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Nurses Rules

Volume 757: debated on Monday 22 January 1968

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10.1 p.m.

I beg to move.

That an humble Address be presented to Her Majesty, praying that the Nurses (Amendment) Rules, Approval Instrument 1967 (S.I., 1967, No. 1704), dated 17th November, 1967, a copy of which was laid before this House on 24th November, be annulled.
I always think that it is as well on these occasions, for the benefit of those outside this House who are not as well acquainted with our procedures as we are, to make it clear at the outset that when in cases of this kind the Opposition want to draw attention to a Statutory Instrument, the proper procedural way of doing so is to pray against it. While I appreciate that the Parliamentary Secretary understands that that does not mean that we are hostile to the contents of the Statutory Instrument—indeed, there is no intention of seeking to turn it down—the only procedural device open to us is this one. That is the object of tonight's discussion.

It is valuable for there sometimes to be opportunities in this House for discussion of what at first blush may appear to be detailed matters of this kind, and there is certainly great benefit in a close scrutiny of all Statutory Instruments. I am sure that the Parliamentary Secretary would not resent the close, watchful care with which, at least, the present Opposition watches all Statutory Instruments which emanate from his Department.

It may be helpful if I first, however briefly, seek to explain what I understand, in heading only, to be the objects of this otherwise seemingly detailed Instrument. I understand that it has four objectives. The first is to extend the date a little, or to define it more accurately, by which an examinee for the final examination must have attained the age of 21 before he or she may sit. This is Rule 13, and I will return to it presently.

The second objective is to remove the restriction at present applying on fever nurses which prevents their name being entered on the Register before they attain the age of 21. This is covered by Rule 16.

The third objective is to shift the emphasis, as I shall seek to show, significantly where a nurse applies to have his or her name restored to the Register—that is Rule 38—and, fourthly, Rule 67 extends the category of those who may be qualified as nurse tutors.

Since I am certain that this will be an agreeable and friendly discussion, I shall start by rapping the Parliamentary Secretary sharply on his Parliamentary knuckles. To thread one's way through the various matters which we are discussing, it is necessary to have before one no fewer than six Acts of Parliament or Statutory Instruments. One has to start with the Nurses Act, 1957; one has to go on to the Nurses Rules, 1961, which were made under that Act; one has to go on to the amendment of those Rules of 1965; one has to go on to the amendment of those in 1966; one has to go on to the Teachers of Nursing Act, 1967; and now here we are with the further amending Rules of 1967.

I should like to say to the Parliamentary Secretary that this is not just simply a debating point. Let me illustrate factually what I mean. There could hardly be a more detailed provision than that which, in this Statutory Instrument, further amends Rule 13, the very small point of the date by reference to which the age of 21 is calculated. One normally goes straight to the parent Regulation of 1961, but one does not and it there because Rule 13, which governs it, was amended in 1965; so one has to go to the amending Regulation of 1965, which one then finds has been further amended in 1966 and 1967.

I really must say to him firmly that while he of course takes personal responsibility, and wishes to, as is normal procedure, I must ask his help in the ceaseless war which I wage, not merely with his Department but with others, to ensure that in intensely human matters like this we should have these things set out clearly and see that they do not get out of control, for this is a very good example of legislation, some of it at secondhand, which has got quite out of control. I hope, incidentally, that he will be able to tell us that he and the General Nursing Council will be issuing some simple explanation of the changes which are now being made in the Instrument before us.

The first objective of this Statutory Instrument we need spend very little time over. I should like the Parliamentary Secretary, if he will be so good, to make clear, what I think must be the case, that this is simply a matter of tightening up by definition; it is a simple and convenient method; there is greater precision of drafting in the Statutory Instrument now before us, so that the appropriate paragraph of the Nurses Rules makes it just that bit much clearer than it was before. I assume that the General Nursing Council has taken the opportunity to submit to him this matter to deal with anyway. This is a comparatively small and detailed matter with which I will not deal except to ask for that confirmation.

The second is an equally small, detailed point. When I say that, of course it is important to those concerned. A fever nurse can take her finals before she is 21. As things are at present, there is exemption for her; but she cannot apply to go on the register before she is 21. That is the very small change which the Parliamentary Secretary is seeking to put More us as the second provision in this Statutory Instrument; it is the deletion of the proviso to Rule 16(1).

The third is a more substantial point. This House is always very watchful and careful, and need not make any apology for that, when it is dealing with the rights of individuals. With the third object of this Statutory Instrument, that is to say, the amendment of Rule 38 of the Nurses Rules, 1961, we are dealing with the restoration of a nurse's name to the register. Clearly, this is a matter of the greatest importance to the nurse concerned. It is also a matter of importance to the great profession of which she is a number, and it is obviously right that there should be stringent requirements before her name can be restored. The House can understand that.

It might be helpful to have a little explanation of the changes which the Parliamentary Secretary now puts before us. The nurse applying to have her name restored to the register will have to find two referees
"with knowledge of the facts found against her".
I do not quarrel with that, but the Parliamentary Secretary will understand that it places on such a nurse an additional burden. It may be perfectly right. It is done upon the advice of the Nursing Council, and that is very powerful advice, but I should like to feel that the Parliamentary Secretary and his Minister have applied their minds to this request as well.

It is clearly nothing like so easy for a nurse in this position to find two or more persons who have to be within the class specified in the Order and, in addition, have knowledge of the facts found against her, particularly if they are facts found against her some appreciable time previously. I repeat that I do not necessarily quarrel with it, but I make no apology for looking closely at matters concerning the personal rights of individuals, as does the House.

The second change is in her favour. Whereas before her referees had to be able to give a reference as to her character and the nature of her employment before the date of her removal from the register as well as after, it is now loosened slightly in her favour, but this is only where practicable, and this seems to be an eminently wise requirement.

Third, the Parliamentary Secretary is removing a slight doubt which might apply in the rule as it is at present, where it is provided that, if necessary, the investigating committee may call for
"such other evidence as the investigating committee may reasonably require."
Quite obviously, a nurse seeking to have her name restored to the register might be in doubt as to what evidence the investigating committee might reasonably require. As I understand it, the Parliamentary Secretary is now doing away with that proviso, which is a change within the interests of the nurse.

I am not generally hostile to this, but in matters of such delicacy I should like to be clear that thought has been given, with particular reference to my first point. Perhaps I might leave it with a gentle and friendly dig at the Parliamentary Secretary. If he studies the Amendment carefully, he will find that whereas ministers of religion appear in small print in the Rule, the words have initial capital letters in his Amendment. I am obliged to him for his gentle bow to ministers of churches and his further blow to humanists in this House.

I continue with my fourth point on this set of Regulations. It is perhaps the most important. It extends the categories of those who may be qualified as nurse tutors. The Amendments to Rule 67 which are now before us add three new categories to those who may be qualified as nurse tutors. The first is a teacher with three years' nursing experience. That is generalising the careful provisions which are set out in front of us. The first thing that we should like to know from the Parliamentary Secretary, repeating again that we on this side are not hostile to this Amendment, is whether he can assist the House by telling us how many people, according to his information, will be affected by the Amendment; that is to say, those who will henceforward, if the House so agrees, be eligible as nurse tutors under this provision. Can he tell us how many teachers there are with three years' nursing experience? With, as I understand, a chronic shortage of nurse tutors, this seems a wise provision and one which certainly does not dilute the standards otherwise set out in Rule 67 of those who can qualify for this very important teaching and lecturing position. It would be helpful to have some idea of approximately how many, at the moment at any rate, are likely to be affected. The layman would suppose that however valuable—and they are immensely valuable in themselves—the numbers are likely to be comparatively small.

Also, I should be grateful for an explanation about one of the requirements of these teachers who have had three years' nursing experience—I am using that phrase loosely—namely, that they shall have spent not less than a year in the teaching of nursing at an approved training institution under qualified supervision. I should like to know whether there is an appreciable number of persons teaching under supervision at an approved training institution and, if so, what their qualifications are. At first blush it seems a little unusual that they should be in this position. If the Parliamentary Secretary could assist further about this group of people the House would be much obliged.

The second category of those added are the health visitors—again I am using shorthand—with two years' nursing experience. The House would be grateful for the briefest of indications about how many this is likely to cover.

The third group is very wide; that is to say, those shown in paragraph 7(e),
"in any particular case she appears to the Council and the Minister to be qualified for the teaching of nursing otherwise than as mentioned…"
in any of the provisions of Rule 67 as it will become amended. In other words, with this very important reservation that the Council and the Minister, as I understand it, must individually approve each case, he is taking unto himself blanket powers. The House is always watchful about this, quite rightly. Admittedly, in this case the safeguard lies in the immense standing of the Nursing Council which, if it does not agree, has the veto. The Minister would act only upon its recommendation. However, at first blush this is a fairly major step in a profession of great repute, the nursing profession. It might be helpful if the Minister would briefly outline the kind of person he has in mind and how frequently he would envisage having to use this power, or whether it is a reserve power so that he shall not frequently have to return to the House for Amendment of a detailed nature of the kind that we now have in front of us.

One of the most significant parts of this Statutory Instrument is that which deals with those who may be brought in as nursing tutors and who have teaching experience. I must not explore this in any width, but does this presage a change in the Ministry's policy, and does the hon. Gentleman envisage that some of the future training of nurses, and in this case nurse tutors, is likely to be co-ordinated with the training of teachers?

The Minister is taking power to allow teachers to become nurse tutors in certain specified circumstances. There have been some interesting developments here. We cannot explore them in any depth, but there have been some interesting suggestions for the combining of the training of certain people, including nurses, whose work among young people tends to have certain features in common. The hon. Gentlemant will be aware that in certain colleges of education there are proposals for bringing in nurses for this purpose, for parallel training and drawing on experience between both professions. It will be helpful to know whether the new powers in paragraph 7 herald a change, or whether they stand on their own.

I make no apology, and I feel sure hat the hon. Gentleman would not expect me to, for having detained the House on a comparatively detailed matter. The House takes the deepest interest in, and has the greatest concern for, the nursing profession as a whole, and therefore the training of its members, or certain aspects of it, which is what we are discussing tonight, is an extremely important matter. I sometimes think that one of our difficulties is that we are so overborne and overburdened with great weighty national matters that we cannot always give sufficient time to exceedingly human and, some would say, detailed matters of this kind. I hope that it will go out from both sides of the House that we are never too busy to take trouble over and pause to do our duty in considering comparatively detailed instructions which deeply affect the lives of the members of a highly honourable profession.

10.23 p.m.

The House could not possibly object in arty sense of the term to the way in which the hon. Member for Wokingham (Mr. van Straubenzee) introduced this important matter.

Last Session the Teachers of Nursing Bill was introduced by my hon. Friend the Member for Glasgow, Central (Mr. Tom McMillan). It was warmly welcomed by both sides of the House as a useful Measure to increase the supply of qualified nurse tutors. It was duly enacted, and it received the Royal Assent on 22nd March last year.

I hope that the hon. Gentleman will forgive me if I deal with the provisions of this Statutory Instrument in the reverse order to that which he adopted. To give effect to that Act a revision of Rule 67 of the Nurses Rules was necessary. The principal object of this Statutory Instrument is to make this Amendment, and the three minor Amendments mentioned by the hon. Gentleman, to which I shall refer later.

Until the passing of the Teachers of Nursing Act the General Nursing Council could grant certificates only to those teachers of nurses who had undergone prescribed training in institutions approved by the Council. The powers did not permit the granting of a certificate to a person who had not undergone training in an institution approved for the purpose, even though the Council regarded the person as qualified to teach nursing.

The aim of the Act was to enable the Council to recruit as qualified tutors nurses who needed no further training and could therefore be immediately available. It also removed an injustice from those nurses who had teaching qualifications which could not be recognised and who, if they nevertheless took posts as nurse tutors, could only be paid and graded as unqualified tutors.

The Act achieved this by giving the Council powers to make rules prescribing qualifications which should be held before a certificate could be granted, and also permitting the granting of certificates to persons who do not possess the prescribed qualifications, but who, nevertheless, appear to both the Council and the Ministry of Health to be qualified to teach nursing. This latter provision should, we hope, permit flexibility in dealing with unusual cases or new qualifications.

The House will probably accept the general proposition that with the development of the National Health Service, with new techniques and new uses of nurses, it has been probably a rather more necessary step to amend the rules in a shorter space of time than has been the case in the earlier history of the nursing profession. This does not denote any reduction in standards it just means that it has been necessary to make amendments rather more frequently than before.

The amendment to Rule 67 is made under the new powers and adds to those who may be certified as teachers of nurses, nurses who have specified nursing experience and who either are recognised by the Department of Education and Science as qualified teachers or are on the roll of teachers of the Council for the training of health visitors.

It may be argued that there are other qualifications which might equally well have been recognised and included in the revised rule, but the General Nursing Council takes the view at present that it has taken the steps as far as they can be approved. But it is always open to any nurse possessing any other qualification which she considers equips her for a teaching post to apply to the Council for recognition. It could be that as a result of considering individual applications the Council will decide that some other particular qualification is generally acceptable, and this can be added when the Rules are next revised.

What I wish to say now in part answers one question put to me by the hon. Member, although on a matter of detail I shall have to look at the question again later. The effect of the changes should be to enable about 30 additional nurses to be given certificates as teachers of nursing and perhaps at the rate of a further 10 per year thereafter. This does not quite answer the hon. Member's question but it is interesting information. This will be a welcome addition to the numbers of qualified tutors.

The numbers of qualified tutors in posts has varied very little over the past few years. In March, 1967, there were 1,110 whole-time and 46 part-time qualified tutors in post, compared with 1,097 whole-time and 41 part-time in March, 1964. During the same period there was a marked increase in the numbers of unqualified tutors, there being 738 whole-time and 99 part-time unqualified tutors in post in March, 1967, compared with 567 whole-time and 116 part-time in March, 1964.

I fully recognise the great work and contribution made by unqualified tutors, but it is not satisfactory that they should form so high a proportion of the whole, and any addition to the number of qualified tutors is to be welcomed. There is no generally accepted figure for the number of tutors needed, nor general agreement on the optimum ratio of tutors to students. To meet this situation officers of my Department will be joining representatives of the General Nursing Council and Royal College of Nursing in a working party to look into the numbers and pattern of teaching staff to meet current and foreseeable needs for the training of student nurses.

At present, there is a shortage of tutors, which is aggravated by maldistribution, but the position will be much clearer when the working party has done its work and it will then be pos- sible for both the Council and my Department to make a coherent plan for meeting the requirements of the service for teaching nurses.

I am well aware of a feeling among many nurse tutors that their role and their problems in the training of nurses are not fully appreciated. To help overcome this, my Department has held two meetings with the representatives of the tutors at which their problems have been discussed, and I hope that there will be other such meetings. It is sometimes argued that the best way to improve the number of nurse tutors is to improve their pay. I would remind the House that the pay of nurses, including nurse tutors, is at present being considered by the National Board for Prices and Incomes, and we hope to have its report in the next few weeks. It would not be profitable, therefore, to discuss their pay until we do receive the report.

It is also sometimes suggested that the posts of nurse tutors are undergraded and, in particular, that the Salmon Committee did not do them justice in this respect. But that Committee had a predominantly professional membership and four of the five nursing members were certificated teachers of nursing who had previous experience as nurse tutors. It considered the senior nursing staff structure very thoroughly and while its recommendations preserved approximately the present position of the basic grade of nurse tutors, they provided higher posts in nurse teaching than heretofore, with much better prospects of promotion, incidentally. The Minister accepted the Salmon recommendations, and these are now being tested in a number of pilot schemes. If these should reveal any anomalies in the grading of tutors compared with other nursing staff, remedial action can, of course, be considered.

It is sometimes also argued that the teachers of nurses should be related for pay and grading to teachers in colleges of further education rather than to the generality of nursing posts—

Order. I hope that the hon. Gentleman will not go too wide of his own Order. It does not relate to the pay of nursing teachers.

Yes, Mr. Speaker. I was trying to paint a rather broad canvas because, as the hon. Gentleman pointed out, the conscience of the House is concerned about the nursing profession and I did not want to leave any uncertainty. But I take your point, with great respect.

I was saying that it seems to me that the current trend on basic nursing training is towards closer integration of theory and practice which, if it continues, seems likely to involve the teaching staff more closely and to enhance their links with the nursing administrative hierarchy. Many who serve for a time as nurse tutors subsequently move on to other nursing posts and may become matrons.

I was very happy the other evening, incidentally, to accept an invitation from the Royal College of Nursing to meet a very large body of matrons. It was quite a formidable evening and I learned a great deal from them. I believe that we are now over the hump as far as the public attitude to matrons is concerned. They are very fine women, and, contrary to some of the old stories, they definitely march with the times: we owe them a great debt.

There will be less difficulty in this kind of movement if the salaries of the various nursing posts are related to one another: that is why the idea of going outside the immediate nursing profession is probably not a good one.

I now turn to the other three Rules which are to be amended—

Before the hon. Gentleman leaves Rule 67, would he deal with my point about whether this is a pointer towards a change in the training of nurse tutors? I ask for only the briefest of indications.

No. It does not indicate a major or significant change. It is to give more flexibility. I give that assurance.

I turn to the other three Rules which are being amended. I take the hon. Member's point about the way in which the Statutory Instrument is drafted in respect of Rule 13. I will not conceal from the House that it took me a long time to understand it. It does not seem very good sense to have to go through six previous documents to achieve understanding. The Select Committee on Statutory Instruments queried this proposal. They wondered why it had not been possible to reprint the whole of the draft, possibly with the amending words in italics.

We provided an explanation. It was not merely a question of an Amendment to the original 1961 provision, for there were the subsequent amendments of 1965 and 1966, and it was considered in this case not desirable to reproduce the whole Rule because that would have necessitated three forms of special lettering in the amendment. It is a nice point, and I feel that my Ministry is wise in accepting that, generally speaking, it will be desirable to reintroduce the whole Rule with the amending words, perhaps, in special type. No one has suffered more than I have in trying to find out where the truth lies in amendments over the years.

The need for amending Rule 13 arises from a change in the General Nursing Council's timetable for examinations. These were usually held in February. June and October, but in future it will sometimes happen that the written examination will be held on the last day of the preceding month—for example, on 31st January for the February examination. This arose from the fact that the examining authorities needed a little more time to bring together the necessary examining staff. Since Rule 13 required a student nurse to have reached the age of 21 years and to have completed a specified period of training by the last day of the month in which the examination is held, bringing the date of the written examination forward a couple of days could have involved a student nurse in three or four months delay before she was eligible to take it.

The best way to work that out is to get a calendar and to work it backwards. By relating the requirement instead to the month in which the examination was completed, this is avoided. Similarly, nurses taking an 18-month course of training to obtain a second qualification would also have been held back by the change in timetable, and their position is likewise safeguarded.

The Amendment to Rule 16 arises from the closure of the Fever Register as from 31st December, 1967. Under the old Rule 16 a student fever nurse could take the final examination at the age of 20 but could not be registered until she was 21. The Amendment was designed to enable any who had passed the examination but who had not reached their 21st birthday before 31st December nevertheless to be registered.

The Amendment to Rule 38, on which the hon. Member spent some time, is designed simply to correct a fault in the drafting of the original Rule. As it was previously worded, Rule 38(2) required applicants for restoration to the Register, where practicable, to submit two character references. This was never the intention. The Council's intention was that an applicant must submit two references and that the referees should, if possible, have knowledge of the applicant before her name was removed from the Register. It is this latter requirement which is not always practicable, and with the Amendment the Rule correctly states the Council's requirements.

I hope that I have made that point clear because restoration to the Register produces understandable anxieties in the public's mind. Nevertheless, it seems to us that a change which is fully approved by the General Nursing Council should receive the approval of the House.

It is important that we are clear on this point. I thought I understood the hon. Gentleman to say that the Rule, as it will be if this Order is approved, will say that a nurse who applies must find two referees with knowledge of the facts found against her, if that is possible.

I suggest, however, that the words "if possible" are not to be found in the Rule.

Nevertheless, that is certainly the intention of the redrafted Rule. If it is capable of the doubt which the hon. Gentleman has mentioned, we will have a look at it again, although I am advised that that is not the case. The real intention is that two witnesses must be provided in the circumstances I have suggested and that, where practicable, the nature of the employment before removal should be known to those witnesses. I take the hon. Gentleman's point that reasonable doubt may exist and I assure him that we will look into the matter.

The hon. Gentleman went on to refer to teaching experience and he asked whether colleges of education could provide the sort of facilities for at least part of the training which these people should undergo. I am advised that no such proposal has yet been made, but we will be happy to look at the matter in conjunction with the General Nursing Council.

Provided a scheme fitted in with the general interlocking of these provisions with associated professions, we would certainly be sympathetic to these ideas; provided, of course, that the proposals were approved in principle by the General Nursing Council. I am advised that, while there is no intention of integrating courses with teacher training courses, there is a course running now at the Technical Teachers' College at Burton, which we are watching carefully.

I hope that I have been able to allay some of the hon. Gentleman's doubts and have answered the points he raised. Accordingly, I ask the House not to approve the Motion.

10.43 p.m.

The whole House is obliged to the Parliamentary Secretary for his careful explanations and for the interesting statistics which he gave, which, if nothing else, undoubtedly justifies the Amendments before us. I hope he will feel that, apart from the important nature of these matters, my intervention—in which I pointed out that the phrase "where practicable" refers exclusively to the employment before the date of removal of the nurse's name—justifies our going into the subject carefully.

If it is the Minister's intention that the Rule, as amended, shall do what he said it should do, he will, with respect, have to return to the matter again. But, in view of his undertaking, and of what I sought to say at the outset, I beg to ask leave to withdraw the Motion.

Motion, by leave, withdrawn.