NURSES BILL [H.L.]

HL Deb 03 May 1949 vol 162 cc159-98

2.37 p.m.

Order of the Day for the Second Reading read.

LORD SHEPHERD

My Lords, it was said during a recent discussion in your Lordships' House that until the time of Florence Nightingale it could not be claimed that there had been any serious training of nurses. That may be perfectly true. Consequently, the name of Florence Nightingale has gone down in history, and her name is ever in our minds when we come to discuss nurses and their conditions of employment. It is remarkable, however, that not until the year 1919 did the State think it worth while to give statutory form to the training of nurses. Significantly enough, that was the year following the end of the First World War, a fact which indicates a clear reason for the introduction of that measure.

The Bill being introduced to-day, in the year 1949, follows the Second World War, and it might seem at first sight that the experiences of the country during that war had led to the issue being brought forward. I think it would be wrong if we were to think only of the Crimean War, the war of 1914–1918, and that which has just been closed, as providing the main reasons why there should be public notice of the necessity for training nurses. Much as we admire those who have been instrumental in bringing these matters to our attention, I think it would pay us if, from time to time, we gave serious thought to the tens of thousands of men and women who, through several generations, have given either of their wealth or of their services to render possible the great hospital system of our country and to give us a standard of nursing such as we have today. Certainly I, as a person who from the beginning of my political career have thought it desirable that the State should take an ever-increasing part in hospital welfare, would not shirk the issue of giving thanks to the men and women, mostly unknown, who have made that system possible—that system which has now come under the control of the community.

The Act of 1919 had two main purposes. The first was to maintain a Register of State Nurses, and the second was to prescribe methods of training and examination to qualify persons for the Register. In the thirty years that have elapsed since that time, great changes have taken place. The status of the profession has risen, and it can be claimed, I think, that we in Britain enjoy a nursing service second to none in the world. It would be wrong to assume that a measure passed in 1919, even though it was based on the experiences of the Great War, could stand for ever. It would equally be a mistake if we assumed that no amendment would be necessary at this date. Despite all the work that has been done, we have not sufficient trained nurses; there is far too much wastage in the training of nurses, and the hospitals are much too dependent upon the probationers for the services they require.

It is well to remember that between the two World Wars many Committees were established, and in due course reported, and our thanks are due to them for their work. The Lancet Committee in 1932 gave us the suggestion that there should be an early scheme of training for the period between school years and the nursing-training age. That is now an established fact in our land. It is to be regretted, however, that far too much persuasion and drive is necessary to make the scheme the great success that in the early days we hoped it would be. The Athlone Committee in 1939 gave us grading of assistant nurses, and this principle was established by the Act of 1943. Then the Horder Committee of the Royal College of Nursing suggested that we should have a "student nurse status" grade and that there should be regional and local committees for carrying out the work of training. The Bill that we are considering this afternoon seeks to bring into operation the regional training committees, and we trust that as a result there will be a great improvement in training methods. It is also well, however, to remember another series of Committees, because the recruitment of nurses will depend largely on the results of their recommendations. The Athlone Committee and the Rushcliffe Committee have now been superseded by the Whitley Councils, who have greatly increased the allowances to be paid to nurses when in training; on that side, therefore, there ought not to be the trouble in recruitment that we formerly experienced.

But, despite all that has been done, there still remains a chronic shortage of trained nurses, amounting now to about 46,000. Of the 127,000 full-time nurses, only 45,000, or 30 per cent., are fully trained. When these figures are realised, it becomes apparent at once that something in the nature of the measure that we are introducing to-day is required, in order to give the hospital services the staff they will require. Not only have we to deal with the hospitals as we formerly knew them, when they were supported by private contributions, but we have to think of the hospitals as they now are, giving free service to vast numbers of people who, for the first time in their lives, are able to go to such institutions for their treatment. In addition, we have to think of the developments that have taken place in industry and elsewhere, leading to greater employment of nurses. It is therefore important to mention that since the war there has been appointed an expert Working Party, under the Chairmanship of Sir Robert Wood. That Working Party reported in 1947. Whilst most of their important proposals will need legislation, and will ultimately come before Parliament, the Government (so far as adminis- tration can carry the matter) have put into operation some of the proposals that the Working Party made.

We are now experimenting in the selection of student nurses to make quite sure that the material entering will be suitable for the courses and, eventually, for employment. We are experimenting also with the further training of registered nurses for higher positions, and in connection with that we are receiving help from the Royal College of Nursing, King Edward's Hospital Fund, and the General Nursing Council. Research which was recommended by the Working Party is now being carried on by the Nuffield Hospital Provincial Trust. The work in which they are engaged is to decide the kind of jobs that have to be performed in hospitals, and the labour or staff that will be required to carry out that work properly. Some of us are looking forward rather keenly to their Report, because it is possible that, having studied it, we may see much more clearly than in the past what we actually require in trained nursing staff. The more important recommendations of that Working Party will, however, have to be dealt with by means of legislation.

The Bill we have before us is a finely-balanced document, trying to please as many parties as possible who are interested in nursing. It has been of some importance, therefore, that the Government should take every possible step for consultation before bringing matters before Parliament. In a matter on which so many diverse views have been expressed in the past, by both experts and laymen, it is not to be expected that unanimous approval will be obtained for any set of proposals, however carefully they may be devised. Nevertheless, it is desirable in a matter of this kind that all shades of opinion should be taken into consideration before action is taken. Accordingly the Minister of Health has been at great pains to ascertain the views of all the organisations, representing the nursing profession, the medical profession and the local authorities, and of the regional hospital boards and boards of governors. The subject has been discussed at representative meetings of all these interests, and the Minister's views have been considerably modified in the light of the opinions expressed. Thus, while it cannot be claimed that the provi- sions of the Bill will satisfy every interested party—for no one consistent scheme could do that—it is certain that the Bill has been framed with full knowledge of, and with careful regard to, the views of all the responsible authorities and organisations.

I should now like to say one or two words about the Bill. I do not think that a great number of words will be required, because the Bill has already received great publicity. Its main features have been printed and discussed in many parts of the country. The first feature, however, is the decision of the Government to increase the status and the strength of the General Nursing Council, to make it stronger and to put it on a more widely representative basis. It is also proposed to give to the Council an additional statutory committee. The statutory committee given to it in 1943 related to assistant nurses; the new committee refers to mental nurses. There are to be established in the regions standing nurses' training committees, and the financial side will be under the control of the Council. As to the representative character of the Council, I would remind your Lordships that hitherto the membership of that body has been no more than twenty-five. It is now proposed that its membership should be increased to thirty-four, of whom it is suggested that seventeen, or one-half, shall be elected. Of the other seventeen members, fourteen will be elected on the nomination of fourteen areas; two will be elected on the nomination of the mental nurses, and one on the nomination and election of the sick children's nurses. Perhaps it ought to be added that, of the members to be appointed by the Minister, five or six also have to be nurses, so that out of a total membership of thirty-four, the nurses will occupy on the Council twenty-three places. In circumstances of that kind, it ought to be apparent at once that the new General Nursing Council should carry the confidence of the nursing profession, and will therefore be of very great value, especially in the training of nurses.

It has been suggested that, in dealing with the case of mental nurses, an entirely different organisation should be established. The Government, however, have come to the conclusion that the same purpose will be served by providing for this new statutory committee. The Mental Nurses' Committee will have referred to it without question all matters coming before the General Nursing Council which refer to mental nursing; the committee will consider the matter, and will report back to the General Nursing Council when decisions have been reached. The General Nursing Council reserve their right to take action in case of emergency, but in all other cases, before the General Council reach a decision, the Mental Nurses' Committee must be consulted. There is a provision, too, that where the General Nursing Council are of opinion that the work should be carried out by the Mental Nurses' Committee authority can be given to that committee to carry out the functions allotted to it. The committee will consist of six members appointed by the General Nursing Council and four by the Minister. Perhaps I ought to add that in all probability the medical and other professions will receive notice of the members to be appointed by the Minister, and will certainly be consulted in respect of the appointments.

The standing nurses' committees, which I have already mentioned, are of considerable importance, and around them a certain amount of controversy may easily arise, unless we fully understand what they are for. Therefore I will read a short paragraph from my instructions which will enable me to exercise especial care in putting the point before your Lordships. The Government accept the Working Party's view that, under the present arrangements, the training of nurses tends to be subordinated to the staffing needs of the hospitals, and their conclusion that, so far as may be practicable, training should be dealt with independently of hospital administration—in particular, that the finance of training should be separate from the finance of administration. How far, in the circumstances attending the administration of the hospital service, the student nurse can be given the full student status which the Working Party recognised as the ideal, remains to be seen. The Bill, while leaving this question open, creates the conditions in which the answer to it may be evolved by trial and experiment. It provides for regional committees, independent of the hospital authorities, whose main duty it will be to co-ordinate training arrangements, and it provides for the expenses of training to be separated from the expenses of hospital administration.

The membership of these standing nurses' training committees will be defined ultimately by the Minister by Order. That principle is adopted because it would be difficult to find a kind of committee which could conveniently function everywhere, and especially when conditions change from area to area. By taking power in this way, the Minister can, after proper consultation, build up standing nurses' training committees to meet the requirements of respective areas. The principal view of the Minister in establishing these committees is that the General Nursing Council is too far removed from the students themselves; therefore, the Council has meant less to the nurses in training than is justified or is useful. By the establishment of the regional committees, there can be a close contact between those who are responsible and the students themselves. These committees will have the duty of advising the hospital management committees, the boards of governors of teaching hospitals and any other authority in the preparation and carrying out of schemes of training.

My Lords, I should add that the powers and duties given by the Act of 1919 to the Central Nursing Council of that day did not require very great alteration; indeed, they are only very slightly to be amended by this measure. The General Nursing Council will be given control of the formation of the Register; the conditions of admission to the Register, and the conduct of examinations for entry; in prescribing the grounds for removal from the Register, and in laying down the training for examination and experience required for a nurse to be placed on the Register. Each of those powers will be preserved to the Council, and I think it is something to be proud of that, in the rush which occurred after the First World War, Parliament did so well in reaching a conclusion about the requirements in the training of nurses.

I come now to one or two of the other features of the Bill about which I want to say just a few words. Clause 3 provides that there shall be power in the General Nursing Council to introduce experimental training. It will be the duty of the Council to lay down in the rules to be ultimately approved by Parliament the kind of training that will in general operate. It is our experience in such cases that rules and regulations of that kind remain unaltered for far too long a time; in fact, they sometimes become so fixed that they do not keep up with the progress of events. The General Nursing Council is to be given authority so that, outside the rules and regulations which receive Parliamentary sanction, they may, from time to time, give authority for experimental training schemes. I believe I am right in saying that the suggestion about the student nurse status is one of the matters that could be brought in under this clause. Where, in a particular locality, the bodies concerned are anxious to put it into operation as a matter of trial then it will be within the power of the General Nursing Council to authorise and approve such a scheme. So numerous are the theories about the training of nurses, many of which can be settled only after a course of trial and error, that this clause ought to find a very useful life in front of it.

Clause 8 deals with nurses trained abroad. In this country to-day, when we have full employment, there is extreme difficulty in many directions in finding enough labour, and the hospitals themselves have experienced trouble in securing a sufficient number of nurses, either for training or for service. Power is given to the General Nursing Council to register nurses from abroad where they are satisfied that the nurses have undergone appropriate training; and in other cases where the training is considered to be insufficient, the Council will have authority to give further training, followed by examination and registration if the candidates are successful.

Clause 9 deals with the closing of the Register. I think there may be some little misapprehension about this clause, and I will briefly explain it. First of all, the part of the Register which concerns male nurses will be closed shortly after the Bill becomes law. The male nurses will be transferred to the General Register, and with the women will become part and parcel of that Register. But the part which deals with mental nurses and with the nursing of sick children will remain for the time being. Authority is given to the Central Nursing Council that if at some time in the future they think those parts of the Register ought to be closed, then they can be closed, to the extent that no further names will then be added. Those nurses whose names are still on that part of the Register will remain thereon.

I think there is only one other point in the Bill itself with which I need bother your Lordships on this occasion, and that has reference to the printing of the Register. Because of the great expense and trouble involved in publishing a Register, the General Nursing Council have sought to be relieved from the obligation to publish the Register. It should be noticed that they are to be relieved of that obligation. If in the future they consider it desirable that the Register should be printed, they will not be prevented by the new Bill from taking that course. The Register will, however, be maintained by the General Nursing Council, and that Register, retained in the office of the Council, will be the only authentic document which will receive consideration in the courts or elsewhere. An awkward point about the publication of a Register is that at the date of publication it is already twelve months old, so that if one has recourse to the Register at the date of publication—perhaps in order to be certain about the correctness of one of the points therein—one must communicate with the General Nursing Council in order to have it attested. So the General Nursing Council are to be relieved of the necessity, at any rate for the time being, of publishing the Register.

My Lords, in view of what I have already said, I do not think it necessary to continue my speech in an examination of the Bill. There will be ample opportunity for that purpose on Committee stage. I will close now by asking your Lordships to give the Bill a kindly welcome and to give the Government aid in putting it through. Your Lordships may rest assured that in so doing, noble Lords will be performing a good piece of work, not only for the nurses but for the hospital service and all concerned therewith. I beg to move.

Moved, That the Bill be now read 2^a.—(Lord Shepherd.)

3.8 p.m.

LORD LLEWELLIN

My Lords, I, at any rate, can rise and, in the words of the noble Lord who has preceded me, give to this Bill a "kindly welcome." I do not think anybody in your Lordships' House will in any way object to the principles that underlie the Bill and, if it can do something to help that devoted profession, the nurses, I am sure everybody here will welcome it most heartily. In the main, it brings up to date the provisions made in the Act of 1919 for which, if my recollection serves me aright, the Leader of the House the noble Viscount, Lord Addison, was so largely responsible. To some of us in this House it may seem odd that the nurses struggled from 1903 till 1919 before they could get established the principle of registration of nurses. It is very difficult to understand in these days what strong opposition there was at the beginning of this century to that essential provision for this great profession. Whether or not it became mixed up with the struggle for women's suffrage one does not quite know, but at any rate it seems to me that the original registration proceedings ought to have been conceded to the nurses much earlier, and it was only right that the noble Viscount, Lord Addison, when he was Minister of Health, should have introduced that Bill for them.

Passing from that, I would point out that one of the things some of the nurses lay great stress upon is that having, after all this agitation, extending over some sixteen years, obtained their Register, they are now a little anxious concerning the provision of which the noble Lord spoke at the conclusion of his speech, and to which, accordingly, it may be appropriate for me to refer now—the provision in Clause 14 (2) of the Bill whereby the Register can be taken away from them. Up to date the Register of Nurses has been published annually, and it is true, I believe, that it costs the General Nursing Council about £6,000 a year to publish it. But I would ask the noble Lord how we are to get on when fourteen nurses are elected—one for each region—without some kind of a Register. It is no good having merely a manuscript register at the central offices when this has to form an electoral register (for that is what this Register will be) and has to be correct for each of the fourteen regions. What I would suggest now to the noble Lord, and what I shall suggest again at a later stage, is that we should make it obligatory on the General Nursing Council to publish this Register once every five years—that is, a year before the election takes place.

We shall thus kill two birds with one stone: we shall have the Register right for the election and we shall also relieve the anxieties of the nurses. Part of their struggle from 1903 to 1919 was to get this Register—and, after all, who is there among us who does not like to see himself or herself in a published list, if he or she is qualified to be in it? I should think—though probably most of us would not admit it—that we in this House all like to be able to look up Doer s Parliamentary Companion and see that our own name appears correctly in that publication. Nurses may well like to be able to do the same thing with the Register, and, when they have gone through their course of training and have passed the necessary examinations, to say, "You will find my name in that Register." They may well think it pleasant to be in a position to take along their fathers or their mothers to have a look at their name in the Register. So I suggest that this Register should be published at least once every five years, both for the practical reason which I explained and for the more sentimental reason which I mentioned. Your Lordships will find, if you look at the First Schedule, that the fourteen nurses to serve on this Council are to be elected by persons who on the date of the election are registered, and one representative has to be elected for each area. There will quite clearly have to be a Register, so let us have it published once every five years. This election by areas is one of the main provisions of this new measure and I think it is a good idea. It is well known that in the past the General Nursing Council has consisted largely of people from London hospitals, who were no doubt eminent representatives, but it is a good thing that the representation should be spread more widely than has been the case in the past.

The Bill incorporates another recommendation of the Working Party—namely, that there should be stronger educational representation on this Council. That, too, I think is all to the good. But here I would ask your Lord- ships to note that although in the composition of the General Council, which we find in the First Schedule, the representation is clearly fixed and balanced, when we come to the standing nurse-training committees, we find the matter is left very wide and to be determined in each case by Order. The noble Lord, Lord Shepherd, said that it was difficult to include in the Bill the composition of these committees because there might be differences in each area. But I would suggest that, within some limits, we might lay down in the Bill what should be the representation as between X and Y. That would at any rate ensure that in the framing of these Orders the nurses themselves will be given an assured representation on these standing nurse-training committees. That is a point into which we can go later.

In that connection, I would like to ask this question of the noble Lord. With regard to the General Nursing Council, in the case of the extra representatives whom the Minister can appoint (not those referred to in paragraph 3 of the First Schedule, but the six he is required to appoint) does the Minister intend to appoint any doctors? I think we shall all agree that the training of nurses should be mainly in their own hands. Just as the training of solicitors is in the hands of the Law Society, and the training of barristers is in the hands of the Benchers of their Inns, so I think nurses should have the main say in training matters. But as it is important from the start that the liaison between the doctors and the nurses should be complete, I should like to know whether the Minister will be appointing any doctors to the General Nursing Council to live advice and have a say in the training schedules.

For my own part, I like the idea underlying Clause 3, the provision for experimental training, although I know that there are some people who do not. But one of the most depressing things in connection with the nursing profession is the number of student nurses who never finish the course, who never become registered nurses at all. The Working Party put the wastage at 35 per cent. in the old voluntary hospitals, and 43 per cent. in the old municipal hospitals. Of course, some student nurses leave on account of marriage, and one certainly does not blame them for that With others, their departure is due to illness. But about 25 per cent. of those who leave too early resign for no very apparent reason. I believe that we should be able to retain more of these student nurses if a little more imagination were shown in their training in hospital, if there were a little less drudgery put upon student nurses when the hospitals are short of domestic staff. Student nurses often begin their training as housemaids or charladies for a great part of their time in hospital. I think we want a little more imagination shown in regard to the treatment of these young girls than we have had in the past.

The Working Party give several reasons for the wastage, in this order of importance. First, there is the code of discipline, which young girls feel to be unnecessarily severe, and the unfriendly relations between the senior nursing staff and the students. This is coupled with what is regarded as the unreasonable regulation of their off-duty hours. I am one of those people who think that when a girl is off duty, she ought to be off duty. Surely she ought to have these hours to herself, so long, of course, as she returns by the right time, fit and ready to carry on her job. Apart from that, I do not see that it is any concern of the hospital what student nurses do when they are off duty. The next reason is inadequacy, both in the quantity and quality, of food. I do not see why that should be a complaint. I believe that it is still the practice, as it was when I was Minister of Food, for hospitals to receive a preferential ration. Unless there is forced economy in buying food, or (which is very likely), in not paying the wages of the right kind of cook, I do not see why staff are not properly fed in hospitals. The next reason given is the span and pressure of working hours. That is rather a difficult question with such a shortage of staff. Next comes poor accommodation, bad recreational facilities and an unnecessary amount of domestic work. I believe that if we show more imagination in implementing the provisions of Clause 3 of this measure, we can attract more young girls to this profession and save some of the wastage of those who resign part-way through their course.

I see that the standing nurse-training committees may be given power to conduct examinations. I hope that certificates will be awarded only through the General Nursing Council so that there will be a general standard for all admitted to the list and no diversity caused by nurse training committees adopting different standards and giving different certificates. I am glad that mental nurses are to be given their own committee and, what is perhaps more important, a definite place on the General Nursing Council. They have a most difficult job—one I would not take on myself—and everything possible should be done to make their work as pleasant as possible. Some of our mental institutions are old and out of date, and I suggest that the replacement of these out-of-date institutions should be given a better place in the Government's capital expenditure programme, because they are really frightful places to work in. While I am on this subject, I would mention that the Working Party estimate that while the percentage of the population who are mad is now 2.1 per cent., it may well increase to 4.1 per cent. over the next fifty years. That is rather a horrifying thought. Just as we say now that we cannot think why the registration of nurses was held up for so many years, I can imagine people fifty years hence asking why we did not do something to prevent some of these wretched people being born. I know that the problem of the sterilisation of the mentally deficient is a difficult one, but I am certain that within the next fifty years it will have been adopted.

I should like to touch for a moment on the financial position of the General Nursing Council. In the past, their only source of revenue has been fees for registrations and examinations. In March, 1948, the deficit stood at £18,000, although in the balance sheet it will be seen that they made £5,000 on the sale of investments. The anticipated deficit for this year is £33,000. The Council may save some £6,000 a year by not having their annual publication of the Register, but that would save only £24,000 in five years. But at any rate it would be a saving. Although they are now to be allowed to take a lump registration fee, that will be of only temporay help; it cannot give much help at a time when we are so anxious to increase the number of recruits to the nursing profession. We find that under this measure, as we are finding with every new Bill that comes before us, there will be increased expenses. The Council will have to make payment for training nurses, to hospitals under Clause 4 and to bodies other than hospitals under Clause 5. Under Clause 6 they will have to pay the expenditure of the standing nurse-training committees, of which there are to be some fourteen. Under Clause 15 they will have to pay the members of the Council and their travelling expenses and also the members of the Mental Nurses Committee and the standing nurse-training committees. The only money they will receive under the provisions of the Bill is for the inspection of institutions. I suppose that is the amount of £9,500 we see in the estimates for this year.

I would ask the noble Lord whether there are to be further clauses inserted when the Bill comes before another place and whether they will be backed by the financial Resolution. If not, I should like to ask whether the Government are satisfied that the General Nursing Council, with all the commitments to which I have referred, will be able to pay their way. One thing we want to avoid is a position in which the Council would be forced to increase their fees for examinations or registration. That falls directly on those young people who are willing to enter this honourable but understaffed profession. One further question I would like to ask s this. In the Working Party's recommendations there was one that there should be a General Nursing Council for Great Britain. This Bill applies, of course, only to England and Wales. Have the Government decided that there is to be a separate Nursing Council for Scotland? If so, are we to expect a Bill for that purpose?

There are, of course, details to be gone into at later stages, and in particular as to the standing of the General Nursing Council in respect of the provisions of Clause 4, but, taken as a whole, as I said at the beginning of my speech, this is a measure which I feel we can all welcome and support. We hope that by giving it a Second Reading to-day, and by passing it through all its stages, we shall give some encouragement to the honourable profession of nursing, to which each of us probably owes some of his health, and to which the whole country will always be indebted.

3.32 p.m.

LORD AMULREE

My Lords, speaking for noble Lords on these Benches, I would like to join the noble Lord, Lord Llewellin, in giving a warm welcome to this Bill. However, there are one or two points about which I am not quite sure, and one or two suggestions I would like to make which, if they are adopted, I think will make this a better Bill than it is at present. The first point I would like to mention is one to which the noble Lord, Lord Llewellin, has already referred. The medical treatment of patients is something which is completely indivisible between the nurse's care and the doctor's care; but what finally occurs in the treatment of a patient, the final decision and responsibility for the patient's welfare, does rest entirely on the shoulders of the doctor. Therefore it seems to me a pity that medical practitioners are not represented on the General Nursing Council. It is true that there is a possibility that one or two may get on that Council, because there is a provision in the First Schedule that two teachers shall be among those appointed by the Ministry of Health. It is possible that those teachers may be doctors, but they need not be. I feel it would greatly strengthen the Council, and make it a much more satisfactory body, if there were medical representation upon it. I am sure the appointment of certain representatives from the Ministry of Education upon the Council will be generally welcomed. Naturally, they must have a good deal to do in any form of training; they have a great deal of advice to give and much work to do in the training of the girls before they are eligible to become nurses, and to make them more suitable for that profession.

I would like to refer back to the debate on the Motion moved by the noble Lord, Lord Crook, on November 9 last, when some rather frightening figures were given. I cannot remember who said it, but various speakers brought out these points. It was then said that the total number of nurses employed in the country is something over 170,000, which is higher by 31,000 than it was in 1938, but that we still have a deficit of 50,000. That is not due to the lack of new people coming in, because the same speaker pointed out that there are now 51,000 student nurses, as compared with 42,000 before the war. The deficit, I think, is due to the fact that nurses are working in shifts They now have a 96-hour fortnight, whereas in my young days they had much longer hours. It seems to me that, no matter what is done, it is unlikely that we shall be able to fill this gap entirely. I am not even sure that it is a good thing that we should, because the type of young women who are being taken in are well trained and educated. I am not at all sure that we can afford to have a great number of those people taking care of the sick. The country has only a limited amount of man-power and woman-power, and we have to be very careful as to how we employ it.

Therefore, I would like to suggest that the new Council should make up their minds what functions a nurse should perform and keep her firmly to the performance of those functions, and not let her waste her time doing things which are not strictly nursing matters. Also, I think the Council might give their attention to the position of quite a large number of young girls who have a real vocation for taking care of the sick, but because they have not a particular type of mind they are not very good at dealing with complicated training and at passing the rather stiff examinations which the modern trained nurse has to pass. We do not want our nurses to become like minor partners, knowing as much as the doctors do. Although the sisters in charge of wards are rather of that class, it is not really necessary for many of the junior nurses to occupy such a position. That is why I wonder whether it is not possible to get some representative of the Ministry of Labour on to the General Nursing Council. That representative could advise on the type of young women available, and on other matters of that sort. I put those suggestions forward, not in any sense of criticism of the Bill, but with the idea of improving it as much as possible.

Another point about which I am not very happy is putting the entire responsibility for the training of nurses on these nurse-training committees. I feel that, although a great deal should be done by them, the final charge must be that of the management committees and the boards of governors of the various hospitals. One cannot entirely divorce training from staffing, but a great deal of trouble has been caused in the past by their being too closely connected. The training must depend in some sense on the number of beds available, and on the facilities available in any particular hospital. It might be very helpful if there could be some link-up of the management committees and the boards of governors on the question of training.

There is a further matter which I know causes a certain amount of worry to some people I do not think it is very important, but I would like to mention it. Although there are not a great number of hospitals that have not been taken over, there is a fear that when these new training schemes get going, these hospitals may be prejudiced in their supply of nurses. I think that is unlikely, but I would like to hear what the noble Lord may have to say on the point. To return to what I said at the beginning, I think there should be some medical representative on the nurses' training committees and these committees should be linked up with the management committees, because some medical opinion should be given about the kind of training which is necessary. Let me take an example which is completely absurd. A training committee might insist upon a knowledge of Greek or German, and if they had complete power they could then accept a person with a very good knowledge of Greek or German but with no nursing knowledge at all. I wonder whether it would not be an advantage if the boards of governors had direct access to the General Nursing Council. At the present time they are not regionalised at all; they have no contact with the regional hospital boards and, so far as I know, if they have any questions they are put directly to the Ministry of Health. I wonder whether it would not be simpler, administratively, if the nursing connections of these boards were all with the central body.

I am sure that all of us who have anything to do with nurses will welcome the financial aid which is to be given, because at the present time—or at any rate before July 5—the training of nurses was part of the hospital budget and certain hospitals were not very well off. There was a good deal of parsimony in the training of nurses, and that training should be taken out of local hands and be made a general charge on the Treasury. I think the point raised in Clause 3 about the value of experimental training is excellent. There, again, there might be some kind of training for young girls who wish to take care of the sick but who have not the mental ability to become well-trained first-class nurses or sisters. I should have thought there was a very good case for some kind of experimental training. It is no good having a completely dead-level training; it makes the profession very dull and uninspiring. So long as we keep a standard of minimum training for our senior nurses, I do not think we can come to much harm. A point about which I am not quite clear is with regard to post-graduate training. One of the most important branches of the profession has been the nurses trained in the care of children, say for the Hospital for Sick Children in Great Ormond Street. Nurses trained in that branch have been able to save a great many lives. I am not clear whether that kind of training is possible in the future, or whether there will be a basic training, plus a post-graduate training. I hope it will be possible to keep up this special training.

Finally, I wish to refer to the non-publication of the Register. I agree with the noble Lord who has just sat down that it would be a great advantage if the Register could be published a certain number of times. If that cannot be done, I take it that there would be no objection to the Register being perfectly free for inspection, because there may be all sorts of strange women saying they are nurses and if there is no Register to be inspected we will gradually return to an insecure state. I do not want to criticise the Bill; indeed I give it a very warm welcome. I have made these few suggestions only in order to improve the Bill.

3.45 p.m.

LORD MORAN

My Lords, the wellbeing, sometimes the fate, of everyone sooner or later depends upon the judgment of their doctor, and I think we may say almost as much of the nursing profession. Therefore, this Bill, which sets out to improve the training of nurses, is of some consequence to the country. The crux of the Bill is to be found in Clauses 4, 5 and 6, which for the first time separate the funds which are given to nurse training from the general hospital budget. In those few words the nurses have been given self-government as far as their training is concerned. In the past there were no funds available for training nurses. When the authorities wished to pay lecturers or provide equipment they had to go cap in hand to the hospital and compete with the many calls on the hospital budget. I think it is perfectly true to say that in the past nursing training has been starved financially. But what mattered more was that the hospital too often treated the nurse as a pair of hands. Where the nurse worked and what she did was governed not by the requirements of her training, but by the needs of the hospital for cheap labour. I remember a nurse who did three years in a children's hospital and obtained the appropriate certificate. She then went to a general hospital to complete her training, and was promptly put in the children's ward because she would be more useful there. That was not an exceptional occurrence. What you are doing to-day is to give a charter of freedom to the nurse where her training is concerned.

The consequences of that are far more than we can immediately see. Your Lordships will remember that, in the report of the Working Party, the wastage during the training, which was nearly 50 per cent, was ascribed mainly to this subordination of the nurses' training to the exigencies of staffing the hospital, and it may well be that the step you are taking to-day may reduce that wastage in the future. If I appear a little critical in the rest of my speech, I should be sorry if it obscures this fact: that I, like every person who is a nurse or a doctor, feels that this is a milestone in the history of the training of nurses. It would be ungenerous of me if I did not add my congratulations to the Minister on doing at last what I personally have for forty years impatiently waited for, and which previous Governments have not done.

There is another provision in this Bill which I think is almost equally important, and that is the provision for bringing the standard of efficiency of the smaller hospitals up to the level of the best. That is an attempt to remedy what I might call the neglect of the periphery. In the past there has undoubtedly been a feeling on the part of the smaller hospitals that the great teaching hospitals have not been sufficiently familiar with their needs and their difficulties. The steps which have been taken in this Bill—some unexcep- tional and some more debatable—are an attempt to put an end to that. I shall begin naturally with what is unexceptional. I think everybody will welcome the fact that there has been a bridge put between the teaching hospitals and the smaller hospitals in the shape of these regional committees, known as the standing nurse-training committees, which are not under the regional hospital boards. These committees have two executive functions: they distribute to the training institution the funds given them by the General Nursing Council; and they will in certain circumstances examine nurses as a substitute for the general Central State Examination. I am sure everybody is in favour of the setting up of these committees, particularly—and this is very important—if the nurses are in the majority on them. If that provision is made, I am sure everybody will welcome the fact that these committees have been established, and will welcome the financial powers given them. Their advisory powers, too, will gain momentum and persuasiveness from the fact that they have the power of the purse behind them.

It is quite another story when we come to the other executive function, that of examining. In 1919, when State registration came in, there was established the Central State Examination, which I think everybody will admit has done a great deal to raise the minimum standards everywhere. From this time onwards I am afraid we have to admit that there will be no national minimum standard, and some of us fear that there may be a lowering of the standard, because it will be difficult for these regional committees, under the pressure of local opinion, which is naturally agitated by the desire to get nurses, to maintain the standards as they have been in the past.

Noble Lords may inquire at this stage how it comes that in a Bill which is seeking to improve the training of nurses we are in danger, apparently, of lowering the minimum standard of the examination. I think the explanation is quite obvious: that, grafted on top of our desire to improve the training of the nurses, is this abiding anxiety concerned with the shortage of nurses at the present time. It is a very natural anxiety, and some of us feel it very strongly. Here, for instance, is a sanatorium with 300 beds closed down, and it is said that those beds are closed because the matron insists upon each of the nurses doing two years in the sanatorium and then two years at a general hospital—that is four years in all. It is argued that if she were content that they should have two years only and take the examination of the Tuberculosis Association at the end of that training, the hospital would be adequately served and no harm would be done. It is not my purpose here to discuss this shortage of nurses and the remedy. What I am concerned to say is this: that the more we are driven, and inevitably driven, to shifts and expedients for meeting this shortage, the more essential it is that we should preserve, somewhere and somehow, the standards which we have known in the past and to which we can refer if we have taken the wrong turning and have to retrace our steps. That is why I, with others, feel some concern that the teaching hospitals are put into regional machinery for this purpose of training of nurses.

I would call your Lordships' attention to the fact that this is the first departure from the principle laid down by the Minister in the National Health Service Act, that teaching hospitals should be kept outside the regions, so that the growing edge of medicine should not be blunted. Was the Minister right in making the decision to keep the teaching hospitals outside the region? At first I had some misgivings, on the ground that it would undoubtedly lead to a certain amount of suspicion and ill-feeling on the part of the non-teaching hospitals, who would feel that the teaching hospitals were being favoured. But I have no doubt at all, from experience in working this Act, that the Minister took a far-sighted step and that he was completely right in taking it. He did it because he wished the "growing edge of medicine not to be blunted."

If he was right in putting the teaching hospitals outside the region for the training of doctors, should he not have kept them outside also for training nurses? I shall be told by those responsible for the Bill that the cases are not analogous; that the teaching hospitals teach all medical students but only a fraction of the nurses. It is admittedly a very large and important fraction, but it remains a frac- tion. But it is not quantity with which we are concerned, but quality. We are not rewarding these teaching hospitals as places of privilege, but keeping them outside the region because they have set up standards which we may have to revert to. They have spent ten or fifteen times more money in training nurses in the past than have the other hospitals. At a time when nurses were tremendously short they took nurses out of the wards for a six-weeks course of theoretical training, thus showing courage comparable to that of Mr. Churchill when, in a time of emergency, he sent aircraft to the Middle East, although we had practically none at home. It is a progressive move. They recognise too that a nurse must be more than an apprentice; they have trained her in the elements of the basic sciences, and they have constantly sent nurses to all parts of the country to become sisters in hospitals where they set up new standards, to the benefit of the country. It is not only in teaching hospitals that this is done, it is true, but it is mainly there. In these hospitals you have the "growing edge" of nursing and I look with grave misgiving on the possibility that that edge should be blunted by putting these hospitals under the region.

Another argument that has been used by those responsible for this Bill is that if you take, for intance, Guy's into a region, you may strengthen that region and give it inspiration. But precisely the same argument could have been used against the Minister when he kept the teaching hospitals outside the regions in the Act. I know I shall be met at this stage with the remark that it is no good taking up a high educational line in these matters, because there is a shortage of 46,000 nurses and because a very large number of those we have, have never been to a secondary school. I need not tell anybody who is engaged in education that that is a defeatist argument; as Mr. Churchill once said in even more difficult circumstances, "Do not raise difficulties; anybody can do that." The original decision to keep these hospitals outside the regions was a far-sighted move. It was the decision of an individual. It showed political courage, because it was politically disadvantageous. This is a lapse. I need not remind your Lordships that progress in education comes from lonely thinking. Pascal, protesting against the irritable desire to act quickly, the wish to be doing something, said: Most of the evils of the world are due to men being unable to sit still in a room. He knew that ages of sedentary, quiet-thinking men had done what is most worth doing in the world. It is particularly true in the educational world that we owe most to men whom their contemporaries have thought to be dreamers, who, in the words of the proverb, have walked into the well of truth through looking at the stars.

4.1 p.m.

LORD CROOK

My Lords, I hope I shall not be considered out of order if preface what I want to say on this Bill by saying what I believe to be the feeling of your Lordships—namely, how much we welcome back for the discussion on the Nurses Bill this afternoon our two distinguished invalids on the two respective Front Benches. I am sure we were all glad to see with us again the noble Marquess who leads the Opposition, smiling and looking as if he is much fitter for his lengthy rest, and also our own Leader on these Benches who has had a shorter period of absence. Perhaps I may be forgiven for mentioning another invalid who is not present to-day, the noble Lord, Lord Rushcliffe, whose name one inevitably associates with all subjects connected with nursing, and who had problems for me in November when we were associating in the earlier discussions, referred to by the noble Lord, Lord Amulree, dealing with the objectives of this Bill.

I want to congratulate the noble Lord, Lord Shepherd, who with his customary clarity has given us a clear exposition of the contents of this Bill—a Bill which I should like heartily to support. I should also like to congratulate the noble Lord on the further fact that he was able to tell us that some progress has been made in those fields dealt with in the Report of the Working Party to which your Lordships gave some attention last November. While I welcome the Bill, there are a number of queries in my mind which have been put to me by other people. There are some suggestions and questions which I should like to put to the noble Lord—questions of which, so far as was practi- cable, I gave him notice prior to this debate.

What worries me about the Bill is that I fear that, as a result of it, good as it is, there may be grave delay in dealing with some of the issues which affect the general shortage of nurses in this country. We are to have a General Nursing Council which I hope will be more thoroughly representative of the nurses than the present one has been. We are to have a Council which will be given powers of experiment that are workable; but it is in respect of just those powers of experiment that I have some doubts. I am not worried about the experiments themselves, but I have some fear that they may cause delay in reaching decisions upon general principles, decisions which would help us in solving the problem of the shortage referred to in the Report of the Working Party. So far as I can see, what this question of experiment means is that the three years general training argument, as dealt with in the Working Party's Report, will be shelved for a period which, so far as I judge, may well be ten years from the date on which the Working Party was set up. I do not know whether the noble Lord, in his reply later on, can give me any assurances on that point.

The Working Party were appointed in 1946; we had their Report in 1947; we looked at it in 1948, when the Nuffield Foundation started on its examination of job analysis. This Bill gives the General Nursing Council powers to experiment in January, 1951. We cannot hope to start planning an experiment before the middle of that year, and shall not embark upon an experiment until 1952. If the experiment runs the whole period of three years—which one would expect to be the very minimum—the year 1956 becomes very clearly the year for decision on the point whether there shall be certification of any kind at the end of two years, or whether the three years' period is to be maintained. I do not want to suggest to your Lordships that we should reach any conclusion on that three years' point, or that I myself have reached a conclusion. But I am clear that the Ministry of Health, if they are to maintain the health service, cannot afford to put off for a long period of years a decision on a vital question of that kind, tied up as it is with so many others of staffing inside hospitals.

In this connection, I should like to know what attention has been given by the Minister to proposals put up by the medical profession, which included their suggestion of the use of aides, more on the American pattern. I do not for one moment suggest that without further examination I necessarily accept the proposition of aides. But I think we ought to know this. Are we to have that kind of system introduced? Are we going to have a further extension of orderlies? If no decisions have yet been reached, when are the decisions to be reached, and how will they tie up with the duties which the General Nursing Council have to carry out? In November last we talked of the shortage of nurses. We have to face the fact that in the next few years there will be a much more restricted field from which recruitment can take place. As I understand it, the number of women available for all employment in this country will drop by no fewer than 300,000 or so in the course of the next four years. Already, even on our existing figures, the field of recruitment for nurses, on the present standards which we have for the profession and which I am sure we all want to maintain, is very low.

For instance, I understand that the total number who leave grammar schools of the age of seventeen to eighteen is only 14,000, and if the whole of that figure of woman-power were made available to the nursing profession, it would go nowhere near far enough to meet the ordinary annual requirements. If we look at the lower school education standard, we find that a further 25,000 girls leave secondary grammar schools at ages of sixteen to seventeen. Even if the total of 39,000 were devoted to the nursing profession, it would not be enough. For that reason, I reach the conclusion that the carrying out of the real student status idea, as desired so much by the nursing profession, will remain a dream for a considerable period of years, and that we shall have more and more difficulty in obtaining enough people to staff the hospitals as we have them to-day. We must remember too, that at the moment, owing to this shortage, we have 66,000 beds not in use. I know that, in this problem of bridging the educational gap to provide the students, there has been valuable co-operation between the Ministry of Health, the Department for Health for Scotland, the Education Department and the Ministry of Labour. I would welcome any information which the noble Lord can give us of the progress which that programme of bridging the gap is making. It seems to me that these things are so tied up together that, whilst welcoming the new powers of the General Nursing Council, including the power to experiment, we are bound to ask that firm and definite decisions on general staffing problems of the hospitals as a whole should be forthcoming from the Government in the course of the next twelve months.

While speaking in general about these extended powers of the General Nursing Council, may I say that there is one thing about the Bill which rather surprised me?—and I ask the noble Lord whether he will look at it, and perhaps at a later stage let us know something about it—namely, the omission of any suggestion of an annual report. I know that the 1919 Act makes no provision for such a report, and as this Bill is based largely on the general propositions of the 1919 Act I can understand why the idea of an annual report was not introduced at this stage. But it seems to me that the growing importance with which we invest the profession of nursing by this particular Bill, coupled with the fact that there is now national responsibility for the health services, makes the position one in which we ought to expect that some form of annual report would be given to the Minister by the General Nursing Council.

If for the next couple of minutes I may turn to one or two detailed points about which some of those particularly interested in the nursing profession have raised doubts, I would ask the noble Lord whether he can give any information, first of all, as to the general standard of examination. The noble Lord, Lord Moran, with his admirable authority, raised this matter much more pungently than I can. Probably because the Explanatory Memorandum at the beginning of the Bill refers only to experimentation in training there has been a tendency to forget that the appropriate clause provides for experimentation not only in training but in examination. I know that in letters addressed to your Lordships the College of Nursing has referred to considerable doubts, both as to the experimentation in length of time and in quality of examination. Personally, I think that the experimentation in point of time must be agreed to, but I would not like to see anything done in respect of the standard of examination that would reduce the very high standard which the nursing profession has always had in this country and which we all want to see maintained.

Like other noble Lords, I welcome the new provisions in regard to mental nurses. I am bound to say that any of us who have looked at the deplorable mental institutions in many parts of this country, and have seen the poor standard of training given to mental nurses, will realise that in dealing with this problem the General Nursing Council will have a very hard upward road to travel. What we want are a great many more hospitals such as the Maudsley Hospital, for the purpose of training and experimentation in that connection. Some people in the hospital world have been pressing the claims of a limited number of people who failed to take advantage of the opportunity offered, both in the 1919 and 1943 Acts, to secure registration. I do not want to keep your Lordships by arguing the merits of the claims of those people—indeed, I do not know that they have particular merits; they had opportunities for registration of which they failed to take advantage. But I think we are concerned to see that they have the chance of registration if it is at all possible, because we do not want to deprive ourselves, merely because some technicality has not been complied with, of the opportunity to employ any one person who has valuable experience.

Clause 9 deals for the first time with the proper position of men in the Register, and I should like to urge that the points to which I directed attention in November last, notably the one for higher posts for men, should be given early consideration—possibly both by the Ministry and by the General Nursing Council under its new set-up. The noble Lord, Lord Llewellin, had something to say about finance, and I am bound to say that I associate myself with his remarks. I do not want to see an increase in the fees payable for examinations. Indeed, many of us fail to understand why fees for sitting examinations should be expected in the future set-up of the nursing profession. Nor do I want to see a high fee for this registration commutation payment. I agree that the argument may be advanced, that people value things only to the extent that they have paid for them. I do not object to the payment by nurses of some fee, but I do not want to see that fee imposed merely in order to provide for the Nursing Council finances which, probably, ought to be provided by His Majesty's Government. I think the same is true of the observations which the noble Lord, Lord Llewellin, had to offer about the publication of the Register. I am in complete agreement that in these days of man-power difficulties, and the shortage of materials such as paper, and so on, publication of the Register annually is expensive and unnecessary. But I am impressed by the compromise suggestion which he made between those who advocate annual publication and the mere leaving of the matter. I recommend to the Government for consideration the suggestion he has made, so that we may have a statement, perhaps from the noble Lord, Lord Shepherd, when we reach the later stages of the Bill.

Before I conclude, I would like to refer to one or two of the items in the Schedules, again in order to clarify points which seem to be in doubt in the minds of different camps in the hospital world. For instance, as to the elections, everybody welcomes the division in regard to the fourteen regions; but there seem to be two different methods of interpreting the provisions in the Schedules, and there are two different schools of thought in the profession. One is that only people in region A would vote for people in region A. The other school of thought says that under the measure every nurse will have the opportunity of voting for people in each of the fourteen regions. If the noble Lord could clarify that matter, I think it would case the minds of some people, and would also make it more possible to consider one suggestion which we should like the Ministry to look at—namely, some ability inside the voting organisation for these fourteen regions to provide that at least half those elected representatives are not above the rank or status of departmental sister. We know that we want good matrons sitting on the General Nursing Council, but we do not want it to be a body consisting entirely of matrons of hospitals over the fourteen regions. What I think would give satisfaction to the profession would be that some of the rank-and-file people, who have to do the ordinary day-to-day work of the hospitals, should sit on the body which is controlling their welfare and general position.

My Lords, I also have some doubt about the Second Schedule. The noble Lord, Lord Llewellin, had some observations to make about it with which I was in fairly general agreement. He is right, of course, in saying that there has been inserted into the Bill no provision as to numbers. I have no doubt that if we consider the matter carefully, that is wise enough, because of the varying conditions that there may be in some of the fourteen regions. But I heard from medical members of this House who have been in consultation with the Ministry earlier, that a number of something like fourteen was originally contemplated with regard to the composition of these nurse-training committees. If the suggestion as to a figure of fourteen, or anything like it, is correct, and also the suggestion that they should include only four members from the General Nursing Council, I think it bears out the point of the noble Lord, Lord Llewellin, about the small number of nursing representatives on the local committees. That is particularly so when it is remembered that there are at least seven kinds of nurses or nursing interests who probably need to be represented, or, at least, given consideration in respect of these committees—general sick, children, mental, fever, T.B., male and the women public health officers who, clearly, at some time or other must become associated with the General Nursing Council.

I have a number of other points but I do not propose to detain your Lordships by raising them now. I shall hope to embody some of these in Amendments which I shall put forward in Committee. The observations which I have had to offer, while they have been in some instances critical of particular provisions of the Bill and in other instances have contained suggestions, do not in any way mean that my general views about the Bill and its main purpose are not completely favourable. I welcome the Bill, I wish it a speedy movement through this House, and I hope that the noble Lord, Lord Shepherd, will be able to see it on the Statute Book before many months have passed.

4.22 p.m.

LORD WEBB-JOHNSON

My Lords, I do not wish to detain you long, but as a representative in this House of the medical profession I wish to say, like my colleagues and other noble Lords who have spoken, how warmly I welcome the introduction of a measure to provide for the independent financing of the training of nurses apart from the payment for their services. I naturally welcome it because I have been pressing for it for years and, indeed, have often urged that the status of the student nurse should be equal to that of an undergraduate in any faculty of a university, and that her collegiate amenities should be equal to those provided for students at any of our universities. Moreover, I have had the unique privilege of planning a nurses' college, the result of an individual gift from that generous-hearted man, Colonel John Astor. That gift provided in one of London's hospitals a nurses' college equal to any to be found in any of the older universities.

At the same time, I am not altogether satisfied with the means chosen by the Minister of Health for bringing about this improvement. I was a little disappointed from the outset that he should have selected the General Nursing Council as the body for the general control of the funds for this purpose. I am sorry that the noble Viscount the Leader of the House is not now present, because I would have liked to see how he took the suggestion that something comparable to the University Grants Committee, for the creation of which he was largely responsible, would be a more suitable body for this purpose. It may well be that, as the noble Lord, Lord Shepherd, has said, the Bill has had to be very nicely balanced in view of the conflicting opinions which were brought to bear upon the Minister of Health. At the same time, if the original anxiety was to separate educational grants from ordinary hospital maintenance grants, it would have seemed better, I should have thought, that, those grants should reach the nurses through some other channel; that from the Exchequer the grants should pass either through the Ministry of Education or through some body comparable to the University Grants Committee. However, I feel sure that we shall have some explanation on that matter. But if it is ultimately decided by Parliament that the General Nursing Council is to be the body to administer these funds, and administer the whole scheme, then, indeed, the constitution of that Council becomes of paramount importance.

Many noble Lords have spoken about the Schedules, and arguments on matters of detail will doubtless arise in Committee. I was rather surprised to see, in Clause 2, that the Minister is empowered to set up standing nurse-training committees in any area. I should have thought that it would be impossible to exclude an area and that the clause might quite reasonably say that he shall set up a standing nurse-training committee in each area. When we look at the definition of "area," we find that there is no getting away from the fact that it is a region. These so-called standing nurse-training committees in my view would be better called "nurse-training councils." This, I suggest, would avoid the possibility of their appearing, as they do, to be subservient to some other body like the region. I find it is impossible to put out of my mind that these bodies will be essentially under the control of the regional board. The regional board is to appoint some of the members; it is to be made responsible for providing officers, servants and accommodation. That, to my mind, makes it inevitable that these committees will be largely under the control of the regional boards. If that is so, then I agree with the noble Lord, Lord Moran, that it is a matter for great anxiety if the teaching hospitals are to be brought under the control of such a committee and under the control of the regional board.

There are other points in the Bill, most of which will come up in Committee, and I will not detain your Lordships by dealing with them. But great anxiety has been expressed about Clause 2 (3). There again, perhaps, the danger can be avoided by a proviso safeguarding the length and quality of training. In regard to experimental matters, surely the great teaching hospitals, with their large and efficient scientific departments, should be able to carry on their pioneer work. They have raised the prestige of scientific nursing in this country and they now hold a very proud position. Surely they can proceed independently with experimental work, without reference to regional committees.

There is one clause which, I think, no noble Lord has so far mentioned, and that is Clause 5. Or perhaps I should say that it may have been mentioned but the same anxiety which springs to my mind concerning it has not been expressed. This clause provides that A standing nurse-training committee for a hospital area may make to any authority or person engaged in the area in training nurses (not being a hospital management committee or the board of governors of a teaching hospital) contributions towards the expenses incurred … Now does this, as it should, make provision for educational grants to hospitals not vested in the Minister? I hope it does. If it does—and I see that the noble Lord, Lord Shepherd, acquiesces in the suggestion that it does—why is it that those hospitals only should be required to pay fees for being inspected and approved, as is laid down in Clause 11? There is a curious point in Clause 8. I am not so familiar with the drafting of Parliamentary Bills as some of your Lordships, but I am surprised at the constant use of the masculine gender throughout this clause and other clauses. Perhaps it is a Parliamentary rule that "man" embraces "woman," but in the circumstances we are considering to-day, surely it would be more gallant to allow "woman" to embrace "man"—or, at least, that "woman" should be mentioned, as she is in so large a majority.

I should like to ask the noble Lord, Lord Shepherd, to give attention to subsection (1) of Clause 8, under which a person trained abroad in an approved hospital may be admitted to the Register. I find difficulty in reconciling that with the strict limitations put upon the British person who may have made an application to be admitted to the Register. As this Bill is a Bill to amend the Nurses Acts of 1919 and 1943, among other things, I should have thought the opportunity might be taken to re-open the Register. The numbers affected may not be large, but the injustice inflicted may be great. There are people who, for technical reasons, are not eligible now to be admitted to the Register. There are ladies who are left widows and are prepared to go back to nursing but who cannot become State-registered nurses; yet somebody who comes from abroad can be registered, no matter how long they may have been away from nursing, if their training is accepted as adequate. I hope the noble Lord will give an assurance on this point, because the Minister is urging married ladies who are qualified in nursing and who can spare some part of their time for nursing duties to return to the hospitals and help. Surely it should be possible for them to be put on the Nurses' Register and accepted as State-registered nurses.

In regard to Clause 9 I trust that the Government will consider accepting an Amendment empowering the General Nursing Council to recognise postgraduate courses and to register extra qualifications obtained. Otherwise there will be great anxiety, particularly in regard to nurses trained for the care of sick children, that nurses with extra qualifications will not be fairly treated. I will not detain your Lordships longer. The points in the Schedules to which I have referred will come up during the Committee stage. I feel sure that we are all embarking on these discussions with the sincere desire, by consultation, by give and take, and by the acceptance of proposals which have merit, to evolve an Act which will be of real service to the cause we all have at heart, and that we shall succeed in improving the Bill as it stands at the present moment. From his introductory speech, I feel sure that the noble Lord, Lord Shepherd, wishes to accept proposals which may improve the Bill.

4.25 p.m.

LORD SHEPHERD

My Lords, we have had a full discussion, not so much on the broad principles of the Bill as on the details. If I ventured to trespass on your Lordships' time to the extent of replying on them all, I am afraid that by the time I had reached a conclusion there would be few noble Lords left in the House. I will do what is possible within a reasonable time to meet a number of the points mentioned by each speaker. If, in this way, I do not refer to all the matters raised, there will, of course, be further opportunities for the discussion of the details when we reach the Committee stage of the Bill. The noble Lord, Lord Llewellin, who opened the debate, had something to say about the decision to do away with the obligation to publish a Register. I thought I had made it plain in my speech that this would not mean that the Council would have no power to publish a Register.

LORD LLEWELLIN

I think the noble Lord made that quite clear, but I was seeking to maintain the obligation upon the Council to publish the Register once in live years.

LORD SHEPHERD

That is a matter which will have to be considered when we reach Committee stage. But there are grave reasons which prompted the General Nursing Council to ask the Government to be relieved of this obligation. I want to make that quite plain, because the proposal did not originate with the Government. It is not merely that the Register costs £6,000 or £7,000 a year, but because only 200 copies were published and of those only 140 were sold. It will be realised, therefore, that for a very large expenditure, there was a very small circulation return. Unless there are great alterations to meet the election idea the noble Lord has in mind, what has been published in the past would not meet the circumstances at all. But we can reconsider this matter when we reach Committee stage. The noble Lord and my noble friend, Lord Crook, asked whether progress is being made in relieving nurses of domestic labour. It is the policy of the Government to relieve nurses of all work not requiring nursing skill. This policy was announced in the Memorandum, Staffing of Hospitals, in 1945, and has been brought recently to the attention of hospital management committees in notes issued for their guidance. A substantial increase has taken place in the number of domestic employees in hospitals. Since June, 1947, the numbers have increased by over 5,000; that is to say, from 117,000 to 123,000.

The noble Lord, Lord Llewellin, rightly dwelt for some time on the subject of income and expenditure. He wondered whether, when this Bill reached another place, provisions would be included to make grants to cover the greatly increased expenditure which would fall on the General Nursing Council. It is the purpose of the Government (and this is made clear in the Bill) that grants will be made, not merely to the General Nursing Council but, through the General Nursing Council, to the training committees, to cover the cost of training. Indeed, the expenditure of hospital management committees having relation to training within the hospitals will also be chargeable, through the training committees and the General Nursing Council, to the Government. There is a short provision in this Bill for that purpose. I would add, in reply to the point of the noble Lord, Lord Llewellin, that a Bill for Scotland will be introduced at a later date.

The question of whether figures can be included in the clause dealing with the appointment of standing nurse-training committees is one for consideration in Committee. As advised at present, because of varying circumstances in the different areas, the Government feel that it is better to deal with this matter by Order, rather than in the Bill. I would, however, say that the Orders, when they are made, will have to come before Parliament, and therefore each of us will have an opportunity of expressing an opinion about them. The last point raised by the noble Lord, Lord Llewellin, to which I think I ought to reply on this occasion, is that dealing with the members of the General Nursing Council, or the standing nurses training committees, to be appointed by the Minister. In all these cases there will be prior consultation, us there has always been consultation with the various organisations representative of the medical and other professions. In the past, medical men have found their way on to these committees, and I think the noble Lord may rest assured that under the new dispensation there will be no change.

I now come to the speeches of the noble Lords, Lord Amulree and Lord Moran, who had something to say about medical representation on the General Nursing Council and the standing nurse-training committees. The Minister has, for many years past, included both medical representatives and hospital adminis- trators amongst his nominees to the General Nursing Council. There is no reason to suppose that any change in this practice is likely in future, and, in the absence of any evidence of the need for specific requirements on this point, the Minister feels that the Bill, which in this matter follows the lines of the original Act of 1919, should be left as it stands. As regards medical representation on the standing nurse-training committees, it would be open to either the regional hospital board or the boards of governors of teaching hospitals to include medical representatives among the members to be appointed by them, and the Minister considers that at present it is unnecessary to specify that more precisely in the Bill. The actual constitution of nurse-training committees will be settled by Order. The suggestion of the noble Lord, Lord Amulree, that the Minister of Labour should be brought into the picture is, I am afraid, unacceptable. The General Nursing Council is responsible for training, not for recruitment. Training must be settled in the light of functions to be performed, about which the Ministry of Labour are not in a position to judge. The function of the Ministry of Labour is to advise on the source of supply after functions of training have been settled.

The question was then raised about disclaimed hospitals. There is no reason to think they will be prejudiced, as Clause 5 provides grants for the standing nurse-training committees for training expenses. Disclaimed hospitals are also covered by provisions under Clause 1 (2). The subject of regional examinations was raised by the noble Lord, Lord Moran. He need not fear that the standard of training will thereby be lowered. Not only will the General Nursing, Council be involved, in co-operation with the training committees, but it must be noticed that the influences on the side of the hospital management committees and, indeed, the regional boards, will be those of the Minister, and the Minister, above all, will be anxious to ensure that the training shall be efficiently done, in accordance with the plans laid down by the General Nursing Council.

I feel I ought to say a few words on the noble Lord's remarks about the position of the teaching hospitals and their relationship to training. In the National Health Service Act the teaching hospitals were dealt with separately from other hospitals because the position they occupied in relation to the teaching of medicine was unique. The same analogy cannot be drawn with reference to the training of nurses. While all medical students are taught in the teaching hospitals, only a small proportion of trained nurses are trained there. While the teaching hospitals include some which provide the best training for nurses, there are non-teaching hospitals where nurse-training is of an equally high standard. There are also teaching hospitals where nurse-training, is not of the same standard as the best among the non-teaching hospitals. In relation to the training of nurses, the teaching hospitals occupy a small part only of the total field, and, in the Department's view, it would be most detrimental to nurse-training as a whole to seek to separate this small part (which also contains some of the best training) from the rest. Under the Bill the teaching hospitals will be given an opportunity to raise the whole level of nurse-training throughout the country. They cannot make their influence felt if they are kept in isolation. They should welcome the unprecedented opportunity to raise the general standard.

THE MARQUESS OF READING

May I ask the noble Lord whether, when he refers to the Department's view, he means the Minister's view?

LORD SHEPHERD

When one speaks of the Minister one usually speaks of the Department as well. If one speaks of the Department one always associates the Minister with it. I am speaking of the Ministry in its corporate sense. I hoped that my remarks at the beginning of my speech this afternoon would have indicated that the present Minister of Health has been amenable to reason and has seen fit to change his view in directions where advice has been given. I hope we are not going to jeopardise the chances of success of this measure because of our apparent dislike of a certain person.

THE MARQUESS OF READING

My Lords, that remark must cause me to intervene again, although I had not meant to do so. The noble Lord has entirely misunderstood the purpose of my previous intervention. I raised the ques- tion as a mild protest against the representative of the Government in this House telling your Lordships what the Department's view is, and not what the responsible Minister's view is. It has nothing whatever to do with the personality of the Minister.

LORD SHEPHERD

I stand rebuked. The noble Marquess knows that I am a new member of this House. I am also new to my position at this Table. If I have transgressed in any way, then I apologise at once. I really thought the noble Marquess was raising a question about the Minister of Health and not about myself. I am sorry.

My noble friend Lord Crook raised the question whether the General Nursing Council should make a report to the Minister. That is not provided in the Bill, but consideration is being given to the matter and I hope that between now and the Committee stage we shall be able to say something more about it. I wish to say a word or two about the point which was raised by my noble friend Lord Crook and by the noble Lord, Lord Webb-Johnson, about the number of persons who have been affected because they failed to register when opportunities were given. It is probably true to say that those who have been responsible for nurse-training have not been particularly glad to re-open these matters, but there has been a change of opinion, and I hope that it may be possible by the Committee stage to give some indication whether the lists can be re-opened for registration.

In reply to the question put by my noble friend Lord Crook regarding the younger people under eighteen years of age, I have to say that, in co-operation with the Minister of Education, a number of pre-nursing courses have been organised throughout the country, but in many districts it is not possible to obtain sufficient students to make those courses worth while. In any case, the pre-nursing course is insufficient by itself to bridge the gap, and a satisfactory method is thought to be the employment of young girls in hospitals on suitable work, under suitable conditions, coupled with the continuance of their education. The Ministry are at present working out a scheme on those lines in consultation with the General Nursing Council. Progress has been made in respect of aides, but the Government are holding off somewhat until more experience has been gained with the training for assistant nurses. The subject is not being lost sight of, and I am sure that the noble Lord can expect further reports later on about progress. The other matters are of very small detail, and I do not think I should trespass further on the time of your Lordships at this stage. The matters with which I have not dealt in this speech will receive consideration, and I hope, therefore, that the Motion for the Second Reading will be carried.

LORD AMWELL

My Lords, before the noble Lord sits down, may I ask whether he can say a word with reference to the point raised by the noble Lord, Lord Amulree, and the noble Lord behind me, with regard to post-graduate teaching and its recognition, especially in reference to children's hospitals?

LORD SHEPHERD

I mentioned in my speech that this matter is not only receiving attention but is being operated, and to that extent we are receiving the assistance of the Royal Nursing Council and other bodies.

On Question, Bill read 2^a, and committed to a Committee of the Whole House.