§ Order of the Day for the Second Reading read.
LORD ALNESSMy Lords, I hope that you will not regard me as unduly intrusive if I again essay to address your Lordships —this time in support of a Nursing Bill. I am reassured when I recall the consideration which your Lordships have always been good enough to extend to me, and also when I recall the intrinsic importance to Scotland of the Bill, the Second Reading of which I am about to move. The Bill, like Gaul of old, is divided into three parts. One part sets up a new grade of assistant nurse. A second places restrictions on the use of the title "nurse." A third establishes control, by a system of licensing and inspection, of certain institutions or agencies for the supply of nurses to the public, which are commonly known as "nurses' co-operations."
The need for action to be taken on these lines was considered and realized by two Committees which sat, one in England and one in Scotland. The English Committee was presided over by the Earl of Athlone, and of the Scottish Committee I had the honour to be Chairman. Both these Committees reported in 1938. The Bill for 352 England was introduced following upon the recommendations of the Athlone Report, and also the recommendations of another Committee which sat under the presidency of Lord Horder. That Bill, the Nursing Bill for England, is now upon the Statute Book, under the title of the Nurses Act, 1943. In Scotland, after consultation with the appropriate nursing authorities, my right honourable friend found that while there was general agreement with regard to two of the points which I have mentioned—namely, with regard to the use of the title "nurse" and the control of nurses' co-operations— nevertheless there were serious reservations made by those who were consulted regarding the question of whether there should be set up a grade of assistant nurse. A grade of assistant nurse was approved of, and recommended, by the Athlone Committee. My Committee, on the other hand—and it was a very strong and representative Committee—unanimously declined to favour that proposal.
When the Bill for England became law it became apparent to my right honourable friend that something must be done concerning the questions which had been elucidated in the English Bill with regard to Scotland. Accordingly he reassembled, or rather I reassembled at his request, the Nursing Committee which had sat with me in 1938, and discussed with them anew the question of the grade of assistant nurse. They intimated that they stood by their Report. So did I. They told me so, and they told the Secretary of State so. But the Committee and I felt that, looking to the march of events in England, something must be done in Scotland. Accordingly, with some reluctance, the Nursing Committee for Scotland agreed to the insertion in the Bill of a provision setting up the grade of assistant nurse for a temporary period, which has been fixed by the Secretary of State at five years. I may say that that limited proposal has the approval of local authorities in Scotland and of medical officers of health in Scotland, who assent not only to the proposal but to the form in which it is embodied in this measure.
As regards the term "nurse," as your Lordships must be well aware, there is nothing to-day to prevent any person from describing herself as a nurse and from carrying on nursing duties, though 353 she may have no training or experience whatever and no qualification for the purpose. The general public is thus very often misled, and the shortage of nurses, which has been aggravated by war-time conditions, has made it very clear that there are many of these unqualified persons employed to-day who have no right to claim the title "nurse." As regards nurses' co-operations, some of these are entirely reputable organizations, but some are quite unscrupulous, and supply nurses who have and had little or no training or experience, at high fees, to an unsuspecting public. Scotland certainly needs to be protected, having regard to the restrictions which are now on the Statute Book applying to England, against an invasion by that type of "nurse," and accordingly this Bill essays to stop that undesirable invasion.
It is trite to say that, in any remedial measure, such as this is, one inquires first of all what is the mischief which exists, and secondly whether the remedy proposed is apt and appropriate. I hope that I have demonstrated that there are mischiefs which require remedy, and I hope now to satisfy your Lordships that this Bill provides a remedy which is both apt and appropriate.
Part I of the Bill, Clauses 1 to 6, and the First Schedule, provide for setting up a roll of assistant nurses, with certain ancillary machinery. That roll is to be kept by the General Nursing Council for Scotland. They will make rules for admission to the roll, for training to qualify for the roll, and with regard to institutions where the prescribed training may be given. The rules made by the Council will be subject to the approval of the Secretary of State, and will also be laid before Parliament. The roll will consist, in the first place, of existing assistant nurses, who will be admitted without examination if they satisfy the Council of their knowledge of and experience in nursing. The roll will be enlarged by women who are admitted by examination after having undergone the prescribed course of training.
Clause 2 (3) is vital. It provides that no person will be able to qualify for admission to the roll unless her training has begun before the expiry of five years from the commencement of the Act. That clause embodies a vital compromise, and is an integral part of this measure. Then come Clause 3 and the First Schedule, 354 which provide for the formation of an Assistant Nurses Committee of the General Nursing Council, on which assistant nurses will be duly represented. This Committee will deal finally with all disciplinary problems which relate to the roll, and will report to the Council on any other problems as they think proper.
To protect the general public against unqualified nurses, the Athlone Committee and the Horder Committee favoured action being taken to secure that only State-registered nurses, assistant nurses and student nurses should qualify to nurse the sick habitually and for gain. In other words, they favoured a closed profession. Clause 6 of this Bill, while it does not go so far as that, provides that no person other than a registered nurse or enrolled assistant nurse may use the title "nurse," with certain exceptions. This clause will give the public the assurance that a person who calls herself a nurse in fact has nursing qualifications. I have referred to certain exceptions. These exceptions are to be decided by regulations made by the Secretary of State for Scotland.
I now come to Part II of the Bill, Clauses 7 to 12. This sets out to control nurses' co-operations. These co-operations, under the Bill, can supply only registered nurses, enrolled nurses, certified midwives and other classes of person prescribed by the Secretary of State. That means that these co-operations can no longer supply unqualified persons to nurse in hospitals or to nurse private patients. These co-operations must also inform the patient of the qualification of the nurse with whom the patient is provided, and the selection of the person to be supplied must be made under the supervision of a registered nurse or a doctor. As a further measure of control, the Bill proposes to make nurses' co-operations subject to licence and inspection by county councils, and by town councils in the larger burghs.
I now come to Part III, Clauses 13 to 21. These clauses include certain miscellaneous provisions, two of which are of such importance that I feel constrained, even at this late hour, to draw attention to them. The first is Clause 14, which is designed to provide a ladder from the assistant nurse group right up to the State-registered grade. In its original 355 form that clause was not found acceptable in another place, and was therefore remodelled. The effect of the clause as redrawn is that a remission of a period of training for the fully-qualified grade will be available only to women who have been enrolled as assistant nurses and who have at some time before their enrolment been student nurses, training for the fully-qualified grade. This seems to us a reasonable proposal. The Royal College of Nurses is satisfied with Clause 14 as it now stands.
Lastly, I would refer to Clause 18 and the Second Schedule of the Bill. Clause 18 provides for the establishment of a new list of nurses by the General Nursing Council. This is a purely transitional provision. Admission to that list will be open to nurses who would have qualified for admission to the State register during the period of grace conferred upon them by the Nurses Registration (Scotland) Act, 1919, which I had the honour of sponsoring, but who, for a variety of reasons —for example, being abroad, or being about to get married—omitted to qualify in the way prescribed by that Act. Accordingly this clause proposes that a new list of these nurses should be made out, and should be kept by the General Nursing Council in Scotland. This list will be entirely separate from the State Register, and nurses who are on this list will not be entitled to designate themselves as State-registered nurses.
I apologize to your Lordships' House for the length of this exposition. I felt that it was due to your Lordships that I should give a comprehensive view of the measure, not only because it differs in a material particular from the English Bill, but because of its inherent importance to Scotland as a whole. I hope that I have demonstrated, first of all, the existence of certain mischiefs and, next, that the remedy proposed by the Bill to cope with and cure these mischiefs is adequate. I now beg to move that the Bill be read a second time.
§ Moved, That the Bill be now read 2a.— (Lord Alness.)
§ LORD CRAIGMYLEMy Lords, I am loath to trouble your Lordships at this late hour. I had prepared a Second Reading speech, but I think it will best meet the general convenience if I put it in my pocket and 356 confine myself to a very few observations, among which I should like to place first the fact that the noble Lord, Lord Alness, who has so successfully steered many measures through another place in other days, retains his noted skill at the helm. Of course, the noble Lord could not say everything about this Bill, and he has skated, with his usual agility, over some extremely thin ice. I do not intend to trouble your Lordships with observations which would perhaps be more relevant and convenient on the Committee stage, but I really must, in justice to two great classes of people, say a few words.
My first word is this, that those who criticize this Bill endorse what the noble Lord and other distinguished people have said about the need for keeping this great profession efficient. There is no difference of opinion between us on that whatsoever. The noble Lord himself is an expert on this question. On the question of nursing efficiency and on the question of remuneration of nurses, Scotland owes a great deal to the noble Lord, for the Alness Committee's Report is one of the landmarks in this stretch of country. It surely ought to be possible to keep the profession dignified and fully efficient, and yet to do justice to a fairly large class of nurses to whom the noble Lord has not referred, and to do justice to the people of Scotland. Scotland differs from England in this respect, that Scotland has a waiting list at this moment for hospital treatment of some 11,000 persons. The Secretary of State for Scotland has great sympathy with these people. He has done a great deal for them. He has opened to them, so far as it is possible during war, the Government hospitals owned and managed by the Department of Health in Scotland, and many hundreds of these people have been cured.
I have spoken to some of these people myself. Some of them have been seven or eight years upon a waiting list, and the long waiting list in Scotland is due as much as anything to a shortage of nurses. It is a shocking fact, but I have it on very high authority that, to take one class of ailing persons alone, persons afflicted with tuberculosis are dying to-day in Scotland in tragically large numbers for the want of nurses; and that shortage of nurses this Bill will tend to aggravate. So I plead first on behalf of the suffering population of Scotland and I plead next on behalf of the 357 large body of nurses, V.A.D.'s, Red Cross Nurses and nursing auxiliaries who, during more than three years past, have in fact been trained, and, as the noble Viscount, Lord Elibank, knows from his intimate connexion with the Red Cross, have been doing fine service in responsible nursing in these Government hospitals as well as in military hospitals. I went the other day into one of these E.M.S. hospitals and saw a seriously wounded soldier who had just been brought in from the operating theatre: by his side was standing a nurse with a red cross on her apron. I said to the skilled State nursing sister: "You have a few good nurses here." She said: "This one is a Red Cross nurse; you can trust her with everything."
I desire therefore to draw attention to Clause 14. This clause in its original form was acceptable, but in its present form it bars out any consideration whatever for these nurses. It treats them as outcasts permanently from the profession unless they go through the whole thing from the very beginning—washing and scrubbing and all. That clause is not in a condition in which it ought to leave your Lordships' House. I have some hope on that matter. I hope that the noble Lord will, on the Committee stage, do something to put that injustice right. It seems impossible to argue that the responsible nursing being done by these people might as well never have been undertaken, it seems hopeless to say that no value whatever can be attached to it. There is also the financial side. These people are earning from £55 to £70 per annum—much too low a wage. But if, after having done four or more years of responsible nursing, they seek to take up the nursing profession, they have not only to go back to the very beginning and return to "train" for the work they have already been doing, but their salaries will drop from £55 to £40, rising to £50 in the third year. In view of the urgent need for nurses in Scotland, such discouragement to a class who have acquired some skill and training is surely not consistent with elementary common sense.
On this point I have some hope from the noble Lord, and also on another point. In Scotland, as I have ventured to indicate, we have a condition of affairs in regard to hospitals which does not prevail in England. We have a number of ex- 358 cellently equipped and finely staffed hospitals which are Government hospitals. They are owned and managed by the Department of Health for Scotland. They are just as much Government hospitals as Naval or Military or Air Force hospitals. They could not, of course, be included in the 1919 Bill because they did not then exist, but there seems to be no reason why this Bill should go through Parliament without creating these hospitals into institutions where under proper conditions the necessary training will take place so that they may be, under proper conditions, treated as training institutions. I hope the noble Lord will see his way to meet us and those who speak on behalf of these Red Cross and other nurses on that point too.
I now come to a point where I am without hope—that is on the question of the closing down of entries to the roll of assistant nurses after five years. That is not in the English Act at all. The English Act creates this roll of assistant nurses and says nothing about its being purely temporary. And had it not been for the knowledge and the persuasive qualities of my noble friend Lord Alness, the Scottish Bill would no doubt have followed the English Bill in that particular.
§ LORD CRAIGMYLEOh, yes. It was entirely owing to the special qualities and persuasiveness of the noble Lord that the temporary nature of that clause exists and that I have no hope whatever of his acceding to any demand on the subject. The main point of those who criticize the Bill is the injustice to the suffering Scottish public by a Bill which tends to perpetuate the shortage of nurses, and the injustice to the nurses who have now nursed in a responsible way for several years, that some little encouragement should not be offered to them to go into the profession where their services are so much needed.
LORD KINNAIRDMy Lords, I should like to say a word or two in support of Lord Craigmyle particularly from the point of view of the V.A.D.'s and the Civil Nursing Auxiliaries. My noble friend made the point, and Lord Alness made the same point, that the number of State registered nurses is insufficient. Even if this situation were improved we maintain that there always will be, both 359 for hospitals and for private nursing, a demand for less highly trained and less expensive nurses. Therefore not only in justice to the V.A.D.'s and the nursing auxiliaries but in justice to the public and the patients, the services of the V.A.D.'s and nursing auxiliaries should be recognized. We have one thousand V.A.D.'s in Service hospitals and over one thousand in Government hospitals in addition to thousands of Red Cross nurses, so that the number is important. Are we to encourage these nurses, consistent with skilful nursing, to take up nursing as a profession, or are we to discourage them, as Lord Craigmyle has made clear this measure will discourage them? I say "skilful nursing" because it has been urged that the important point is that the standard of nursing should be kept up. Your Lordships will find it hard to believe that the standard of nursing is going to be lowered because such people as experienced V.A.D.'s are kept in the service.
It is the public and the patients who will suffer if these nurses are driven out of the service. Driven out a very large number will be. Their services are regarded as of no avail and are not to count when they wish to take up the profession of nursing. Is it not just from these nurses that we can get the very best material in the country—nurses who are able to take up the responsible posts? What type of nurses are we referring to? As Lord Craigmyle said, there is no thought that we should in any way lower the standard. These nurses new occupy responsible posts in hospitals. In hospitals I know, V.A.D.'s under a sister are doing the entire nursing duties of the wards. Is that of no value in their training? They are being trained in Government and Service hospitals by some of the most experienced sisters and matrons in the service. Is that of no value to them? They are people who, of their own free will, in peace-time, gave up their time and their services to be trained in hospitals, in classes, and in camp in order that they might come to the help of their country in time of war. Is that not to count at all when we consider where we are to put them as regards training?
An important economic point is this, that by the experience they have had 360 these nurses know whether or not they are suitable and prepared to adopt nursing as a profession. Matrons from their experience know whether they are suitable persons who may be recommended. That is not the case with the ordinary probationer. In the case of probationers you may have a large number on whom you spend time and trouble in training, and finally they turn out not to be satisfactory. In that way it is an economic folly to turn down these V.A.D.'s of whom you have already had experience. I read in a leading nurses' journal that a distinguished matron says that the most essential qualities for a nurse are common sense, courtesy, and kindness. These same qualities are very important for all of us. From what you have heard from Lord Craigmyle your Lordships will find it hard to believe that these nurses are people whose services should be regarded as of no avail. If all that we can say to those who have given the best years of their lives in training to help their country, and are willing to give further service by becoming professional nurses, is that their previous service has been of no use and is not to count, you will agree it is time that some drastic changes were made.
If under the present system it is held that their years of service are not to count, I would appeal to the Secretary of State to take steps to see that the system is altered. Surely some arrangement can be made so that the years they have spent in Government hospitals under the training of good matrons can be recognized. Of course it can. It is nonsense to say that this time has been wasted and is of no avail. I shall not keep your Lordships longer, but in conclusion I do hope the Government will agree to Amendments which will make this measure fair and just to V.A.D.'s and nursing auxiliaries so that the patients and public of Scotland will not be deprived of the services of these nurses in the years to come.
§ LORD GEDDESMy Lords, all of us who have looked into the question of V.A.D.'s realize that they are in a very hard and difficult position. They were asked to volunteer and they volunteered. They trained, and within their capacity they have done splendid work. I have the greatest appreciation and admiration for the V.A.D.'s, but I trust that the point urged by the two noble Lords who have just spoken will never be conceded by the 361 Government. What we are trying to do is to build a highly skilled nursing profession. In order to get a highly skilled profession there must be systematic training, and the continual confusion that arises in all lay minds about nurses is that if women have had experience in a hospital they are trained. They are not. A properly trained nurse is very nearly as highly skilled a person as a properly trained young doctor in the actual work of the ward and the attendance on the patient, and it is most important that the Council responsible for the standard of nursing training, the maintenance of discipline and the professional standard of the nurses should control the training right through just as the General Medical Council is responsible for the training of doctors.
It is absolutely clear to me that although the V.A.D.'s have been, through no fault of their own, put into a most difficult position the best thing they can do, if they wish to take up nursing as a profession, is to enter at the beginning and get the training. Some of them have had training of a sort, some of them have had a good deal of experience, but not, perhaps, foundational training, and it is in the interest of the public, who will be nursed by these women later, that they should be trained thoroughly. What we have to aim at is a high standard for the future. If you take into the nursing profession now a large number of women who have not got the basic training you will just set the clock back, and I beg your Lordships to support the Government if it be the intention of the Government to resist the Amendments which are put down in the name of Lord Craigmyle for insertion in the Bill in Committee. If the Government show signs of being weak on the subject I hope your Lordships will try and stiffen them. It is in my view, speaking as a person of considerable medical experience, most important that we should not allow anything to be done that will mortgage the future standard of nursing that we are going to have in Scotland and throughout the country.
VISCOUNT ELIBANKMy Lords, I am sorry to have had to listen to a speech of the kind just made by my noble friend Lord Geddes, because I know he carries great weight in these matters on account of his experience and former association 362 with the medical profession. I should like to ask him to go back in his mind to the year 1756, I think it was, when the General Medical Council was inaugurated. I looked at the Act and I found that in it permission was given to appoint to the doctors' register, in order to start that Council and enable the register to be inaugurated, individuals who were not properly trained but had practical experience and were regarded as good doctors by their colleagues. It seems to me we are dealing with a very similar case to-day.
This is a Bill to register nurses. There are quite a number of nurses who are entitled to be included in the register set up by this Bill. There are also quite a large number of nurses who have had practical training in hospitals of different kinds during this war who, I venture to suggest, from the point of view of nursing, are far more capable, because of their practical experience in war hospitals, of finishing their training and becoming accomplished nurses than some of the younger people who will come in right from the commencement. After all, nurses who have shown a sense of duty because they believe in the nursing profession, and have given, on a voluntary basis, not only their time but everything, sometimes for very little pay at all, surely ought not to be flung incontinently away, as suggested by my noble friend Lord Geddes in his speech.
§ LORD GEDDESWhat I suggested was that they should now undergo training.
VISCOUNT ELIBANKMy noble friend suggests that they should undergo training, as if they never have had any experience. My whole contention is that the experience they have had during this war should be taken into account and they should be admitted to this register, it may be after such examination as would prove them to be sufficiently good to be appointed to this initial register. I think the greatest and most grave injustice will be done to the V.A.D.'s and to the auxiliary nursing services if this Bill passes through Parliament in its present state. I quite understand that the Royal College of Nursing, like my noble friend, desires to have on the registers the most skilled and experienced nurses that can be found, but they must face up to the situation as it is and also have a certain 363 human feeling regarding those who have been rendering these services to soldiers and sailors and others during this war.
My noble friend Lord Craigmyle referred to the dearth of nurses in Scotland to-day. He is quite right. Village nurses are non-existant, or almost non-existant, to-day. Maternity nurses are not to be found. If this Bill is passed in its present state, what is going to happen after the war? My noble friend says, "Oh well, wait, we are going to build up a very fine skilled nursing profession." In the meantime what is to happen to the unfortunate people in the country districts who cannot get nurses to help them and who cannot themselves go to the infirmaries or hospitals because of the distance or lack of means of conveyance? We have got to face up to this Bill not from the point of view only of the Royal College of Nurses, but from a practical point of view and from a Parliamentary point of view, from the point of view of what is best for the community as a whole in the circumstances in which we are living to-day. I shall have the greatest pleasure in supporting any Amendments, assuming I agree with them, when they come before this House. In the meantime I sincerely hope 364 that the noble Lord, if he is going to make any reply to-day, will give us some indication that he intends to consider the Amendments that are to be brought forward not only sympathetically but practically.
LORD ALNESSMy Lords, I think it will best suit the convenience of the House if I defer my reply to the speeches which have been made until we reach the Committee stage. All the speeches which have been made have been, not so much on the Second Reading as on Clause 14. My noble friend Lord Craigmyle will no doubt move an Amendment to that clause in Committee, and I shall then make my reply for what it is worth to his speech and the other speeches which have been made to-day.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.