§ Order of the Day for the Third Reading read.
§ Moved, "That the Bill be now read 3a."—(Lord Ampthill.)
§ * THE EARL OF WEMYSS
My Lords, I am not going to make a speech, but before this Bill leaves your Lordships' House, I wish to say a few words concerning it. I do so because two days ago I received a letter from a nurse in one of the London hospitals, who is the daughter of an old respected tenant of mine, and who, on the death of her father, took to nursing as a profession, in which letter she expressed the hope that I would resist this Bill. I thereupon put three questions to her. The first was whether the whole of the staff of the hospital where she was employed—the London Hospital—were of her opinion. To that question she replied in the affirmative. I then asked whether the nurses in the other hospitals shared that view, and she replied that, with the exception of two hospitals, the whole nursing staff in London were opposed to the Bill. In my last question I asked for the reason. The reason she gave was this. That when once a nurse's name was on this register, though she might not be of high character, nothing but a crime could lead to her removal; and she asked me to read an article in this journal, The Hospital, which really confirms her own view, and the substance of which is that a person who is not at all fit for nursing may pass the examination, whereas a nurse who is in every way suitable may fail to pass. This lady also mentioned that Miss Nightingale is deadly opposed to State registration. I have great respect for the opinion of my noble friend who has shown great ability in carrying this Bill through its various stages, but in a matter of this kind I prefer to take my position alongside Miss Nightingale rather than with my noble friend. Therefore, if any Member of your Lordships' House moves the rejection of this Bill, I shall certainly vote with him. I shall not, however, take upon myself to move its rejection, but I have thought it right that your Lordships should know the opinion of nurses generally with reference to this Bill.
* LORD KINNAIRD
My Lords, I am sure it is the wish of every Member of your Lordships' House that consideration should be shown to ladies engaged in this honourable and useful profession, and that nothing should be done by this Bill to injure their position. It is however necessary that the interests of the public should be more adequately protected than the Bill at present does. I therefore venture to hope that when the Bill goes down to the other House it will be carefully considered there, so as to secure that unfit nurses are not allowed to continue to hold a certificate of efficiency.
LORD BALFOUR OF BURLEIGH
My Lords, I desire before we part from this Bill to say a few words in regard to it. I have not taken much part in the discussion of the Bill during any of its stages, but your Lordships may remember that earlier in the session, I made myself responsible for another Bill, which, on a division, did not meet with your Lordships' favour. I still think, though I am not going to re-argue the matter, that the policy foreshadowed in that Bill was wiser, both in the interests of the nursing profession and in the interests of the general public, than the proposal contained in this Bill; and if I could look into the heart of the Privy Council, I am confident I should find that, although they have taken a not altogether unfriendly interest in this Bill, the Privy Council—at any rate, the noble Lord who was Lord President of the Council at the time when the Bill for which I was responsible was before the House—largely share the opinion which I have just expressed.
This Bill has certainly been considerably amended, largely at the instance of the Privy Council, during its passage through your Lordships' House. It has been, I frankly say, a good deal improved; but I think it has been improved almost out of recognition as compared with what was contained in it when first presented to your Lordships' notice. I venture to say that very seldom has any Bill upon a topic which is largely uncontroversial been so altered as this Bill has been. But even now I am afraid that it is more likely to do mischief than to do good. I do not propose to divide the House against the Third Reading, having regard to the 6 course which has been taken by the noble Viscount who represents the Privy Council in amending it as he has done; but I venture to say, with some confidence, that the apparent guarantee which is given in this Bill by registration will be found in practice to be largely a delusive guarantee, and will not effect the intentions—the laudable intentions, to some extent—of those who are promoting it.
Now, my Lords, what does this Bill do? It proposes to have a register of nurses, and it appoints a council for the purpose of keeping that register. Practically everything else in the Bill is machinery. Taking, then, the fact that there is to be a public register of nurses kept by an authority largely under the guidance of the Privy Council as the central fact of the Bill, what will it, in practice, effect? It will only tell the public that upon that register such and such nurses' names appear, that those who are upon the register have undergone a certain minimum of training in their profession, and that they have passed a certain examination. There will be, by the fact that their names remain upon the register, not the slightest continuing guarantee that their efficiency is maintained. There is no sort of guarantee really given. Yet what many of those who think with me feel about the proposal is this, that the public will be deluded into believing that, because a particular nurse's name is on this register, therefore the State is guaranteeing the efficiency of that lady for the honourable and noble profession which she intends to pursue.
It surely is perfectly obvious that many of the qualifications most required in a nurse are just those which cannot be tested by any form of examination, whether qualifying, competitive, or otherwise. The examination is a test of knowledge, and it is a delusion to say that there is any analogy between the profession of nursing, and that of either the medical profession or the calling of midwives. In both the medical profession and the profession of midwifery it would be idle, of course, to deny that personal qualifications and personal adaptabilities are not of the first importance. In both those professions there must be, for the public safety, a certain modicum of actual professional training and skill; 7 but no one, I think, who knows the circumstances can deny that, as compared with them, the profession of nursing is one in which personal characteristics, adaptability, and suitability of the individual—just those qualifications which cannot be tested by examination—are of the first and the highest importance, registration will certainly prove that the nurse has passed a certain technical examination, but it will not give the slightest clue to her character, her adaptability for all the requirements of the sick room, and her capacity for working with others with whom she may be called upon to work; and many of the evils which are now alleged will be only too liable to go on unchecked, because, although for certain professional misconduct there is a power to strike a name off the register, I think it is perfectly obvious to those who know what human nature is, that, except in cases of almost notorious misconduct, people will prefer not to make the complaint and certainly not to go through all the difficulties and obloquy involved in having any woman's name struck off the register. Therefore it seems to me that on that ground, even if it stood alone, the supposed guarantee given by this Bill will not be effective.
Taking the other line, the examination guarantees probably certain efficiency at the time of passing the examination, but will the efficiency be continued? Supposing a woman passes an examination now in nursing qualifications, her name will be placed permanently upon the register; but what will be the guarantee that is given of efficiency twenty, twenty-five, or thirty years hence? Yet, however much, either from advancing age or any other cause, a nurse has deteriorated there will be no power on those grounds to remove her name from the register. I cannot speak from personal knowledge in this matter, but I am told that even if a nurse was hardly sensible and hardly able to look after herself, it would not be under this Bill considered sufficient ground for striking her off the register, nor would there be any power to do so. It seems to me that far the wiser course would be to give the public the means of protecting themselves, by providing for a register in which the full qualifications and training of nurses should be set out. 8 There is no obligation in this Bill, so far as I can see, to give more than the mere fact that such and such a lady has had a certain amount of professional training and passed a certain examination.
That is all I have to say as regards the main part of the Bill. I hope it will be carefully scrutinised in another place. I believe that there is much field still for inquiry in regard to the whole matter. I ventured during the Committee Stage of the Bill to allude to the power given to a certain body known as the Matrons' Council in the bringing into operation of this proposed measure. I understood the noble Lord who is responsible for the Bill to say that there were some 200 persons upon that council. The noble Viscount the Lord President undertook to make inquiry in regard to that matter; he has most courteously supplied me with a certain amount of information, and the accounts of the Matrons' Council were sent to me in print. If I read them rightly, the income from subscriptions is something like £30. I may be wrong, but that is how I read the accounts. The annual subscription for membership of the body is, I understand, 5s. Therefore this does not work out to anything like 200 Members. I understand that some further information has been supplied to the Lord President of the Council; but the suggestion I make—and I make it in all seriousness and earnestness—is that, if not in this House, at any rate before the measure passes the other House of Parliament, the fullest public information should be given as to the constitution of this Matrons' Council, where the members come from, of what hospitals they are matrons, how long they have been members of the council, what guarantee they have shown of their interest in the matter, and how far, in fact, it is a body which ought to be trusted with the great powers given to it under this Bill. As I have said, I do not propose to divide the House on the Third Reading. I think that, upon the whole, the course recommended, as I understand, by His Majesty's Government, that the Bill should be allowed to pass, is probably the wisest in the circumstances in which we are placed; but I am personally far from satisfied that the Bill has not in it the seeds of at least as much mischief as it has promise of good.
THE LORD ARCHBISHOP OF CANTERBURY
My Lords, the noble Lord in charge of this Bill will, I presume, say something to the House before the Motion for the Third Reading is put. Possibly the noble Viscount the Lord President of the Council may desire to say something too. If so, there is a point upon which I at least greatly desire further information. This Bill deals with a matter as to which we multiply to a certain extent on the evidence of experts; it is obviously not a matter on which we can speak first hand with real authority and full knowledge.
When this proposal was first made a number of years ago, lists of names were produced of those in favour of and those against the proposal. Those lists were closely scanned, I have no doubt, by many of your Lordships, certainly by me, and never in my life have I, in comparing two lists, felt more markedly the contrast between those names which should weigh and those which merely count numerically. The weight of authority put forward against the measure as it then was, first of great leading physicians and also of matrons of practically nearly all the hospitals and nursing institutions in London and of a large number in the provinces as well, seemed to me to outweigh the mere numerical statistics put forward as to the number of ladies, all unknown to fame although no doubt most excellent, who thought the passing of such a Bill desirable.
We were told that in some points the Bill would be modified, and it has been modified to a very large extent. Will the noble Lord in charge of the Bill tell us whether the eminent physicians and the matrons to whom I have referred have changed their opinion in consequence of the modifications made, and are now prepared to support the Bill? If they have, I shall be ready to bow to such a decision, but I have seen no evidence in the public prints to show that they have changed their opinion. Failing that, one has to fall back upon such private information as one can get; and from the inquiries I have made I find no evidence of such a change. I have no hesitation in saying that anyone who will examine and weigh the names of those who stand on the two sides will come to the conclusion that we are somewhat precipitate if we go ahead 10 in a matter of this kind in the teeth of such counsel. I have no wish to obstruct the Bill unnecessarily, but if the information for which I have asked is not forthcoming now I hope it will be forthcoming in another place before the Bill becomes law.
§ * LORD AMPTHILL
My Lords, I had hoped that a Bill which had passed through all its stages in your Lordships' House without a division, in spite of the fact that it had been twice in Committee and that considerable Amendments had been introduced, would have been allowed a Third Reading without further criticism of comment, and that it would not have been necessary for me to take up your Lordships' time by once more recalling the circumstances in which this Bill has been introduced, and reminding the House of the support which has for twenty years past been given to the movement in favour of State registration. I confess that I am extremely astonished at the nature of the criticisms just made by the three noble Lords who have spoken, and most particularly by those which fell from the most rev. Primate. I think I can trace the origin of them I all. Those attacks were all inspired from the same source; but that is a personal matter which I will leave alone.
Let me, in the first place, deal with the very astonishing comments which have been made by the most rev. Primate. He said in the first instance, that he desired the evidence of experts, and, secondly, he asked your Lordships to believe that those in favour of the Bill could only show mere numerical superiority, whereas those opposed to it could bring forward a list of weighty and eminent names. I cannot for the life of me conceive where the most rev. Primate has obtained his information. I can only suppose that he has thrown into his waste paper basket the numerous printed papers and other sources of information which have been sent to him and to other Members of your Lordships' House. In the circumstances, and as the most rev. Primate has challenged me to give him the information, I am obliged to detain your Lordships by going once more over old ground.
This movement, as I said just now, started some twenty years ago, and 11 during the whole of the intervening period it has obtained a steadily increasing measure of support. If there had been any opposition to the movement which was reasonable and strong, surely that opposition would have organised itself in that time; but the contrary is the case. There is absolutely no organised opposition to the Bill. On the other hand, we can show that practically all the nurses who have any sort of organisation for the benefit of their profession and for the promotion of their mutual interests are in favour of the principle of State registration. I will give chapter and verse. Its supporters include the Asylum Workers' Association, with 3,000 members; the Society for State Registration, with 2,360 members: the Royal British Nurses' Association, with 2,000 members; the Matrons' Council, with about 200 members; the Irish Matrons' Association, with 40 members; the Irish Nurses' Association, with 450 members; and twelve separate leagues of nurses, with a membership numbering 1,700. If that is not expert opinion, I do not know what is. Certain it is that no organised body of nurses has taken steps to oppose the Bill. I should also add that, though nurses are not organised in Scotland, the Scottish Registration Committee is strongly in favour of the Bill.
Then we have the support of, I will not say the overwhelming majority, but of a very large and striking preponderance of opinion in the medical profession. The General Medical Council, the governing body of the medical profession, pronounced unreservedly in favour of the principle of State registration in 1889. The British Medical Association, which numbers 21,000 medical practitioners throughout the country, voted decidedly in favour of the principle on three occasions—in 1895, in 1904, and in 1906; in 1906 they carried a resolution in favour by a vote of ninety out of ninety-three, which is about as near unanimity as you can possibly get, and that was not a casual vote, but a vote of delegates from constituencies which had considered this question for two years. You could hardly have a more deliberate and decided opinion from any body than that given by the medical profession.
A number of other representative institutions interested in the subject in 12 various ways, such as the National Union of Women Workers and the Women's Industrial Council, have expressed similar opinions, and I should be very much surprised if those bodies had not sent their representations to the most rev. Primate, just as they have done to other Members of this House and to myself. Further, the question was considered in two sessions by a Select Committee of the House of Commons, who heard all expert witnesses who were willing to come forward. You cannot go further than that. Noble Lords have asked that there should be further inquiry, and have suggested, in a manner which I cannot regard as quite ingenuous, that this Bill has been rushed upon the House and that there has not been full inquiry. I do not know what more you can do than have a Select Committee which hears all the evidence. That Select Committee pronounced in favour of registration, and in favour of the particular Bill of which I have the honour to have charge.
§ * LORD AMPTHILL
Yes. Two Bills were before the Committee, and this was one of them. If your Lordships wish for further evidence of the opinion that exists, you have only to look to the immense commotion which took place in, Ireland when His Majesty's Government decided temporarily to exclude Ireland from the Bill. Meetings were held in every prominent centre in Ireland, and the most eminent people connected with that country wrote letters of sympathy if they were not able to attend.
There is opposition, and I will not copy the example of that opposition by using the argumentum ad hominem, by scoffing at and deriding the personnel of the movement. I will merely refer to their objections. They were stated at greater length than by other speakers by Lord Balfour of Burleigh, and his first argument was the worm-eaten one that you cannot register character. That has become a sort of catchword amongst the 13 opponents of registration, and they seem to think it satisfies every requirement of reason or logic. The answer is that we do not propose to register character. What we propose to register is proficiency, and we say that you can register proficiency amongst nurses just as you register proficiency in many other important professions. The noble Lord said that even if you record that a nurse has passed an examination and attained a certain standard, that proficiency might be lost. I think it is hardly necessary to argue in your Lordships' House that technical skill, manual dexterity, and trained powers of observation once acquired are not lost. A nurse who had once attained proficiency after three years training would not become professionally unsafe except from physical disability or moral deterioration. The former is easily ascertained by those engaging a nurse, whilst the latter would be dealt with by the nursing council who would have power to remove from the register any nurse unfit to be upon it. We do not expect lawyers to read up every new law that is passed, and yet they are not considered to deteriorate in proficiency. Nobody, again, expects a doctor to keep abreast of all the rapidly increasing improvements and advances in modern science, and yet when once upon the register he is considered fully qualified. The familiar instances of swimming, riding, skating, shooting, and other exercises of skill, show that proficiency once attained is generally retained for long years even when the art is not practised.
But there is another advantage in registration which those who oppose it seek to obscure by loose reasoning. The value of any professional register is dependent not on the fact of registration, but on the supervision of training, the enforcement; of national standards, and the maintenance of discipline. I am quite aware that a considerable number of London hospital managers do not care for what they consider State interference. That attitude was reflected by the noble Earl who opened the discussion. That attitude is perfectly intelligible; but you might just as well have stayed the whole course of reform in factory legislation because there were a few model employers who thought, perhaps with right and reason, that they could do better for their workmen if they 14 were left to themselves. But legislation, surely, must be for the imperfect general mass, not for the perfect few. I offer that to the noble Lord as a gentle retort to the arguments which he used against me.
The noble Lord said that the Bill was improved out of all recognition. I cannot agree. No essential principle in the Bill has been changed in the smallest degree. The drafting has been improved, and for that I owe grateful thanks to His Majesty's Government and to the Department of the Privy Council. Largo Departments of State have been safeguarded. I refer, of course, to the sick berths of the Navy, and to the nursing department of the Army. Amendments for that purpose have been introduced, but otherwise the changes have been merely in the direction of improving and simplifying the machinery which the Bill is to set up. The noble Marquess who sits below me expressed himself on a previous occasion as opposed to the Bill. He declared that what really needed remedying were the scandals in nursing homes, of which he admitted the existence to a very serious degree. I should like to take this opportunity of assuring the noble Marquess that that is one of the principal objects of the Bill. The mere creation of a standard is in itself the only means of removing scandals. A nursing home with nefarious designs will no longer be able to engage nurses who have no proper qualification when once the public are able to ascertain for themselves whether or not a nurse has attained to the recognised degree of proficiency.
The noble Lord on the cross benches, Lord Kinnaird, is, I think, anxious on behalf of cottage nurses, and I think that some other noble Lords have shared his anxiety. I should like to remind the House that cottage nurses, as apart from trained district nurses, are almost always midwives, and that as such they are registered under the Midwives Act and hold their certificates. Surely it is fair and reasonable to do for nurses what has already been done by legislation for midwives. I have some practical experience of the administration of the Midwives Act, with which I have to deal in my own county, and I can assure jour Lordships that there can be no doubt whatever of the benefits which that Act has conferred. There is a most marked and visible improvement 15 in the methods of the midwives and in their desire to comply with the law and to become more proficient; and the survivors of the system which is now obsolete are fast making way for a new and more efficient class of midwives. I believe there is a movement for extending the Midwives Act to Ireland, which is in itself proof that the registration of midwives is valued in practice.
The noble Earl who opened the discussion asked your Lordships to consider that the opinion of Miss Florence Nightingale outweighed all the professional and expert opinion which I have quoted in support of the Bill. Although I yield to nobody in admiration of Miss Nightingale as a great and patriotic woman, to whom we owe the whole foundation of the system of nursing, I cannot take quite that view of the influence of her opinion. Miss Nightingale must be getting on in years, and it is hardly credible that she should have been able to keep up with the present movement. Again, the noble Earl was in error in regard to the provisions of the Bill. He admitted that he had received his information from the London Hospital, whnn he stated that the only cause for removal would be crime. I must call the noble Earl's attention to Clause 10, subsection (6), of the Bill, which provides that the council "shall have power to decide upon the suspension or removal from the register of the name of any nurse for any breach of the rules and regulations from time to time laid down under this Act by the Council, or for conduct disgraceful in a professional respect." I must say I should have thought that the noble Earl, before using the undoubted weight of his influence to criticise this measure, would have at least taken the trouble to acquaint himself with the Bill, and would not have based his opinions, as he admittedly did, on the word of one single nurse from one single hospital.
Again, I believe the noble Earl has been entirely misinformed in regard to his statement that all the nurses in the London hospitals are against the Bill. I have very good evidence that there are many nurses in the hospitals of London, and even in the London Hospital, who ate in favour of State registration; but they dare not say so, because it would be as much as their situations were worth. 16 In conclusion, I cannot omit to mention the debt of gratitude which I owe to His Majesty's Government for the sympathetic consideration they have given to the Bill and for the valuable assistance they have rendered in amending it in such a manner as to suit the requirements of the various Government Departments. And perhaps I may also be permitted to thank your Lordships for the interest you have taken in the Bill, to which I trust you will now be good enough to accord a Third Reading.
§ * THE EARL OF WEMYSS
I might explain that what I said with regard to Miss Nightingale was that on a question of nursing I would prefer to take her opinion to that of my noble friend; and, as regards the opinion of nurses generally, the information given to me was that, with the exception of two hospitals, all the nursing staffs in London were opposed to my noble friend's Bill.
§ * THE LORD PRIVY SEAL AND SECRETARY OF STATE FOR THE COLONIES (The Earl of CREWE)
My Lords, as it happens, I was concerned with this question before my noble friend behind me (Viscount Wolverhampton), and therefore I rise to say a word upon the Third Reading of this Bill. The noble Lord who has just sat down has made a very clear and able defence of his measure, and if he put its claims somewhat higher than the facts actually warrant, after all that is only what most of us do when we are in charge of Bills, and we sometimes credit them with having more effect than they will have in practice.
Whatever may be the merits of this measure, I do not think it will create a revolution either in or out of the nursing world. The main criticism which has been levelled at it was fairly expressed to-night in the speech of Lord Balfour of Burleigh, and on one point I confess I find myself, as I have already often stated from this place, in some degree of agreement with him. I have always held the opinion that, unless some means could be found for establishing a continuing guarantee of proficiency, registration must lose a great part of its value; and I do not think that the noble Lord who has just sat down really answered the point that was made by my noble friend opposite, and has been made by others 17 to the effect that, after all, unless you can secure this continuing guarantee your register, so far as that part of it is concerned, does not very materially differ from the directory proposed by Lord Balfour—that is to say, it does not do much more than give the actual statement that a particular kind of training has been received by a particular woman a certain number of years ago. That, of course, is a serious criticism, and it is one with which I confess that I myself in some measure agree. And what also brings home to my mind the unreality of the whole business is that I do not think that if noble Lords are unfortunately obliged to call in the services of a nurse for themselves or their families—and I take noble Lords merely as an example—they will even inquire whether the nurse is on the register or not. I am sure that if I had occasion to call in the services of a nurse, I should get one, of course, through the recommendation of a doctor or from a hospital, but should not inquire whether or not the lady's name was on the register.
But there are considerations on the other side which have been stated very fairly by the noble Lord in charge of the Bill. In the first place, we must remember that a Select Committee of the House of Commons did give a very decided opinion in favour of a system of registration, and although we do not always follow the advice of Select Committees, yet that is a material fact quite apart from the weight of evidence which was brought before that Committee. In the second place, I do not think it can be disputed that, at any rate, so far as numbers are concerned, a very considerable majority of the nursing profession do ask for a register; and although I should not be prepared to say the same as regards the medical profession, I have no doubt there is a considerable weight of opinion in the medical profession on the side of the noble Lord. Then, in the third place, it is only fair to mention that the noble Lord has considerably modified his Bill, at the instance, I think, very largely of my noble friend's Department, in a manner which removes some of the objections taken to it by its opponents. The principal change, to my mind, is that the Bill is not now a Bill to register the whole nursing profession and in any way to treat being or not 18 being on the register as a test of efficiency; as the Bill now stands, the register is there for those who choose to take it, but there is no sort of imputation upon those who do not choose to join. That is a marked and material difference, which I think ought to be borne in mind. Under these circumstances I think that a balance of advantage undoubtedly exists in favour of the Bill, and consequently His Majesty's Government are fully prepared to support the Third Beading.
§ On Question, Bill road 3a and passed, and sent to the Commons.