HL Deb 31 October 1946 vol 143 cc924-52

4.9 p.m.

Order of the Day for the Third Reading read.

THE LORD CHANCELLOR (LORD JOWITT)

My Lords, I beg to move that this Bill be now read a third time. Your Lordships may remember that, on the last occasion when it was under consideration, we had some discussion arising on an Amendment in the name of Viscount Cecil of Chelwood as to whether or not we should try to alter the Bill in some respect to deal with deafness. I do not wish your Lordships to think, because we have not brought forward any suggestion for an alteration to-day, that we have not been into this matter very carefully. I say, frankly, that I am very, very sorry that we have not been able to make the necessary Amendment.

I say it for three reasons. First of all, I always particularly like, if I can, to oblige the noble Viscount. That, no doubt, is a very inadequate reason, but still it is a real one. Secondly, I am reaching an age when, I must admit, I am not quite sure that I am not beginning to get a little deaf myself. At any rate, it seems to me that counsel do not speak up like they used to do when I was a young man at the Bar! That also is an improper reason. The proper reason is that I do believe that there is, to-day, a vast amount of unhappiness caused by deafness which, if it is not preventable, can at least be alleviated by modern scientific methods. Therefore I should have very much liked to be able to put something in the Bill about it. But I am bound to tell your Lordships that, having done the best I can and having used such small ingenuity as I have, I cannot see how to do it.

The noble Viscount wanted a provision to go in Clause 41 which is a clause dealing with supplementary services. I am afraid there is nothing supplementary about this at all. This matter of the ear is not in the least like the matter of the eye. In regard to the eye, if you want to get a pair of spectacles—which, after all, is more or less a standard article, although, of course, you can go gay about the setting and have tortoiseshell or something of that sort if you like—there are numbers of people, called I think ophthalmic opticians, who are highly skilled in measuring refractions (if that be the correct way of putting it) and can tell you what spectacles you ought to use. I should without hesitation go to one of those people if I found that I wanted a pair of spectacles. But I am bound to say that if I had anything the matter with my ear, I should dislike intensely going to someone who was not a properly qualified doctor.

I remember once, some years ago, having the duty of cross-examining a witness before a Select Committee of your Lordships' House. He was explaining to us how he could cure deafness by manipulation. It appeared that it was done by his little finger, and he was explaining how he inserted the little finger into the eustachian tube. I was looking forward to a good afternoon's cross-examination. I expected to hear—and no doubt should have heard—that his finger came out the other end, rather like a ferret out of a rabbit hole. Unfortunately, it was more than Lord Dawson could bear, and taking a match he asked the man: "Do you know what the size of the eustachian tube is?" Thereupon the man stated that the ferret had never entered the tube at all! It seems wrong that intricate mechanism such as the eustachian tube should be subject to the mercy of people not qualified to deal with it. Therefore, it seems quite impossible to say that there is any analogue between those who deal with ears and opticians with regard to glasses.

If ears could not come as a supplementary service, they should come as part of the general hospital service, under Clause 3 where the Minister is under a duty, in subsection (1) (b) to provide for "medical, nursing and other services required at or for the purposes of hospitals," and, under subsection (1) (c), "the services of specialists, whether at a hospital, a health centre...or a clinic." If I were to put in particularly deafness then various noble Lords would want to put in other things particularly. I am sure that the noble Lord, Lord Horder, who is not here, would want to put in rheumatism, and the noble Lord, Lord Moran, tuberculosis; and other of your Lordships would want to put in various other things, until we had set out a whole chain and achieved, nothing. I came to the conclusion that that was impossible, and having discussed this matter with the Minister I am afraid that the best I can do is this (I am reading his words): I suggest, therefore that you should repeat on Thursday my definite assurance that a comprehensive service will, and must, include provision for deafness". By that, my Lords, I mean not merely the trained assistants who would be required, but I mean the provision of those instruments which can, to some extent, at any rate, alleviate the distress and worry caused by deafness.

I was impressed by what the noble Viscount, Lord Cecil, said about the exploitation which is going on to-day—the system whereby various people are concerned to sell for the highest possible price instruments which have very little effect. It may be that that is brought about by the fact that we are reluctant to bring from America other instruments and to use our precious dollars. It is a matter, however, which I might well take up with the President of the Board of Trade, and I give you an assurance that I shall do so. I regard it as most important that we should do everything we can at the earliest possible time, to produce in as large numbers as possible the best scientific instruments which we can, to allow no exploitation by anybody, but to make them available to the public free of charge.

So much for that matter. For the rest, there are a fed other matters with which I want to deal. I am very grateful to your Lordships for the constructive way in which you have helped me to discuss this Bill. I say quite frankly, that I followed the advice of the noble Lord, Lord Beveridge, who said it was such a good Bill that we need not be 'the least ashamed of considering Amendments to it. I hope your Lordships will not think, because the Minister authorizes us to discuss the matter, and to accept Amendments, that thereby he is showing any weakening or lack of resolution or lack of courage, or anything of that sort. On the contrary, by allowing me, as far as I can, to meet the wishes of your Lordships, I think that the Minister is showing his good sense and good judgment. It is not a matter, I repeat, whereby hereafter any one Party is to seek credit—at least, I hope not—that some of these Amendments are made. If that should happen, it would make my position in regard to future Bills before your Lordships quite impossible.

For the rest, some of the alterations—the main part of the alterations—which your Lordships have suggested, and which I have accepted, are those which had the effect of writing into the Bill an undertaking which the Minister had given but which was not written in the Bill. An illustration of that is the case of the denominational hospitals. There was a good deal to be said for writing into the Bill what I regard, and many of your Lordships regard, as a very important matter. I need hardly assure your Lordships that the administration of the matter by the Minister will be in no niggardly or reluctant spirit.

So far as endowments are concerned, here again I am very glad to think that we have been able to hit upon a method which meets the general wishes of your Lordships. It does not interfere with the broad general principle, that endowments are to be devoted generally to all hospitals, but it does protect those specific endowments intended for some particular purposes. I think it is a good thing, too, that the powers of the hospital management committee should have been set out in the way that they are in the Bill. I am very anxious that everybody should understand that the hospital management committees will have a real job of work to do. We want to get—and we rely on getting—the very best people that we can on to the hospital management committees. They need not hesitate to come for fear that if they do they will be mere cyphers, without a real job of work to do.

With regard to discovery of documents in the event of litigation, I may be right or I may be wrong but, personally, I take the view that we had already safeguarded the position. Other noble Lords took a different view and there was no reason why we should not make plain what we had intended. We have made one alteration of real substance. It affects only a limited time—the time between the appointed day and the passing of the Act. It may be an interval as long as eighteen months. The Minister had already arranged that, after the appointed day, endowments given to a particular hospital should not be taken away from that hospital. What we have done is to extend that principle to the interval of time directly after this Bill becomes an Act of Parliament.

I confess that I think the Bill has two blemishes. I think your Lordships were wrong in saying that no part of a doctor's remuneration should be by way of salary. May I tell your Lordships why, from my particular angle, I feel that very strongly? No one could have been, as I have been, Minister of National Insurance, without realizing that the success or failure of all our schemes depends in a very large measure on our getting satisfactory certification. If we are going to have lax—still more, dishonest—certification, then all our schemes are going to break down on that rock. I have a most profound regard for the medical profession, and for their standard of honour, but I am bound to tell your Lordships that I did come across cases—not many—where there were two competing doctors, where one was strict with his certification and the other was lax. The people who were on the panel of the strict doctor were inclined to leave that panel and to go on the panel of the lax doctor, not because the lax doctor was a better doctor, but because from the lax doctor they could more easily get certificates.

If you had abolished this per capita payment altogether and made it a straight out-and-out salary, of course, that temptation would have gone. But I do not for a moment suggest that. That would have brought in other troubles of all sorts and it would not have been practical politics. But to the extent that you would have alleviated this treatment, by giving something in the way of salary, would, I believe, have been a very valuable thing. It is my sincere and honest belief that your Lordships have made a very great mistake in taking that line.

The other blemish, as I see it, is the blemish which results from his special treatment of London. There is an old saying that "hard cases make bad law." I say quite frankly that I have no doubt that any organization which is fortunate enough to have the enthusiastic support of the noble Lord, Lord Balfour of Burleigh, is going to be a pretty efficient organization. He combines the wisdom and the stateliness which we associate with a great banker, with the enthusiasm of youth; and he has, I feel, a very considerable disregard for what I may call "red tape," a point of view with which I humbly sympathize. Hard cases do make bad law, but just because the administration of the health services in his particular borough are, as I am sure they are, exceedingly efficient, it does not really deal with the question whether they would be more efficient if you are going to spread that system throughout London. As I have told your Lordships, I believe it is a very great pity that health service (should be split between two authorities, part of them being the concern of borough councils and part of them the concern of county councils, because as your Lordships will remember, the Amendment of the noble Lord does not seek to transfer to the borough councils all the new powers. It seeks to transfer to the borough councils the powers they already have with perhaps some slight extension.

I dare say I overstated it before. I do not want to overstate it now. Home nursing goes rather farther now than before. But substantially he seeks to retain the existing powers. I. think perhaps I went too far in saying that no Minister had ever agreed to this, because I think it is a fact that Mr. Willink, at any rate, in his negotiations, did agree to this, but certainly—I think I was concerned with this matter from its earliest days to the very end of the Coation—I can say sincerely I never heard such a suggestion. So far as I knew, we always thought that, whatever else you did, you must have all these services dealt with and provided by one authority. Therefore I think it right to say I think this is a pity.

For the rest, may I just say this? We do preserve—and I hope the public will realize this—the absolute right of choice of doctor. We are not going to force anybody to take any doctor he or she does not like. May I say it is plain that we are not going to move people about. Nurses are apprehensive that they may be moved to any part of the region. That is not so. If they have a contract to serve in a particular place, they can only be called upon to serve in that place. May I conclude with this word? There is still a great need for well-disposed people to help—there will always be that need—by their money and by their service. I believe under the new scheme, although the construction is very different, that there will be great scope for voluntary service, and I hope that the passing of this Bill into an Act of Parliament, if that does take place, will not prevent that voluntary service from being forthcoming.

Moved, That the Bill be now read 3a.—(The Lord Chancellor.)

4.25 p.m.

LORD LLEWELLIN

My Lords, I think we are all grateful to the noble and learned Lord on the Woolsack for the speech which he has just delivered. We are also grateful to the Government—and I do not merely mean the noble and learned Lord on the Woolsack and the noble Viscount, the Leader of the House, but also the Minister of Health himself—for the way in which they have met what I venture to think were the constructive proposals which we put forward. They were put forward not with a view to ruining this Bill, or in any way making it in-effective, but in order to make it more workable, as we thought, than it was when it came to this House.

There is really no need in a case like this for either House to think that they have all the knowledge in the world. Different views are expressed in the two Houses, and so long as we continue to have, as I hope we always shall, our two Chambers, we should be prepared, when constructive arguments and suggestions are put, in whichever House, to adopt them if they are reasonably practicable. I certainly do not think that any lack of courage is shown by any Minister who accepts Amendments; I think exactly the reverse is the case. It is always much more courageous to say: "That is right and I will accept it; I think it is good sense," rather than rest on one's laurels in the knowledge that one enjoys a large majority in another place and, as a result, have a Bill which is not as good as that which we think the Minister has got from this House.

I think that in our six days' work on this Bill we have effected some improvements—nothing quite so earth-shaking as happened, we are told in the first chapter of Genesis, when the whole world was created in six days. Nevertheless, some quite good improvements have been made in the Bill in this House. For one thing, we have made certain that a doctor—whether acting in an honorary capacity or not—who serves on the staff of one hospital may get his patient admitted or may even treat him in another hospital. I think that is important. It is important because in a lot of these small hospitals in the country there is no resident stall. For a long time the doctors in the locality have all acted in an honorary capacity, and followed their patients and indeed treated other people's patients in that hospital. Although I quite agree that we should have a large hospital unit, I am one of those who hope that we shall not have, as a result of this Bill, the closing down of those smaller hospitals in the country towns, which will still have their function to perform in attending to the minor type of ailments that do not need the special treatment of the larger regional hospitals.

I think, too, with the Lord Chancellor, that the provisions we have been able to put in the Bill with regard to endowments are an improvement. I was fearful—and I know those who have taken a great interest in the voluntary hospital were also fearful—that if in the interim stage nobody knew quite where their capital donation, whether left by will or by gift, was going, they would cancel it. Clause 59 as it came to us would not be much good unless some provision were made for that interim period as well. The Amendment will allow of this continuity of voluntary gift, to which the Lord Chancellor has recently referred. I am grateful to the Government for drafting an Amendment—because a lot of us did not know whether a satisfactory one could be drafted—dealing with endowments given for a special purpose, especially gifts which commemorate either a class of persons such as those who died in the war, or a particular person. I think we now have a satisfactory provision to see that that continuity of memory is maintained in a hospital which has had some donations made for a specific purpose or purposes.

Noble Lords on both sides of the House wanted to see the hospital management committees given a better function in the Bill as printed, and the words that they will now "control and manage" seem to have met us on that point. I think it is all-important that these bodies should not represent mere titles, but should be bodies with obvious powers, otherwise you will not get the kind of people serving on them who have served our hospitals in the past. The noble and learned Lord has referred to the matter of the disclosure and production of documents. I was one of those who did not think that was covered in the Bill. I thought that when it was stated you could sue a hospital, putting these actual words in and leaving out words about disclosure and production, it probably was not covered in the case of an action where the hospital was not a party, but where the documents in its possession were most important for the patient or other person suing, probably a surgeon there, in respect of something that had happened in hospital. Now we have resolved the doubt, and I am quite satisfied the words that have been accepted by the Government are all that we want in that direction.

I am obliged for the assurance we have had in this House on two points. One is that the doctors will be given adequate time before the appointed day to know what their conditions are. I think that is all-important. We were also given an assurance that dentists would be allowed to have their names on two lists, so that a patient from a different area could still continue to go to a dentist although he might not be in that particular area. Another thing, too, I think has been of use; because you must remember that the whole of this vast health service is not going to be operated by a Minister or by a person who is always looking up old copies of Hansard. That is that where a new partner is coming into a partnership the existing people in that partner- ship shall be consulted, and that in a proper case a relative—I am not talking about nepotism, but a proper case such as that of a son—should be given a reasonable opportunity of succeeding to the practice that has been built up.

We were also right in putting in the provisions that we have done in regard to appearances before the Tribunal who decides whether a doctor should be taken off the list or not. I felt there was quite a lot to be said for the Minister, who, after all, has the responsibility of the whole of this Health Service, having the ultimate word as to whether a person should continue to serve in it or not, and not leaving it to a Judge of the High Court. But I think we have greatly improved this measure by providing that a man who might lose the whole of his livelihood through a decision of this Tribunal, or of the person appointed by the Minister to hear the appeal, shall be entitled to be represented by counsel or a solicitor, to call evidence and to produce what documents he likes. Another improvement is the provision that the chairman of this Tribunal shall be a barrister or a solicitor of at least ten years' standing, and that if the person coming before it so desires the proceedings of the Tribunal shall be held in public. It is, I think, one of the best safeguards of our legal system that, except in the rarest possible cases where official secrets are concerned, the hearing of any of these Courts must be in public.

We are all obliged that the Government saw their way to put into the measure itself the assurance the Minister has given with regard to hospitals connected with some religious denomination. It is important that on boards of management and in the hospital management committees some consideration should be given to the kind of people who worked on them before. If it were a Catholic hospital, or whatever it is, it should, if possible, still be staffed and managed by a certain number of people associated with that religion. There are two other small matters to which I would like to refer, if I may. As regards the rather wide draft we found of what the powers of the Minister were to alter, of his own volition, the Act or regulations under it, I think we were right to restrict this to the purposes for which the particular section was really meant to apply. I think we were right to restrict the power to lay down in regulations the terms and conditions of officers of local authorities to those who were concerned with the health services, and not to leave it of so general a character as it was in the Bill originally.

Now I come to three other matters, one of which I am glad to think that the noble and learned Lord did not refer to as a blemish on the Bill. That was an Amendment which made these management committees capable of suing and of being sued. Whether or not that is generally advisable, I am one of those who hold strongly that it is, because that alone could give them a status which they ought to have. Amendments were put in the Bill to allow them to have endowments transferred directly to them to carry on for a specific purpose, and it is quite clear that if that is going to be enforced and dealt with under the Act, it must be possible, if they are not fulfilling that function, for somebody to take them before the Court, to compel them-to apply those endowments in the proper way. Therefore, I hope that that particular Amendment can now be a part of the Bill, and will finally come before us in that form.

I come to what the noble and learned Lord said he thought were the two blemishes now in the Bill. He is quite justified in considering them blemishes because he voted against them going through, just as I am justified in thinking they are improvements because I happened to vote the other way. I understand that my noble friend Lord Balfour of Burleigh is about to address your Lordships on the Amendment in regard to the London boroughs. I will not therefore take very much time over this particular point because the noble Lord has such a far greater authority on the matter than I have. It does seem to me that there is a difference between these vast boroughs in the County of London and the country as a whole.

Vast numbers of people are living in some of these metropolitan boroughs. Certainly the London County Council will be a huge area for administering these services and will quite clearly have to delegate this authority somewhere down the line. If that is so, why not leave it with people who on the whole have been doing it extremely well? I have made inquiries since—and the noble and learned Lord on the Woolsack dealt with this point—and I am given to understand that the last Government was only too glad, under Mr. Willink as Minister of Health, for this thing to be settled between the London County Council and the metropolitan boroughs. They did accept what the authorities had agreed between themselves on a matter which, after all, mainly concerns them rather than the general health service of the country. When they did agree, as they did at one period, the Minister of Health was quite delighted that they had come to an agreement. As a wise man, he was ready to accept and so avert what might have been a difficult position. We had a very strong case put to us by the noble Lord, Lord Balfour of Burleigh, who, if I may say so, put it extremely well. After all, it is right when we have such a forceful case put, and when a number of your Lordships are convinced that it is right, to give the other place an opportunity of second thoughts on the matter. Second thoughts are often best. In any event, it is quite within the functions of this House to send back a matter of that sort and to ask those in another place to think again. That is how the case stands at this moment.

Finally, I come to the question of a salary or capitation fee. My Amendment, which was carried—and I do not think the noble and learned Lord on the Woolsack meant to quote it completely—did leave exceptional cases to be dealt with by salary and capitation fee, but only capitation fee as the normal rule. On this particular matter this fact is rather sticking in the back of my mind, that we have never yet been told what in the normal case is going to be the kind of proportion between the salary and the capitation fee. If it were going to be only 20 per cent. capitation and 80 per cent. salary, noble Lords on these Benches would think that was getting too far towards a complete salary. If it were only going to be 25 per cent. salary—I am not talking about the Scilly Isles, or some exceptional case, but the normal case—and 75 per cent. capitation, I do not suppose there would be very much between us. What I do suggest is that if the Government cannot see their way to accept the Amendment moved in this House, at any rate they should tell us what kind of proportion for the normal case they have in mind. That would put a lot of anxieties to rest.

There are obvious things to be said—and the noble and learned Lord, the Lord Chancellor, has said them—against the capitation fee, if it does mean people taking on more patients than they can properly handle, or getting them, perhaps, because they are slightly lax in the way they give certificates. Perhaps that is the only thing a patient wants; he may not be ill for five or ten years, but he may require these certificates and he may feel that one doctor is better than another for that purpose. In these days unfortunately we have to have licences for everything, and I am told that a lady cannot even get a pair of corsets without a certificate from a doctor. In that event there would no doubt be a considerable temptation to change her doctor to one who would say that the particular garment was necessary for medical reasons. But by and large you do not want to take away from doctors the sense of energy and hard work, and part of that depends upon his being able to attract patients by giving them good service. In this House, on this particular matter, we have had the advantage of the opinion and the advice of, I suppose, the two foremost doctors in this country, the noble Lords, Lord Horder and Lord Moran. Doctors do not always agree and I have even known those two noble Lords not to agree with one another. But in this case they were both in favour of the Amendment that we carried. So once again I think we were right in sending this Amendment back to another place and asking them to take second thoughts.

I will conclude by saying this. I think the whole course of the debates we have had on this Bill show how well on most occasions this House can act as a kind of Council of State. We have worked together. Some things have been accepted, and some things have been objected to for one reason or another; but of the vast number of Amendments we had on the Order Paper on this measure there were only three on which we had to take our differences to a Division, and on one I am still hopeful that there is no division between us. At any rate, I think we can generally pride ourselves on the fact that this measure, having been through this House, is now a better measure than it was, and one which will enforce the authority of the management committees, allow the voluntary services to go on, and make the other various provisions to which I have briefly referred in this speech. We can say to ourselves quite honestly and sincerely that we have made this Bill one which will in the end ensure better service to the sick in our land.

4.48 p.m.

THE MARQUESS OF READING

My Lords, we have from these Benches welcomed this Bill from the outset, and I am bound to say that, for myself, having had the opportunity during the course of its passage of giving it yet closer and more intimate study, I am all the more convinced that we were right in the original attitude that we adopted. I hope that during the course of its passage through this House we have been able to display not merely benevolent neutrality but beneficent partiality towards it. We have, as has already been said by the two noble Lords who have spoken, introduced a number of Amendments during the time that it has been in our hands. I think your Lordships will agree, in general, that the Bill has been considerably improved by those Amendments. I do not propose to deal with them individually, but I would just say this. I think it must be a satisfaction to all of us that so many of these Amendments have been accepted by the Government, so that when this Bill goes back to another place there will presumably be little discussion upon them, and they will not be regarded merely as irritants arising from a tainted source but as representing a general consensus of opinion of your Lordships' House.

If I may say so, I think that for that fortunate state of affairs your Lordships owe a considerable debt of gratitude to the noble and learned Lord on the Woolsack. He appears to have the faculty of exercising a singularly benign and mellowing effect upon some of his colleagues, and we can only hope that the process which goes on behind the scenes is as effortless as the results make it appear to be when they are proclaimed to us. But whatever the procedure may be, we should be the last to attribute to the Minister the slightest degree of weakness in making concessions which, after discussion with the noble and learned Lord on the Woolsack, he thinks proper to make at the instigation of your Lordships' House, in the interests of creating a better Bill.

This Bill has, as I say, undergone quite considerable changes. I want to say a word on one Amendment which stood in the name of the noble Lord, Lord Balfour of Burleigh, in the light of what the noble and learned Lord on the Woolsack has just said. The noble and learned Lord said (and he would not claim for the remark entire originality) that hard cases make bad law. He must surely recognize that to make an exception of London, to treat London in a different way from that in which the rest of the county may be treated under any measure of this kind, is not in any way to create a precedent; it is not making new law or dealing with the problem on novel lines. There are, I should think, hundreds of Acts of Parliament which are peculiar to London and which recognize, by being peculiar to London, that the problems of London are different from those of the rest of the country and require special treatment appropriate to London.

Another Amendment on which I want to say a word is one on which I am bound to say I agree with the noble and learned Lord in thinking that it does constitute a blemish on the Bill. I refer to the one which establishes payment for doctors purely by capitation fees. During the Committee stage I ventured to express the views of noble Lords on these Benches on the subject, and I do not propose to go over them again. On further consideration, I am satisfied for my own part that the attitude we then adopted was the right one, and I hope that that method of payment will not be the one which is eventually embodied in the Bill.

On the Second Reading, when this Bill was new to us, I. ventured to say that I hoped the Government, in the interval between then and the time when it became operative, would consider whether it was humanly possible for one Minister to exercise the double function of Minister of Housing and Minister of Health. That suggestion received, perhaps rightly, no attention from any of the noble Lords who spoke from the Government Benches; but I am not altogether prepared to abandon it and I hope that in the interval which must ensue the Government will give real consideration to the administrative problems which would be involved in any one Minister trying to carry out adequately this double task.

There is one other point to which I want to call the attention of the Government. There is likely to be an interval of something like eighteen months before the scheme is actually in operation, and I believe that the Government would spend that time, or a portion of it, well in making Plain to the people of this country what this scheme includes and what it does not include, because the amount of ignorance—some of it wilful ignorance, and some of it just ignorance—which is still prevalent in the country is quite incredible. You still meet people—presumably educated people, and presumably people eager to give credit to the Bill for what it contains—who proclaim that under it no one is any longer entitled to go to the doctor of his choice; and that if you have a temperature of 105 degrees you are forced, under the Bill, to go out to a health centre and to stand in a queue extending down the road until it gradually filters through the doctor's consulting room, and other matters of that kind. I think there is a very large field for publicity and for education of the public during this intervening period, and I hope the Government will take advantage of it.

The Government will readily recognize that although the specific scheme embodied in the Bill may be their production, this idea of a national health service did not originate with them but with a Government which happily embodied members of all Parties. When I look back at the White Paper which was issued in 1944, I see that the position and the ambition of the scheme was summed up in a very few words: There is not yet a comprehensive cover for health provided for all people alike. That is what it is now the Government's intention to provide. That was so in 1944, but I agree that the actual scheme is the one which takes shape in the present Bill. I believe myself that this scheme has infinite potentialities for good and I think it may yet be found, if it is administered, as I have little doubt that it will be administered, in a lofty spirit of public service and not in a narrow spirit of personal or political advantage, that this plan will stand as a memorial to the enduring courage, foresight and humanity of a country which is still barely convalescent after the long and bitter agony of war.

4.57 p.m.

LORD BALFOUR OF BURLEIGH

My Lords, I should like, in the first place, to add my tribute to those which have been paid by my noble friend opposite and by the noble Marquess to the way in which the noble and learned Lord on the Woolsack has conducted the proceedings, if I may put it in that way, on this Bill in your Lordships' House. Then I should like to thank him for the very kindly personal reference which he made to myself and, more particularly, for the fact that he gave me notice that he was going to animadvert upon the blemishes "on the Bill. That has given me an opportunity—which may, I think, be of service to your Lordships—to restate the case for the Amendment which your Lordships thought fit to put into the Bill. That Amendment is now in the Bill; the Bill has to go back to another place and it is for that other place to consider it.

I endorse very strongly what the Lord Chancellor said about the spirit in which the Amendment was made in this House and in which it will, I hope, be considered in another place. Of course, it would be a tribute to the good sense and the good judgment of the Minister if he saw fit to accept this Amendment. We should welcome it as proving that he was open to second thoughts. Noble Lords beside me laugh, but I tell your Lordships that the case which I am going to try to make to your Lordships is just as good a case as any I have ever had to argue either in your Lordships' House or anywhere else. It is of vital importance to the people of London that this Bill should be allowed to become law in the form in which it now stands, as far as that Amendment is concerned. There were two major objects which your Lordships had in view in putting that Amendment in. One was to maintain the high quality of the maternity and child welfare services in the London boroughs and the other was to cease the process of undermining the quality of local government in the whole of the metropolitan boroughs. I do assure your Lordships, and I will attempt to prove it, that both will be in serious danger if that Amendment is not allowed to remain in the Bill.

Before I turn to the broad picture which I want to put before your Lordships, let me say one word on quite a minor point about home nursing, to which the noble and learned Lord referred. In the Committee stage, when I moved my Amendment, the noble and learned Lord found fault with me because he said that the Amendment imposed on the metropolitan borough councils functions which they never yet had. When I challenged him he said it was home nursing, and that being so, he thought it seemed to him to be a retrograde step. I am not going to weary your Lordships with references, but as a matter of fact the Lord Chancellor was not right. He has been broadminded enough to admit that he was wrong, and he says that he went a little bit too far. Well, I accept that as a very generous climb-down by the Lord Chancellor. It is not often that a mere layman can have the pleasure of securing an admission of error, however infinitesimal, from the Lord Chancellor, and I do not desire to press the advantage any further.

As a matter of fact, the power is given to the borough councils in a section of the Public Health Act, 1936, but it did not give us anything more except in so far as the new Bill, under Section 25, imposes the power of borne nursing on all the local health authorities. Consequently, there was an extension, but I think it was a correct one in the circumstances. What worries me is that he said it was a retrograde step. A retrograde step is a step downhill, but what we are trying to do is to stand firm where we are and to go forward where there is room for going forward. It really is not an accurate description of this Amendment to call it a retrograde step. To get right down to brass tacks, let me read you a portion from the noble and learned Lord's speech, which shows what he wants to do. He says: But I do not believe it to be wise or sensible administration, & to have one body dealing with the under-fives and another body dealing with the over-fives. I do not think it is sensible. It is all very well to say this is a matter for local skill. So it is. What is far more important than that is the doctor who gets to know the family, who is the servant of ore particular authority. Surely to goodness if we have a doctor to look after a child of four and a half, should not the same doctor be able to look after the child of five and a half? I entirely agree with the noble and learned Lord. His object and mine is the same, and I will explain to your Lordships why that object is served by the Amendment and not by rejecting it.

To complete the noble and learned Lord's case, I want to read your Lordships another short extract, because it is very relevant to the discussion which follows. This was on the Report stage, when I regret to say I was not in the House. I could not foresee that it would arise, but it did arise on the Amendment of the noble Lord, Lord Addington. It reads as follows: If you are having, as you are, local authority services in any area, you must have one local authority and not several local authorities in that area responsible for those services. I am absolutely certain that that is a vital principle. I am very much opposed to the Amendment moved by the noble Lord, Lord Balfour of Burleigh He proposes to pick out from the various local health duties some of them, and some of them only, and in all the London boroughs, if his Amendment becomes law, you will have two authorities, some working in some services and some in another, and all of them to be carried out in a health centre. I believe that is absolutely chaotic. My answer to that is a double one. To put it quite briefly—and I will substantiate it—that is what is happening in Kensington now, and so far from there being any chaos we have got the best services in London—

SEVERAL NOBLE LORDS: No, no.

LORD BALFOUR OF BURLEIGH

If noble Lords say "No", that only means that the other metropolitan boroughs are very good too, and that destroys the other argument of the Lord Chancellor. That is one answer. The other answer is that this chaos of different administrations will take place under the Bill and I will prove it to you. Take the existing position. First of all I would say a word about health centres. This health centre is a new idea and it is an experimental idea.

VISCOUNT ADDISON

It is not a new idea; it is twenty-five years old.

LORD BALFOUR OF BURLEIGH

In the history of the world twenty-five years is not a very long time. Perhaps the noble Viscount will agree with me when I say that if it is not an absolutely new idea in the sense of being invented to-day, at all events it is still an experimental idea. We do not quite know what there is going to be in the health centres, but I can give your Lordships an idea, because as long ago as before the war we planned a health centre in Kensington, when we got as far as buying the land and our plans for the building were all passed. We were going to put in that health centre the borough council infant welfare centre, the borough council antenatal clinic, the ante-natal clinic for the accommodation of the Queen Charlotte's Hospital district midwives service, the London County Council's school treatment centre, the borough council infant treatment centre, the borough council dental clinic, the sunlight clinic, a day nursery, a lecture room, the borough council tuberculosis dispensary and spare rooms for additional services. We were regarded as being rather ahead of the times in doing that. We have carried out the idea of services in a health centre by having at this moment our infant welfare clinic in the same building as the County Council school treatment clinic. We in fact own the building and the county council makes a small contribution for rent and heating, etc.

Consequently, we have there two local authority services working in the same building and accomplishing the very object which the noble and learned Lord has at heart. The mere duplication of administrative services does not matter a bit so long as you get co-ordination in the building where the services are carried on, and in proof of that let me call the Minister of Health to witness. Here is what the Minister says about the conditions in the health centres which are to be set up: A main feature of the personal practitioner services is to be the development of health centres. The object is that the health centre system, based on premises technically equipped and staffed at public cost shall afford facilities both for the general medical and dental services … and also for many of the special clinic services of the local health authorities … and also for out-post clinics of the hospital and specialist services … There you have got three authorities; you have the general medical and dental services which will work under the Executive Council; you have got the maternity and child welfare services which will work under the local health authority and you have got the consultant specialist services which will work under the Regional Board. You have got three administrations with three different sets of people working in the same building, and I assure you that there will not be chaos. If there is going to be chaos then of course the Lord Chancellor's argument is a condemnation of the Bill.

Let me give you one other example of apparently overlapping services which will happen under the Bill, and which I am quite certain will not give rise to chaos. Take the case of the expectant mother. An expectant mother, before the child is born, will attend the antenatal clinic of the local health authority, that is the maternity and child welfare service, where she will be attended by a doctor. She will also be attended at home by the midwife who is the servant of the local health authority, the London County Council. She will be attended by her own doctor who, under the Bill, will work under the local executive council, and when she is in labour she will be in hospital under a doctor who is a servant of the regional authority of the area. On paper, it is chaos, but, in fact, it is not. It will work. Why should it not work to allow the borough councils to do this maternity and child welfare service which they do so well in these health centres, as, for example, at present in Kensington? There is no answer except that the Government are seeking to impose the pattern of the whole of the rest of the country on London, and, as the noble Marquess, Lord Reading, has said, London is entirely different from the rest of the country. The local government of London is, as everybody knows, a thing entirely by itself.

One word about Kensington. The noble and learned Lord, the Lord Chancellor, was good enough to say that the service given at Kensington might be good because it had the benefit of the direction of myself and people like me. But I can truthfully disclaim any personal credit, for in all the twenty-five years that I have served on the borough council, I have never been a member of the maternity and child welfare committee. But if you take these services away you are going to destroy the incentive to people who can render most useful service. They will not be tempted any longer to go on to a borough council if there is not this work for them to do. Nor is there any force in the argument which was used in another place, but not in this House, to the effect that Kensington being a wealthy borough, can afford these services. Everybody has heard of the block grant. Everybody knows that it is at present under reconsideration. Any unfair advantage which a wealthy borough has will be removed.

If the noble and learned Lord desires to stress the fact that Kensington is exceptionally good, let me remind your Lordships that under the Amendment as it now is in the Bill the arrangement is that the London County Council, the local health authority, will delegate its power to the borough council and, of course, that delegation will not be unconditional. In the agreement come to between the London County Council and the metropolitan boroughs there was an arrangement for default. If the metropolitan borough maintains its services with efficiency and on the level which is held to be desirable, all will be well. If it should not maintain the services at the desirable level, or if its services should be deemed in any way to be unsatisfactory, then default can be imposed. The threat of use of the power of default can be employed on the appearance of any sign of slackness in order to induce a borough council whose services have deteriorated, to bring them back to the level of the past. Where services are fully maintained at the proper level, then of course they would be left alone.

What then will be lost if this administration is handed over to the London County Council? It will be the case that this intimate service will be managed from County Hall. At present, when a mother has a complaint to make, she has nothing to do but to seek out one of the local councilors. In Kensington we have nine wards, each represented by six or nine councilors. In North Kensington alone we have twenty-five aldermen and councilors who are quickly available to go to the help of any mother who has a complaint to make, or a suggestion to put forward, or who desires information. If the County Council is to take over these services they will have to decentralize and set up a regional office. There are only two members of the County Council for North Kensington and, as a matter of fact, neither of them lives in the district. That happens to be a coincidence, but it means that if some mother living in a poor street in North Kensington has some slight difficulty with the regional officer she will have to write to County Hall. I wonder how long it will be before the report is considered by one officer, submitted by him to another officer, and the answer sent down the chain to the local regional officer. These regional officers of the County Council work to very detailed rules and detailed rules which may be suitable for one area are not suitable for general application to a vast area such as London. Our local borough councilors are there on the spot, and they are ready to intervene and iron out difficulties. The medical officer of health and the health visitors tell me privately that "of course the borough councilors are a nuisance but it is they who keep us up to scratch."

As an example of the sort of control which you get from the vast London County Council organization I can tell your Lordships this. I have ascertained—and you can take it as a fact—that in one of the County Council hospitals (it is one which I know very well) neither the medical superintendent nor the matron can condemn a bed-pan without authority from County Hall. I do not know whether there is a door in County Hall with "O.C. Bed-Pans" on it. There certainly would be if it was the Army. Anyway, there is actually an officer who fulfils that function. That is the sort of detailed administration you get when you have a vast bureaucratic organization governing an area with a population of 4,000,000 people with only 120 councillors.

The noble and learned Lord Chancellor was very kind and he did not only admit that he had gone a little far with regard to home nurses, but I think he said that he had perhaps not been quite right about the Coalition Government and their attitude towards this arrangement. What the Lord Chancellor said was: This is a topic upon which I feel very strongly and have done for the last four years. It was a topic on which the Coalition Government felt strongly, and it is a topic on which the present Government feel strongly. I think that that is very likely perfectly correct about conditions in the provinces, but, unfortunately, that passage in the noble and learned Lord's speech was followed by remarks concerning my Amendment which must have given the House the impression that that attitude of mind of the Coalition Government also referred to London.

At the risk of delaying your Lordships I must quote to you what Mr. Henry Willink, the then Minister of Health, said in another place, because it is vital to this issue. He said: When that White Paper was published in February, 1944, it was obvious to all those in London that these very matters would need consideration: what was to be done by the London County Council and what was to be done by the boroughs? With my complete concurrence but under no pressure whatever, the Metropolitan Boroughs Standing Joint Committee, of which the Parliamentary Secretary to the Ministry of Health was Chairman, then had discussions with the London County Council as to what their respective functions should be. By December, 1944, a most remarkable event happened: a full agreement on principle had been reached between the boroughs and the London County Council—a full agreement. No doubt there had been general discussion; there had been two full and formal conferences. A little later, in the same speech, Mr. Willink said: I was informed of this agreement and thought it was on very sound lines. It had been arrived at independently of me, but with my concurrence. However, I suppose that if I had said that this was all very bad they might have considered looking at it again. But we were all quite happy. My Lords, if that means anything, it must, I think, clearly mean that the then Minister was prepared to accept the arrangement that had been arrived at by the London County Council and the metropolitan boroughs. And not one single member of the London County Council has come forward to say that there has been any change in the circumstances since then to justify an alteration of the arrangements then made and the agreement which they intended to put into effect. One had hoped that Lord Latham might have come here to tell your Lordships something about this but unfortunately he has not been able to do so and we have not had the benefit of his views upon this Bill.

I do not think I can add very much more. I hope the Government will have a very good look at this Bill as it now stands. Your Lordships, not for the first time, strange as it may appear to noble Lords sitting near me, have represented the real interests of the people. No one will be better pleased than we to feel that our efforts as a revising Chamber have improved this Bill. And this Amendment is not the least of the improvements which your Lordships have effected.

5.21 p.m.

LORD QUIBELL

My Lords, I feel that I cannot let the occasion pass without expressing, on behalf of myself and friends associated with me, our great pleasure at the acceptance of the Amendments that have been made to this Bill. The noble Lord, Lord Balfour of Burleigh, must feel particularly gratified that an Amendment which he moved was carried by this House. He has informed us how very important the London boroughs are, and how very pleased he is with the services they provide. All I can say is that the London boroughs are no more important that the county of Lincolnshire, and the several boroughs which there are in that county. I am equally proud of them, and of their health services. If your Lordships look at myself, and at the noble Lord who preceded me, I am sure you will come to the conclusion that the health services of my county are no less efficient than those of the county of London, and no less important! So far as administration is concerned, it is just as efficient in my part of the country as it is in London, and although I have been in the capital for a considerable time I am not one of those people who have become completely Cockney-minded about a measure of such vital importance to the country as this.

There were two things which disturbed me very much indeed, but I am happy to say that my mind has been put at rest by the acceptance of Amendments to this Bill. The first was the question of endowments. Quite recently I had the experience of a working joiner, not an employer of labour, but a workman, giving me 1,500 guineas for Scunthorpe War Memorial Hospital in appreciation of the services rendered to his wife in that hospital. That was a most magnificent gift, when you come to think that that man was not receiving more than £3 or £4 a week. He gave ten years' earnings. In addition, after a speech by a certain member of the hospital board, he decided that he would give another 1,000 guineas. When this Bill was introduced, I thought of that money being pooled among our hospital and other authorities, many of whom have not done much propaganda to obtain money to extend and improve the services of their hospitals. I wondered, too, how I should be able to look the donor in the face. But, thank goodness, the Government and the Minister have accepted from this House an Amendment which will enable me not only to accept the 2,500 guineas, but to look the man in the face and to ask him if he will further consider the hospital in making his will. And I shall have no hesitation in doing so.

The other point about which I feel very satisfied, is the constitution of the hospital management committees. In my view, if this Bill had been passed as it was introduced into this House, no man of dignity or of ability would have consented to serve on a single committee of importance in this country. I was very disturbed about it. I am President of a hospital, and I think that everyone on the board, whatever his politics—and there are no politics in regard to the administration of a hospital—thought this was the end. We thought that if we wanted to deal with a member of our staff we would have to write to some regional authority, from whom ultimately we should have a reply fixing an appointment. There would then be an inquiry. This would mean that, so far as the resident staff were concerned, there would be neither discipline nor service in the hospital. No man of standing would continue to serve on a hospital committee that was powerless in that way. I am very pleased, and I think your Lordships' House must feel very gratified, that the noble and learned Lord on the Woolsack and the noble Viscount, the Leader of the House, have represented the views expressed here on this question in such a way that the Minister has at long last conceded that local committees shall be committees of management in a real sense.

I know a hospital which had on its resident surgical staff a man with every credential, but who in practice did not seem to be very successful. Finally, a member of the honorary staff told the subcommittee that they must get rid of the man—a specialist—at once. He was called before the committee, and was told that he must give a month's notice. He was given his money, and was told that if he did not resign he would be given a month's notice by the committee. I can conceive that if we had had to appeal to a Regional Board we should not have dispensed with that man's services without prolonged inquiry. Many of the men intimately acquainted with the reasons for his dismissal would have had to give evidence which might have incriminated even themselves. For that reason alone, so far as committees are concerned, this Amendment is one which the Government, and every member of this House, can justify. May I conclude by saying how pleased I am with these two major Amendments, and with the spirit in which the Bill has been accepted by the House? I am quite certain that it will give great joy and encouragement to the voluntary hospitals of this country to continue the good work Which they have done so well in the past.

5.28 p.m.

LORD JESSEL

My Lords, we on this side of the House are much gratified by the remarks of the last speaker, because they prove to the public that this Assembly, which has been so much abused, has its uses. To have a member of the House on the Government side coming down and thanking the House in general for what it has done for the Bill, is gratifying. I should like to deal with one other portion of the noble Lord's speech. He asked, why should not London be treated in exactly the same way as the rest of the country? Of course, there is a great deal to be said for that argument, but it must be remembered that London government is entirely different from county council government in other parts of the country.

A very different state of affairs applies in London. I am not going into the constitution of London government or the way in which London, with its nearly 4,000,000 people, differs from other parts of the country. At the same time I reinforce the argument that has been put forward, that London for that very reason has always had separate treatment. To my mind, a very grave departure is being made. In a most eloquent speech, the noble Marquess, Lord Reading, put the case extremely well. Not having served on a local authority in London, nevertheless he knows, as Chairman of a Commission—which I am sorry to see has now been suspended—something about the London position. Probably with his acute mind he knows a great deal more than many of us who have taken part in actual administration. From my long experience I say that you will very greatly discourage many of the best workers—especially women, who take such an enormous interest in this work—from coming forward as candidates for the London borough councils.

No better example of what will happen can be given than that mentioned in the speech of the noble Lord, Lord Balfour of Burleigh, when he told your Lordships what happens under L.C.C. pro- cedure. Routine work is very slow. As an education manager, I know how difficult it is to get anything done without going through the very necessary routine. It is a very long process. The same thing will apply in this regard in future. With reference to what the noble Lord, Lord Balfour of Burleigh, said about his experiences during twenty-five years, I might point out that when I was Mayor of Westminster I founded a health centre as long ago as 1902. As to what was said about Kensington being a rich borough, and being able to afford these things, the noble Lord, Lord Balfour of Burleigh, reminded us of the equalizing effect of the block grant, which enables every borough in London to share in these services. Therefore, I think that when this Bill passes this House and is discussed in another place, it should be remembered that there is no political angle in this. There is no political advantage in it. Both parties will agree over the transfer of these services. It is very extraordinary that when my party was in power in the borough council we never could get an agreement with the L.C.C. Now that the Labour Party is in power in both the borough council and the L.C.C. they do agree.

It shows that there is an awareness of deficiencies and a desire to make up for those deficiencies, to the advantage of London as a whole. Having had experience of local government in London for so many years, and having had some connexion with the Bill which afterwards became the London Government Act, 1900, I am very concerned about the difficulty of getting people from all three Parties to take part in London local government, if you rob it of a great deal of its interest. I do not quite understand the argument about making up to the L.C.C. for having taken away their hospital services. The L.C.C. have done and are doing splendid service. They are overworked already, and it is no use trying to make out that, because you are taking away certain services, they will have so little to do that you must give them these additional services which you are taking away from the borough councils. You can ask anybody in the L.C.C. what an immense field there is. They are not in touch on the spot with the people as are the borough councils. The borough councillor is usually a very accessible person, perhaps serving in his shop. Anyone can approach him and say: "I want my dust cleared" or "My rates are wrong." The individual does not have to go down to the town hall. One's representative on the L.C.C. probably lives miles away, and is not cognizant at all of the petty details of local life, which the borough councillor knows so well.

I do hope that the noble and learned Lord on the Woolsack will try to see the position from our point of view. Taking an interest, as I do, in this vast question of the future of London local government, I am perfectly sure that, if the Government accept our Amendment, they will not only give great satisfaction to those who work so hard for the good government of this great city, but will encourage people to come forward and share in that good work.

On Question, Bill read 3a, with the Amendments, and passed, and returned to the Commons.