25 March, 1926.]

[Continued.

tion is given to the legitimate interests of the present managers. With regard to that first point, is it not the policy of the Ministry of Health, now that we have the national registration of nurses, to press the claims for registered nurses as far as possible in the interests of public health? (Mr. Brock.) I should not care to give an unqualified affirmative to that, and I should rather say that the registration of nurses had in fact proved so sucessful and such a large number were on the register that there was no necessity for pressing it by administrative action or further legislation.

59. Would you say that the fact that the State had felt it necessary to register nurses and to have this register made it almost incumbent upon the Ministry to press the claims of the registered nurse wherever possible because they had decided that it was so necessary?—The Nurses Registration Act set up a register of nurses and gave an opportunity to any nurse who chose to do so to register, and therefore gave the public an opportunity, if they cared to exercise it, of securing the services of people who had received a certain minimum training, but the Act did not make registration compulsory, and it has never been the policy of any Minister to put any pressure on local authorities to employ only registered nurses. That, no doubt, is coming; it will tend to come more and more in course of time; but the Minister has never felt that there was any obligation on him to press the claims of the registered nurse as against the nurses who, for one reason or another, had not thought proper to register.

Sir Richard Luce.

60. On that point is there not exactly the same position with regard to the medical profession; the medical profession is put on a register, but it is not laid down that no one may go to anybody but a medical man. The profession of nursing is put exactly on all fours with the medical profession in that respect?— Yes; there is no prohibition of unregistered practice.

Sir Richard Luce.] There is no prohibition of unqualified nurses any more than there is a prohibition of unqualified doctors.

Dr. Shiels.

61. But at the same time, is it not the case that the Ministry of Health

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encourage qualified doctors rather than unqualified? I think there would be a good deal of trouble if they did not. Is it not, therefore, on the same analogy desirable for the Ministry of Health to ensure that nurses who are registered, and therefore showing a minimum qualification, should be in every nursing home in sufficient numbers to ensure adequate nursing of the people there? Surely that is quite in line with the determined policy of the Ministry of Health? If the nurses on the register were in fact the only nurses possessing reasonable qualifications that might be so, but as long as there are nurses not on the register whose qualifications cannot be questioned, would it not be rather unfair to penalise them in that way?

62. Not if that is the only method by which you can be assured that a nurse has even minimum qualifications. There not are many medical men who are registered who are qualified, but it is a general rule that in public appointments registration is required as well.

Miss Wilkinson.

63. As a matter of fact, owing to the words of the Bill: "A registered nurse or a person eligible to be registered on the general part of the register" the nurse who had not in fact registered but whose qualifications were equal to those of a registered nurse would not be barred out; it would only be barring out unqualified people; is is not that the position? Of course, the test of eligibility for registration is a test that is very difficult to apply. You might be able to say in a large number of cases. "This nurse would have been eligible had she applied," but there are a great many other cases in which it might be a matter of conjecture whether she would have been registered or not.

64. You say in (c) that beyond allowing a period of grace no consideration is given to the legitimate interests of the present managers. Seeing that the Bill proposes to ask for at least one person, the person in charge, to be registered, and that 4 years' grace is allowed, do you think that is an unreasonable protection for the public even against what might be called the trading interests of the present manager?-It does seem to me rather unfair.

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25 March, 1926.]

65. Do you think then that because a person who is running something for profit is asked to have a certain minimum standard of qualifications among his staff to protect the public, that that is unfair? (Mr. Gwyer.) That is not what the Bill provides, is it, "The matron or other person having management and control of the nursing of patients." Supposing you have a case in which a lady with great experience in nursingsupposing she has the midwives' qualification, not the full nursing qualification, but many years' experience of nursingis running a nursing home of her own, she would have to be shut down after the period of grace had elapsed under the provisions in the Bill. I have one case of that kind in my mind of a lady who has carried on a nursing home for many years, much sought after by the doctors of her locality, and, so far as I know, no possible objection ever taken.

Dr. Davies.

66. That is the point, if I may say so. (Mr. Brock.) In the parallel case of dentists when Parliament prohibited in future the practice of dentistry by unqualified persons it gave at the same time a very liberal recognition to the bona fide practitioners then in practice. On grounds of health, if it were possible to deal with the thing apart from the question of justice to the individual, there might have been a good deal to be said for making the conditions of entry of the unqualified practice much stricter, but I think that Parliament has always taken the view that the prohibition of unqualified practice must be coupled with a liberal recognition, so to speak, of the rights of the existing holders.

Chairman.

67. Would Mr. Gwyer finish his story? -(Mr. Gwyer.) This lady's home would come to an end under the Bill altogether.

Miss Wilkinson.

68. Not if she employed a qualified nurse?-No; that is the point.

Chairman.

69. Supposing she got somebody in to assist her who is a qualified nurse within the 4 years, would she not then rectify

[Continued.

her position?-No, because she is the matron in charge of the nursing home. Major Price.] It is the wording of the section; I think it is a Committee point. Chairman.] Well, that is a matter for amendment.

Dr. Shiels.] The intention of the Bill is at any rate that there is a qualified

person.

Dr. Davies.

70. Does the Minister take up the attitude that the nurse with the C.M.B. maternity training is competent to nurse any case in the nursing home?-No.

71. You were not talking of maternity cases pure and simple, as I understood you?-No.

Chairman.

72. No; yours was only an instance?Only an instance.

Miss Wilkinson.

73. I want to come back to this point that no consideration is given to the legitimate interests of the present manager. In that case that you cite you might have a very bad surgical case that needed extremely competent nursing?— Yes.

74. This lady might not have had that type of case before; it might be a new type of operation. Do you not think that in that case the legitimate interests of the public should be considered in forcing her to have a qualified person?-Yes; she has qualified nurses on the premises.

Chairman.

75. Is not the only point this, that she has got to be qualified herself to rectify her position?—Yes.

Chairman.] The fact that she has got a dozen qualified nurses does not rectify her position.

Miss Wilkinson.

76. That is merely a point that can be met in Committee?-With great respect, no, if I may say so. How are you going to say that one qualified nurse with a staff, possibly the junior nurse of all, saves the situation?

Major Price.] No, but you might easily say that a staff, commensurate with the number of patients, properly qualified should be employed. The person who runs the home might very well be far

25 March, 1926.]

better in the public interest a person of business than a person of nursing; that the person should be qualified I do not agree with at all, but they should provide proper qualified nurses for the actual nursing of the patients.

Chairman.

77. You were citing a particular instance, Mr. Gwyer, and in your particular instance the lady in charge was not a qualified person?-That is so.

78. Surely you do not suggest that that is the right position, do you? You would agree with me, would you not, that if she had properly qualified assistance she might carry on, she herself being the business head of the establishment?She has very great experience in nursing except that she has not, I think, qualified actually to be on the register, but as I have been in her hands myself I have no complaint to make of the nursing 1 received from her. May I make this suggestion on the point: is it not really a matter which is to be left to the local authority? Under the Maternity Homes Bill registration can be refused if the staffing and equipment of the maternity home is in their opinion not sufficient; does not that cover it? In the home which takes in difficult surgical cases, obviously if there is not an ample supply of trained nurses the staffing would not be sufficient, but is it not a matter to be left to the inspecting authority? You cannot lay down, I submit, any hard and fast rule.

Miss Wilkinson

79. But they have no power?-If the Committee recommend a Bill, I suggest that they should direct their attention to the analogous provisions in the Maternity Homes Bill. The Maternity Homes Bill does not say that no home can be registered unless every person in it is a certified midwife.

Chairman.

80. No, but it says what? They can refuse registration or cancel registration if the staffing and equipment is in their opinion inadequate.

81. That does not ensure or make it obligatory that the head of the establishment should have qualifications at all?— No.

Dr. Shiels.

[Continued.

82. In the Nursing Home (Registration) Bill that you are discussing, the actual clause says that a licence shall not be refused, among other things, unless the matron or other person having the management and control of the nursing of the patients is not a registered nurse? -I know.

83. So it is quite allowable for the matron to be the lady you referred to and have a qualified nurse in charge of the patients or in charge of the other nurses, and she would be quite eligible even under this Bill of Mr. Hurst's?-But in the converse case, of course, you might have the matron a qualified nurse, and every other the premises unqualified.

woman

on

Chairman.

84. That would be a much worse position? It seems to me to be a worse position.

Major Price.

85. The case against supervision is put here: the real responsibility of seeing that the patient is properly looked after rests with the Doctor who is bound to be in regular attendance; where do we get that from? What law is there that says that every patient in a nursing home must be under the proper superintendence of the Doctor?-The ethics of the medical profession.

86. Not a bit. Any patient can go into a nursing home, whether a Doctor is in attendance or not?-I thought you meant a patient who went in under the care of a Doctor.

Major Price.] No; that is one of the reasons given.

Captain Ernest Evans.] That only means where there is a doctor attending.

Major Price.] No; it goes further. It says: "The real responsibility of seeing that the patient is properly looked after rests with the doctor who is bound to be in regular attendance ".

Sir Richard Luce.

87. That is only in a general way?(Mr. Brock.) I think "bound to be " is rather an overstatement perhaps; we should have said "who would normally be."

25 March, 1926.]

Major Price.] "The immediate responsibility is on the proprietor or the matron. But it is against the interest of the doctor to send patients to an unsatisfactory nursing home." If you take these senile cases that we were discussing just now, they may go into homes without any doctor in attendance at all, and there are many other cases where they may go into homes that may be nursing homes in one sense, and perhaps not in a general sense, that have no doctor in attendance, and nobody to look after them; so I do not quite follow that as a legitimate case against supervision. I am not trying to make a case for supervision, but I am trying to get at these objections.

Captain Ernest Evans.] Surely that only means that in the great majority of cases of people going into a nursing home there is a doctor in attendance.

Major Price.] If there is a doctor in attendance it is possible that there is no need for registration.

Dr. Davies.] No; that does not follow at all.

Major Price.] I should say so. If I had been a doctor I should say that most emphatically.

Chairman.] This does not mean that the doctor must be held responsible for the conditions of the nursing home?

Major Price.] That is how I take it.

Chairman.

88. That is, I take it, what you mean? -(Mr. Gwyer.) I think the idea underlying that paragraph was that, I suppose in nine cases out of ten, a patient goes into a nursing home under doctor's orders and remains attended by a doctor, and in those cases it is the doctor's business, I should have thought, to see that the patient was properly looked after; that is what the paragraph meant. (Mr. Brock.) All that we were trying to do was to summarise the arguments commonly advanced against registration. Chairman.] Can anyone tell us how far has that happened? That is exactly what I put in the margin of my paper here : I wanted to know that. Here is a person, as you say, sent into a nursing home by a doctor. Sometimes I believe doctors have interests in nursing homes; is not that so?

Dr. Shiels.] Yes.

Chairman.

[Continued.

89. Here is a patient sent into a nursing home and as a matter of fact the conditions are not good; is the doctor Can to be held responsible for that? anyone hold the doctor responsible for that?-No.

Captain Ernest Evans.] If he is interested in the nursing home, yes.

Chairman.] How far is the doctor able to ensure good conditions for the nursing home?

Dr. Davies.] If the doctor goes into the patient's room everything is probably satisfactory as regards that patient, but how many doctors who attend nursing homes have been into the kitchen, the sanitary arrangements and the bedrooms? All he knows is what he sees, and if the matron has any sense she sees that things are made to suit the doctor; but he has no idea how the home is run; he just comes to the particular bedroom of his particular patient.

Sir Richard Luce.] He knows what his patients say. He would not send another one if the patient objected.

Dr. Davies.

90. The Doctor is no use at all in that respect. (Mr. Brock.) I think the utmost you can say is that the doctor in practice generally sends his patients to one of a limited list of nursing homes. In the course of time he would, through their experience, acquire a fair knowledge of the homes. I should not personally be disposed to put it much higher than that.

Miss Wilkinson.

91. It might have been a rather unpleasant experience from the patient's point of view in the particular case, might it not?-Oh, yes.

Sir Richard Luce.

92. I want to ask one or two questions about the finance. Have you any sort of idea how much this is likely to increase the cost of nursing homes ?-No; we have no material really upon which we could give an estimate. It has been said that in the past a good many homes did part of their nursing through probationers. If they were subject to any inspection it is quite possible that the supervising authority would say that that was not satisfactory, and that the whole of the nurs

25 March, 1926.]

[Continued.

ing should be done by fully trained people. That would tend to run up the cost of the nursing staff. On the other hand, that result will follow, quite apart from any question of inspection, because as the General Nursing Council have never recognised training in nursing homes they will not in fact in future be able to recruit probationers; they will have to take fully trained people.

93. With regard to the actual cost of inspection of such homes, is it likely that a reasonable registration fee would cover the cost of that, and, if so, what sort of registration fee is likely to cover the actual cost of inspection?-I should doubt very much if the fee would cover the actual cost of inspection. (Mr. Guyer.) In some areas it would be prohibitive. (Mr. Brock.) It depends on the distance that the inspector has got to travel. In a County area it is going to be more expensive than in a County Borough.

98. There is also the question of the inspection. I see in the Nursing Homes (Registration) Bill, the old one, it is suggested that the inspection of the nursing should be by nurses; would that mean that you would have to have a specially highly-qualified inspector for that purpose -one that would have to be at any rate of the standing of a matron of a hospital? -I should have thought clearly. It seems to be very difficult to have a nurse except with the very highest possible qualifications inspecting in effect a Doctor's nursing home.

99. That would mean, therefore, that you would have to have an entirely ad hoc person for that purpose in each district? (Mr. Brock.) Of course, it is very difficult to say, because after all it depends on the discretion of the local authority, but I can imagine that the proprietors of nursing homes, particularly where they happened to be Doctors, would be likely to protest very strongly unless whoever came to inspect them possessed very special qualifications.

100. That is the point I wished to raise. It is, therefore, going to be a very considerable expense to provide a nurse at any rate, if you are going to have a nurse to do it? I think it might if it were really done thoroughly.

Dr. Shiels.

101. Is it not the case, as the paragraph states, that the Medical Officer of Health or other person being a Medical Officer of a State registered nurse are on the staff of the Medical Officer of Health? A State registered nurse might be one of the nursing staff of the local authority?-(Mr. Gwyer.) I should have thought it would tend to lead to friction, but if the Bill were left quite vague, inspection by a person duly authorised for the purpose by the local authority, I should have thought, would be almost sufficient.

Miss Wilkinson.

102. Could you really rely on local authorities, if you made it as vague as that, for standards among local authori