THE PROFESSIONAL REGISTER (Hansard, 7 February 1979)

§ Dr. Vaughan
I beg to move amendment No. 31, in page 7, line 19, at end insert, The Central Council shall prepare and maintain a register of persons in training to become nurses, midwives and health visitors who will be accorded full student status until registration.

§ Mr. Deputy Speaker
With this it will be convenient to take amendment No. 45, in clause 23, page 15, line 2, at end insert 'a person of student status' means a person in training who is not an employee.

§ Dr. Vaughan
The purpose of this amendment is that a register should be kept of persons in training to become nurses, midwives or health visitors and that while in training they should be accorded full student status until they are fully registered.
I am rather surprised that the Government should have ducked the question of giving guidance and leadership to the profession on the employee status of student nurses. This is a very important question which has implications which stretch outside the health area. I should have thought that it was a mistake simply to leave this to the Central Council without giving some opinion on what is a very complicated matter.
The Briggs report rightly said that nurses in training should not consider themselves, nor be considered, as part of the ordinary labour force of the National Health Service. This has great implications for their status and the question whether their finances should come largely by way of educational grants. It also has implications—this may be why the Government ducked even discussing it properly in Com- 474 mittee—for the manning of the National Health Service.
There are two sets of arguments. One set, which I understand was considered by the Briggs working group, is that the only way for pupil nurses to have a satisfactory course of training is for them to cease to be health authority employees and to become students throughout their training and have to subsist on education grants. The alternative view is that that would be detrimental to their future.
The argument for student status is that it would enable health authorities to plan and provide a more effective service based on a balanced nursing team. That being so, authorities would have a better idea of numbers coming into the service and have better control of the numbers coming out of training examinations. It would also free student and pupil nurses from the pressures which undoubtedly arise when they are part of an established work force. There is frequently a clash between the needs of the wards and the needs of a training programme.

§ Mr. Powell
I apologise for interrupting the hon. Gentleman on the point which he has just passed. I understood him to say that it would be possible for an employing authority to estimate the number of trained nurses who would be coming into service. I am sorry to have to tell him that is a fallacy, as I experienced with the professions ancillary to medicine in the early 1960s when large numbers were under training year after year. When I inquired, after a time, what was happening to them and why they were not coming into the National Health Service, I was told that as soon as they qualified they got married. Therefore, unless that factor is known, the number of students gives no indication of the number of trained nurses who will be coming into service.

§ Dr. Vaughan
I am grateful to the right hon. Member for that very pertinent and relevant observation. It is clearly based on his great experience in this area. The next point which was made by the Briggs working party was that, by removing the status and implication of employees and the pressures which fall on them as part of the general work force, for some girls it would make 475 entry into the profession much more attractive.
There are considerable anxieties—this point was put by the Royal College of Nursing to the Secretary of State recently—about a fall in the number of young girls in the population and, as a result, the possible fall in the numbers wanting to go into nursing. The alternative argument is really based on doubts whether present grants would be sufficient to finance these girls right through their training. A very important point is that, if they ceased to be employees, they would cease to enjoy rights under the employment protection legislation.
These rights are seen by some people as a great benefit and protection. My information—I have discussed this matter with various health authorities—is that the Employment Protection Act works in a very unsatisfactory and restricted way in this area. It means that if a girl comes into training and is protected by the Act and it turns out that she is unsuitable, her training cannot be stopped. If she has entered a branch of nursing training for which she is subsequently found unsuitable, she cannot be moved to another branch.
This is a very complicated and important area. I say again that the Government have made a mistake in ducking this issue, because it will arise again and again in the next few years. I think it is wrong to leave the decision to the Central Council without any guidance from this House on how it should view this issue. It will need to discuss this matter very early after its formation.

§ Mr. Pavitt
As the hon. Member for Reading, South (Dr. Vaughan) said, there has been considerable discussion about this matter in the working party. In an ideal world, with all the man or woman power available, nothing would be better than to be able to say that we should retain a work force in a hospital in addition to student pupil nurses whose sole status and responsibility was that of learning the job. The Confederation of Health Service Employees, dealing mainly with mental nurses, had considerable discussions and came to the conclusion that, in reality, however much we may care to give those concerned the necessary status, and whether or not we have a register, in 476 the main the work still had to be coped with. Therefore, I shall listen with interest to my right hon. Friend's reply to the debate.
I think that the hon. Member for Reading, South was quite right when he said that when the Central Council was established there would still be the problem of how to find the right balance between education and training and the real and heavy demands on pairs of hands and feet rushing about a ward, especially when recruitment had not been good or when the attractiveness of the girls referred to by the right hon. Member for Down, South (Mr. Powell) meant there was a depletion in numbers because they got married the moment they qualified. I do not think that the establishment of a second register would solve those problems. However much we should like nurses in training to be students, unfortunately they will more often find themselves working in wards. I shall listen with interest to the comments of my right hon. Friend, who, I know, had discussions on this matter with the working party.

§ Mr. Hodgson
I think that we owe a debt of gratitude to my hon. Friend the Member for Reading, South (Dr. Vaughan) for giving us the opportunity to debate this subject. After all, we come here to the heart of the Briggs report. Of the 728 paragraphs in the Briggs report, between 200 and 300 are concerned with nurses and midwives in training and the educational processes and future organisation. A relatively minor number of paragraphs—the last 100 or so—concern the organisational framework, timetables, and so on. I note the point made by my hon. Friend about the nature of student nurses. It seems that a fair comparison can be drawn between a girl or a man undergoing nursing traning and a university student. We would not seek to extend the provisions of the Employment Protection Act to university students undergoing a general degree course. Therefore, it seems inappropriate that employee status should be afforded to student nurses. There is the question not only of their relative position in our economy, or within their profession, but of the vocational nature of their training. Therefore, it is important that the authorities, which are psychologically well attuned to the demands made upon 477 nurses through the pressures of modern medicine, should be clear, before final registration is afforded to these people, that they are entirely suitable and right for the job.
If we are not to have temporary registration, we run the grave risk of unsuitable people coming and perhaps staying in the profession, with the authorities unable to get rid of them. If that happens, the general standards of nursing, which we are hoping to maintain through the medium of the Bill, will suffer. I hope that the Minister will take all these points on board and consider whether the student nurse should be put on a par with the university student undergoing a degree course.

§ Mr. Cronin
I understand that the hon. Member for Reading, South (Dr. Vaughan) intends that student nurses should depend upon educational grants. If so, that would seem to be unsatisfactory. Speaking as a Member for a university town, I know that many students get into difficulties as a result of their grants. For instance, their parents may not pay their share. Such a course would bring total chaos into the financial affairs of nurses prior to registration. I am sure that the hon. Gentleman, with his experience, appreciates the financial difficulties that nurses have to face.

§ Dr. Vaughan
I think that, normally, this subject would have been discussed in Committee. I was seeking to bring up a matter which was not fully discussed there. I put forward views from the various bodies which have actively been discussing this problem.

§ Mr. Cronin
I do not think that, in the circumstances, the hon. Gentleman should reproach the Government for not having aired this subject before.
The hon. Gentleman said that student nurses should be less liable to duties in the ward and be able to concentrate more on their training. I suggest that would be contrary to the interests of patients. The first concern in any hospital should be the patients, not the training of nurses. I appreciate that in some ways there are clashes between those two views, but I think that patients must have absolute priority.
478 The effect of the amendment would be to withdraw from nurses the benefit of the Employment Protection Act. I suggest that is an important Act for employees of all kinds and that it would be unfortunate if this deserving body of young women was withdrawn from its protection.
There is an important psychological aspect to the matter. A student tends to regard herself as learning something exclusively and therefore adopts a more lighthearted attitude towards her duties and to life than a fully trained, qualified person. It is important that nurses should be employees and realise that they have duties and responsibilities.

§ Mr. Pavitt
Would my hon. Friend give the same preference with regard to the training of medical students? Does he regard medical students as having their first responsibility to the patient and their second responsibility to their medical training?

§ Mr. Cronin
That is a different matter. Medical students do not have any serious duties in hospital, whereas student nurses do.

§ Mr. Pavitt
My hon. Friend cannot be serious.

§ Mr. Cronin
I am perfectly serious. Medical students keep notes and examine patients, but the responsibility for patients is always undertaken by house physicians and surgeons. Of course, one gets the impression that students do useful things in hospitals. Indeed, they often do; for example, holding up a patient's arm when he is being operated upon, and so on. However, one could dispense with medical students without seriously affecting the running of a hospital.
I hope that if the hon. Member for Reading, South ever finds himself in hospital he will be looked after by a nurse who realises that she is an employee and has responsibilities rather than a student who can always say "I am only trying to learn. This does not really concern me very deeply."

§ Mr. Moyle
With respect to the concluding remarks of my hon. Friend the Member for Loughborough (Mr. Cronin), I hope that the hon. Member for Reading, South (Dr. Vaughan) finds himself in 479 hospital from time to time. Otherwise, he will be in a very parlous state indeed.
The hon. Member for Walsall, North (Mr. Hodgson) said that this matter went to the heart of the Briggs report. It may well do that, but it does not go to the heart of the Briggs Bill. The bodies about which we are talking have no responsibility for recuitment, selection of trainees or financial provision, whether through grants or anything else. Those bodies have a remit for the provision of training, not the persons undertaking training. Strictly speaking, the subject is outside the scope of the Bill altogether.
The hon. Member for Reading, South accused the Government of ducking the issue and saying that it was a mistake. I have never been more firmly convinced about anything than that we were wise not to have taken a decision on the matter between Committee and Report and, indeed, for some time to come. He said that the matter would come up again. That is perfectly true; it will come up again. It will be a matter of considerable interest to the profession under the new Briggs machinery.
The hon. Gentleman also said that we cannot leave it to the Central Council. I agree there, because at the moment learner nurses come under the Whitley Councils for negotiation of their terms and conditions of service, and any change in their role or status would required negotiations with that body.
Hon. Members who have spoken are right in saying that the various unions concerned say that more nurses now enjoy the benefits of employment protection legislation and that from their point of view it is a good thing that student and learner nurses should continue to do so.
The Briggs committee was not entirely clear about what should happen to nurses. It discovered that it was not clearly understood what student status meant. Many trainees thought that it meant having a students' union. Others thought that it would mean getting a Government grant instead of being paid a salary. As my hon. Friend the Member for Loughborough divined, that put a dampener on enthusiasm for the change. The other matter is that students and pupils would learn theory in college and not in hospital, 480 and students and pupils would work in wards only to get practice and would not help in staffing them.
We set up a working party on the Briggs co-ordinating committee to look into these matters, and it was not able to define what it really meant by "student status", as opposed to learner status, employee status or any other status. From that point of view, it ran into a number of problems. I concede that there are problems here. There are tensions between those who want to use student or learner nurses in a service capacity—and, of course, they must have some service capacity in order to learn—and those who want to use them entirely for educational purposes. There is a continual tension.
Normally, in most hospitals, good human relations create a balance here. But it may well be that the eventual solution of the problem is not a matter of considering status but of reaching a solution as to how the time of these young people should be allocated between providing practical help in a hospital and undergoing pure instruction. However, the Government are of the view that this is one of the matters which should be left primarily to the Central Council which is to be set up under the Bill.
Another point of importance here is that most of the matters—recruitment, training and that sort of thing—are the responsibility of the Health Service. It will be a provision under the Bill that as the Central Council propounds schemes for training the people whom it covers it will have to go to the Secretary of State and say "We would like our young people trained in this particular way. Can you provide the money for us to do it?" Only to the extent that the Government of the day are able to provide the money to do it will the new schemes come into operation. Therefore, the Government are involved in this in the long term, but we should want the united advice of the professions before we took action.
It is an expensive business, though that is not the prime reason why the Government have ducked a decision on this matter. The prime reason is that we find an uncertain voice coming from the profession. The bodies on the Briggs coordinating committee have not really come to a conclusion about the way forward. The best estimate that we can 481 offer is that if learner nurses became purely and simply students that might result in a maximum expenditure of about £200 million per year, which is equivalent to about a 3 per cent. growth rate for the National Health Service, to provide fully trained nurses to do the work which learner nurses do at present.
When the Briggs committee looked at this issue against the background of those problems, it came to the conclusion that it was not necessary, in the best interests of the individual learner nurses, to make a change to student status because he, or she, would then be worse off on a grant than on the present training allowance. The Briggs co-ordinating committee reached an overall tentative conclusion that, in the long term, student status should be an objective, but it felt that there was a need for health authorities to look at nurse training as part of their overall planning It did not recommend any major change at this time and felt that this whole question should be one for the new Central Council to consider and then make proposals to Ministers.
This means that the Government, in adopting the attitude that they have done, have followed the most considered advice of the nursing professions at this juncture. For that reason, I hope that the House will not accept these amendments.

§ Dr. Vaughan
It was quite clear, I think, from the way in which I moved the amendment that we wished to discuss this issue rather than take it to a vote. In view of what the Minister has said, I beg to ask leave to withdraw the amendment.

§ Mr. Hodgson
I beg to move amendment No. 32, in page 7, line 22, leave out 'standards' and insert 'levels'.
This is a modest amendment which has some quite serious implications attached to it. The implications have been put to us very strongly by the Royal College of Nursing and by other representatives of the nursing profession. We debated this matter in Committee. Therefore, I do not want to take too long on it. However, I should like to draw the Government's attention to the concern in the Royal College of Nursing and other places about the different use the word "standards" implies.
482 It was put to me in Committee that "standards" means that, by analogy, one is dealing with the quality of an individual type of training—that is, to take an A-level pass in the General Certificate of Education, there are grade A grade B and grade C to indicate a different standard of A-level pass. By comparison, O and A-levels are different sorts of examinations. They are not inferior examinations but they are merely examinations which one takes one before the other. It does not imply any inferior nature of the examination itself. It is just something that one takes early in life and is more suitably set for people at certain stages of their development.
This the Minister is not able to accept, and I think he made two particular points in refutation of that point. First, he was surprised that we waited until clause 10 when in fact clause 2 used the word "standards" in subsection (2). The use of "standards" in clause 2 is, in fact, quite a different matter. There we are talking about standards of training. The whole purpose of the Briggs Bill—as we might call it—is to improve the standard of training. Therefore, for the Minister to use that analogy as a refutation of the argument for this amendment is not correct.
The Minister made a further point, namely, that in other areas of nursing legislation the word "standard" was used. In particular, he quoted the Nurses (Amendment) Act 1961. I am afraid that I was not sufficiently quick on my feet in Committee to note—as I did when looking through the Bill afterwards—that on page 30 of the Bill, as now amended, in lines 43 and 44, the Nurses (Amendment) Act 1961, with such critical use of the word "standard", is wholly repealed by the Bill.
The Minister said that this would lead to a duplicatory use and interpretation of the words, whereas the example he gave before in support of his argument was from a statute which will be entirely repealed by the passage of this Bill.
I should like to ask the Minister to take on board the serious nature of the comments that have been made to us by the Royal College of Nursing and the inherent and slightly semantic differences between the use of the words "standards" 483 and "levels", and accept that the profession which he is so ready to call in aid at other times when he wishes us to accept an amendment which he is putting through—which I and my hon. Friends are perfectly ready to accept—should be called in aid here. I ask him to accept that this change would be a useful one.

§ Mr. Moyle
In Committee, whereas no one was prepared to say that "standards" was the most perfect answer to the problem, many hon. Members found that "levels" was no more attractive. In the end, I said that if the Royal College of Nursing wanted to pursue this matter with me, I would probably take its preference. As a matter of fact, the Royal College of Nursing has not pursued it with me since the Committee stage. I do not, therefore, see the point of substituting one word for another when the word to be substituted appears to be almost equally as unattractive to half of the House as the existing word is to the other half. I beg the House not to accept the amendment.

§ Mr. Hodgson
If the Royal College of Nursing wishes to come back to the Minister subsequent to the passage of the Bill through this House to another place, will he consider himself still ready to receive representations on this point?

§ Mr. Moyle
I do not mind doing that, but I am rather loth to inflict this sort of debate on another place.

§ Mr. Hodgson
In the light of the Minister's assurance that he will at least consider the representations of the Royal College of Nursing, I beg to ask leave to withdraw the amendment.

§ Dr. Vaughan
I beg to move amendment No. 33, in page 8, line 23, leave out "a fully qualified nurse" and insert State Registered Nurse (SRN) or State Registered Practical Nurse (SRPN)".

§ Mr. Deputy Speaker
With this we are to take amendment No. 50, in schedule 6, page 25, line 31, leave out "fully qualified nurse", and insert State Registered Nurse (SRN) or State Registered Practical Nurse (SRPN)".

§ Dr. Vaughan
Again, this amendment concerns something that we discussed in 484 committee, so I shall endeavour to be very brief. It also concerns a rather unsatisfactory situation.
As the Bill now stands, the terms "State, registered nurse" and "State enrolled nurse" will disappear, and in their place will come "fully qualified nurse". This is open to objection, because a nurse who at present is an enrolled nurse is a fully qualified nurse, as is the nurse who at present is a State registered nurse. They will be termed "fully qualified nurse." Therefore, it could be taken as derogatory in some ways to one of the nursing groups. Our advice from the various professional groups is that they do not like the term "fully qualified nurse". So far, I have heard no one who is in support Of it. Therefore, it seems wrong to write it into the Bill.
At one time, the Minister told the Committee that he, too, did not like the term "fully qualified nurse". He suggested that over the Christmas Recess, perhaps, some sort of competition might be organised, and that out of that might come a better term. Nothing better came until we had some discussions with the Royal College of Nursing, which suggested—this is not a unanimous view in the Royal College of Nursing, but it is one that I share—that "State registered nurse", "SRN", is a time-honoured term. Everyone understands what it means. It has great status in the community. I know that when nurses qualify they are very proud to put the letters "SRN" after their name. Therefore, I suggest that if "SRN" can be retained it should be in place of "fully qualified nurse".
That leaves us with the situation of the State enrolled nurse and what she should be called. Again, I suggest that "fully qualified nurse" would be confusing and that we might adopt the practice used in some other parts of the world—in the United States and in some parts of Europe, for instance—of the enrolled nurse becoming a State registered practical nurse. That is that she would then be able to put "SRPN" after her name.
Perhaps that is not quite as attractive a term as "SRN", but it is the best that people advising us have produced so far. It certainly seems to Opposition Members very much better than the term "fully qualified nurse", which everyone seems to agree is unsatisfactory.

§ Mr. Molloy
I follow what the hon. Member for Reading, South (Dr. Vaughan) said about the letters "SRN". This is an acknowledged and well-known proper description for a State registered nurse, and everyone outside the profession recognises it as such. I cannot see the need to add more confusion by changing this description.
There is one other point which I should like my right hon. Friend to consider. Many people who have become State registered nurses, entitled to use the letters "SRN" or "SEN" or the description "State certified midwife", have documents in which these terms are incorporated. In the nursing profession, the young ladies call them their gongs. Some of them are anxious about the new letters indicating that there may be a difference between a State registered nurse and someone with the proposed nomenclature. I ask my right hon. Friend to consider that aspect as well.

§ Mr. Moyle
I agree with the lack of enthusiasm with which the term "fully qualified nurse" is regarded in the House, and I said so in Committee. In fact, in desperation, I was driven to adopt a sort of "goal of the month" approach to the solution of the problem by saying that I would give a substantial reward—substantial in my eyes—to any member of the public who came up with a suggestion that might be adopted, the first acceptable solution to the problem to be the one that would win.
Unfortunately, in spite of the fact that one of the nursing publications took up the idea, there was no great response from the nursing profession. We have not been left with a rich fund of names to trawl. Fortunately, we still have a little time. I have noted that it has been said by my hon. Friend the Member for Ealing, North (Mr. Molloy) and the hon. Member for Reading, South (Dr. Vaughan)—indeed, my hon. Friend the Member for Brent, South (Mr. Pavitt) made the same point in Committee—that the term "State registered nurse" is one which is highly regarded in the profession. We ought to hang on to it as far as possible.
I shall bear this point very much in mind. We have a week or two yet in which to think of a solution. I promise to bear this in mind and to table amend- 486 ments at the appropriate stage. I have made no particular commitment to the phrase which is in the Bill now.

§ Mr. Boscawen
I hope that the right hon. Gentleman will take the views of the House very seriously. "SRN" is a title that we all prefer to keep if we possibly can. I believe that that is the unanimous view of the House. We shall not get an ideal description for the change. I hope that the right hon. Gentleman will take this matter very seriously and that when the Bill goes to another place it will have included in it the description "SRN". The question of the description "SRPN" is a different matter. We might be able to produce a better description than that.

§ Dr. Vaughan
In view of the Minister's assurance on this matter, I beg to ask leave to withdraw the amendment.

§ Dr. Vaughan
I beg to move amendment No. 34, in page 8, line 24, at end insert: '(9) The Central Council shall make regulations for the temporary registration of nurses, midwives and health visitors having recognised overseas qualifications.'. We think that the Government are making a mistake in not providing something short of full registration. There will be people coming from overseas, from other parts of Europe in particular, who will want to stay and practise nursing in this country for a very short period. We think that it would be wrong that they should have to go through the full process of registration.
We discussed this matter in Committee. I hope very much that the weight of the argument will have sunk in with the Minister and that he will accept a temporary registration as a part-way solution for people temporarily in this country and intending to go overseas.
We know that the various nursing groups have been looking at this matter. I think that it is their view that some sort of temporary arrangement will be necessary. I can see no reason why it should not be written into the Bill at this stage.

§ Mr. Moyle
I do not think that a specific power for temporary registration is necessary. By clause 10(3)(c) there is 487 already provision for a person's registration to lapse after a specified period and in specified cases. For example, if a person comes to this country from a Common Market country, we cannot prevent registration; but if that person has not learned English to a sufficient extent to communicate with patients in this country after six months or a year, he or she could be removed from the register. That is the equivalent of temporary registration in practice. Therefore, there is no need to introduce the concept of temporary registration when we can handle these problems without it.
It may be felt that limited registration could be introduced. I gather that some members of the Briggs committee felt that there was need for a mechanism by which some overseas nurses whose training has not been sufficiently advanced could be given a kind of half-way house. That is unacceptable on a philosophical level because either an overseas qualification is equivalent to registration or it is not. If it is equivalent to registration, the person concerned, subject to his or her knowledge of English, can go ahead to provide a service. If the knowledge of the language is not sufficient, such a person should not provide a full nursing service unless under certain conditions he or she is being taught that knowledge.
We would also run into trouble with our EEC partners and with the Commission if we were to adopt such an approach. The present approach enables us not to fall into difficulties with the EEC. There would be great difficulty in deciding which tasks an overseas nurse with limited registration could undertake without risk to patients and which tasks she could not undertake, whereas under the present system such a nurse, if not fully registered, would be regarded as a learner. Furthermore, in the case of accident there may be problems of legal liability.
For this reason, health authorities are not particularly anxious to see this kind of registration. Indeed, the registering authority of the General Nursing Council does not wish to undermine the present high standard. For these reasons, I ask the House to reject the amendment.

§ Dr. Vaughan
I do not know that the Minister has convinced the Opposi- 488 tion on this matter. However, in view of his explanation, I beg to ask leave to withdraw the amendment.