to seek the approval of the Secretary of State on all major matters and it will be obvious to him whether there has been full agreement between, say, the midwives' statutory committee and the Central Council on matters of consultation and content. He will be able to ask questions and, if he is content with the answers and decides to proceed, all the rules will have to be included in orders which will be laid before the House. They will, admittedly, be capable of being dealt with by the negative procedure, but they will come before the House and if hon. Members are dissatisfied with what is proposed they will be able to speak and vote against the orders.
There is little opportunity for the bulk of the nursing profession to pull a fast one on the midwives or the health visitors, who have a pretty strongly entrenched position. We are extending this sort of protection to district and mental health nurses and may extend it further, as my right hon. Friend explained earlier.
§ Dr. Vaughan
Will the Minister say a little more about the sort of safeguards he has in mind when extending this provision to district and psychiatric nurses? In addition, what time scale does he have in mind for major educational changes being brought forward?
§ Mr. Moyle
District and mental health nurses will have their statutory committees set up by regulation rather than have them written into the Act. I give an undertaking that regulations will be laid before the House following the setting up of the Central Council to put those statutory committees into effect. I cannot give exact dates for the timetable, but I would not disagree with the assessment that it will be the early 1980s when the new schemes of education and training are coming into force in the nursing profession generally.
§ Dr. Vaughan
What does the Minister of State see as the future of the Council for the Education and Training of Health Visitors?
§ Mr. Moyle
My hon. Friend the Member for Northampton, North (Ms Colquhoun) expressed the hope that the Central Midwives Board and the Council for the Education and Training of Health Visitors would not have their status impaired, but the functions of the board and the council will be taken over by the statutory committees of the Central Council. However, we shall obviously have the closest possible regard for the future of the individuals involved in the present machinery. I join my right hon. Friend the Secretary of State in expressing thanks for the noble work that all these bodies and the General Nursing Council have done for their professions.
The hon. Member for Reading, South expressed amazement that there was no access to papers for nurses and others in the field. I had all the representative bodies of the nursing professions on the Briggs co-ordinating committee, together with the three trade unions principally concerned. It was their job to keep their constituents in close touch with what the Briggs co-ordinating committee was discussing.
I am glad to learn that the right hon. Member for Down, South (Mr. Powell) is pleased at the appearance of the Bill—not always for reasons directly related to 123 the nursing profession, perhaps, though possibly including them. The two years that I spent as the Minister responsible for health and social services in Northern Ireland helped me to appreciate the arguments of the Northern Ireland representative on the Briggs co-ordinating committee. I am sorry to have to tell the hon. Member for Wells that he got it wrong. The board for Northern Ireland has 30 members and the boards for Scotland, England and Wales each have 45 members. The Northern Ireland representatives said that with their low level of manpower they did not want to build up a substantial bureaucracy. For that reason, we have given them exemption from setting up some of the statutory committees to which other boards are committed.
§ Mr. Moyle
If I please the hon. Member for Wells, I shall lose the support of the right hon. Member for Down, South. I have made my choice in the Bill and I stand by it.
My hon. Friend the Member for Preston, South (Mr. Thorne) thought that health visitors might come under local authorities. There is no reason why health visitors should not be employed by local authorities, but for historic reasons their training is related to nursing, and that is why we are keeping it that way.
My hon. Friend the Member for Brent, South (Mr. Pavitt) asked whether legislation was necessary to modify the Salmon set-up in nursing and whether we would consider establishing a clinical careers ladder for nurses. Alteration of the Salmon structure does not require legislation and the Bill is not a vehicle for making the changes that he proposed. I shall certainly take his suggestions into account, but if we are to change the career structure as he suggests it will require substantial consultation and the ultimate agreement of the profession. We have not begun that process, and even if it were agreed it would take the usual rather lengthy period of time.
My hon. Friend the Member for Brent, South also asked about registration fees. Fees will be charged to people who go on the register, and I am not giving any undertakings about how that will be 124 dealt with in subsequent pay negotiations. My fellow Ministers have heard what my hon. Friend said.
The hon. Member for Galloway (Mr. Thompson) asked about the implications of devolution. Professional standards are a United Kingdom matter, but education and training are devolved and will be the responsibility of the various Assemblies if they are set up. One complication is that the Assemblies are not yet in existence. In addition, the border line between professional standards and education and training, which are closely intertwined, has not yet been settled and we should like to consult the Assemblies involved. The matters have been reserved to the Westminster Parliament until the Assemblies are set up, when the appropriate consultations will take place and a solution found.
The hon. Member for Galloway raised a number of other points, including the EEC connections. One of the reasons for the Briggs committee and for there being no education and training content in the Bill is that when the Briggs committee reported we were not members of the Common Market. Now that we are a member, we are under a compulsion to ensure that there is interchangeability of qualifications between our nurses, midwives and health visitors and those on the Continent. I do not believe that the machinery that we are setting up in the Bill will prevent midwives being properly assimilated with their colleagues on the Continent in due course.
The hon. Member for Galloway also asked why EEC nationals who came to work in this country as health visitors, midwives or nurses did not have to take a language test. I am advised that the EEC says that we are not entitled to impose a language test on nationals of other Common Market countries who come to practise in this country. We have a language test for such people who want to come to this country to be doctors. I understand that that is not entirely uncontroversial either when it comes to our colleagues in the EEC. This is obviously a point that we shall have to note. I appreciate the drafting point made by the right hon. Member for Down, South, and I will see that a correction is made,
The question of home confinements was also raised. In my view, there is no 125 relevance in this legislation to home confinements. I do not want to mislead anyone. It is departmental policy that, as far as we can, in the National Health Service and as Ministers responsible for it, we will encourage women to have their babies in district general hopsitals, with a full range of supporting facilities, so that, if anything goes wrong, aid, comfort and assistance at the correct technical level will be on the spot immediately to help them. But we also say that if a woman, having considered all this health advice, still wants to have her baby at home, we will provide the facilities for doing so. That is departmental policy.
I have now indicated our departmental bias, but this Bill will have no effect on that policy. If anyone feels that there should be more confinements at home and fewer in hospital, his quarrel is with Ministers and their policy and not with the Bill. I hope that that statement puts the matter into perspective.
Finally, there was the question about the differing treatment for health visitors and midwives. I remind the House that health visitors have a joint statutory committee—that is, a statutory committee of the Central Council—which will serve not only the Central Council but also the four national boards as well. Midwives have a statutory committee at Central Council level and a statutory committee also at national board level.
My hon. Friend the Member for York (Mr. Lyon), my hon. Friend the Member for Hemel Hempstead (Mr. Corbett) and others asked why this should be so. First, it is because the midwives asked for it in this way. My right hon. Friend the Secretary of State also drew attention to the question of numbers. We do not refer to numbers in this context with the implication that small bodies are unimportant, but obviously, when there are between 7,000 and 8,000 health visitors compared with about 24,000 active midwives in the NHS, the elaboration of the administrative machinery which one needs for the health 126 visitors can be different from the machinery for the midwives.
Secondly, the health visitors have never asked for a statutory committee for each of the national boards. Our advice—and they are at liberty to take it or not—is that they are far better off with one joint central committee and a simpler structure rather than the structure that the midwives have voluntarily set for themselves. I hope that that explains the background.
The Bill is to receive an unopposed Second Reading. I think that we are opening a new stage in the development of the nursing professions. They will be able to work more closely co-ordinated with those professions that have been associated with them. They will be able to share in the development of their basic joint training. I think that the morale of the nursing professions will, in spite of some of the doubts cast today, be improved, and it is the desire of the overwhelming majority of midwives and general nurses that this measure should go forward. I look forward to a fruitful and constructive Committee stage.
§ Question put and agreed to.
§ Bill accordingly read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Committal of Bills.)