25 March, 1926.]

ties, differ so enormously? It is a very common power to give in local authorities' Acts, I think; with a little research I could point to half-a-dozen.

103. In a case like this, where nursing is such a specialised job, and it is really the nursing that one wants inspecting one does not want the medical side inspecting-it would seem to be a case where some kind of definite statutory qualification would be necessary? Do you think it is possible to contemplate the inspection of the actual nursing which goes on in nursing homes? I should have thought that was impossible, and that the inspection would be rather different-of premises, sanitation, cleanliness and all those things without which efficient nursing is impossible, but the actual running of the home, the actual nursing of the patients, I should have thought was beyond the power of any local authority to inspect.

104. Quite? (Mr. Brock.) Unless it came to an Inquiry and an investigation. into a definite complaint from or on behalf of a patient, then I can imagine that the circumstances of that particular case would have to be investigated.

105. But the nurses' standard of cleanliness after an operation and that sort of thing would possibly be a different standard of cleanliness from, say, a sanitary inspector, and you might easily, if you have a vague clause like that, have a local authority that was not particularly keen just saying that its sanitary inspectors could have this job?-(Mr. Gwyer.) I do not think any local authority would do that; I should be very surprised if they did.

Dr. Davies.

106. Have the Ministry formed the opinion that the local authority is the best authority for attending to this? Have they thought of the possibility that it would be very much better worked entirely from London where they could have a certain number of highly trained lady nurses or inspectors to do the whole country? If you put it into the hands of the local authorities you will absolutely, as Miss Wilkinson said, have great variety, you would have local jealousies and you would not in all cases get efficient inspection?-Are you suggesting that the Ministry of Health should undertake this task?

[Continued.

107. That is my idea; that the only way in which it could be satisfactorily done would be through the Ministry of Health? It is not for an officer of the Ministry of Health to deny that, but I am not sure what the Minister would say.

108. I can see very many objections to local inspection, and I wondered if the Ministry had definitely made up their mind that local registration was a proper way out of the difficulty ?-I think the Ministry are humble minded and such a thing as inspection by themselves alone would never occur to them.

Major Price.] If you have the local health looked after by the local people and the local school children inspected by the local Medical Officer, surely the nursing homes could be inspected by the local people?

Dr. Davies.] That is a different thing entirely. You get local jealousies.

Major Price.

109. It is a difference of degree. I should have thought that the children's health was more important than the inspection of nursing homes? (Mr. Brock.) Where it is a question of ascertaining the efficiency of a grant aided service, it is very difficult for the central department to escape some duty of inspection, but where there is no question of a grant from public funds the policy hitherto has been to leave the work to the local authority.

Chairman.

110. Has anybody any other questions to ask on the memorandum of the Ministry; I think we have gone through it fairly well? The point that we were taking just lately was the point on page 10, clause 8. Yes, the question of cost, I think.

Chairman.] "This clause gives any medical practitioner or registered nurse authorised by the registration authority the right to enter and to inspect homes and their records. Thus a nurse might be called upon to inspect a home possessing a resident medical officer, a course which the objections are apparent." Sir Richard Luce.] The fat would be in the fire then.

to

Chairman.] That is a picturesque way of saying the same thing, is it not?

Dr. Davies.] Except, of course, you must remember that medical man probably is not a competent judge of the

25 March, 1926.]

[Continued.

kitchen arrangements,

the cooking arrangements and the cleanliness; you must have a medical man and a trained nurse; I think you must have the double inspection; you cannot have either alone.

Dr. Shiels.

111. No. (Mr. Gwyer.) It does not follow necessarily that even a registered nurse is qualified to pronounce on sanitation and sanitary matters.

Dr. Shiels.] A public health nurse would.

Dr. Davies.] That is why I think that the type of nurse who does this inspection should be the highest possible type you can get, a lady with the best nursing education and experience, a lady equivalent to a matron of a good hospital; I think that is the type of woman you want to inspect nursing homes.

Major Price.] What about a lady Doctor.

Dr. Davies.] A lady doctor, of course. Chairman.] Mr. Brock, you are contented with your own definition of a nursing home on page 4. You say it

should be so framed as to include so and So. I take it we should have to have some kind of a definition if we put any recommendation forward; have you anything further to say on that: "It is suggested, therefore, that if it is decided to recommend registration of nursing homes, the definition should be so framed as to include any premises used or intended to be used for the reception of persons suffering from any sickness, injury or bodily or mental infirmity for the purpose of providing such persons with nursing where any payment reward is made or promised by or on behalf of any person so received." That would include mental cases, which is another matter, which you mention on page 11, would it not? Other institutions ought to be excluded, you say, from the operation of the Act, institutions for the reception of lunatics and mental defectives; where do you draw the line? Sir Richard Luce.] Those are under inspection already.

Chairman.

or

112. I understand there are certain nursing homes where they take people who are suffering from mental trouble, or, let us say, from nervous disease, which subsequently may develop into

mental trouble, and then the difficulty arises that they may stay there, although they really ought to be certified; is that so? (Mr. Brock.) I understand that that is so, but, of course, it is a matter that does not come directly within our cognisance; it is rather a matter on which the Committee may wish to consult the Board of Control. We do know that there are a certain number of homes which take cases of nerve trouble. There is some ground for believing that they not infrequently or occasionally keep a case after the certifiable stage has been reached. Of course, if they do, that is a breach of Section 315 of the Lunacy Act of 1890. but without any power of inspection it is a very difficult thing to detect.

113. Registration and inspection would detect those cases?-It would help to.

114. Therefore that is one of the arguments really in favour of registration and inspection of nursing homes?—It is. In the case of that particular type of home, I think there is probably a stronger case than there is in the case of the nursing home in the popular sense of the term.

Sir Richard Luce.] Does not that introduce a new kind of inspection altogether, because hitherto we have been practically inspecting only the general arrangements and the building, and so on, of an institution. If you are going to inquire into that side of it, you have got to inspect the patients, which is a very different matter.

Captain Ernest Evans.

115. It is really a sort of Court of Appeal while the doctor is attending the case? (Mr. Gwyer.) That seems to be a much more appropriate case for inspection by a central department than the ordinary case. The Board of Control, of course, do inspect places for the reception of lunatics all over the country now. (Mr. Brock.) I think what might possibly happen in actual practice would be that, if the supervising authority had a right of entry into these homes, it might very well be the case that in the course of their round some suspicion might arise with regard to the certifiability of the patients without any actual examination of the patients; then that would be reported to the Board of Control, and the Board of Control could then apply to the Minister for an order to visit.

25 March, 1926.]

[Continued.

Chairman.

116. And if inspection was efficient, that would generally happen, I take it? -Yes.

117. With regard to your definition, Mr. Brock, have you anything to say? There is your definition and the definition of the Bill in Clause 13, is there not? Of course, a nursing home is an extraordinarily difficult thing to define. I do not regard this as an ideal definition by any means, in fact it is a modification of the definition in the Bill of last year.

118. What I am distressed about is "injury or bodily or mental infirmity." Do you want to stick to these words, "mental infirmity "? That is my difficulty rather.-I think, unless you have some reference to mental infirmity, then the home for nervous cases might slip

out.

Dr. Shiels.] I think it is possible, yes.

Chairman.

119. Are there any other questions any member of the Committee would like to ask Mr. Brock or Mr. Gwyer?-(Mr. Gwyer.) It has occurred to me that it is just possible that we might be able to get some statistical evidence through the Registrar-General about the number of nursing homes, or at any rate the people who are carrying on nursing homes throughout the country, which might be of assistance to the Committee.

120. How many of them are mixed homes? That, I should think, is more difficult; information of that kind is more difficult.

Dr. Shiels.

121. In London there are only about 300, and there must be, I should think, thousands of nursing homes in London? -I should think more than 300, certainly.

Dr. Shiels.] There are only 300 in the directory.

Sir Richard Luce.

122. Have you any sort of idea how many what you might call illicit homes there are?-No, none at all.

123. I am not speaking now of homes that are not run on proper lines at all?— I should doubt if there are many. I should think that that type of home you would find probably among the low class maternity home rather than the ordinary nursing home. I doubt very much whether there is a market for the really low type nursing home. (Mr. Brock.) I should agree. (Mr. Gwyer.) There is for the maternity home, for reasons which the Committee will appreciate.

Chairman.

124. Those you have put down in your paper? Yes, but not, I think, for the others. We have not any definite knowledge about that; that is a mere inference from one's own knowledge and opinion.

125. We may, I take it, ask you to come again if there are any particular points that we want clearing up?-(Mr. Brock.) We are at the Committee's disposal whenever you want us.

Chairman.] Thank you very much.

Chairman.

126. I think you come here representing the British Medical Association ?— (Dr. Bone.) Yes.

127. That is a very large Association, is it not?—Yes; we have 30,000 members. 128. And you consider yourself an Empire Association, do you not, not merely a British Isles Association ?-That is so.

129. Tell us what is your general view on the subject of the registration of nursing homes? We do not oppose the registration of nursing homes as a principle, but we do object to certain things that appeared in the last Registration Bill that was before the House. The three particular points that we object to are stated in this Memorandum that you have before you. First we say that there ought to be a provision for representation of the local medical profession on any local Committee formed by the supervising authority.

We

130. Shall we take that point first and elaborate that? The last Bill permitted the delegation of the powers of the Registration Authority to a Committee. think that it ought not only to be permitted but compulsory that such a Committee should be set up, and that medical men should be represented on such a Committee.

131. Supposing the County Councils are the authority, do you mean that there shall be medical men definitely put on the County Council to represent them in connection with their work?-No. The idea is that we think the County Council should compulsorily set up a special Committee for this purpose, and that on that special Committee there should be representations of doctors and nurses.

132. They would be co-opted people, I take it?-Co-opted or elected; we do not

care.

133. Well, you cannot ensure that they are elected, you see?-Especially elected by the representative professional bodies.

134. If there were elected people it would not be necessary to co-opt?-Quite. In addition to that, we think that there should be consultation with the medical profession in an advisory capacity, that is to say, we contemplate that this new Committee should consult the representative bodies of the profession in the localities on these particular matters.

135. Can you tell us a little more about that? I should like to know what you mean by that. Can you give us an instance-something that you have in your mind? We contemplate the setting up of local professional Committees in all areas to work alongside the local authorities. It is rather a scheme of the future, but it is the thing that we have in our mind.

136. What is the next point?-The next point is that we think that the case sheets and medical records of any nursing homes should be regarded as highly confidential; that there should be no access to them at all by anyone who is not a member of the medical profession.

137. Can you give us your reasons for that? We think that if case records were open to lay persons they would probably not be kept in a proper way, that is to say, confidential matters would not be put into these sheets, and consequently the patients themselves would suffer in the records not being properly kept.

Sir Richard Luce.] Which part of the old Bill does that refer to?

[Continued.

Mr. Hurst.

138. It is the end of Section 8; that is the only reference I can find.-I do not know. We decided that this Bill would permit these records being open to inspection by lay people.

139. The Bill looked as if it laid itself open to that suggestion?—Yes.

Chairman.

We

140. You think that is very dangerous? -We think that is very dangerous. think that it would destroy entirely the value of these records.

141. Your idea is that the records would not be truthfully drawn up because something would be suppressed; is that it? That is the idea; that they would no longer be records of any scientific value.

142. Is it not your opinion that that would rather limit the use of inspection? --No, I do not think so at all. I know of no instance where confidential records of this kind are open to inspection by lay people.

143. What exactly are these records? -Records of the exact nature of the diseases from which patients are suffering. We had a letter this morning from one of cur members who has a large surgical nursing home in the North of England, and I may read you perhaps a phrase from that: "What is likely to happen is that in some small towns where a person of local prominence is a patient in a nursing home it is open to unauthorised persons to acquire information as to what the prominent local personage is suffering from. Curiosity would be so great that it would be almost impossible to suppress information in some cases, and if anyone has, say, a malignant growth, it is that person's personal matter, and why ever should anyone else know to whom he objects, and rightly objects? That is the sort of thing.

144. You think that the Inspector should have no access to any records dealing with the complaints from which the patient is suffering?-We do, most decidedly.

145. Records being what-the card over the bed, the temperature, and that kind of thing, or what?-Anything of the sort; any medical record.

146. The next point is about the doctor's private house, is it not?—There we think that all premises which are

under the control of a registered medical practitioner should be excluded from the definition of a nursing home, and should not be subject to registration.

147. That is to say, any home which is run by a doctor; is that the idea?-That is the idea.

148. That is for commercial reasons?. Any home that is run by a doctor for any reason, yes.

Miss Wilkinson.

149. That is a little wide, is it not?It is a little wide, but it is the attitude taken up by the Association. These three particular points were considered at our representative meeting at Bath, when representatives from the whole country were present, and these three particular resolutions were carried. Of course, I must pass them on to you; they were carried by our representative body, which is our Parliament.

Chairman.

150. You would only be in favour of the registration of nursing homes if those three particular points were met?-That

is so.

151. In the way in which you want them met? That is so. We are instructed to oppose a Bill that does not contain these three points as far as we can. (Dr. Fothergill): May I say on nursing homes, as I am personally interested, that the medical profession is under the General Medical Council. If there was any complaint either from the servants, the nurses, the matron, the patients, or the patients' relatives, the whole question can come up through the General Medical Council. With regard to nursing homes run by private individuals for profit whose previous experience may have been in a linen draper's shop, or anything else, if they thought they might venture in a private nursing home, they are under nobody's responsibility except to themselves and to the police in any case, but the medical profession is under the control of the General Medical Council, and we take up the position that it would be intolerable in our private houses where our families and our children live, with patients put under our care so that they might have the benefit of the atmosphere of a family life -border line cases who might be prevented from becoming permanently certified lunatics-that we should have the