[Continued.

whole atmosphere destroyed by an inspection by some authority when we already, so far as our conduct is concerned, are under the control of the General Medical Council.

152. To what extent is the General Medical Council exercising any control, supervision or inspection over the doctor who has a home of that kind?-Any complaints that are lodged with the General Medical Council-on sworn affidavit, of course they have to inquire into; anything to do with his conduct; and they take very strong disciplinary action.

1S

cases

153. That assumes that somebody going to lodge a complaint?-Quite so. 154. But there may be many where the patient is badly treated, where there is nobody to lodge the complaint?-I think you will get plenty of complaints of that sort. We are also inspected in our houses, as far as that is concerned, by the Board of Control.

155. In mental cases?-In certified cases. I have had experience where disgruntled nurses and others have deliberately attempted to do injury to the doctor, and they have reported what they considered to be illegal actions; these cases are duly inquired into. It does not only depend on the patient. You see, the patients are purely optional; it is not a State business. They can leave the day after to-morrow, or their relatives can take them away at any moment. The whole thing is purely voluntary arrangement between both parties.

son

a

156. But if a sick person who cannot get away because he is too sick to get away is living in a doctor's house, how is anyone to find out whether that peris being well treated or badly treated? Do you say that it follows that because a doctor is running the establishment everywhere must be all right?— It does not at all follow that everything must be all right, but I think the onus of proof for the necessity of inspection of a doctor's house is on those who require it. I submit that the doctor is sufficiently under the control of the Council and his colleagues in the district and the relatives and friends to make that quite unnecessary. We have had no cases put up to us.

medical practitioners who received even one case into their private house. We think that the disciplinary powers, as Dr. Fothergill said, already existing are sufficient where registered medical practitioners are concerned, and we point out that inspection and registration would destroy the particular advantages that these patients have, that is to say, the single patients who live in the houses of doctors.

158. A little further down you say you wish to exclude all hospitals conducted by groups of medical men and nursing homes for private patients which are being provided in connection with voluntary hospitals?—Yes.

159. That is another large class or group of homes which would be excluded? -That is so. We suggest that there is a responsible Committee in charge of those particular institutions and that inspection would be unnecessary in that particular group of nursing homes.

Sir Richard Luce.

160. Could you give any examples of the class of home to which you are referring? Yes. One in my own district is a nursing home which has been set up in connection with the Bedford County Hospital. We have in the grounds of the Hospital set up a nursing home in which patients are taken who pay about five guineas a week for maintenance, and pay the surgeon who operates on them a small fee or pay the physician who attends them a small fee. This particular nursing home is under the management of the Committee of the Bedford County Hospital, and is, I believe, one of the best institutions in the country. Similar institutions are being set up in many of our country towns, and of course in the large towns they are quite common. There is, I believe, one here at St. Thomas's Hospital.

Mr. Hurst.

161. The 1925 Bill does exempt that type of institution under Section 13, subsection (2), apparently?-Well, we were not clear that it did exempt it. 162. It intended to.-Well, we thought it did not.

30 March, 1926.]

[Continued.

66

Hospital." Of course, a nursing home might be considered to be a different entity.

165. A small drafting amendment may be needed, but I think it does meet it?— (Dr. Bone.) Of course, if that does meet it, we need not pursue it.

"The

166. Your next paragraph is: Association is of opinion (a) that any institution managed by a responsible Committee and wholly or largely supported from voluntary sources (including income derived from endowments or investments, the object of which is to provide medical and surgical treatment of a curative character) should be exempted from registration." Have you anything further to say about that?-No; that would come into the same group.

167. "And (b) that any institution which is recognised as eligible for a grant by the Voluntary Hospitals Committee for the area in which the institution is situated should be exempted from registration."-That is an extension of the same idea, of course. We want as far as possible to get an institution controlled by medical men exempt from registration, and we are trying to go as far as we can in setting out those which are the strongest cases first.

Mr. Hurst.

168. As a matter of fact, I think that last half-paragraph is word for word in the Bill already if you look at Section 13, sub-section (2), of the Bill?-Yes, that is SU. As Dr. Lord points out to me, one of the points is that this particular Bill has gone and we are dealing with the

future.

Chairman.

169. Yes. You are assuming that we are here to see what legislation should be necessary?-Quite so.

a

170. That we may have that as a sort of pattern; it is not necessarily pattern that we shall follow in every detail? Yes.

171. Then you have a suggestion as to the authority, and you suggest that the authority should be the Ministry of Health? Yes.

172. That the County Council and the County Borough Council should be the local authorities ?-Yes.

173. And it is on those local authorities that you want representation of medical men and nurses, I take it? No. It is on the Special Committees that those

local authorities set up; that is what we want. We want the administration to be by Special Committees set up by the local authorities, and on these Special Committees we want representation.

174. It will be a Public Health Committee, I suppose?-Well, call it what you will. We do not contemplate that the County Council or the County Borough Council would themselves carry out this registration and inspection, but that it would be done by a Sub-Committee specially set up for the purposesome kind of a Health Committee.

175. You come to the question of inspection in your next paragraph, and you say it would be extremely unfortunate if the inspection were to be carried out as was suggested in the 1925 Bill by registered nurses, or, as would have been equally possible, by junior officials doing public health work. What is the objection to registered nurses?We have set out here some of the points in our memorandum. (Dr. Fothergill.) Might I take up that point about the inspection by nurses. The nurse, if she inspects a home, would obviously look at it from the point of view of a nurse, and we contemplate that these nursing homes will be under the control of a registered nurse, a matron, who will organise her staff in accordance with what she thinks fit for carrying out the care of the patients, according to the wishes of the doctor visiting the patient; and if an inspecting nurse is to come in she will come in as a nurse and criticise the conduct of the matron and the conduct of the home. We take the position that if you have a registered nurse there conducting that home the inspecting nurse should have no locus standi at all. Of course, if the matron is inefficient, the particular Committee, or whoever it is who placed her there, will control her actions; and if it were her own nursing home, the Council responsible for the nurses would be able to deal with her efficiently on complaint just like in the case of a doctor.

176. The nursing is to be in the same position as the medical question?—Yes. She is responsible to the State. Being registered, she is responsible for her conduct to her Council, and every complaint would come through the usual channel for her to be dealt with.

177. All that would be inspected, then, would be the general sanitary condition and structural efficiency of the building?

[Continued.

we

-Quite so. We go even so far as to suggest that they might inspect to see that there is a proper proportion of fully trained nurses. Of course, appreciate that one of the complaints is that a lot of these homes are run with what you may call cheap girls, who are not nurses at all in any sense of the word. We are quite with anybody that that sort of thing ought to be put an end to, and that while they might have two or three probationers in proportion, the staff must be an efficient staff of fully trained nurses; it should be inspected from that point of view.

Miss Wilkinson.

178. Would not only a nurse be really able to judge of the quality of nursing? If you have an unqualified person at the head you might have a qualified nurse under her who was dependent upon that head for her job, and she is naturally not going to make complaints, and the sick person does not know the sanitary conditions below stairs, perhaps insanitary kitchens and so on, and in that case no complaint would be made, but a most insanitary condition of affairs and a dangerous state of affairs might exist?We quite agree that the sanitary inspection should be made; it says so at the top of page 3. "The matter would not be of such importance if inspection was strictly limited to obtaining evidence that the person responsible for the home was a registered medical practitioner or a certified nurse; or that the matron in charge was a certified nurse; that the premises were suitable for the nursing of the patients, that the accommodation for the nursing staff and domestic staff was satisfactory; that a proper proportion of fully trained nurses was employed and that the sanitary arrange ments were adequate."

179. Leaving that for the moment, surely the nursing of the patient is one of the most important things; why should you exclude that specifically from the scope of the visiting inspector?-Might I put it the other way round? How could a woman walking into a private room where the patient is ill in bed be able to determine that the nursing given to that private patient is adequate? She would have to live on the premises, you might say, to be a sort of inspector; she could not do it in a visit of an hour.

180. Surely a really qualified nurse who knew her job could find out by cross

examining the nurses who might not themselves be registered, but might be parlourmaids or just untrained people. Take the case of an operation; they may have an operation case on their hands and really not understand the dressing and so on. A really qualified nurse who knew what to ask would not just go into a room and just casually glance round, but she would be able to ask questions which would give some idea as to how the nursing was being conducted, do vou not think?-Can you appreciate the position what would happen in a nursing home with a registered nurse of the highest status, doctors of the highest status, a patient of the highest rank living in Mayfair; a qualified inspecting nurse walks in and holds an examination of the place even down to the kitchen maid and any woman she may happen to buttonhole on the staircase in order to determine whether Lady So-and-so is being adequately nursed. There would be chaos in that home in half-an-hour, friction all round, and a patient with a high temperature needing a sedative.

181. That surely is rather an extreme case? No, not at all.

Miss Wilkinson.] If you are going to have a highly adequate nursing home with highly trained practitioners and so on, you would not have the same type of inspection that you would have where there is reason to know that the people at the head of it are not qualified people, and it is not under a qualified practitioner. Do you not think under those circumstances that the public interest demands that somebody should be there?

Chairman.] That is actually down in the précis, you will see, Miss Wilkinson. Miss Wilkinson.] Yes, I see that.

Chairman.

182. This is the definite opinion, apparently, of the British Medical Association. It is your definite view that the inspection should be very considerably limited, and it should not extend to anything connected with nursing, to anything connected with the medical side, and I do not know how far you would say that it ought to look into the qualifications of the existing people who are running homes? We say that a proper proportion of fully trained nurses should be there.

183. And they are to find that out?Naturally. They would have a list given them and by looking at the nurses' regis

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[Continued.

184. It would be very easy, would it not, to differentiate what might be regarded as strictly confidential records of a patient and those records of the nursing home which ought to be open to inspection?-(Dr. Bone.) I do not quite follow which class of records you mean.

185. You object in toto to the disclosure of the records of the home to any inspector, but I take it that such records as the lists of nurses employed, the number of patients taken-?-No; that is not at all what we meant. We mean case sheets and medical records.

186. Assuming that the case sheets were treated as privileged, it really would meet your point? Quite.

187. It really is not a big point; it is a narrow point?-It is the Doctor's notes of medical matters that we are talking about when we talk about private case sheets and records.

188. Keeping those confidential and privileged is quite compatible with the general principle of the inspection of nursing homes?-Oh, yes. We raise no objection to the general principle of inspecting nursing homes; I have said so here.

189. Was it your Association which promoted the Midwives and Maternity Homes Bill of this year?-No.

190. Is that supported by your Association? To an extent only.

191. I see here that the excepted homes, the homes which are made immune from

inspection are "Hospitals or other premises for the conduct of which a duly qualified medical practitioner resident therein is responsible "?-We do not accept that, and we are going to oppose it very strongly. We object to the word "resident" altogether. We think that that limits it very unduly, and we are opposing it very strongly.

192. Apparently the promoters of that Bill take, as it were, the half-way view? -That is in the air at present. That word "resident" was put in to try to satisfy us, and it has not satisfied us at all. In the first place, we were not consulted about the Bill at all. In the

original Bill they proposed to inspect all these homes, and that was put in in an attempt to satisfy us, but it has not. satisfied us.

193. I suppose there are a certain number of homes which in a sense are controlled by a Doctor inasmuch as the Doctor sends the patients there, but with regard to which the Doctor has very little knowledge as to the interior economy of the home?-I do not think So. A Doctor sending his patients to a home is not in any sense controlling it. Many a Doctor sending patients to nursing homes has no control or interest of any kind.

(Dr.

194. Merely because a Doctor sends patients to a home it does not mean that he in any way makes himself responsible for the conduct of that home?-No; that is not what we mean by control. Lord.) There are quite a number of Doctors, particularly in certain towns, who have always run what they call private nursing homes. They have found them there when they have bought the practice, or they have succeeded their parents and they have gone on running these nursing homes, which are really little private hospitals under the complete and absolute supervision of a medical man. That is one class which we say ought undoubtedly to be exempted from inspection.

195. How many complaints do the General Medical Council yearly receive on an average from patients or persons who have been inmates of nursing homes? -(Dr. Bone.) I do not know.

196. We have been told it is possible to lodge complaints by affidavit; I suppose those are very few, are they?(Dr. Fothergill.) I do not know that myself. I may say incidentally that we had a deputation from the College of Nursing, and we put to them the question as to how many complaints they had had, not by doctors, but by everybody. We asked if they had had 50, and they said, "No," and we got down that they might have had 13.

197. I think they are going to give evidence. You were saying you would suggest a safeguard that persons could come and make complaints by affidavit, but, so far as you know, that safeguard has never been utilised at all?-It has not been necessary.

198. There are, I suppose, a very large. number of these homes?—Yes. I heard

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from a large association which deals with the profession, that is, the Scholastic Association, that there many hundred doctors who took single patients, and some of them two. They have a list of doctors, to whom they recommend patients, and they told me that they had not had complaints themselves. That, of course, is a private business; it is not disciplinary.

199. Assuming that you do favour, or at any rate, do not object generally to supervision or inspection to see how the patients are accommodated, and whether the nursing staff and the domestic staff are properly housed and so on, and that the sanitary arrangements are satisfactory, who do you say ought to do the work of inspection, if not registered nurses? It would seem to be the duty of a medical officer of health to see that the sanitary arrangements are right, and that the house is suitable. The future authority, if we look far ahead, I submit, will be probably the County Council or the Borough Council responsible for all health questions. will all come under the purview of the medical officer of health; he will be the administrative officer for the area, and it will be one of his duties, or that of his deputy, probably, to inspect these various places from the health point of view..

It

200. Do you not think essentially nursing questions will be most properly supervised by a very highly qualified nurse working, possibly, under the local Officer of Health? (Dr. Bone.) No. The association take a very strong view that it should be the Medical Officer of Health, or some person appointed by him, that is to say, somebody in a good position in his Department.

201. The view of the association is that they regard the inspection of nursing homes as a good thing provided it is done by a doctor?-Not necessarily a doctor, but by the Medical Officer of Health, or some responsible person in his office.

202. But when you say "responsible person," you would rule out a nurse, apparently? Yes.

203. Whom would you leave in that category if you exclude nurses? This really means doctors only, does it not, practically?-(Dr.

Fothergill.) Except that the Sanitary Inspector would do the sanitary part like any Sanitary Officer comes round and inspects houses now.

[Continued.

204. Apart from this Memorandum, have you heard of bogus nursing homesnursing homes which have no claim to that title at all?-(Dr. Bone.) I have heard of them, but I have had no experience of them.

205. Would you regard that as a common abuse?-No, I do not think so.

206. Have you heard of any specific cases in your experience?-I have never heard of a case in my experience.

207. But I suppose it is common knowledge, is it not, that there are a very large number of nursing homes where practically none of the nurses are in any way qualified at all?-No, I do not think it is common knowledge.

208. Certainly with regard to maternity homes, are there not?-I have no such knowledge.

209. You have never heard of a maternity home run by unqualified nurses? I would not like to say I have never heard of one, but I do not think it is common knowledge that there are such things.

210. You really think that all nursing homes are now staffed by qualified nurses and well run?-I should not go so far as that; that is putting a very different statement.

211. But the immense majority, in your view, are?-Certainly.

212. Including maternity homes?—I do not know much about maternity homes. We are speaking about nursing homes

now.

213. Is there any principle for differentiating maternity homes from theordinary nursing homes?-I think there is a very good reason.

214. What is it? (Dr. Lord.) I was going to suggest with regard to the maternity home that patients go to maternity homes for a specific purpose, that is to say, to be treated for a physiological condition which is perfectly legitimate. If you go into a nursing home for any condition that may crop up, there are very marked reasons why you do not want all and sundry to know why you are in that place at all. Take, if you like, the case of syphilis; it may crop up in any walk of life, and it may lead to the patient having to go to a nursing home. Do you not think that if that case were to occur in a member of your own family you would feel very uncomfortable if that patient had to go into a nursing home which was liable to inspection by someone who lived in the