Comment: No wonder her temperature's up

THE metamorphosis of the nurse from slatternly inebriate into secular saint was surprisingly swift. Mrs Gamp - drunken, dirty and dangerous - made her public appearance in 1843, in Dickens's novel Martin Chuzzlewit. Less than two decades later, the legend of the Lady with the Lamp was firmly established. And on the whole Nurse has had a good press ever since, retaining the high regard of the public.

And rightly so. Of course, no professional body of 330,000 can be composed exclusively of saints, and the job itself offers many opportunities for the expression of sadism, from the subtle to the brutally explicit. I never hear a young nurse call an old patient by his or her first name without shivering at the cruel insensitivity of it. For the most part, however, nurses are good people - still mainly women, by a factor of nine - and there can be few of us who have no reason to be grateful to them.

Our gratitude and warm sentiments, alas, confer no privileges and buy no luxuries. Hard cash and an easy life are what most young people want now. The high regard of the public does not compensate for a life in uniform under a stern discipline at pay which is less than that to be had elsewhere for less stressful work: the average income of a staff nurse is pounds 15,000. Recruitment into nursing is therefore at an all-time low, and, as we learnt last week, there is now a shortfall in newly qualified nurses of 8,000 a year.

So Nurse is not happy at the moment. She has many causes for dissatisfaction. Her job grows ever more technically demanding, which means that there is more to go wrong and more to be blamed for. There is much less tucking up and making patients comfortable than there was, and much more attention to electronic screens. Patients who still think they ought to kiss her shadow as she goes by are inclined to suppose that her absence from their bedside means she is idling her time away, indifferent to their discomfort. They imagine she is smoking, drinking coffee and chatting about her boyfriend at the nursing station. In fact, she has an immense amount of paperwork to do: so much, in fact, that it has become grounds for dissatisfaction in itself. Most nurses want to look after people, and they end up looking after pieces of paper.

Patients are more liable than ever before to complain about the treatment they receive in hospital, but at the same time are more liable to behave badly themselves. They feel free to abuse Nurse, in the full knowledge that she is not in a position ever to retaliate. Such are the ethics of nursing that no conduct on the part of the patient can deprive him of the right to nursing care, and so Nurse often feels herself in a fundamentally unjust situation: she can be complained about but must herself be uncomplaining. This imposes quite a burden upon her.

Other pressures on Nurse have increased greatly in the last few years. Many of the wards are now short of staff, so she is rushed off her feet. With the emphasis on processing patients like sausages through a machine - never mind the quality, record the numbers - Nurse has less time than ever to get to know her patients. Ask Nurse about your grandmother who was operated on yesterday, and the chances are she won't know who you are talking about. Your grandmother is known to her only as the old gall bladder in bed six who is due to go home today if her blood results are OK. This is a far cry from the days when Hattie Jacques was matron to James Robertson Justice's consultant surgeon.

Nurse has changed in other respects. Her uniform is much less starched than it was, and therefore strikes no terror in the heart of wrongdoers, such as illicit smokers. She no longer wears a little frilly hat whose hygienic purpose was always a little unclear, but which no doubt served to hinder a little the hanky-panky in the linen cupboard. It is harder to misbehave with a frilly hat on, and it improves the deportment no end. It is a distinct disadvantage in an emergency, however.

Top Nurse is no longer Matron, whose daily sweep round the hospital, sometimes with white gloves to detect dust on shelves or radiators, inspired terror - and, strictly in retrospect, affection - in the nurses and junior doctors alike. Typically, Matron was a formidable spinster who lived in grandish apartments in the hospital, the queen of a hive, with a beady eye which alighted on any breakage of the rules.

Nowadays, Top Nurse has a different title: something like Director of Nursing Practice. (In the new NHS, Directors have proliferated like bacteria in a Petri dish.) She dons no uniform, but is likely to be a power dresser, and has meetings at eight in the morning to establish her managerial credentials. She is always busy, though the nurses aren't quite sure what with. Certainly, she gives no sign of ever having touched a patient, some- thing she regards as rather infra dig. Indeed, she forgets her own origins in the profession more completely than the average doctor forgets the anatomy he learnt at the dissecting table. Her authority is not military, as Matron's was, but more akin to a high-ranking civil servant's. She poses as a business woman: in other words, an ambitious nurse must abandon nursing.

But for the most part, Nurse is still socially unambitious, content to remain within the ranks of the lower middle class. In only a few selected medical schools does the tradition live on of high-class girls hoping to capture the heart - and future earnings - of prospective doctors. (Apart from anything else, half of medical students now are women.) And Nurse is not greedy or grasping. No one is less afraid of hard work and, amazingly enough, she still harbours the desire to do good, despite her disgruntlement.

Her good nature cannot be presumed upon for ever, though; and a lack of greed is not the same as complete indifference to what she is paid. There is now a chronic shortfall of nurses, worsened by the ability of nurses to find better pay elsewhere.

It is precisely the modesty, reasonableness and dedication to duty of Nurse, and the high public regard in which she is still held, which places the Government on the horns of an embarrassing dilemma. If her pay is not increased, she might resign, and will certainly not be replaced on retirement.

On the other hand, the Government is committed to increasing expenditure on the NHS without seeing the increase disappear, as it often has in the past, in increased wage bills. It wants any such increased expenditure to go directly on improved facilities for patients, not on higher living standards for those working in the service. Thus it is committed to resisting Nurse's request for more money, compliance with which would not only be expensive in itself, but would quite possibly unleash a flood of similar demands.

But a health service without sufficient nurses is automatically a health service with insufficient facilities. Hitherto, the Government has always assumed that exposing the NHS to market forces would make it cheaper rather than more expensive, that it would get more for its money rather than less. But it is now learning, through the shortage of nurses, that market forces can work the other way as well. If labour at the level of education and skill required by nurses is better paid elsewhere, there will be a shortage of nurses. And if the shortage becomes severe enough, the whole system implodes. Waiting lists will grow longer and standards of care will fall, regardless of what is spent elsewhere in the service. Technological whizz-bangery is not so far advanced that human labour is altogether dispensable.

The Government would do well to go back to Hilaire Belloc, and learn well the moral of the story of Jim, who ran away and was eaten by a lion: always keep a-hold of Nurse for fear of finding something worse.