§ 4.15 p.m.
§ LORD CROOK rose to call attention to the Hospital Nursing Services; and to move for Papers, The noble Lord said: My Lords, it is something over four years since your Lordships were last invited to discuss nursing subjects, and to-day, in moving the Motion standing on the Order Paper in my name, I move a Motion phrased in somewhat wider terms, in order to afford an opportunity of looking at a rather wider aspect of the subject than the general aspect of the shortage of nurses which we discussed in 1948. I think it will be agreed by all of us that our efficiency as a nation depends, to a large extent, upon the way in which we can deploy our manpower; and the deploying of our manpower depends, again to a large extent, upon the health that we can bring to our people. At times, such as the occasion of the recent tragic Tube accident and other tragedies, we hear much of the heroism of doctors and nurses; but, as many of your Lordships know, the daily task goes on for all of them, all the time, often unrecognised and unrewarded. How much we owe to them some of us know, and let me say how glad we are to see the noble Lord who is to reply to this Motion to-day sitting there fit and able to reply because he has been the recipient recently of such excellent care from the medical and nursing services.
§ The truth is that we are fortunate to have in employment in our hospitals today as many as 47,000 fully trained nurses and some 8,000 part-time nurses. I note with some concern that this campares with the statement in 1948 that there were 52,000 trained nurses employed and another 48,000 in training. I quote from the OFFICIAL REPORT, Column 308 of November 9, 1948. The figures, therefore, of present employment fall far short of the ability to meet the needs of the present situation, much less the potential growth of the Health Service.422
§ On the former occasion to which I have referred, I ventured to bring to your Lordships' attention some of the problems which meant that young women were discouraged from becoming student nurses; and I pointed out, or sought to point out, with the assistance of other noble Lords, that the total manpower that was available in the hospital service was not deployed effectively and to the best advantage. On that occasion I suggested that too much domestic employment was given to nurses, and that that was having a prejudicial effect on recruitment. Not only was the value of the nurses already recruited reduced by their wrongful use, but the knowledge of the wrongful use of nurses on domestic work caused others not to come into the service. On that occasion, I had the support of the late Lord Rushcliffe, speaking from his great knowledge of nursing conditions.
§ I also ventured to suggest to your Lordships' House that the greater employment of part-time nurses would be of considerable value. I had in mind trained nurses who got married and left the hospital service but whose home duties were such that they could spare some period of time in the day to come back and help in the nursing services. I was fortunate to have the support on that matter on that occasion of the noble Earl, Lord Beauchamp, and also of the noble Lord, Lord Amulree, who I am glad to note is again with us this afternoon. Lord Amulree made a number of most valuable suggestions, and I hope we shall hear from the noble Lord who is to reply that the Government have looked at them and, indeed, may have found it possible to accept them.
§ One of the reasons I have waited so long before putting a further Motion on the Order Paper is that on that occasion the noble Lord who was replying for His Majesty's Government indicated that there was about to start work a Committee of Inquiry set up by the Nuffield Provincial Trust. He said he expected that the results of that Inquiry would be of considerable assistance to the Ministry of Health, the Government and this House in showing what the staffing problems were and in showing up by job analysis the best means of using skilled nurses in the most skilled jobs. It is precisely because the Report of the 423 Nuffield Provincial Trust has just been published that I have now ventured to invite your Lordships to look at this Motion to-day.
§ If there is one thing which stands out in that Report, it is that the most skilled nurses are not being used in the most skilful jobs. The Report makes it clear that the allegation which some of us made in 1948, that proper use was not being made of the grade of ward orderly, was true, though we are glad to note that there are 25,000 members of that grade now employed. Perhaps I may detain your Lordships for two or three minutes to tell you of the method which was adopted by the Nuffield Trust team in order to prepare what The Lancet has described as "this most unique Report."
§ Your Lordships who were interested in the 1948 debate will recall that we had the benefit of the Report of a Working Party set up by the Minister of Health who had undertaken a "job analysis" in hospital life. It was a very small "job analysis." They had looked at the daily routine of thirty-six student nurses, a few midwives and a few staff nurses, in order to establish the nature of the time spent on domestic duties, the amount of time spent on repetition work in nurses' training, and the extent of the overlap between the various training courses. The "job analysis" undertaken by the Nuffield Provincial Trust, which is the subject of this Report, was, however, on a much larger scale. It involved continuous observation over a period of time in entire wards in some twenty-six wards in twelve general hospitals scattered over England and Scotland, so selected as to get the maximum possible coverage of all types. For instance, nine were formerly voluntary hospitals and three were formerly municipal hospitals; eight of them served urban or industrial populations, and four of them served rural populations. They ranged in size from the 200-bed hospital to one with only fifteen beds. They varied in that the two rival systems of training of nurses were each being used in approximately half of the hospitals. The three-shift system for the employment of nurses which some of us advocated to your Lordships in 1948, and to which the noble Lord who replied for the Government on that occasion gave his blessing, was in use in only three 424 of the hospitals; the remainder used the two-shift system, with a spell of split duty during the day.
§ In these twelve hospitals, the happenings in the twenty-six wards were charted minute by minute throughout the twenty-four hours, so as to show not only all the tasks that were performed but even the most minute of interruptions, down to telephone calls. So far as nursing duties were concerned, the most outstanding finding was that almost three-quarters of the time spent on nursing duties in the wards was contributed by student nurses—one of the tragic things that some of us were forecasting in 1948 would happen. Indeed, only 16 per cent. of the time spent on nursing duties was shown to have been given by trained nurses. The sister of a ward is so engaged these days with administrative functions and the like that she gives only a very small percentage of her time to nursing. Nor is the staff nurse in a much better position; she has only a small amount of time to devote to actual nursing. Most of the nursing is done by the girls who are studying and, as I think noble Lords felt in 1948, the total amount of training is established to be absolutely negligible. The highest figure of training recorded in this Report was eleven hours in a week and, be it said with great regret, the lowest was only seven minutes in a week. The Report establishes that a ward sister, in a nine-hour day, gives no less than four and a half hours of her time to organisation matters inside the ward; whereas the student nurse, who is supposed to be learning nursing, gives 75 per cent., or at least 68 per cent., of her time to nursing, depending upon the year of her training period which she has reached.
§ The Report shows the importance of the ward orderly grade to which some of us referred on that past occasion, but of course the ward orderlies are untrained people. The British Medical Journal, commenting on this Report about the employment of ward orderlies—I do not pretend to be competent to judge, but some of my medical colleagues in this House who follow me may be able to comment on it—expresses the view that many of them could become fairly good auxiliary nurses if they were given the proper opportunity to train in that employment. I should like to know from Her Majesty's Government whether attention is being given to that suggestion.425
It is only right to say that in the time that has elapsed since we last discussed this matter there has been a considerable change in respect of domestic work. One of the deterrents to recruitment which worried us so much in 1948 has at least been reduced, in that the total volume of domestic work now performed by student nurses is very much lower—and I am sure we are all glad to know it. Indeed, as the Report makes clear, the amount varies from thirty-five minutes a day, in the first year of the training period, to as low as fifteen minutes a day, in the nurses' fourth year in the hospital. The worrying thing, however, is the nature of the work shown to be performed by student nurses in this large amount of time which they now devote to nursing. They receive only a diminutive instruction, which might well be described by a layman such as myself as alarming. To the taking of pulses and temperatures by student nurses I think we are all accustomed. but when we learn from the Report that, apart from doing dressings, student nurses now give injections, are responsible for checking drugs, carrying out urine tests, and in one case were noted as taking blood pressures, then I think a very serious situation has arisen; and at least one is entitled to express some surprise and concern. Indeed, 72 per cent. of the total time spent on the dressings of patients was shown to be contributed by student nurses, and the theory of wound dressing is, in the main, shown to be picked up rather than taught. I think the Lancet
comment was the right one—namely:
This kind of practice is a useful makeshift when teachers are scarce, but it cannot be classed as efficient training.
I think that paper well summarised the general position in its editorial, when it reached the conclusion that the student nurse is so little of a student and so much of a nurse, for the same reason that the ward sister is so little of a nurse and so much of a clerk.
§ My Lords, it works out that the end result of training for nursing to-day is not nursing at all, because the maximum amount of nursing is now done when the young lady is a student. As soon as she becomes a staff nurse the amount of nursing that she does falls. When, by her ability, she manages to become a nursing sister, she cart satisfy herself that thereafter she will never be able to spend 426 more than 16 per cent, of her day engaged on nursing. So, just as some of us advocated, four years ago, the relief of the nursing staff by the introduction of more people to do domestic and lower grade jobs, so it seems that there is now a case for considering the appointment of a person of clerical or secretarial type who, without any interference with the nursing functions of the sister or the staff nurse, might take over some of those jobs of filling in forms and looking after telephone calls which are now done by the ward sister, to the great misuse of the skill which she has attained by such devotion to duty during the years before.
The misuse of the services of sisters and staff nurses in general is clearly established in the Report. Nurses walk backwards and forwards carrying bowls of water, nobody apparently having thought of organising a system in which the bulk supply of water in the ward is moved on a trolley by a domestic or ward orderly. But how can one expect that some of these things would have been thought of, when there is a bland little paragraph, which I am sure must have amused the noble Lord who will reply for the Government, as it has me—to the effect that
a shortage of matches was the cause of many wasted journeys to and fro with a taper.
I cannot believe that that is general, but it is typical of the kind of thing which someone ought to start trying to put right. Similarly, there are comments relating to the manner in which food has to be dealt with It is recorded that long loaves are sometimes sent up for the nurses to cut up by hand for the patients. These are trained people, and they are kept away from their task of looking after patients in order to spend time laboriously cutting up these long loaves. The average hospital does not seem to have heard of ready sliced loaves—in fact none of the hospitals under review does.
§ Much of the waste of manpower, I want to say straight away, is due to the poor design of buildings and the shortage of good equipment. I am a realist, and therefore I do not want to blame anyone particularly for that, or to throw criticisms about. Being a realist, I realise that the National Health Service inherited a large number of Poor Law buildings the construction of which paid regard all the time 427 to keeping down the rates and costs generally. The Service also inherited a large number of hospitals which were in a parlous condition financially, being unable to get sufficient money from the public on whom they had to rely for voluntary contributions. I realise, too, that because we were rather ahead of other countries in providing hospital treatment, many of our hospitals are now completely out of date, whereas some other countries that took up later the kind of treatment with which we started have somewhat better hospitals.
§ It follows, therefore, that the mere fact that in the last few years the State has taken over these buildings and this equipment does not mean that the State, whatever Party are in power, can, as it were, through the Ministry of Health, wave a fairy wand and immediately produce a cure for all these troubles and difficulties. For that reason, I would press upon the Government that there should be some system of priorities to make certain that the expenditures are now made in the right way, that they are made so as to get the maximum possible results in the easing of the manpower problem, generally making the job easier than it is, and providing some of the equipment which is so badly needed. Parts of the Report really are tragic to read. For instance, the Report makes it clear that there is a great shortage of such elementary hospital equipment as bedpans and wash-bowls. In one instance, there were only five bedpans for twenty-eight female patients, and seven wash-bowls for thirty-seven patients. Those are regrettable figures. And this ought not to be the position in respect of a State Health Service of this kind. Sterilisers for the bedpans have rarely been installed. Student nurses were seen wasting time daily disinfecting bedpans, and I was amazed to read that three wards performed the sterilising operation with fish kettles on gas rings. Two other wards had no means of sterilising bowls other than by flaming with methylated spirit. In one hospital, which I believe is supposed to be modern, the sterilising room had no running water. The only water for sterilising purposes was brought in jugs from the kitchen.
Let me say how much I welcome the publication by the Ministry of Health in the last month or two of the valuable
document entitled The Reception and Welfare of In-Patients in Hospital. This document was prepared by the Central Health Service Council. I was glad to note, in paragraph 74, the recommendation to hospital management committees that equipment of this sort should be up to date and hygienic, and that every ward should have adequate facilities for sterilisation of bedpans. I was glad to note, too, that the comment is made that this is the kind of thing which can be afforded, even at this time. The Council say that they see no reason why financial stringency should prevent the carrying out of these recommendations. Whether these recommendations are to be accepted by the Ministry of Health I do not know—perhaps the noble Lord who is to reply on behalf of the Government will tell us, and perhaps he will tell us also if this publication is to be circulated. It would be very gratifying if we could get this allocation of priorities, and we might then see, even if major structural changes at hospitals cannot yet be undertaken, such things as new water taps, wash basins and lavatories installed where there is a shortage. All of this would help the considerably over pressed and overworked nursing services. At this point I would venture to give your Lordships a quotation from the Lancet. Somewhat sarcastically in reviewing this Report, that journal said:
It is customary just now to talk about economising our nursing power. One simple way to do it would be to provide nurses with the tools of theft trade in adequate quantity.
I could never hope to say anything quite so well and so adequately.
The comfort, the welfare and even the safety of life of the people of this country may depend on some of the improvements which we ought to make. By ancient custom the patient must be awakened, washed, eased and fed before the medical staff appear on the ward. This is the subject of a very valuable chapter in the Report. The custom means, apparently, getting patients up as early as 5 a.m. Of twenty-two wards, of which there are details in the Report, only four had the patients' tasks commenced at any time after 5 a.m. In eighteen cases the time was actually 5 a.m. The earliest was 4.15 a.m. Indeed, in only one ward was the washing round started after 5 a.m. In some cases the round started at 4.30 a.m. The making
of the beds for the day was the actual starting task, as early as 4.45 a.m. in one case. I deliberately mention that part of the Report in order to bring to your Lordships' attention a further extract from this valuable document, The Reception and Welfare of In-Patients in Hospital. It reads:
We suggest that no patients, apart from those receiving special treatment, should have to be awakened before 6 o'clock, and later if possible.
I hope we may hear from the noble Lord who is going to reply that that recommendation of the Council has the support of Her Majesty's Government.
§ All these things would help to relieve the pressure on these short staffs. And how limited these staffs are was shown by the replies to Questions which I put to Her Majesty's Government a few weeks ago. The number of under-staffed hospital beds in April this year was shown by the Government reply to one of my Questions to be no fewer than 28,502. The same reply indicated that the employing authorities responsible for hospitals estimated to the Ministry of Health that the present shortage of nurses of which they are conscious is 10,420. At the time of our last debate the estimated shortage was 12,575. So, in the four and a half years that have followed, the improvement in the shortage position has been very slow.
§ Time will not permit, and your Lordships would not wish, me to go on from general hospitals to deal with a number of very serious points about mental hospitals and sanatoria; but some of the facts in that connection are shocking. In many mental hospitals, particularly on the female side, a nurse is responsible for up to seventy patients. I have been given in the last few weeks details of one mental hospital where a nurse goes off duty and leaves a patient in charge, locking the door behind her as she leaves duty. In those cases the only care and attention is the visit by an administrative sister or nurse from another ward, who has to leave her own ward while she pays that visit. That is not the fault of anyone in the hospital it is entirely due to the shortage of staff and the existing inability to do anything about it.
§ I hope, therefore, the House will be given one important assurance by the noble Lord replying for the Government this afternoon—that is, about the 5 per 430 cent. reduction in staffs which I believe the Ministry have told management committees to make. Indeed, I hope the Government will go further, because I believe that management committees have been instructed to submit to the Ministry details of staffs in post at a fixed date, and that the number given is to be recorded as the establishment and to represent the maximum number of posts which there can be inside the hospital. Thereafter, no additional staff will be engaged without the prior approval of the Ministry. I am all for fixing establishments, and I quite appreciate the necessity for submitting the figures to the Ministry, so that the Ministry may see that there is no wrongful use of manpower by diversion of people to the wrong places, at a time when female labour of this kind is so scarce and we are trying to staff the hospitals under these conditions. Nevertheless, I suggest to the noble Lord that to impose this kind of condition on management committees who have wards closed because there are 10,000 nurses short and who have 28,000 beds unused because of under-staffing, is to tackle the thing the wrong way round, especially when, as we all know, so many thousands of members of the public are waiting for medical and surgical attention. I do not think that such restrictions should be imposed on management committees. If the noble Lord, Lord Woolton, can tell us either that this is not true or, alternatively, that for under-staffed hospitals, and hospitals with beds not in use, there will be some easing up in the proposed cut, that will go some way towards helping the position.
§ This issue goes even deeper. If this 5 per cent. cut is applied to domestic staff, where do we stand? Cutting the domestic staff by 5 per cent. does not cut down domestic work by 5 per cent., and once again this will cause the domestic work to fall on the student nurses. They will flow out of the hospitals faster even than now—and we know how fast they are going. Then, too, the knowledge that domestic work is falling on student nurses will slow down the already slow rate of recruiting of nurses. I think the Ministry need to look into this carefully.
Finally, I hope the noble Lord will be able to assure us that there is to be no waste of time in examining the valuable Report of the Nuffield Trust and adopting as many as possible of its
recommendations, only a few of which I have touched on sketchily in the course of the last half-hour. This is a most valuable Report, as I imagine the Minister will say, and my noble friends who are doctors and who are to follow me in the debate will agree. Probably there is nothing new in it from the point of view of many of us, but it contains a record of facts set down by a reputable body—not just casual suggestions of people like myself with no real authority. As the Lancet said:
…this report gives the backing of fact, which those advocating experiment have long needed.
It does not bring to light much that many of us who have taken part in these debates do not know, but it gives the facts necessary to help us to improve this great service of ours which has a great part to play in this country. I hope the Government will be able to tell us this afternoon of their plans for future action, and that they will be able to promise us a further debate at an early date, when perhaps we may hear that further progress has been made as a result of this Report. I beg to move for Papers.
§ 4.45 p.m.
§ LORD MORAN
My Lords, more than three-quarters of the inhabitants of these islands—that is to say, the majority of the population—when they are ill in hospital are nursed by student nurses who have neither completed their training nor passed their final examinations. Therefore it is of some consequence that these nurses should have the benefit of instruction and supervision by trained nurses. When that does not happen, either because there is a scarcity of nurses or, alternatively, because the nurses are occupied with other duties in the wards, then it becomes a matter of public concern.
The scarcity of nurses is not a passing factor. The wastage of student nurses in training is 50 per cent. Of every two girls who begin with the intention of becoming nurses, only one completes the course. When one hears that the chief factor in that wastage is marriage, it becomes less hopeful to tackle it. I think we may say there is general agreement that we cannot look for any great increase in the number of trained nurses in the 432 future. We have to concentrate on making the best use of those we already have. Therefore, we come at once to the question: is the time of the nurse wasted in any way? Are there any of her activities which could be done by somebody who is not a nurse or, alternatively, could be cut out altogether? The job analysis, to which the noble Lord, Lord Crook, has referred, gives us the material with which to answer that question.
I do not imagine you will think I am ungenerous to the authors of this valuable Report if I sound a note of warning. A man of many years must have seen many fashions come and go. I remember, in the kindred field of medical education, how Abraham Flexner descended on us from across the Atlantic and bestrode us like a Colossus. We who were concerned with medical education were left with a feeling that, compared with middle Europe, we were unscientific and unorganised. Any system of education must be judged by its fruits, and nowadays we are not so certain as we were that the German ideals of education are sound. Nowadays, the fashion is for working parties and job analyses. They are invaluable to prevent thinking without the facts, but there is always a danger that we may get the facts without the thinking.
Let us apply this valuable Report to the question I put a moment ago—namely, are there any activities of the nurse which could be done by somebody who is not a nurse or cut out altogether? At the outset, I wonder whether some of the nursing procedures are not apt to degenerate into rituals. Some months ago I had an operation. I was not ill—I golfed the day before—but when it was all over, although I was admirably nursed, at all hours of the day nurses came and vigorously rubbed my back in order that I might not get a bed sore. When they had gone, others appeared and chaperoned me through deep-breathing exercises, to prevent my getting pneumonia after the anæsthetic. No doubt these procedures are invaluable in the appropriate cases, but I think we might plead for a certain amount of discrimination in the choice of the victim. Again, is it really necessary to take the pulse, respiration and temperature of every patient twice daily up to the very moment he walks out of the ward as a convalescent?
433 Again, take the ward sister's nine-hour day—take only two items in that day. One hour is devoted to clerical work. I went through this and found that nearly all of it could be done by a secretary. But when an enterprising and well-known provincial hospital instituted the secretarial system, they were told to desist on the grounds of economy. Another hour of this nine-hour day is given up to going round with doctors. In the male ward, surely, much of that is unnecessary. At the risk of offending many of my own calling, I would say that no doctor should go round before ten o'clock in the morning, or between the hours of twelve noon and two o'clock, or after five o'clock. We must co-operate more with our nursing friends if they are really going to economise their time. Then we come to the almost complete absence of labour-saving devices, to which reference has already been made. I give your Lordships only one example. In the twenty-six weeks which this Report covers, 194 hours were spent by nurses in moving heavy screens from point A in the ward to point B. If we could simply have curtains around the bed, with a flick of the wrist all that might be eliminated. Surely, when we are spending £400 million or more every year on the Health Service we should not shrink from a single, non-recurrent, small capital expenditure of this kind. And I have given your Lordships only a few examples of how some, at least, of the activities of the trained nurse might be eliminated or done by somebody who is not a nurse.
I pass to the much more controversial question: Are there any of her activities which must be done by a nurse, but not necessarily by a trained nurse? Why is this more controversial? It is because there are two conflicting arguments, both of them very strong. On the one hand, the very centre of the theme of this job analysis is that administration has taken away the trained nurse from the bedside, and that it is our job to get her back to the patient. That is an overwhelming argument. How do we judge a nurse? We judge her by the accuracy and the discrimination of her observations. Where will she learn that, except at the bedside; and where, having learnt it, will she keep it fresh but at the bedside? If it be said, as it will be, that many of these bedside nursing operations are 434 repeated time and again, I would quote a wise matron who said to me: "It is by doing these things many times that nurses learn to adjust their procedures to the very various temperaments of the innumerable patients they have to nurse." Again, a wise woman, who was not a nurse, said to me: "My babies were all bottle-fed, but I did it myself, because that is the only way to get to know the difference between my babies and other babies." In other words, the repetition of these apparently menial duties allows the nurse to get to know her patient. It seems to me that that is an overwhelming argument.
But the argument on the other side is almost equally strong. Perhaps before I go on to that other argument I ought to take up one point in this job analysis—namely, the stress that is laid upon the taking away of the nurse from the bedside by administration. The Committee obviously regret profoundly that the average nurse looks upon administration as her end and aim in life. It is inevitable, because administration is not only looked upon as promotion, but it is better paid. We have the grave warning of what happened in the Royal Army Medical Corps. There, after a certain stage, a man must give up clinical work for administration or he will not get to the top. As the result, that service has been made less attractive to the doctor and is at present very short of personnel. The other argument is this. It is said that all these bedside duties, or most of them, should be done by a pair of hands belonging to a person who is not as skilled as the trained nurse. This Report shows that three-quarters of the nursing is done by student nurses, arid apparently adequately done, and therefore, it logically follows that at a time of great scarcity of trained nurses we should provide to do those duties a pair of hands belonging to a person less skilled than a trained nurse.
This brings me to the question of dilution. Nobody that I know has ever introduced dilution into any trade or profession without profound controversy. But we have had dilution amongst almoners; amongst dentists it is still being considered; and the doctor has already been diluted. After all, what is the nurse? The nurse is dilution. She is now doing jobs which the doctor did 435 years ago. It is inevitable that we should have dilution in the nursing profession. Those who speak for the nursing profession, like those who speak for my calling, are generally attached to teaching hospitals. The result is that perhaps our horizon is a little narrow. But I would remind the nursing profession that half the hospital beds in this country are in mental hospitals. Surely the case for dilution of the nursing profession is overwhelming. Who is to be the diluting agent? If it could be the assistant nurse, we should all be happy. The assistant nurse trains for two years instead of three or four; her training is practical, with a minimum of theory. Unfortunately, many nurses if they are not getting on well with their examinations, when they are advised to become assistant nurses, say: "If I cannot be a proper nurse I will not become a nurse at all." That is a grievously mistaken attitude. These assistant nurses are invaluable. But, whatever we may say about them at the present time, there does not appear to be any prospect of getting anything like enough of them.
That brings me to the controversial subject of the orderly. I believe I am not misquoting the nursing profession when I say that, generally speaking, they feel that an orderly should do domestic duties and not even engage in minor nursing procedures. But I feel that if an orderly were trained for a year, he would be a most useful pair of hands, at any rate in hospitals where acute cases are not treated. I hope that the nursing profession, in the crisis we are now going through because of the scarcity of trained nurses, will give the most careful attention to the use of the orderly. When you get these two conflicting arguments, the verdict is quite obvious. If we had enough trained nurses, then they should be taken to the bedside; but, in the present scarcity, we have no option but the dilution of the nursing profession. When we are concerned with the proper use of trained nurses, it is obvious that we ought for a moment to glance at the question of redistribution. The tidy mind will find that in the sanatoria devoted to tuberculosis, in the mental hospitals and in the institutions devoted to the chronic sick and to the elderly, there is probably—I have not the figures—a gross shortage of trained nurses. I would say only two things about that: first, if 436 a nurse is to be sent there she must go voluntarily—there can be no direction of labour; secondly, at a time when nurses are so scarce, it is surely wise to be very prudent before we further deplete the hospitals where acute illness is nursed.
Now I end as I began, with student nurses. This Report says that the student nurse is left to her own devices; that she is neither taught nor supervised, and that even the arrangement of her hours is so constructed that many finish their training and are found not to have served in important departments. If that is true, it does not matter, because very shortly, before she will be able to go up for her final examinations, she will have to be signed up—that is to say, she will have to produce a certificate to testify that she has worked a proper time in each department. I think the trained nurse would say of these criticisms that they are gross exaggerations. She would say that they take no account of the teaching which takes place outside the wards; of the three months' preliminary instruction before she enters the wards at all, and, where the block system operates, of the twenty-six weeks—more than six months—when the nurse is taken away entirely from the wards and given theoretical training. My answer would be that that is no substitute whatsoever for teaching by the bedside. When I think of all the hours and years that I and other physicians and surgeons have tried to stimulate the student's mind to observation and to make him ask the "Why?" of everything, I cannot believe that the student nurse's mind is less in need of this stimulation, this encouragement to observe and think.
But if we are to do this, then let us do it after an English model, and not in the manner of our American friends. I speak from hearsay only, but it would appear that in America there are two kinds of nurse—the nurse who can do technical procedures is called a graduate nurse, and the nurse who cannot is called a practical nurse. Now it is the graduate nurse who counts. She is really a junior doctor, but she dislikes very much what may be called menial duties. If you have been ill in America, as I have, you will realise that you do not get anything of what we mean by nursing. Even in England, of late years, technical nursing has been exalted over basic nursing. For example, as the training of the junior nurse goes on, more and more time is 437 devoted to technical nursing at the expense of basic nursing, and in her examinations emphasis is almost entirely on technical procedures. Does it matter? It matters very greatly, because there is an element in human nature which finds great satisfaction in rushing about and doing things. It is so much more preferable to the lonely processes of thought. And it has always been so; more than 300 years ago Pascal said that most of the wrongs and the evils of mankind arise through man's inability to sit still in a room and think. Therefore, these procedures are weaning the nurse away from the difficult art of observation.
It is very easy, in a debate of this kind, to over-simplify—to fall into error in that way. I have been content to try and submit to your Lordships that, at a time when there is a scarcity of trained nurses, much of their activities must be reviewed, because so only can we get the supervision and the teaching of the nurse in training, the nurse of to-morrow, to teach her the elements of her art. I even hope that in a properly constituted State, administration may not be the peak of every nurse's ambition. It is a great pleasure to your Lordships that the Government reply will be made by the noble Lord, Lord Woolton. I do not think anybody is really fully qualified to discuss nursing until they have been a patient, and I am sure that what he will say will have the truth that comes from actual experience.
§ 5.6 p.m.
§ LORD AMULREE
My Lords, before I address a few remarks to your Lordships, I should like to join the two previous speakers in expressing my great pleasure that the noble Lord, Lord Woolton, is to reply to this debate, and to say how glad I am to see him back in his place once again. The subject of nursing has been very widely covered by the noble Lord, Lord Crook, and my noble friend and colleague, Lord Moran, and I do not propose to cover the ground that they have already traversed. I should like to make one or two extra observations which may be germane to the subject.
We are told that about 10,000 or 12,000 nurses are still required, and that the total number involved in hospitals is not quite so big as when we had our debate four years ago. One of the things which puzzles me is whether we can continue 438 to make this great call upon the young educated women of the country to take up the nursing profession. One of the rather frightening things is something that I read in the Report of the Royal Commission on Population, which came out in 1949. In Table 40, they estimated that the number of persons between the ages of fifteen and forty will drop from 18 million to about 16½million by 1962. On page 98 of the Report they report the conclusion that the number of young grown-up people between fifteen and thirty-nine years of age will show a fall of about 1½ million during the next fifteen years. It will be from among those kind of people that the young nurses will be called in the future, and I wonder whether hospitals, local authorities and industrial firms employing nurses realise what is likely to be the position.
I was pleased to read in the Ministry's circular, B.G. (52) 127 Economy in Manpower, which has already been quoted, that hospitals were encouraged to look at their staffs to see whether there were any means by which they could economise. When I raised this matter before, I thought it was a command from the Ministry, but I was told by the noble Earl that it was only an encouragement. I think that is the sensible line to take, because I believe that the supply may fall a great deal more below the demand than it is now. Therefore, I should like to join the noble Lord, Lord Moran, in saying that some form of dilution is the only way round our difficulties. I do not want to cover the ground that the noble Lord has already traversed, because I am in agreement with. what he said, but there are one or two other ways in which I think we can dilute the nursing profession without doing any serious harm. One is by making different arrangements for them to care for more people in the future than they do now. I do not mean that I wish to increase their work or hours or anything like that, but recently one or two schemes have been set going whereby patients can be discharged from hospital properly and rather more quickly than before, which means that the same staff can deal with rather more patients. There is the rather interesting scheme at Cambridge, where, by co-operation with general practitioners and with the district nursing service, patients—that is to say, mainly surgical patients 439 with clean operations—can be discharged within four or five days, instead of ten days. As far as I can make out, this has led to no increase in the district nursing service and means that nurses can take more patients.
The noble Lord, Lord Moran, referred to the chronic sick. In one hospital at which I work, which was a chronic sick hospital, they managed to use the nurses in such a way that they visited patients at a particular time before they were due to go into hospital, and in many instances it was found that the people did not need to come into hospital at all. Furthermore if you can choose your patients rather carefully—not in an unpleasant way, but because they are ill—and bring them in quickly, you can get them back to their homes again in a much shorter time than if they had had to wait a long time before they came in. That, again, is a form of making your nursing power go a great deal further than before. Those are the points that I want to make to the noble Lord who is going to reply for the Government.
There is, however, just one further point which I should like to make with regard to what a nurse should do. After all, we must not forget that the most important person in a hospital is the patient. The second most important is the nurse; but the patient comes first. Therefore when you say that the training of nurses has got to be paramount and the needs of the hospital second, I do not altogether agree. I agree very much with the noble Lord, Lord Moran, when he says that the teaching of nurses should be done at the bedside. Teaching is done by taking care of your patient. One of the things which the Working Party emphasises is that the patient gets to know the nurse when the nurse is doing the daily nursing—looking after the daily hygiene, comfort in bed, feeding, taking away of body waste. The patient gets to know the nurse in this way, and it is very important that the student nurse should concentrate on that and not try to become a doctor.
It is curious to note that in 1947 a Working Party on the training of nurses suggested that the training might be made two years' or eighteen months' basic training, followed by specialised training for a period. That proposal has not been 440 accepted, so I take it that it was frowned upon by the powers-that-be. But it seems to me that the danger now is that we get too many nurses trained to too high a standard. They are, in fact, going to be not very good doctors, rather than very good nurses. Although the medical service has been diluted by nurses it is possible to carry that a little too far and make these trained nurses of a higher standard than is necessary. It always seems to me to be rather a pity to make the trained nurses' standard too high. The nurse so trained looks for an administrative job; no other would give an increased salary. The standard is so high that it approaches very closely to what was the final you could obtain when you were trained. I thank the noble Lord, Lord Crook, for bringing up this question, because it is one of great interest and importance to everyone. I am sure that we shall have an encouraging reply from the noble Lord who is to speak for Her Majesty's Government.
§ 5.15 p.m.
§ LORD HADEN-GUEST
My Lords, I too should like to express thanks to the noble Lord, Lord Crook, for bringing this matter forward, and for the way in which he made clear many things which are at present obscure. The noble Lord mentioned that there were 47,000 fully trained nurses actually in service. A Question put down by Lord Crook the other day produced the Answer that there are in training 50,470 student nurses. That is a considerable number. I think it is very unfortunate that this proportion exists, because the difficulty is to keep the student nurses until they finally get their qualifications. What the noble Lord, Lord Moran, said is, of course, very interesting; we can rely on his great administrative experience and his equally great professional experience over a long period of years. But when he said that dilution of the nursing profession is inevitable, I frankly regard that as a defeatist argument. We must do something more drastic with the nursing profession; we must do something which is more productive of efficiency, something more than merely unlimited dilution. It is true that there is a great deal of difference between ordinary nursing and nursing in a mental hospital, between certain other types of nursing and nursing in the acute ward of some of the big 441 hospitals or the big teaching hospitals, which deal with a large number of accident and other urgent cases. But to use the word "dilution" is unfortunate, because there is already in the nursing profession far too much dilution. That is one of the difficulties.
Lord Moran also thought that orderlies should do certain nursing tasks. But there are already a considerable number of male nurses, properly trained, and other orderlies can be trained to do these duties and can then become nurses; but I adhere to professional standards in this respect. I think we ought to have carefully trained people, rather than those who have just "picked up" the knowledge as they went along and have not had adequate training. I am glad that the noble Lord made reference to the American system of nurses, and that he did not approve of the system. The American methods of nursing organisation are entirely different from our own. I find myself very much in agreement with what Lord Amulree said in his interesting speech, but he also, unfortunately, thought that dilution was necessary. I hope he will reflect on that again and see whether we do not need something more fundamental.
The noble Lord, Lord Crook, mentioned that trained nurses spend only 16 per cent. of their time on nursing, while student nurses spend up to 74 per cent. of their time looking after patients. It is difficult to contemplate calmly fiat state of affairs because it means, in fact, that the student nurses are bearing on their shoulders the main burden of nursing. Most senior student nurses and staff nurses interviewed by those who went round the hospitals under the auspices of the Nuffield Provisional Hospitals Job Analysis work were contemplating further training, presumably to fit them for administrative and other special posts. I notice that the Nursing Mirror has this to say:One cannot escape the conclusion that, at present, the end result of nurse training for the hospital service is not nursing but administration.The Nursing Mirror is an authoritative paper, and its opinions are regarded with the greatest possible respect as being of considerable importance. Basic nursing, although occupying 71 per cent. of nursing time, is progressively less and less the occupation of the nurse advanced in 442 training. Very little time is given to the instruction of student nurses. The Report says:In no wards in hospitals studied did Sister Tutor come into the wards.Many complaints by student nurses about the incompleteness of their ward experiences were received when the members of the Committee went round. Then I noticed an interesting leader in the Nursing Mirror of February 27, which said this:No one reading this Report with an impartial mind can fail to arrive at the conclusion that in this administrative chaos the patient's comfort and whole well-being are lost in the complications of the set-up intended to preserve them.The Nursing Mirror looks forward to the medical and nursing professions analysing and facing the facts brought out in the Nuffield Report, and expresses the gratitude of the whole nursing profession to the Nuffield team for the work they have done.
I think we should face the facts. We must agree, I think, that there is no immediate solution in prospect, and the Report of the Nuffield Trust does not in fact offer one. What it offers is a survey of the facts discovered. I would remind those who may not have looked at the Report that this investigation was carried out, not by doctors but by qualified, high-grade people who were non-medical, in order to look at the thing quite impartially, without any professional bias. In the Nursing Mirror, from which I quote again—because in this way the Nursing Mirror undoubtedly speaks for the nursing profession—a leading article on March 13 speaks of "The proper task of the nursing profession." It says:Something must be done about the 'Job Analysis' report, for it shows up a situation which is extremely disquieting and for which we cannot escape responsibility. We are here, in the nursing and medical worlds, to nurse the patient, and somehow we have let a situation grow up in which the basic nursing of the patient has been turned over to the untrained or the little trained person, with no adequate supervision; a situation in which there are virtually no trained nurses in hospital doing nursing.That is a very serious statement made by a responsible journal representing the nursing profession. May I pay my tribute to the courage and the resolution expressed in the attitude of the nursing profession, as interpreted with such vigour and understanding in the Nursing Mirror?
443 May I draw attention, also, to one other very important fact in the nursing profession, and that is the wastage of student nurses to which the Report calls attention. A large proportion of the nurses who enter the profession as student nurses leave it before completing their training. No doubt, some of them leave for marriage, as the noble Lord, Lord Moran, said, but undoubtedly, if the profession were more attractive, it would probably mean that a good many fewer of them would leave, and it would not be unattractive to those who want to be nurses. Will the noble Lord who is to reply let us know what action the Government are prepared to take to remedy the situation revealed? I do not think it will be enough for him to say that the matter will be seriously examined. I think that some action must be taken to see whether we cannot tackle the nursing difficulties which now confront all hospitals in the land. The truth is that at the present time we are not able to give adequate and proper nursing to the patients admitted to some of the hospitals. It is true that the large teaching hospitals and many of the large hospitals in the big cities give excellent nursing; but it is also true that in some of the small hospitals which not very long ago were places like Poor Law infirmaries the arrangements for medical treatment are by no means as good as they should be, and sometimes they are definitely bad.
The nursing profession is ready to help, and I feel that the medical profession also will help. Here is something which can be done by agreement, and in which the primary consideration is not length of hours or amount of salary received, although these have their great importance. But essentially the demand is: "Let the nursing profession be able to give better service to the sick and suffering." This better service must solve the difficulties and, in fact, the dangers revealed by the present situation, and the nursing profession will certainly throw in its weight to help in every way possible. May I say, in conclusion, that some of the highest medical authorities in this country strongly approve the attitude of the nursing profession and will be willing to help to achieve the better use of nursing services which the Report of the Nuffield Trust shows to be urgently necessary.
§ 5.26 p.m.
§ THE CHANCELLOR OF THE DUCHY OF LANCASTER (LORD WOOLTON)
My Lords, the noble Lord, Lord Crook, not for the first time, has placed both the nursing profession and your Lordships' House in his debt for having raised, as he has done in a broad manner, the whole question of the nursing profession. This is an extraordinary Chamber. In the fourteen years in which I have been a member of it I recall no occasion on which, when a subject has been brought up for debate, we have not found a number of experts who are all prepared to come along and place their expert knowledge at our disposal. To-day the noble Lord, Lord Crook, has done this from his own point of view. We have had the lengthy experience of such eminent doctors as the noble Lords, Lord Moran, Lord Amulree and Lord Haden-Guest, who, from their intimate knowledge of this subject, gained professionally, have sought to help us. As the patient is by general consent the most important person on this issue, I present myself to your Lordships as the person most recently qualified by prolonged personal experience to deal with this subject. Perhaps it would not be considered amiss if I expressed my intense gratitude to the nursing profession for the benefits I have received from it. And will your Lordships forgive me if I say how grateful I was to your Lordships for passing on to me messages of goodwill at a time when I was considerably in need of outside support?
It is always difficult, as your Lordships know, for any Minister to reply in detail for a Department over which he has not any detailed control. I have every reason to suppose that the Minister who is responsible will be very well aware of the debate that has taken place in your Lordships' House, and perhaps it would be convenient if I were to suggest to the noble Lord, Lord Crook, that to the questions which I cannot answer, because I did not know that he was going to ask me them, I should ask the Minister to enable me to reply or, if it would be more convenient, to reply himself.
The discussion in so far as it has gone this afternoon might lead one to think that the situation was rather worse than it is, but there are good sides to this 445 subject. Many of them, I agree, are probably due to the debates that have taken place here. The nursing force in this country has increased by two-and-a-half times in the last fifty years, so we are making some progress. The demand has increased even more, but that also is a sign of progress—we are taking more care of the sick. Nursing was out of fashion for a period in the middle of these fifty years, but I think it has shown every sign of coming back and—so importantly—of being recognised as one of the noble professions of the country. I am sure your Lordships will agree that you recruit nursing staff not so much by stereotyped regulations as by showing the people who might go into it that it is a profession that is held in high esteem by the public of this country, even when they arc well. I submit to your Lordships that during the period since the war the Ministry of Health has done a very good job in encouraging recruiting.
In 1947, the Ministry setup the Working Party to which reference has been made. Since I became interested in this particular subject for the purpose of to-day's debate, I have never been quite certain why when the Working Party was engaged on its task in 1947 it did not take a job analysis and find out what it was that nurses did. That was left to the Nuffield Trustees who, by no means for the first time, have placed this country considerably in their debt. They have produced a wealth of new information. One of your Lordships (I think it was Lord Haden-Guest) asked me what is going to be done, because, he said, this is a time for action. Let me give him some assurance on that point by telling him that the Minister of Health received this Report at the beginning of April this year and immediately summoned his Advisory Committee, which met on April 29, in order that it might advise him as to the action which he should take. He is indeed anxious that no time shall be lost. Your Lordships will appreciate that this Report covers a period of time, although the actual job analysis took only a short time. Evidently the Nuffield team have gone to a great deal of trouble in analysing the figures and in working out their implications, because they have had them for three years, and during that time I hope there have been a certain number of improvements.
446 I think the House will be grateful to Lord Moran, as I am, for many things that he said, but particularly for one phrase which I hope I have remembered correctly—that we must not let the facts prevent us from thinking. Those of us who are very much prone to ask, "What are the facts?" must recognise that there is something else to do when we have got the facts, and that is to think about them. I am not quite so depressed as some of your Lordships appear to be by the fact that 74 per cent. of the basic work in hospitals is done by student nurses. A great deal of that work does not require high professional skill, although it does, indeed, require a great deal of personal kindness. The professional skill that is necessary can be provided by other than student nurses. A great deal of the work that is done for patients does not require such a high rate of skill as to justify a fully trained nurse doing it. I mention that only because I do not want your Lordships to get too depressed by this figure which, put baldly, suggests that 75 per cent. of the work is done by students. This might lead one to suppose that the patients are being badly neglected. That is certainly not my experience.
The point that I gained out of reading the Nuffield Report was the importance that they attach, I think very rightly, to the need for a reorganisation of hospital services. I had many long talks with nurses and, feeling, as I did, very important as the patient, I was horrified to find that promotion went in the line of administration. At the moment I was thinking very little of administration. It is a great pity if highly trained nurses are being called upon to do clerical work which involves an entirely different sort of capacity and a different attitude of mind; and it seems to me from this Report that the things we ought to look to are to see what reorganisation we can get, both in the direction of the personnel employed in administration and also in the fuller use of orderlies—a subject on which, in a different capacity, Lord Amulree and I have had a common interest for some time.
§ LORD CHORLEY
May I ask the noble Lord a question? I am not sure whether he is now passing from the position of the student nurses. Before passing from that subject, would he 447 devote a few words to the very disturbing thought that these student nurses are being employed to make injections, take blood counts and engage in matters of that kind?
§ LORD WOOLTON
I should be quite unqualified to deal with that problem, which is obviously entirely a medical problem, and I do propose to pass from it. In regard to the question of the supply of nurses, I think the noble Lord, Lord Crook, was quoting from figures taken from a different basis when he said that there were fewer nurses now than there were in 1948. While he was speaking I was advised that the figures that he quoted for 1948 were for Great Britain as a whole. The figures that have been given to me are these: that the number of full-time trained nurses in England and Wales only has gone up from 40,000 to 47,600 in the last four years, and that student nurses have gone up in number from 42,000 to 50,500; there has been a drop of 500 in the total of assistant nurses—from 12,000 to 11,500—but other nursing staff has gone up from 16,000 to 25,500. I hope I have not wearied your Lordships in giving these figures, because I could have given you the total figure and saved you the rest. The total figure is one of 135,000 full-time nurses of varying grades now, as compared with 110,000 in 1948. These figures are for England and Wales only. With regard to the shortage of beds, to which the noble Lord referred, in 1948, there was a bed shortage, due to shortage of nurses, of 57,000. In 1952, the number of un-staffed beds was 28,500. I have no doubt about the seriousness of the present shortage—
§ EARL JOWITT
Could the noble Lord equate the shortage of beds with the shortage of nurses? I think he spoke of a shortage of 28,500 beds. Can he give me an idea—or if he cannot do so, perhaps the Minister will do it later on—what that means in terms of shortage of nurses? If the noble Lord does not happen to have the figure, perhaps the Minister will supply it.
§ LORD CROOK
The figure given by the Ministry in answer to a question was something just over 10,000.
§ LORD WOOLTON
Lord Crook asked whether the publication entitled The Reception and Welfare of In-Patients in 448 Hospital has been circulated. It has been circulated to all hospital authorities, and the recommendations in it have been commended to them by the Minister. The noble Lord raised another question and that was concerning the cut in staff. I do not know whether he is aware that when the hospital authorities were urged to cut staff it was stipulated that this must not be done by throwing domestic work on to the nurses. I think the noble Lord would like to know that. Then he spoke about the restriction of the engagement of nurses. The reason for that, I am informed, is that the Minister felt that the problem was becoming to a considerable extent one of distribution of nurses. Some places were considerably better off than others, though still short; and in order that nurses might be employed to the best advantage he brought in the restriction order.
I hope I have done something to indicate the position. It is a position which is improving. It is a position in connection with which, quite clearly, the Ministry of Health and the Minister of Health—and I make the distinction because I want to cover a wider period than the present Minister's occupation of office—have been seriously concerned, I think with some success, in trying to recruit a large number of nurses to the profession. I believe it is inevitable that there will be a considerable wastage in this profession. I gather that one of your Lordships felt it was regrettable that there was so much wastage. But if the wastage is due to marriage then it is not any use any of your Lordships regretting it, for I am certain that it will continue and, probably, to the great advantage of the nation.
What the nurses require is recognition. We are all the children of history. There is no doubt about it that they were underpaid, but that is a matter which has been considerably remedied. There is no doubt that at one time discipline was of a very severe nature. I gather that at the present time over 50 per cent. of the nurses, according to the Nuffield team, are satisfied that the discipline is all right. Over 30 per cent. think that it is not strict enough—they probably belong to the higher age group of those who were investigated. Some 5 per cent. think that discipline is already much too severe. They will probably join the ranks of the 449 wastage as time goes on. In the meantime, I am certain that the nursing profession will be gratified at the step which the noble Lord, Lord Crook, has taken in bringing this Motion before the House, and at the expressions of high esteem which have fallen from the lips of all speakers in referring to this profession. Doctors and surgeons have the knowledge and the skill that enables them to save human life, but it is the nurses who make the process of recovery endurable.
§ 5.45 p.m.
§ LORD CROOK
My Lords, may I first express my gratitude to the three noble Lords of the medical profession who have spoken on this Motion, and also thank the noble Lord who has just replied for Her Majesty's Government. Since he has referred to it, perhaps it will not be wrong for me to say how glad we have been to notice the great interest in this debate which the Minister has shown in the course of the afternoon. Before I withdraw my Motion, I should like to say that I am sure we are all conscious of the fact that there are many good sides to this matter. A most significant fact, when I came to speak, was that I did not have occasion to mention complaints about discipline. Complaints of this nature formed quite a part of what I had to say in 1948. All that have heard in this connection has impressed me as to the easing which has taken place in the hospitals of the country of what in my view, and in the view of many others, including many nurses, was the quite intolerable discipline imposed in earlier years. I find that very few people make complaints on that score to-day. Probably if they do, they are people who have already become part of the wastage and are trying to explain why they are no longer part of the Health Service.
May I also say how conscious I am that our great Health Service in this country 450 has undergone a huge expansion. I know that we started this century with only about 68,000 people, all told, in the nursing profession, and I believe the total manpower now exceeds 200,000. There. fore, when we talk about the grave shortage of nurses it is not a shortage by comparison with the past, but a shortage only compared with what is required to meet the needs of what we regard as the expanding services to which the nation has a right to look forward and which are, in fact, being planned. May I thank the noble Lord for the correct figures which he gave me, arid say that I appreciate the difference between the two sets of figures in the two different places. It was good to have brought to our attention the fact that although there is a shortage of 28,000 beds by reason of the shortage of nurses, the figure four years ago was about twice that number. If we go on improving only at that same pace in the next four years, we shall wipe out that shortage which all of us so much deplored when we last discussed the subject.
The noble Lord told us that we must expect wastage to continue because of marriage. He has had personal experience, as I have, of moving among nurses, and no doubt he realises what good choices are made by so many men who take their spouses from the nursing profession. It would be wrong for me to withdraw a Motion which contains the words "To call attention to the Hospital Nursing Services" without paying my own tribute, and a tribute on behalf of noble Lords, not only on these Benches but throughout the House, to the medical men and nurses who make up this great, untiring and unselfish profession, to which both Lord Woolton and I, and indeed all of us, owe so much. My Lords, I beg leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.