§ Order of the Day for the House to be put into Committee, read.
§ LORD AMPTHILL
My Lords, I understand that several noble Lords wish to speak on this Motion. I think, therefore, it would be more convenient if I reserve what I have to say until I have heard the criticisms which I believe are to be made.
§ Moved, "That the House do now resolve itself into Committee."—(Lord Ampthill.)
*THE EARL OF MAYO
My Lords, it will be remembered that the Second Reading of this Bill was taken in a very thin House, and that Lord Stanley of Alderley's Motion to adjourn the Second Reading debate was withdrawn on the understanding that those who desired to speak on the Bill should have an opportunity of doing so on the Motion to go into Committee. I observe that His Majesty's Government have drafted a series of very important Amendments, which I understand from the noble Lord who is in charge of the Bill are for the benefit of the Bill. But I regret that by one of the Amendments Ireland is cut out. I do not know why the nurses of Ireland should be deprived of the advantages of this measure. They would benefit very largely under the Bill, especially nurses employed in out-of-the-way parts of Ireland who deal with the poorest class. We shall, I suppose, when we get into Committee, hear the reasons for the actions of the Government on this particular point.
I quite realise that the question of registration is a contentious one. I have in my hand the memorial that was handed into the Committee of the House of Commons by the Chairman of the Central Hospital Council, in which it is stated that there are many nurses, matrons, medical men, and others engaged in hospital work who are opposed to registration. The Amendments now put down will, I think, protect the public from unskilled persons being able to act as nurses, and the benefit to the trained nurse, who is alleged to be placed at a disadvantage through the employment of imperfectly trained persons, will be incalculable. The noble Lord in charge of the Bill stated on the Second Reading that he had in his hand the records of a number of very serious cases of women who had posed as nurses, but had been convicted before the magistrate of malpractices. I have here on | the seat beside me many newspaper cuttings dealing with these cases, but I think it is needless to go into them. They are disagreeable cases to mention, and I do not think the present is the 1640 time or place to deal with them. But the requirements in this Bill for registration will, I am convinced, prevent these unqualified people from acting as nurses again.
I have on the Paper a rather drastic Amendment, which I shall move when we go into Committee. It is to insert the following new clause—(1) Any Court before whom a registered nurse is convicted of any offence and ordered to be imprisoned without the option of a fine or to suffer any greater punishment, shall cause particulars of the conviction to be endorsed upon the certificate under this Act held by such registered nurse, and shall also cause a copy of those particulars to be sent to the council. (2) Any registered nurse so convicted shall produce his or her certificate under this Act within a reasonable time for the purposes of endorsement, and if he or she fails to do so shall be guilty of a misdemeanour.If this Amendment is agreed to magistrates will be able to endorse certificates in cases of improper conduct, and this will be the means of driving black sheep out of the flock. I think it is a very great safeguard, though, perhaps, your Lordships may consider it too drastic a remedy. The fact that His Majesty's Government have acknowledged the importance of this measure by so carefully preparing Amendments leads me to suppose that the time will come when the measure will become law; but I do not suppose there is any chance of its passing this session.
*THE EARL OF MAYO
The noble Lord disagrees with me, but I think it is obviously impossible that the Bill should become law this session, owing to the congested state of public business in the other House. Great good, however, will be done by a full discussion of the matter. I must press for an explanation as to why Ireland is cut out of the Bill. The district nurses in the poorer parts of Ireland are real angels of mercy in those districts. I do not think your Lordships have any idea of the enormous amount of valuable work they do. I think it can be said, in the case of many out-of-the-way parts of Ireland, that they have been the means of civilizing those districts. I have myself been through the district 1641 in and around Belmullet, and can personally testify that the nurses there are in favour of this measure. I hope, therefore, that Ireland will not be excluded, or, if it is excluded, that some sufficient reasons will be given.
*THE SECRETARY OF STATE FOR THE COLONIES (The Earl of CREWE)
My Lords, I think it will be convenient if, before we go into Committee, I make some general statement with regard to the attitude of His Majesty's Government towards this measure. Those of your Lordships who are interested in the measure will have observed that a bulky sheaf of Amendments has been placed on the Paper in my name, but, of course, on behalf of the Privy Council. I think that to attempt to deal with those Amendments seriatim in the form in which they are would be an exceedingly lengthy and a rather confusing process. The course which I suggest, therefore, is that, when the House goes into Committee, these Amendments, and, perhaps, some others—there are, I think, two in the name of Lord Mayo—should be accepted en bloc with a view to the Bill being reprinted so that their effect can be made clear. The Bill could then be recommitted and considered in that form at some future time. As the matter stands now, it would be a very tedious and difficult process to go through the Amendments and explain the purport of each. I might, however, state at this stage what the general effect of the proposed Amendments is.
In the first place five clauses are struck out of the Bill, thereby getting rid of the arrangement for a provisional council, which seems to us unwieldly and unnecessary. The next important set of Amendments reduces the council to the number of fifteen, the number mentioned in the Report of the Select Committee of the House of Commons, so arranged as to hold the balance between medical practitioners on the one hand and nurses on the other. The two professions will have six representatives each, the remaining three being appointed by the Privy Council. The third set of Amendments provides for the representation of the Local Government Board on the 1642 council, and secures that their responsibility for the training of nurses in Poor Law institutions should not be interfered with. The fourth gives power to the Privy Council to amend rules submitted by the nursing council, and the fifth provides for the payment of a small annual fee as a condition of the name being kept on the register. Then there is an Amendment which is not on the Paper, but which I propose should be included for the purpose of discussion, dealing with the means by which nurses can get on the register. The next Amendment exempts Ireland from the application of the Bill. On that perhaps I may say a word. The exemption of Ireland is, of course, only provisional, because Ireland might be included at any time by Order in Council. The Irish Local Government Board are indisposed to apply the Bill to Ireland at present for administrative reasons, into which I confess I have not closely looked. Therefore, it is clear that the exclusion of Ireland can only be regarded as provisional, and those noble Lords and others who object to the exclusion of Ireland will, I think, do well, before the Bill conies up again, to state their views to the Irish Local Government Board with a view to the reconsideration of the question. It is, of course, purely an Irish question, and it is one upon which those who represent the Government here would not desire without very strong reason to override the Irish Department. Therefore, noble Lords like Lord Mayo and others should make their representations on the subject to the Irish Local Government Board. The last set of Amendments provides for the creation at the end of four years of a separate register of associate nurses having a lower standard of training—a point also recommended by the Committee. I hope the course I have suggested may commend itself to the House.
*LORD STANLEY OF ALDERLEY
My Lords, as the noble Earl opposite has stated, I withdrew my Motion for the adjournment of the Second Reading debate on the understanding that an opportunity for discussion would be afforded at this stage. I did not interpose as an opponent of the Bill, but rather as a friendly critic. I think that the 1643 Amendments which the noble Earl the Leader of the House has placed on the Paper will make the Bill a much more satisfactory measure. At the same time there are one or two points to which I should like to call the attention of the House.
In the first place, I do not think the noble Earl is justified in claiming that this Bill will prevent possible scandals in the future through persons not properly qualified acting as a nurse. There is no provision in the Bill to prevent anyone practising as a nurse; all that the Bill does in that direction is to prevent a person using the title of certificated and registered nurse. I have received a document from the Society for the Promotion of the State Registration of Nurses, in which it is set out how a woman who, though not trained, got employment and went mad. But hospital training and even registration are no protection against madness.
While I have not the slightest objection to classification, I am very glad that the noble Earl proposes to take out the stigma of "qualified" and "unqualified" from the Bill. If you are to secure a good class of nurses, registration of their initial qualifications will not do much for you. I think that was very strongly pressed on the Select Committee of the House of Commons by Mr Holland and other prominent people connected with the London Hospital. The really essential thing to know is what a nurse has done since her training rather than during her period of training. The Queen Victoria Institute of Jubilee Nurses, which has done more than any other institution to promote good nursing, are strong advocates of this Bill, but they recognise that even the high training which will be the basis of the certificate is inadequate in some cases. This Institute spent, according to their last account, £3,817 on what they describe as district training super induced upon the hospital training of the certificated nurse. None of that would appear in this certificate: yet they find that this further training is necessary for the cottage practice of the district nurse.
There are different classes of nurses. There are those who attend the well-to-do and people who hare important operations performed by eminent surgeons. 1644 Then there is the organisation, through county associations, of nurses for the poor—district nurses. Those nurses, though they come in with little or no medical or nursing training beforehand, are generally sent for a year to Plaistow and places like that to study midwifery and other matters qualifying them to visit the poor in their homes. At this moment, under country associations, there are 540 of these nurses working up and down the country, independent of fully-trained nurses; and these nurses get, what is most important, a continuous system of inspection. Every county appoints a Jubilee nurse as a sort of superintendent of these nurses. They are carefully watched, the Queen Victoria Institute recognising the importance of continuous inspection after the nurses have obtained the certificate. I find that last year in England and Wales they spent over £2,000 on inspection.
Do not let us deceive ourselves by thinking that this Bill is going to be the panacea which some people think. It will only be a guarantee of a certain amount of initial training. Both the highly trained and humbler class of nurses are needed; and I was very glad to see by the last Amendment on the Paper that the noble Earl contemplates another certificate for that type of nurse especially required for the ordinary ailments of the poor. The very highly-trained nurse gets impatient at the routine and commonplace of nursing among the poor, and the humbler women who do this work are often better qualified for it than the highly trained, if under proper supervision. I am glad there is to be a recognition of this class of nurse also, but I regret that by one of the noble Earl's Amendments the creation of this subsidiary register depends on the goodwill and recommendation of the council. The council to be created by the Amendment is better than the council in the Bill as it stands, but I think too much importance is given to the nursing element and not sufficient importance to those who have to judge of the qualities of the nurse.
The Select Committee recommended that the place of examination for nurses at the beginning should be the nursing school. I think any one who has taken the trouble to read carefully the evidence of the Select Committee will see that the 1645 great nursing schools, especially in London, play an important part, and ought to be duly considered in any question of examination and registration. I, therefore, regret that there is no recognition of nursing schools as such. I was looking the other day at the constitution of the Board for the certification of midwives, and I find that it is not made up mainly from midwives themselves, but from persons more competent to judge of what is adequate training. I should like to see the independent side of the council in this Bill somewhat strengthened, though 1 admit the change as proposed is immensely for the better. I have not made these observations because I am in any way hostile to the Bill. It is impossible that the Bill can become law this session, and, therefore, I hope that, after it has been reprinted with these Amendments and fully discussed in Committee later, the Government will bring in an agreed Bill next year on these lines which could be passed as a non-contentious measure. When we consider that so great a name as that of Miss Florence Nightingale is to be found among the critics of the Bill as it stands, it is clear that the question is not quite so plain and simple a one as some people imagine.
§ *THE EARL OF CREWE
My Lords, may I supply one omission which I made by inadvertence? I omitted to state that among the Amendments there is one to Clause 20, making a small fee payable by every registered nurse in respect of registration.
§ LORD ASHBOURNE
My Lords, the I Amendments that have been placed on the Paper by the Government indicate that they have given careful attention to the matter with every desire to put the Bill in a shape that will commend it to general approval and meet some of the objections taken in different directions to its clauses. I think the course indicated by the noble Earl a prudent one. After the Bill has been reprinted with the Amendments incorporated, the 1646 House will be in a better position to judge of the effect of the Amendments. I have read them with close attention; and am disposed to think that the Bill I will be largely improved by the Amendments, with many of which I find myself in entire accord.
I do not propose now to say anything with regard to the details, but it would be unbecoming that I should pass by without any reference to the proposal to exclude Ireland from the operation of the Bill. I cannot for the life of me understand why that step was proposed. The noble Earl stated that the Local Government Board in Ireland felt that there was some administrative difficulty. Why should there be any administrative difficulty? What is it? The Local Government Board are not troubled with hospitals and do not control nurses, except in the case of infirmaries; and, with the exception of a few letters that would have to be written by somebody in the office a few times a year, no labour would be thrown on the Department. I cannot conceive why the nurses in Ireland, persons of high character who have gone to great trouble and expense in becoming thoroughly trained, should be excluded from the advantages to be found in this Bill.
Ireland has suffered a great deal in the past by these exemptions. When the Midwives Act was passed some years ago Ireland was omitted, to the great detriment of a highly-respectable class in Ireland who are now compelled, in order to get their qualification, to come over to England. It is true that power is taken to enable an Order in Council to extend the Bill to Ireland and to make the slight changes necessary in order that that may be done; but why should not Ireland be included in the Bill straight away? I am sure I shall not lack support if, when this measure comes forward again, I move an Amendment replacing Ireland in it.
§ LORD AMPTHILL
My Lords, the noble Earl who leads the House has rather taken the wind out of my sails, if I may say so. I think the understanding was that I was to wait for criticisms and then say what I had to say; and I had arranged privately with the noble Earl that I would make the proposal to him 1647 that the Bill should be dealt with in the particular way he indicated.
§ LORD AMPTHILL
I hope it is permissible to explain that the suggestion was my own. I was going to make it to the noble Earl, and he was going to accept it. However, it comes with much more force from the noble Earl, and I am encouraged to hope that your Lordships will accept it. There are one or two matters of detail to which I should like briefly to refer. I am in the pleasant position of being able to accept all the Amendments of the Government, with a few reservations. I recognise in them an earnest of the goodwill of the Government, and an evidence that they are prepared to treat the Bill seriously and to do their best to help the promoters make it a thoroughly workable measure.
It has been a great satisfaction to me that those who have spoken have recognised that these Amendments do effect considerable improvements in the Bill. I ask therefore to be allowed to agree to those Amendments provisionally—that is to say, without prejudice—so that when the Bill is recommitted according to the arrangement suggested it will be open to me to make a few objections. I can promise your Lordships that those objections will be very few, and they relate principally to the exclusion of Ireland. I cannot help thinking that this exclusion is due to some misapprehension. In the first place, there is no body of nurses who are keener on this subject of State registration than the nurses of Ireland. They have been at immense pains to promote their efficiency, and they had practically the whole of the organised medical profession in Ireland at their back. I cannot help thinking that the noble Earl himself will get into very serious trouble with the Irish Party in the other House if he persists in the exclusion of Ireland. I have very certain information that the Irish Members in the other House have regarded this matter with strong resentment, and the worst of it is that they are putting the blame for what the noble Earl has done upon your Lordships' House. What is being said is that this is simply the doing of the House of 1648 Lords, and another instance of the traditional hostility of this House to I Ireland. I hope, therefore, that the noble Earl will reconsider this proposed Amendment. We have already had his assurance that it was merely provisional. I assume that it is rather more than that, and I hope the noble Earl will give his very careful attention before the Bill comes up again to the question of restoring Ireland. The other Amendment to which I should have to take exception is the Amendment to Clause 17; but, if we are not going to discuss these Amendments, clause by clause, I need not go into that point.
I now come to the Amendments which have been suggested by other noble Lords. First of all there is the proposal of my noble friend, Lord Mayo. I am afraid that his is an Amendment which I should be obliged to object to. It is framed on the analogy of the law relating to motor cars. That is a very misleading analogy. There is no similarity whatever between the duties of chauffeurs and trained nurses. If you were to do as the Amendment proposes and endorse a nurse's certificate, that would be the end of her career. Supposing a nurse does commit an offence which would render her deserving of being struck off the register, that would be done by the council to be established by this Bill. The effect of the Amendment, therefore, would be to take cut of the hands of the council this duty of maintaining discipline, and to put it into the hands of the Civil Courts. I hold, therefore, that the Amendment is out of harmony with the scheme of the Bill as amended by the Government, and one which ought not to be accepted.
The argument used by Lord Stanley of Alderley that no registration would prevent a nurse becoming unfit is old and exploded. Nobody claims that it would. Registration would imply only that at a stated time a nurse had received a certain amount of training and had passed an examination. In no profession is registration claimed to be a guarantee of continuing efficiency. Barristers, for instance, may be unable to keep up their knowledge of the new laws introduced by Parliament, yet they retain their qualification. Similarly, doctors may not be able to keep up with the advance in medical science, but their registration holds good. In the case of 1649 nurses there is another consideration, and it is that the training of the nurse is really a matter of technical skill, and technical skill once acquired by long and laborious training is a thing that you cannot lose altogether. To use a popular illustration, it is very much like skating, or swimming, or riding. Once learned you never forget it, although there may be twenty years of want of practice and disuse.
My noble friend suggested that one of the arguments in favour of the Bill was that it would be a panacea for every kind of evil. I do not think that has been claimed by any of the advocates of State registration. The noble Lord made some further suggestions on the subject of inspection, but I think it must have escaped his attention that the Bill provides that the council shall have power to appoint inspectors if and when that course should be necessary. I do not think I need say anything further except to express once more my gratitude to the noble Earl for the very generous way in which he has treated me with regard to this Bill. I fully appreciate the fact that he has given it most careful attention, and has sought to make it a workable measure at a time when he is overwhelmed with a great deal of other important business. I am certain I can speak for all those who are so earnestly advocating State registration when I say that this action on his part will be fully recognised and duly appreciated, and I think it is a good augury for the future and a reason for confidence that this Bill, in spite of what has been said by one or two noble Lords this evening, may even pass into law before the present Session comes to an end.
§ THE MARQUESS OF SALISBURY
My Lords, I think perhaps the most important circumstance in reference to this Bill which has taken place to-night has been the speech of the noble Earl the Leader of the House. There were not very many of your Lordships present when the Bill was read a second time, but those of us who had the advantage of being here listened to the speech on behalf of the Government on that occasion with a considerable amount of interest, for we did not quite know what line His Majesty s Government were prepared to take with regard to this Bill. The noble Earl, 1650 however, has made a much more definite statement this evening, and has indicated a much more definite attitude than he did on the Second Reading, because he has, on behalf of the Government, given notice of a large series of Amendments which very much vary the machinery and some of the principal provisions of the Bill. I do not know whether that indicates on behalf of the Government a more favourable attitude towards the Bill than they were disposed to take when it was last under consideration. If it were so, that would have considerable weight with me, because I think a Bill of this sort ought properly to be passed with the assent of the Government rather than by a private Member of your Lordships' House, although my noble friend has every right to be heard on a subject of this kind.
As regards the debate this evening, I do not like to say anything which might disturb the harmony of your Lordships' proceedings, but I must express agreement with many of the criticisms of Lord Stanley of Alderley. I am afraid that many of your Lordships expect too much from this Bill. I listened to the speech of Lord Ampthill, in moving the Second Reading, with very great attention, and I expected that he would reveal to your Lordships a state of things showing that reform was urgently called for, and that he would be able to quote instances and adduce arguments which would show that without the registration of nurses great evils existed and would continue to exist. My noble friend, as he always does, made a very good speech, but he spoke under rather adverse circumstances. Many of your Lordships had left the House, intent, no doubt, upon business. It was about 8 o'clock, and there were comparatively few Members prepared to take part in the debate. Consequently it was quite evident that my noble friend cut his remarks much shorter than would have been the case had the circumstances been otherwise; but I am afraid the effect of it on my mind was that my noble friend did not make out his case—that is to say, he did not reveal any great evils under the present state of things which registration would do away with. He did undoubtedly quote certain scandals that had arisen, but it was pointed out by the noble Earl the Leader of the House on the Second Reading and it has 1651 been pointed out again to-day by Lord Stanley of Alderley that none of those scandals would be touched by the Bill.
§ LORD AMPTHILL
I regret to interrupt the noble Marquess, but my object was to show, not so much that there were evils to be remedied, as that there were improvements to be affected.
§ THE MARQUESS OF SALISBURY
I am very glad to have elicited that interruption from my noble friend. I understand, then, that he admits there are no great evils at the present moment which his Bill will remedy, but that there are improvements which the Bill will effect. That is an important statement.
§ LORD AMPTHILL
If my noble friend is going to treat this as an important statement, I should like to say that I did not state that there were no evils. I said my object was more to dwell upon the advantages which would result from the Bill than on the evils which it would remedy. But there are evils, of course.
§ THE MARQUESS OF SALISBURY
Then the evils remain a mystery. The noble Lord thinks that great improvements may result from the Bill. I am not disposed to deny that there may be improvements resulting from the Bill. The noble Lord cited a great weight of authority which he said was in favour of the measure; but I think my noble friend will have recognised by this time that the universal character which he attributed to that support was overstated, for many eminent doctors and others engaged in the training of nurses are opposed to the Bill. I do not deny that there may be improvements resulting from this Bill, but I agree with Lord Stanley of Alderley that the improvements can be very much exaggerated. The truth is that it is impossible to test by means of an examination whether a woman is a good nurse or not. That I have on high authority, and I believe it to be true. No doubt technical qualifications are necessary, but they are not all that is necessary for a good nurse. Indeed they are not the chief part of what is necessary for a good nurse. I heard my noble friend say just now that nursing was like skating, or any other technical accomplishment, which could 1652 never be forgotten. I do not think a more misleading statement could be made. The essence of nursing is a matter of continual practice That is what makes a first-rate nurse and nothing else. It is not like the case of a doctor. You send for a doctor; he gives his opinion, and that is the end of the matter.
§ *THE MARQUESS OF SALISBURY
No doubt he writes a prescription, if the noble Lord thinks that an important correction. But the qualifications of the nurse are much more important than the technical skill winch an examination is designed to ascertain. Her attention is continuing by day and by night. It is in her practice, her conduct, and her temperament, that her most important qualifications are to be sought. While, therefore, I agree that technical skill is essential and that an examination is useful for the purpose of testing technical skill, I submit that you have not then ascertained whether the nurse is a good nurse or not. Therefore, I think the benefits to be derived from this Bill may easily be exaggerated. But if His Majesty's Government and your Lordships think that it is well that the technical qualifications of a nurse should be the subject of registration, I certainly should not desire to oppose that view. The Amendments which the Government have placed on the Paper seem to me to be valuable Amendments, and the few months which will be available before the Bill comes before us again will be useful in securing that a successful and advantageous measure should be the result of the deliberations in your Lordships' House.
My Lords, I think we shall all agree that some improvement has been made by the Amendments which His Majesty's Government proposes to insert, but I do not think they remove the very great blots which are in the Bill. The noble Lord in charge of the Bill adopted the argument, Once a nurse always a nurse. He said they could not forget their qualifications. I venture to think that would not be endorsed by those in charge of many of our large nursing establishments; and before the 1653 Bill is again taken in the autumn your Lordships will probably receive information which will lead you to change your mind and not allow the Bill to go through in its present form. The Bill, even with these Amendments inserted, does not prevent unqualified women from calling themselves nurses and continuing to practice. We shall still have those who are not competent practising as nurses. The only thing is that they will not be able to call themselves registered nurses. Other Amendments will be required in order that hardship may not be done to district nurses. I understand that the period of training in Ireland is only two years. If, therefore, all the nurses in Ireland are to be declared unqualified and uncertificated, that will be a very undesirable state of things. Then I do not think the case of district nurses is entirely protected; and I believe a large number of the best nurses in our largest hospitals are strongly opposed to registration. Even as amended, the Bill is, in many respects, very unsatisfactory, but I hope that, by the provision of further Amendments, it will be made of benefit to all nurses and not merely to a few.
§ On Question, Motion agreed to; House in Committee accordingly; Bill reported without Amendment; Standing Committee negatived; Amendments made; Bill recommitted to a Committee of the Whole House, and to be printed as amended. (No. 164.)