SHORTAGE OF NURSES

HL Deb 09 November 1948 vol 159 cc283-313

3.15 p.m.

LORD CROOK rose to call attention to the grave shortage of nurses; and to move for Papers. The noble Lord said: My Lords, I have ventured to put this Motion on the Order Paper in view of the considerable national importance which in my view attaches to the subject. It fills only one line on the Order Paper and topics are sometimes judged by the number of lines devoted to them. I would point out, however, that the fact that this Motion occupies only one line is no indication of the amount of interest which we should give to the subject. It is not a matter which calls for any division among us in respect of Party feelings, but it is one which we ought to look at in relation not only to the nurses themselves, but also to our own efficiency as a nation. I am convinced that to a large extent the success or otherwise of the Health Service upon which we have recently embarked will be determined by the number of nurses we have, and on the health of the nation which that Health Service an create will largely depend the efficiency of our economic life and the proper use of our man-power.

I think that nobody participating in a debate of this kind should fail to commence by paying a tribute to all that the nurses have done for us in recent years and particularly during the war. Florence Nightingale might well have been proud of the work that the nurses did during the war—standing by in alerts and, though perhaps themselves terrified at times, comforting the patients who were lying unable to look after themselves. Unfortunately, in looking at this problem I think we have suffered from a number of vicious circles. One set of facts has contradicted another, and so we have been presented with a considerable problem. I do not think the public properly understands what the problem is. From some of the comments in the Press and some of the remarks one hears from the public, one would be led to believe that some sudden event had happened depriving us of a large number of nurses; that a sudden shortage, which few people understand, had come upon us. Those of us who have had anything to do with the nursing services know that there has been a shortage since the end of the First World War, and that over a long period of years there have been constant inquiries into it. That excellent medical newspaper The Lancet appointed a commission of inquiry as long ago as 1932.

The truth is that to-day we have more nurses and more trainees in the hospitals than ever we had before; but we have also a graver shortage of nurses than we have ever before experienced. Although there are 7,000 more employed now than a year ago, and in fact 31,000 more employed than in 1938, and although there are 51,000 student nurses training in hospitals to-day, as against 43,000 in 1938, yet this huge shortage persists. I find that at the moment there are 33,000 actual vacancies registered at the Appointments Office of the Ministry of Labour, and that the estimate of hospital committees of the shortage to meet present-day needs is no less than 50,000. But even if we could secure this number of nurses immediately, it would still represent a figure short of the number needed to carry out certain essential reforms and to meet the potential growth of the health service. The very least estimate which can be made of these needs is a further 25,000; and, of course, we have to add to that the making good of the ordinary annual wastage of, perhaps, 10,000 a year, resulting from the loss of student nurses and ordinary resignations.

What the public fail to realise is that over the last half of a century the nursing service has grown right out of its former relation with the growth of the population. From a nursing service of 68,000 at the beginning of the century there has been an increase to 191,000 to-day. The increase has been necessitated in part by the expanding population, but the greater part of the growth has been due rather to the new conception of social care and welfare upon which Parliament and the State as a whole have embarked. I am sure that we all have sympathy with the Ministry of Health in the great problems which they have inherited in launching this new health service at this particular time. On the other hand, the fact that for the first time we now have centralised control at the Ministry of Health over services means that at last we can have effective planning and determination of the relative priorities of various reforms and of services needing expansion.

While we began the century with a hospital or nursing service based mainly on the need of treatment of the sick-poor, we have now developed an all-in nursing service, covering many things other than institutional treatment. Only some 60 per cent. of our nursing man-power is deployed in institutions nowadays; the 1,000 voluntary hospitals and 2,000 State or municipal hospitals taken over in the new State service take about that percentage. The other 40 per cent. are engaged on the other new health services, related to prevention and care, which we have partly built up and which we have to build up further in the next two years. School nurses, for instance, were not known until 1908. To-day we have 2,500 of them, or one nurse for every 2,000 children. But we have committed ourselves, in the new educational standards which Parliament has adopted, to achieving a proportion of not more than 1,000 children to each nurse. That in itself calls for doubling the number of nurses for that service alone.

Then as to health visitors. While, at the end of the First Great War, we had only 2,800 of these, mainly part-time, we now find ourselves with about 6,000, of whom 3,600 are whole-time employed. I understand—and the noble Lord who is to reply on behalf of the Government will correct me if I am wrong—that the Royal Sanitary Institute estimates that until we have 8,000 health visitors we shall not have a sufficient number to handle the problems with which they are charged. Infant welfare, centres, which numbered 650 at the time of the First World War, have increased to the number of more than 6,300, and that figure is growing. The same considerations apply to nursery classes. We had 400 of these at the beginning of the Second World War and by the end of it the figure had grown to 2,000. We added some 415 residential nurseries for children who had lost their parents. We have 500 tuberculosis dispensaries for diagnosis, apart from treatment. We have X-ray and radium centres, pathological centres, blood transfusion services, radiography units, rehabilitation centres and the like in respect of all of which we need to deploy the nursing man-power that we now have.

May I here say a word about another body of people who have given magnificent service to the community, and who have had very little recognition? I refer to the Queen's Institute Nurses, to whom I would like to pay a small tribute this afternoon. As to the future of this body, many of us know very little, and many of us wonder greatly about it. Those tireless women, together with the county and local midwifery services, are rendering every day, in the more remote country districts and also in the densely populated streets of the urban areas, services second to none in the world, and I consider that we should all pay a tribute and express our gratitude to them.

I think we ought also to realise where we are going in the matter of industrial health services. I was most encouraged to learn that, as the result of the activity of my right honourable friend the Foreign Secretary, when he was Minister of Labour, industrial health services grew during the war so that when it ended we had some 7,000 nurses deployed in that work. I am sorry to see, however, that that very poor figure has now dropped to 4,000—I call it a poor figure, because I understand that even with the 7,000 not more than 30 per cent. of the population was covered by the services. Certainly so far as shops, offices and the like were concerned, there was no industrial service at all. I am sure your Lordships would be the first to say that an industrial health service is of vital importance in this country. So long ago as 1938, it was estimated that £100,000,000 of productivity was lost by sickness absenteeism from factories and workshops, which with the additional cost of the treatment represented a total loss of £300,000,000, or about 7 per cent. of the national income of the country. Anything in the way of a shortage of nurses which militates against the growth of an industrial health service is, I suggest, deeply to be deplored.

Looking back over the last half century, I suggest that we have seen the development of a new conception in the matter of this service. It is a service that must go on growing a great deal more, and it is already showing some of its dividends. We see them in the improved physique of the children by whom we are surrounded; we see them also in the declining curves relating to disease—a matter upon which probably the noble Lord, Lord Amulree, who I understand is to speak later, will have something to say. We see them in the increasing span of life of which we are all conscious, so conscious, indeed, that we find Parliament has to consider new problems which have arisen owing to the increasing longevity of the population. All these services, however, will become nothing if we fail to provide the necessary man-power in the nursing service.

I am sure we all welcome both the Red and White Books which we have had, and the Reports of the Working Parties—on the nursing services. I would like to congratulate the Ministry, and my right honourable friend the Minister, on the action which has been taken in connection with these Reports. I feel sure that your Lordships will desire that those of us who speak to-day should say how much we appreciate the great volume of effective work accomplished by those who sat as members of the Working Parties. The Reports—both the Majority and the Minority Reports—make very clear to all of us that the new health service has inherited a large quantity of very bad traditions and very bad conditions. They make clear the difficulties and they make clear, also, the first of those vicious circles to which I referred at the beginning of my speech—namely, that until conditions are improved in the worst of the hospitals both nurses and student nurses will continue to leave the nursing services, while, on the other hand, until we get more nurses we shall be unable to improve the very conditions against which they complain.

I think it is regrettable that in most of the material I have seen in the newspaper reports, it is the inadequacy of pay of the nursing profession which is stressed. The Working Party makes clear, and I am hoping that as a result of the discussion in your Lordships' House this afternoon members of the public will be clear, that it is not true that pay is the main fundamental difficulty in the nursing protession. What is wrong is that the ancient idea of the cloistered life of the sister, on which the nursing service was based, is continuing, far too long, and the traditional detachment from the life of the community is perpetuating a way of life which is different from that which we know in our everyday existence to-day. Matrons and sisters who were brought up in the old tradition, the hard way, seem in many cases to make it one of their duties to see that new girls who come in to-day are brought up the hard way as well.

I have no doubt that the nursing profession is, and will remain, a profession on a loftier plane than many others, but it has to be moulded to the new conceptions of personal freedom that have swept over this country in the past twenty-five years. The nursing profession has no more right to encroach on the personal life of its members than has any other profession to which your Lordships or any part of the community belong. Nurses must have the same sense of freedom in nursing as have the shorthand typists who work in offices to which your Lordships and I may repair, who come in at nine o'clock in the morning and depart at live or five-thirty at night with their day's work done, perfectly clear that at the end of the week they are going to get away for at least a half day on Saturday and a whole day on Sunday, and probably, in the five-day week, from five or six o'clock on Friday until Monday morning.

Not so nurses. Although a shorthand-typist can go out when she likes and with whom she likes, and can come home when she likes, the nurse, when she gets away from the ward, is all too often still tied down by the same traditional rules she has been experiencing all day in the course of her work. Even if she is fortunate enough to work in a ward free of petty restrictions and tyrannies, she will still find in the nurses' home—not in all, but in many cases—poor accommodation and all sorts of restrictions: perhaps no ability to smoke, because smoking is forbidden; no ability to go to the pictures, because by the time the big picture is over and she returns to the nurses' home she will be ten to fifteen minutes after closing time and will be subject to discipline. In one of the cases I investigated recently, a married woman who had gone back in her widowhood to her original profession of nursing left the ward at eight o'clock and went to the local cinema, where the main film started at 8.40 p.m. and finished at about 9.50 p.m. She decided to stop to the end and, as a result, arrived back at the nurses' home at ten minutes past ten. She was made to stand outside the door of the night sister for fifteen to twenty minutes and then was reprimanded like a child for coming in late, with the result that she resigned the following morning. Nothing we could do to dissuade her stopped the resignation from being effective. This nurse was lost to the service because of a complete lack of imagination—a lack of imagination which is evident in various places again and again.

We have only to pick up our daily papers to see what is going on. Those of us who looked at them last Friday saw two instances. We saw reported the discussion at the Margate Employment Committee over the difficulties of staffing the Kentish Hospital, where the matron had tried to discipline two nurses who spoke to male nurses on the same staff. We saw the reply of my right honourable friend the Minister of Health, in which he dissociated himself from the action of a London matron who had imposed a colour bar at a dance in respect of one of her own nursing staff, a Colonial citizen working in the best interest of the London community. And those who study and investigate these maters present us, in documents such as the Minority Report, with even grosser examples.

Many of your Lordships will remember Dr. Cohen, who was in the Cabinet Office and who is now in the University of Leeds. He presented a valuable Minority Report—and by saving "valuable" I am not suggesting for a moment that I accept many of the conclusions to which he came. The Minority Report points out, among other things, that when some more progressively-minded women are given senior responsibilities, they are frustrated in their desire to help in this problem. The Report recounts the case in which a young matron, seeing the absurdity of this ten o'clock rule, prepared to have keys cut which could be distributed to the student nurses to allow them to come into the Home after a social engagement. The nurses who received the keys were very happy, but the sisters of the wards resigned the following morning as a protest against the lack of discipline shown by the matron. When we have a community of that kind we are faced with a good deal of difficulty.

I am not suggesting that a good many rules are not necessary in the running of an institution which has the responsibility for young girls sent by their parents to be trained as nurses; but what I am suggesting is that there can be some sense of balance between two extremes. One thing the new management committees have to embark upon is securing that balance. It should not be difficult for many improvements to be made inside the nurses' homes. For instance, the average girl who lives at home with her mother, however fond she may be of her mother, would resent her checking not only the tidiness of her cupboards but also the contents. For some reason I have never discovered, however, in many of the nurses' homes I have known it is regarded as a perfectly ordinary thing. The Home Sister has the right to check through the contents of cupboard and chest of drawers in the nurses' rooms, presumably to satisfy some curiosity of somebody about something none of us could understand.

There are some good nurses' homes. We have gone a long way from the bad ones of the past. I can remember the time when, as a trade union agitator in the municipal nursing world, I regarded it as a great success to get as improvements the equipment of an old workhouse, with fitments of gas piping built up to six feet high down long dormitories, with curtains to make what we were proud to call "private cubicles" for the girls. To-day, we have homes with individual rooms, properly equipped with hot and cold running water, with good furniture and with the amenities which one is entitled to expect.

I welcome the fact that the Working Party have recommended that attention be given to this matter, and I hope that we shall have action by the Ministry to press the hospital management committees to do what they can in the improvement of nurses' homes. I realise that we are living in difficult days. We want houses built for workers to live in, factories built so that we may manufacture more to export, and it is a little difficult to start pressing the Ministry to put up beautiful new homes for nurses when we have not even enough hospitals and health centres. But the time will come when the Ministry will have to give this matter priority. I suggest that there are many things which can be done by way of adaptation and alteration within existing buildings which will achieve good results until it is possible to accomplish all that we would like to see done.

Similarly, the hospital management committees could deal effectively with what the Working Party regard as the second main complaint, which is about food—the inadequacy of food, its poor quality and its bad presentation to the people. Unfortunately, I have had enough ill health in the last three years to have had experience inside hospitals, as well as having a background of some thirty years of trade union experience in connection with them. I have been astonished at some of the things I have learned. I was a patient at one hospital which prides itself on the good advice given to its patients by its excellent doctors on the subject of their diet and how the food should be cooked and presented. I was amazed to find that at that hospital the night nurses' evening meal is cooked at quarter to twelve, midday, with the meal to be served at midday. It is then put by to get cold and is warmed up at 10.30 at night as the hot meal for the night nurses. In another hospital the food was given to the night staff to be cooked in the small kitchen attached to the ward, as best possible, without any relief time. I know the difficulties, but that is no way in which to organise the effective night life of women who are giving service of this kind. I think local management committees could put those things right.

Local management committees could also deal with the third main complaint of the Working Party—namely, that of the span and pressure of working hours. The recommendations of the Committee presided over by the noble Lord, Lord Rushcliffe, brought about a great deal of improvement in the introduction of the 96-hour fortnight. That has been applied, probably, in the majority of hospitals, although not in all. The operation of a 96-hour fortnight still does not give much of a life to these girls, and certainly does not give them a life which, on hours, compares with the life of a shorthand typist. The nurse still has to report for breakfast at seven, and she is on the ward at half-past seven. She probably comes off the ward at half-past seven or eight at night. Her 48-hour week or 96-hour fortnight is achieved by giving her off-duty periods of two or three hours in the course of the day, which in the majority of cases is of no use to the girls. I am grateful to my right honourable friend the Minister of Health for advising management committees, in the informative booklet which I understand he has sent to them, to introduce the shift system at the earliest possible date. There has been a good deal of criticism of this, and allegations have been made that the shift system is impossible. The noble Lord who is to reply for the Government will be able to tell us, but I believe the Ministry are satisfied that the shift system is practicable and, indeed, that they have worked out schedules showing how it is possible in different types of hospitals.

I want to say something at this point on the views of Trades Union Congress. Since the lamented death of my noble friend Lord Dukeston (he was a very dear friend of mine for many years), I believe that I am the only one of your Lordships who is a member of the Trades Union Congress, and I should like to comment on their views. They have recommended the Minister to introduce the shift system, on the basis of a 40-hour week I want it to be perfectly clear that I am absolutely in favour, both of a shift system and of a 40-hour week. I think the programme of the Trades Union Congress, as a programme for long-term achievement, is completely good. But in face of all the facts and circumstances of to-day, desirable though the 40-hour week is, I am unable to suggest to your Lordships that it is capable of being carried out at present. I believe that if we can manage to get the shift system on a 48-hour week we shall be doing very well. It is up to us to try to make the nursing staffs understand that if we can manage to move that far we shall have gone a good way.

One other thing I should like to say in regard to hours is about time off. When girls are given time off—a day, a half-day or whatever it may be—they should know it is theirs, and that they are going to get it. In certain hospitals there is far too much reliance upon the whim of matron, or assistant matron, at the last minute, as to whether or not the nurse gets her time off. I personally have seen girls told, only an hour or two before going off duty, that their day off the following day is cancelled because there is a shortage on another ward and they are to be transferred. We would not keep our shorthand-typists in our service if we treated them that way. Again, I appreciate the difficulties in regard to administration, but some way should be found to get over those difficulties.

It should be possible to deal with all these problems not only through the management committees but, may I suggest to the Ministry, by joint consultative committees of the staff and management. Hospital staffs have been very little organised, and have been given very little opportunity to say what they think about their own conditions of work. I am glad to see that a National Whitley Council has been set up to deal with their ordinary conditions of service on a general basis. I want to press on the Minister's representative here this afternoon, the viewpoint of the Trades Union Congress Nursing Advisory Council and I suggest that he should take steps to secure that the local management committees set up these joint consultative committees of staffs at the earliest possible moment, with a view to encouraging understanding of the difficulties and of getting them accustomed to many new ideas. They ought to be able to help the local management committees to deal with the seventh item on the list of the Working Party's recommendations—namely, the recommendation for the removal of a large part of the domestic work from the duties now performed by members of the nursing staff.

I know that the Minister has recommended that steps should be taken in this connection. What I want to suggest is that very positive steps should be taken to see that the domestic work, such as cleaning baths and sinks, handling soiled linen, and even doing the linen repairs, should be taken away from nurses and put on to other effective domestic staff, in order that more time may be available for nursing, and that there may be effective deployment of what nursing staffs we have. I know that one difficulty (and this is another problem which the Ministry must face) is that domestic staffs are just about as short as nursing stairs. Therefore, in order to cure the shortage of nurses, we have probably got to tackle the shortage of domestics inside hospitals by organising an effective system of grading and organisation with attractive terms and a uniform. We have to cut out some of the drudgery by getting the help of some of the labour-saving devices which some of the more modern hospitals have. The Westminster Hospital is one familiar to many of your Lordships; and that is very much better equipped than many of the others.

One of the tasks which I think the local consultative committees can carry out is that of getting over to nursing staffs some of the new ideas which they must have about their profession. The staffs want some persuasion, and so, perhaps, do management committees. There are many new ideas. One of them, that of the employment of part-timers, I know, is causing a good deal of difficulty. The Trades Union Congress Advisory Committee have, on behalf of those who are organised in hospital life, urged that there shall be no more employment of part-timers.

I suggest that we must increase the number of part-timers, whatever the staffs think at the moment. It is necessary for us to make the staffs understand that only by increasing the present figures of part-timers can we carry out the reforms and cut down the present shortage. Where we should have been, particularly in the chronic hospital service, without the services of the 21,000 part-timers who have been put into employment during the past year or two, I shudder to think.

I believe we should use part-timers even in fields where they have not hitherto been used in hospitals. Some of the minor clerical duties in wards, which the Ministry have recommended to management committees should be performed by clerical assistants to save nurses doing them, might well be performed by part-time clerical women working two, three or four hours a day. I took some part during the war in the mobilisation of the thousands of part-time clerical workers, and that reservoir of labour, now untouched in many of the suburbs of the cities, should, I suggest, be available for use by some of the hospitals.

Another of the new ideas to which nurses and all of us must become accustomed is the extension of the field of employment of male nurses. I spent many years on platforms agitating for a fair field and no favour for women, and I find myself this afternoon in the position of making an appeal for a fair field and no favour for men, because men are being put into the nursing service and are being offered no opportunity of a career value at all—no build-up of senior posts whatever. If we are to extend the use of male labour, and if we really want to make use of male nurses, we have to see that there are some senior posts to be reached by promotion, and try to build up a hierarchy which they can fill. Another new idea to which we must become accustomed is the use of the services of married women. For some reason, again not easily explained but probably related to that same idea of the cloistered life, the nursing profession inside voluntary hospitals has usually been regarded as something only for celibates. On the local government side of the Health Service we are employing up to 25 per cent. of married women, while the maximum figures ever reached in voluntary hospitals, I understand, are 7 per cent. to 8 per cent. That is another idea to which we must all give consideration.

The Working Party devote much of their time and many of their recommendations to details of training. I should have liked to go on to say something about the training of nurses, but for the fact that it is clear from the gracious Speech from the Throne that within the next few months a Bill is to be laid dealing with that subject. Clearly, your Lordships would regard it as out of order for me to discuss pending legislation here this afternoon. For the same reason, I forbear any comment about the overworked midwives and the grave shortage of midwives in this country. We are to have the Report of another Working Party on this subject, and I hope that my noble friend who is to reply will be able to tell us something about when we may expect it.

All in all, we are dealing with a difficult problem, and in what I have had to say in the past thirty-five minutes I have been able to deal with the subject only discursively, in a very rambling fashion and, I am afraid, without making many useful suggestions. However, I hoped that by raising the question this afternoon, I should at least initiate enough discussion to cause attention to be given to the problem and some spur applied in general, so that a way out might be sought. What I have ventured to say to your Lordships is that not only is there a problem, but there is a solution which a number of people are working hard to find. In particular, the solution must involve a realisation of the fact that there are modern trends and that we cannot run the nursing services only on a Florence Nightingale tradition. It has to be organised as a profession, with proper terms and conditions—conditions which any member of either sex can be expected to accept and to work under. They can still keep the traditions which they have held in the nursing service. The mere fact that we are trying to get them decent pay and conditions does not militate against their living under the rule of St. Benedict: Before all things and above all things, special care must be taken of the sick, so that they may be served in every deed, as Christ Himself, for He said: 'I was sick and ye visited Me'; and 'What ye did to one of these, My least Brethren, ye did to Me.' I beg to move for Papers.

3.56 p.m.

LORD RUSHCLIFFE

My Lords, I do not propose to take up more than a few minutes of your Lordships' time but, speaking for myself, I am glad that the noble Lord, Lord Crook, raised this question this afternoon. He referred to the fact that I have been for some time, and was until my Committee came to an end, the Chairman of the Nurses' Salary Committee which made a number of suggestions and, I think, did a good deal to improve the conditions and pay of the nursing profession. Perhaps the greatest service that that Committee rendered was this: it did, I think for the first time, bring home to the public the enormous debt we owe to the nursing profession. As I have said, it was perhaps realised for the first time how great that debt is and, up to now, how very inadequately that debt has been met. I am a perfect layman in these matters, and anything I say is the result of impressions which I have formed during my association with that Committee. I formed one or two impressions which may or may not be right, but at any rate I should like to tell your Lordships what they are.

In the first place, it is obvious, as the noble Lord, Lord Crook, said, that the major cause of the shortage of nurses is wastage during training. That, of course, is perfectly true. The wastage is something like 50 per cent. to 60 per cent.—it may be more. But it means that a great number of these girls go into the nursing profession and, for one cause or another, before their training is over, they leave it. No doubt many of these girls were from the start unfitted to be nurses and ought never to have entered the profession. On the other hand, I am quite satisfied that a great number of them leave, not because they do not want to be nurses or because they do not feel it is a vocation which they would like to follow, but because for some reason they feel they are being frustrated and are not given the chance which they have a right to expect.

Speaking for myself, I think this wastage will not be checked unless the responsibility for the training of nurses is separated from the responsibility of providing hospital nursing services. That, I imagine, is what we have in the medical profession. We have the medical schools, whose business it is to train the young medical student. He attends the hospital and he witnesses operations and so on; but he is a student. A nurse should be a student, and should have all the opportunities of learning her job as a student. That does not mean that the whole of her training is to be technical. Of course, she must visit the bedside and so on, and learn a great deal of Practical work. At the same time she should have every opportunity of learning her job as a student, like every other student should have an opportunity of learning his job.

What the noble Lord, Lord Crook, says is perfectly true, and I have heard of it so often. The student nurse finds that much of her time is taken up in doing work which ought to be done by either a housemaid or a charwoman. She is expected to help in the kitchen, to do all sorts of odd jobs which have no relation whatever to nursing, and she feels that she is not getting a fair deal to enable her to become accomplished and proficient in her profession. Therefore, those concerned must, if they can—and this ought not to be beyond the wit of hospital managements now—arrange that the training of the nurses is separated from the responsibility of providing the hospital nursing service. I know it is difficult, but, as I say, difficulties of this sort have arisen in industry, and I cannot help feeling that the hospitals ought to arrange for this to be done now.

During the last two or three years I have visited a very great number of hospitals, both in the country and in London. I find that when I go into a hospital I can sense almost at once whether the hospital is or is not what a sailor would call "a happy ship." If the hospital is to be happy (and the vast proportion of those that I have visited have been happy), it depends obviously upon what is done at the top—upon the matron. Of course there are exceptions, perhaps many exceptions, but on the whole I am satisfied that at the present time the great majority of matrons in hospitals are deeply anxious to do the best they can for the comfort and happiness of those entrusted to their charge; the old idea that students should be subjected to all the restraints which were perhaps prevalent fifty years ago has disappeared. I believe that the vast majority of matrons realise that the modern girl expects far more freedom, far more time to herself, and far less interference with her private life than was the custom a hundred years ago.

The noble Lord, Lord Crook, referred to Miss Nightingale. I read the other day a history of St. Thomas's Hospital written by a gentleman named Graves. It is stated there that the matron complained to Miss Nightingale of the conduct of a young nurse; she said of the young nurse "she uses her eyes unpleasantly." The record does not relate what Miss Nightingale said. I wonder whether the offender was dismissed, or whether she had to justify the matron's rather smug hope that: As her years increase this failing, an unfortunate one, may, possibly diminish. Even in these days of austerity I cannot see a modern matron taking up so rigid an attitude regarding the conduct of her students! All I hope is that the young nurse found a nice young doctor who did not think her eyes unpleasant, and that they lived happily ever afterwards. I hope that we shall hear something from the Government on this question of the splitting off of training from the responsibility of providing the nursing service, so that a student may really feel that she is able to learn her trade and become efficient, and will not be subjected to the sense of frustration which is now too often found.

3.45 p.m.

VISCOUNT SIMON

My Lords, I should not like this debate to take place without one or two words from these Benches; and, though I speak with very much less expert knowledge than either the noble Lord, Lord Crook—to whom we are greatly indebted for introducing this subject—or my noble friend who has just sat down, I do not surrender to either of them in point of real interest. If you are the grandfather of a nurse you hear a good deal about nursing! I am particularly interested in the discussion, so far as it has proceeded, as to what is fundamentally the thing that needs to be improved and pressed forward if the supply of young and good nurses in this country is to be adequate. I quite agree that the Working Party that made this investigation has contributed much to our means of judgment. I am quite willing to believe that the question is not primarily one of pay, though I do not know that I think that, generally speaking, the pay of a nurse is very good; compared with some other skilled professions it is certainly not good. Still, I am very willing to accept the point, but I do not think that that lies at the root of the explanation. I should have thought that the thing which is more important than anything else is that the young nurse should be helped to feel, and should feel, a sense of vocation. It is that sense, from such experience as I have had, which is really the essential thing in a successful nursing career.

No doubt it is true, as the noble Lord, Lord Rushcliffe, has said, that the modern nurse sometimes feels that she ought not to be subject to such strict control and that her free time should be in every sense free; and, as Lord Crook has said, when she is expecting to have that free time she should get it. In that respect nurses are rather like policemen: the policeman often finds that the time when he thought he was going to be off duty is the time which, for some pressing reason, he has to give up to duty. Personally, I feel—and I have considered this matter rather closely—that it is the sense that they really are discharging a function which is discharged, as in all tine vocations, for the benefit of other people and not entirely for themselves, which must lie at the basis of improvement of the nursing profession.

I was very much interested in the suggestion made just now, that perhaps there should be a greater separation than exists at present between the training of nurses and the provision of the nursing service. I am sure that if my noble friend says that, there is a very solid reason for the view. It is extremely difficult, of course, because a large part of the training of a young nurse consists in her assisting to do the very things of which her nursing service is composed. I have always wondered how a man begins to be a dentist. I have always hoped that at any rate I was not the person with whom he was dealing when he pulled out a tooth for the first time in his career. I suppose you cannot be a dentist unless you are practically experienced in the business. Similarly, from what I have seen of the nurses in hospital, it seems clear that hospital experience is essential. I feel that, if it is well conducted, a probationer does get in her preliminary nursing service, little by little, a very great deal of training that ultimately makes her a skilled nurse.

I confess to a little doubt—though I dare say that it comes from prejudice or ignorance—as to whether we can meet the present situation by having a considerably increased number of men nurses. Men nurses for mental cases, and for other specialised forms of attention, of course, are quite right; but I do not know about general nursing. Perhaps it is only the sentimental attitude of a man who, fortunately, in his own case is hardly ever ill, but I am inclined to think that I should get better more quickly if I had a ministering angel of the female sex. I question whether even the best trained man would do quite as well for me. It is interesting to consider that this word "nurse" (used for the moment to mean a female nurse) has really two senses. What is happening is that we are now seeking to provide for the community at large—and quite rightly—a nurse in sense other than that which is the more ordinarily understood. In one sense, a nurse is somebody who looks after a person when he or she is ill; on the other hand, in some of the more fortunate homes in this land, there has for a long time been included in the household somebody called a nurse, who is not there because anybody is ill but who is always on hand to help with the children. I conceive that one of the very great developments, in which we should all rejoice, is that we now realise, as has already been indicated to-day, that we ought to have a system of nursing, not merely for the people who are ill but for the general run of the small children in the land. It is a splendid development that we now see them more and more in connection with schools and other local and municipal organisations.

I certainly subscribe to the observation which has been made by my noble friend, that we cannot adequately measure—I doubt whether we can adequately repay—the debt that we owe to the nursing service. While there is still a very great deal to be done, I think we are entitled to say that this at least is one of the things in which improvement is taking place at an ever-increasing rate. Both of the noble Lords who have spoken referred to Florence Nightingale. It was only ninety years ago. As a very young man, I remember seeing her as a very old woman being wheeled about in a bath chair. Your Lordships all recall, perhaps, the observation that was made by the wounded soldier in Scutari when he pointed to the Lady with the Lamp and said: "Before she came, it was all cursing and swearing, and now it is as holy as a church." Enormous strides have been made in a direction in which that heroic person, with great difficulty and in the face of constant opposition, made the first advance. Anybody who has seen the recent film of Oliver Twist, and who considers the kind of nursing that existed in the poor-houses of this land as depicted in that story, can see into what a completely different world we have moved. The noble Lord, Lord Crook has rendered a real service, not only to the House but also to the country and to those who are training and carrying on the nursing profession, in calling attention to this urgent problem of the shortage of nurses and is discussing, as he has, without political bias but with very great knowledge, what are the ways in which that noble service may be further improved.

4.14 p.m.

LORD AMULREE

My Lords, first I should like to say how pleased we all are that the noble Lord, Lord Crook, has raised this question to-day. I would like to join with him most warmly in the kind things he said about the nursing profession. We are extremely grateful for the work they have done and are doing. What we should do without them I really do not know. I join with the noble Lord also when he makes a very good plea for more freedom and kindness in the training of nurses. I agree with the noble Lord, Lord Rushcliffe, that a great improvement has taken place, and, although one may find sonic matrons who still treat their nurses as though they were children at school, I think the large majority of them are rather more enlightened in that respect than they were before. As the noble Lord, Lord Crook, pointed out, one of the most worrying things about the nursing situation is that we have roughly a shortage of 75,000 nurses now, or we shall have in the very near future when the National Insurance Scheme comes into full being. That is a large number, and the chances of picking it up quickly are not great. What I would like to suggest is some different means of solving the problem.

One of the things that has never been made very clear is what is the job of a nurse. We know, of course, that it is taking care of the sick, but that is expressing it in general terms. One finds a large number of patients going into hospital who do not need full nursing attention. I should like to mention one or two types of patient. There are a large number of people who go into hospital merely for investigation. They may go in for one day only, or they may go in with some obscure complaint and it may take up to a fortnight or more while various pathological and X-ray examinations are being carried out to determine what is wrong. At present, those patients are put to bed in a general ward and are taken care of by skilled nurses as though they were sick people needing attention, whereas all they want is a certain amount of care and maintenance. So far as possible it is better for them to be up and about and not stay in bed while those investigations are being carried out. We have an opportunity to put an experiment of this sort into action, now that we have the new National Health Service. My suggestion is that in a certain number of hospitals or institutions, some of the wards should be turned into admission wards or investigation wards where people not needing full nursing care and attention could be properly taken care of, but would not need to be looked after by a fully trained nurse. That would free a large number of nurses to take care of people who were more ill.

There is another type of patient who, I think, may be treated in roughly the same way. Many patients have surgical treatment, and about ten or twelve days after their operation they are not fit to return from the hospital to their homes but they have reached a stage approaching convalescence. Provided there have been no difficulties or complications, they also do not need full nursing care and attention. They should be moved to some other ward where there would be one or two attendants to look after them, but not fully trained nurses, as we have at the present time. Then there is a third type of patient who could also free a good many nurses. I refer to the chronic sick in the large chronic sick institutions in this country.

One of the troubles has been that in the past, as I have mentioned on one or two occasions before, a large number of people who are chronically sick (the long-term sick) cannot get admission into the wards because they are full, and so an enormous number of tragedies have occurred in people's homes with consequent unhappiness. By encouraging the medical profession to take care of this type of patient properly—to treat them and to rehabilitate them—it is possible to speed up greatly the circulation in those wards, and to ensure that more people can be admitted to a given number of beds. That, of course, has two obvious advantages: first, more patients can be treated and, secondly, the nurses in those wards will not have quite the same boredom and distaste with their work, because they will feel they are doing some good. They will not be merely looking after Mrs. So-and-So while she is in bed for the next two years and until she dies; they will be treating Mrs. So-and-So in order to get her back to her family, or, if not to her family, to a home or hostel where she will not require skilled nursing but just some care and attention. I mention those points merely because I think this is an occasion when we might try an experiment of this sort. It is one which I think will be successful and will certainly go a long way to solving the problem of the shortage of nurses in the country at the present time.

4.22 p.m.

EARL BEAUCHAMP

My Lords, the noble Lord who initiated this debate has done a fine service to the country, because I believe a great many people do not know how serious this problem is. I venture to intervene only because since 1940 I have been a member of the managing committee of the County Mental Hospital in Worcestershire. On July 1 last that hospital, of course, passed into the care of the Government. But all that time we have been pursued by this bogey of an increasing shortage of staff, and I believe, especially after hearing what Lord Crook and Lord Amulree have said to-day, that that problem is going to overtake us completely unless something is done.

The present position is this—and I speak perhaps from a narrow point of view, that of a mental hospital, but nevertheless it is a very important point of view and one which will have to be taken into consideration when considering the whole vast sweep of medical services. We have a fluctuating number of patients. At present we have 443 men and 573 women. The 443 men are looked after by 44 male nurses, and the 573 women by 36 whole-time female nurses and six part-time nurses—we have already adopted the remedy which Lord Crook advocated. So you will see that we are seriously under-staffed in this hospital, especially on the female side.

I recently read a memorandum issued in my part of England (that is to say, the Midlands) by the Ministry of Labour and dealing with under-staffing. This memorandum pointed out that there were then—that being a month or two ago-32,000 vacancies for nurses in the whole country, and even more alarming figures have been mentioned by noble Lords this afternoon. The memorandum also stated that in the Midlands at this moment there are 2,000 vacancies for nurses. It explained how there are now so many more demands for labour than there used to be, so that hospitals are, as it were, competing in the market for labour. With regard to mental hospitals, the problem is even more difficult, because it is not everybody who is cut out to be a nurse in a mental hospital.

Several remedies have been mentioned this afternoon. As to short-term remedies, I think it will be generally agreed that anything a hospital can do to improve its accommodation and its amenities should be done. The particular hospital I have in mind is certainly rather old-fashioned. It was built about 100 years ago, so it is not surprising that it should be old-fashioned when you compare it with hospitals built nowadays. But that is not to say that we should not do everything we can to improve the rooms, the amenities and the recreations which are possible for the staff in all respects That is a short-term remedy. As the long-term remedy, of course it will be a long time before we can get new houses and up-to-date homes built for the nurses, but that will be done one day when the present housing shortage has eased somewhat and labour can be spared for it. Everybody knows that that is going to take time.

The noble Lord, Lord Crook, suggested the employment of part-time nurses. I am sure that is the right thing to do. To start with, the part-time nurses' age group is much wider than that of people who want to make nursing their profession. It has a much wider range, and there are, I think, many people who would be able to undertake work of this kind. My hospital has already started with six part-time workers, and we are going to get as many more as we possibly can. I hope the Government will assist in any way they can in getting part-time help, because I think it would largely solve the problem. Many suggestions have been made from all quarters of the House this afternoon which I am certain will be of help if the Government will investigate them, as I am sure they will. My last word will be to take this opportunity of endorsing what has been said by other speakers about the services rendered by the nursing profession as a whole during the war. I was in the Army for about four years and one could not be in the Army long without realising, even though one was not in hospital, the great part played behind the scenes by the nursing services. Later on, however, there was an occasion when I went into hospital for about five weeks, and I would like to take this opportunity of saying that I do not think the nursing and the attention could possibly have been better. For those and many other reasons, I believe every possible help ought to be given to the nursing profession to-day.

4.29 p.m.

LORD SHEPHERD

My Lords, I am in a little difficulty to begin with, because normally I would be required to make some comment on the speech just delivered, as I understand it is a maiden effort.

EARL BEAUCHAMP

May I correct the noble Lord? I have not made a speech for a long time, but it is not a maiden speech.

LORD SHEPHERD

Then I have been misled in that respect, and my task is therefore simplified. This is my maiden speech from this Bench, and I crave the kindness of all members of the House during my remarks and, I hope, the general support of the House for the work of the Government in relation to the hospital services. I could have wished for a different subject for my speech because, although I am fairly experienced in a great number of things, I must confess that the amount of time I have been able to give to the hospital services is very small indeed. As your Lordships will remember, during this discussion today some of the greatest experts in our land have been dealing with the material that has to be reviewed. So, if your Lordships will be kind to me I shall very much appreciate it.

It is important, I think, that it should be made clear that the present shortage in the hospital services is not due to some form of rot that has set in, and it has not been occasioned because the hospital services are going bankrupt. I read yesterday in the Red Book which has been referred to, in a part entitled "Staffing of the Hospitals," this short paragraph which, with your Lordships permission, I would like to read: Actually there has been no diminution in the rate of recruitment; the number of hospital nurses taking up and completing training for State Registration has for many years shewn a steady annual increase. The numbers of domestic staff employed have also increased. The trouble is that the rate of recruitment in both fields needs to be much higher still if it is to come within measurable distance of meeting the need. So the real problem that we are confronted with is not that of shoring up some decrepit institution but to arrange, if we can, for more rapid progress in every respect. Developments in the hospital services have not been altogether even. We want to get them even, so that those Services can become completely efficient.

I would like to quote a few figures, because some of the figures which have been placed before your Lordships to-day have not been quite accurate in their application to the subject with which we are dealing. Figures given, in most cases, have included figures relating to midwives. Now midwifery is a different service at present, and it is a service of which we would not normally think in relation to the staffing of the hospitals. The total nursing staff employed at present amounts to 180,000. This is 28,000 more than there were ten years ago, and the numbers are steadily increasing. The hospitals employ 52,000 trained nurses, and 44,000 other nursing staffs, and 48,000 student nurses are in training. A further 16,000 nurses are employed by local authorities and about 20,000 in miscellaneous services and private practice. Nevertheless, out of the 582,000 beds in hospitals, 64,000 beds are not provided with nursing services. There, I think your Lordships have the problem.

I would like to quote a little more out of that Red Book, because I think that it puts in a few words the reasons why these shortages have arisen. It states in this book that More hospital beds are now occupied than before the war and many thousands of patients are awaiting admission. There has been an increase of over 170,000 births per annum since 1940, which means that many more midwives are needed. The demand for nurses for other fields—e.g. industrial nursing and school nursing—has greatly increased. The Armed Forces, even in peace-time, have to make greater calls upon trained personnel in this field than they used to make, and there are overseas civilian needs which have to be met, in Europe, in the Colonies and elsewhere. I have given your Lordships figures. I have given you what are considered to be the principal reasons for this shortage. But here is another figure which will indicate the number of nurses that must be recruited if we are to cover present needs of the hospital services. The number is 48,000. With that 48,000 we could not merely cover the beds now unattended but we think we could guarantee a 96-hour fortnight, as mentioned in the debate to-day. But unless there can be that recruitment, then the granting of the shorter hours will be delayed somewhat and many reforms which we desire to bring about will not be accomplished.

Obviously, the salaries to be paid to nurses must have a considerable effect on the recruitment. It is clear that, when choosing a profession in the future, young people will think not merely of the amenities surrounding a profession but also of the amount of money that will come to them in return for their labours. A very important Report has been put before us by the Athlone Committee, out of which was established the Nurses' Salaries Committee, and that body, in association with the Whitley Councils, has furnished us within the last two or three years with salary scales which are very much in advance of those which obtained previously. But work in this connection is by no means over, because the work of these Committees and of the Whitley Councils is continuous and, as conditions change, either for the better or the worse, the Committees will be ready to consider them.

I may mention that only recently new salary scales for student nurses have been adopted. This is a subject in which the House, I know, is interested. The basic allowance per annum for the first-year student in training used to be £145, including £75 represented by residential emoluments. The sum has now been increased to a basic allowance of £200 for the first-year student, rising each year as training proceeds. Students who join after January 1 next year will receive their salaries in full, and will then pay out of their salaries an annual charge for their board and lodging. It has been felt that a change of that kind is desirable, because a student will then be able to understand just what is involved of his or her earnings, and he or she will know definitely the amount of money available for other purposes. We have also had an increase for students for the mental nursing services. That, we feel, will help considerably in building up the new services in that important direction.

The noble Lord, Lord Crook, mentioned the conditions of employment for ordinary nurses and said that in his view, unless conditions could approximate to those which applied outside, many people would be hesitant about going into the service. The Government have given great consideration to the Reports of Committees which have been sitting thereon, and they have recently circulated to management committees a Red Book on the subject, setting out the policy of the Government. We find that the Red Book deals with the following questions: recruitment, the conditions of service, nursing and midwifery training, the domestic staff and their conditions of service. The noble Lord, Lord Crook, will be interested to note that mentioned under the last head are such matters as the status of domestic staff, domestic staff supervisors, and the training of kitchen hands, cooks and domestic assistants. It is hoped that by the establishment of this kind of service, much of the drudgery that came the way of nurses will be avoided in future. The Red Book is not merely a document issued for guidance. It represents the policy cif the Government, and it is hoped that hospital management committees will realise this and will operate its provisions. The shift system is one idea mentioned in the Book. The table of a model shift system is given, and if only we could build up the nursing service so that there should be a sufficiency of nurses, the shift system could come into operation.

In reply to the noble Lord, Lord Rushcliffe, I should like to say that their policy on the question of the separation of responsibility for training from the hospitals is being considered by the Government, and although I cannot give much information at this moment, we shall know before we are very much older what the Government are intent upon. We believe that for training there should be some other authority than those who have merely the management of the hospitals.

We have tried to enrol as many male nurses as possible, and your Lordships will be interested to learn that the numbers have increased from 16,000 in December, 1943, to 24,000 in June of the present year. The Ministry of Labour are very active in the enrolment of men and women for the nursing service, and have established a large number of nursing appointment; offices attached to the exchanges. They have so far placed 135,000 nurses and midwives in employment and training, and are now placing them at the rate of 14,000 a year. In January, 1946, a Working Party on the recruitment and training of nurses was appointed by the Minister of Health, the Secretary of State for Scotland and the Minister of Labour. Its Report, published in December, 1947, makes some important recommendations for improving training arrangements, reducing wastage of student nurses and attracting men and women into the profession. These recommendations have been carefully considered by the Ministries concerned, and certain measures which could be taken immediately without legislation are being tried out.

These matters cover the selection of student nurses, the training of sister students, the training of senior staff and the subject of job analysis. I think that the noble Lord, Lord Amulree, will be particularly interested in the fact that the Nuffield Provincial Hospital Trust are engaged on an inquiry into the duties of each member of the hospital team, the results of which will be of great assistance in the solution of staff problems. Presumably, therefore, the point raised by the noble Lord will be dealt with by this body. If we could find some means of using the most skilled nurses on the most skilful jobs, it might ease the situation in many institutions. Some of the long-term measures which it is desired to carry out will entail new legislation and, as announced in the gracious Speech, a Bill will be introduced this Session to change the constitution of the General Nursing Council and to provide for the better training of nurses. In the recruitment of staff, part-time service is not being neglected. Between 7,000 and 8,000 trained nurses and about the same number who are not State registered at present but have had nursing experience, have recently returned to nursing work on a part-time basis. A great many of these are married women with domestic duties.

I should like to thank the noble Lord, Lord Crook, for the help he has given the Minister in this matter to-day. Publicity of this kind will not only be helpful to the management committees of hospitals all over the country but will be a useful aid to the Government. We feel sure the Government will be able to do much better work if the public at large realise their responsibility for the hospital services, and with that help we feel sure that we can win through and build up one of the finest services in the world. I must conclude, and I am afraid that I have missed some of the points which have been raised. I hope your Lordships will excuse me on this occasion. Those points that I have missed I will endeavour to deal with later, either by conversation or correspondence. I thank your Lordships very much for the kind hearing you have given me on this somewhat difficult occasion.

4.49 p.m.

LORD CROOK

My Lords, I rise mainly to thank your Lordships for the kindly reception which you have given to my Motion. With regard to the point raised by my noble friend Lord Rushcliffe as to training and general nursing, may I say that I deliberately did not say anything to your Lordships on those matters, as I indicated that I would reserve what I had to say until the appropriate Bill comes before us in a month or two. The fact that I do not take up the point raised does not mean that I have not a particular point of view. I hope to contribute that point of view when the Bill comes before us.

With regard to the observations of the noble and learned Viscount, Lord Simon, I would not suggest for a moment that the pay of nurses is sufficient, but merely that by comparison the other matters dominate the minds of the staffs. Of course, there is still a long way to go on the matter of pay. May I say that I am in complete agreement with Lord Simon? I stand here in the very difficult rôle of advocating the employment of male nurses while being quite certain that I like having had my brow smoothed by an administering angel of the female sex. So we share that view of nursing. I regret that the economic situation and the manpower situation of the country force me to suggest such outrageous things as taking away administering angels and substituting male nurses.

With regard to the observations of the noble Lord, Lord Amulree, may I say straight away that the suggestions which he made on the medical, as distinct from the nursing side, are of great value? In addition to the things which I have suggested, if there can be planning on the medical side which will ease the burden of nursing it will be very valuable. I am glad to learn from my noble friend Lord Shepherd that the Ministry of Health will look into the suggestions the noble Lord has made with regard to investigation wards, with, perhaps, convalescent buildings or sections into which people can be moved during that semi-state between surgical operation and recovery. The noble Lord made some reference to the difficulties of the nursing of chronics. There I have not the slightest doubt that the Ministry of Health are looking with care, as so many of us have, at the astonishing experiment in Orsett, in Essex, of the new method of dealing with chronics, which has brought down considerably the time occupied in their care. That has changed the whole nature even of the problems of the nurses. To take just one example, in the Orsett experiment there is a reduction in the incontinence figure of 50 per cent. to only 2 per cent.

May I say how glad we are to have the noble Earl, Lord Beauchamp, taking part in our discussions again? Many of us have memories of the noble Lord expressing his view and playing his part as a member of the Government in another place. I will not follow my noble friend Lord Shepherd into any discussion about the "inclusion in" or the "inclusion out" of midwives, whichever it may he—if I may use an Americanism—of the figures of nursing. When we start talking about midwives we get on to the edge of a problem which we may have to discuss a little later, as to whether midwives should be trained nurses or not, and which I know the medical members of this House will tell us has been splitting the medical profession for untold years. May I say how encouraging it is to know from my noble friend's speech that in building up the health service, which is still in its early days, regard is being had to these many problems? We can look forward to debates in this House next year, when we may see a considerable advance on what we have been told to-day. I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.