§ (1) The benefits conferred by this Part of this Act upon insured persons are—
- (a) Medical treatment and attendance, including the provision of proper and sufficient medicines (in this Act called "medical benefit");
- (b) Treatment in sanatoria or other institutions when suffering from tuberculosis, or such other diseases as the
383 Local Government Board with the approval of the Treasury may appoint in this Act called "sanatorium benefit");
- (c)Weekly payments whilst rendered unfit to provide their own maintenance by some specific disease or by bodily or mental disablement, commencing from the fourth day after notice there-of is given, and continuing for a period not exceeding twenty-six weeks (in this Act called "sickness benefit");
- (d)In the case of the disease or disablement continuing after the determination of sickness benefit, weekly payments so long as so rendered unfit by the disease or disablement (in this Act called "disablement benefit");
- (e)Payment in the case of the confinement of the wife of an insured person, who is not herself an insured person, or of a woman who is an insured person, of a sum of thirty shillings (in this Act called "maternity benefit");
- (f) In the case of persons entitled under any scheme made in accordance with this Part of this Act to any of the further benefits mentioned in Part II. of the Fourth Schedule to this Act (in this Act called "additional benefits") such of those benefits as may be distributable under that scheme.
§ (2) Subject to the provisions of this Part of this Act, the rates of sickness benefit and disablement benefit to which insured persons are entitled shall be the rates specified in Part I. of the Fourth Schedule to this Act.
§ (3) The right to sickness benefit and disablement benefit shall not commence before the insured person attains the age of sixteen and shall cease on his attaining the age of seventy, but, save as aforesaid, the right to benefit (other than additional benefits) shall continue throughout life.
§ (4) Except with the consent of the society or committee administering the benefit, no insured person shall be entitled to any benefit during any period when he is resident either temporarily or permanently outside the British islands, or to medical benefit during any period when he is resident outside the United Kingdom.
§ (5) Where an insured person, having been in receipt of sickness benefit recovers from the disease or disablement in respect of which he receives such benefit, any subsequent disease or disablement, or a recurrence of the same disease or disable- 384 ment, shall be deemed to be a continuation of the previous disease or disablement, unless in the meanwhile a period, continuous or discontinuous, of at least twelve months has elapsed, and at least fifty weekly contributions have been paid by or in respect of him:
§ Provided that the benefit in respect of such subsequent or recurrent disease or disablement shall not commence to be payable before the date at which it would apart from this provision, have commenced.
§ (6) Where a woman is herself entitled to maternity benefit she shall not be entitled to sickness benefit, disablement benefit, or medical benefit at and for a period of four weeks after her confinement.
§ (7) Notwithstanding anything in this part of this Act, no insured person shall be entitled—
- (a) to medical benefit during the first six months after the commencement of this Act;
- (b) to sickness benefit unless and until twenty-six weeks have elapsed since his entry into insurance, and at least twenty-six contributions have been paid by or in respect of him;
- (c)to disablement benefit unless and until one hundred and four weeks have elapsed since his entry into insurance, and at least one hundred and four contributions have been paid by or in respect of him;
- (d)to sickness benefit in respect of any disease or disablement which commenced during the twenty-six weeks, or to disablement benefits in respect of any disease or disablement which commenced during the one hundred and four weeks, next following his entry into insurance;
- (e)to sickness benefit or disablement benefit during any period when he is provided with board and lodging by his employer;
- (f) to maternity benefit unless and until twenty-six, or in the case of a voluntary contributor fifty-two weeks have elapsed since his entry into insurance, and at least twenty-six, or in the case of a voluntary contributor fifty-two, contributions have been paid by or in respect of him.
§ (8) As soon as a sum has been accumulated by investment sufficient to provide interest at 3 per cent. per annum on the amounts then standing to the credit of all 385 approved societies the benefits payable to insured persons under this part of this Act shall be extended in such manner as Parliament may determine, but in determining the distribution of such extended benefits amongst the persons who become entitled thereto regard shall be had to the claims or special considerations of persons who have entered into insurance at an early age.
§ Mr. AUSTEN CHAMBERLAIN
I beg to move, in Sub-section (1), to leave out paragraph (b).
I want to raise a very big question. Anyone who has looked at the Amendments which stand early on the Paper today will see that there are others, notably one in the name of the right hon. Gentleman the Member for the Strand Division (Mr. Long) which raise the special question of the propriety of sanatorium treatment. I do not wish to enter into technical questions of that kind, though I have on previous occasions expressed my doubt as to whether the money to be spent on sanitoria and sanitorium treatment is really expended to the best advantage for the prevention of consumption. The question I want to raise is a much bigger one, and that is as to the propriety of this special treatment of the disease of tuberculosis in this Bill. I do not desire to say a word in disparagement of the motives which have induced the Government to attempt to deal with this question in connection with the National Insurance Bill. I do not for a moment deny the vast importance to the community, or the great desirability of taking systematic steps to combat the progress of this terrible disease. Hut I think it must be apparent to anyone who studies the Bill, and this Sub-section in particular, that this very peculiar treatment of this one disease is, for good or evil—I do not wish the word to convey reproach, but for the moment only as a description—for good or evil is an excrescence on the general scheme of the Bill. It absorbs a good deal of the money provided for the purposes of the Bill, and it stands, so it seems to me, on an entirely different footing to the other provisions connected with health which are in the Bill.
We do not propose out of the money provided by this Bill to make special provision in this way for the treatment of any other disease. I do not know why. If we are to treat consumption in this special way why should not the equally terrible scourge of cancer receive similar 386 treatment? This particular disease is selected by the Bill, and a large portion of the funds collected under the Bill are earmarked for this special treatment. The State and the public authorities ought to give much greater attention in the future than they have done in the past to this matter; and the State, perhaps, might properly be called upon for contributions, partial perhaps, for dealing with cases which have already arisen; still more for research in regard to the best method of dealing with the disease, research for preventive measures. I think it is quite arguable—I myself should be inclined to argue—that the State must do more in both of these respects than hitherto. But what I want to ask is whether this Bill is the proper place, or these funds the proper funds, to do it, or charge it on? This Bill is a Bill for insurance against sickness; and this is not really the ordinary work of insurance against sickness. This is taking one disease and putting it in a special category by itself on the ground of the, extensive injury it inflicts on the Nation. I think that is good ground for the special treatment of that disease, but I am in great doubt whether the special treatment that that disease deserves and requires should find a place in this Bill. Anyone who remembers my observations when the Bill was introduced, will be able to contrast what I then said with what I am saying now. They may taunt me with inconsistency. I do not suppose anyone would be inclined to do so, but if they did I would at once plead guilty and urge that on further consideration of the matter I have changed my opinion. I think, at any rate, that the question is one of sufficient importance for the House to devote a little attention to, all the more so because the Chancellor of the Exchequer has not hitherto given us any reasoned statement as to what led him to deal with this matter in this particular way. I do not think it is sufficient to point to the fell ravages of the disease or the fateful circumstances attendant upon it to necessarily justify its inclusion. The same is true of other diseases. It seems to me that what you are proposing in this case is to carry out a health campaign for stamping out a particular disease at the expense of the Insurance Fund, and I cannot see any reason for treating one disease, and one only, in that way. It seems to me that that health campaign ought to be conducted, but that 387 it ought to be dealt with by a separate measure and out of different resources. It is quite fair and right to ask that these insured contributors shall insure themselves against ordinary sickness, or the provision of ordinary medical necessities, and for sick pay during that illness, but I do not know on what ground it is contended that what is a national health campaign in regard to one particular disease is to be charged upon their funds. You do not provide under this Bill full treatment for all the ordinary accidents and diseases to which people are liable. Surgical appliances are only provided to a very limited extent. What exactly has to be done in regard to the dressing required after a person has had treatment in the hospital is not quite clear, but there again it seems to me that the Bill, generally speaking, is limited to what you may call ordinary sickness, and does not profess to travel further, but in this Sub-section it does travel further, and takes upon the fund what really ought to be not an insurance proposition, but what I have described as a national campaign for the improvement of the national health, and it seems to me that these charges for sanatoria or for a special campaign against consumption are much more akin to the popular charges already assumed either by the State or by local authorities than the insurance charges which are included in other parts of the Bill.
§ Mr. MUNRO-FERGUSON
You cannot compare consumption with cancer. We unhappily know all too little about cancer, but we know how to fight consumption, and we have too long delayed in fighting it. I do not think consumption can best be fought by the local authorities. Many of them will do it, and that is my reason for speaking, because in my county, which is not a very large one— about 40,000 people—we have a sanatorium. It was very economically established—it only cost some £1,300 to build, though the upkeep is costly—but I do not think you can combat consumption upon a local basis. The cost of small sanatoria is very large compared with that of central sanatoria, and it is being more and more borne in upon me that consumption ought to have been fought rather by the Local Government Board than by the local authorities. There are districts of the country, the Highlands of Scotland for instance, where there is comparatively no 388 population, but which are eminently suited for a sanatorium. The proper place for a sanatorium is not within the borough boundary of a great urban industrial population. There is room for a sanatorium in such cases, but only for very bad cases, or for very slight cases, where a man can get out to his work and get treatment at the sanatorium. But for the great mass of cases I believe the only effective and economical way of treating them in the proper localities is through a. great central sanatorium, and this I hope to see established under the proposals of the Bill. In fact, I do not know any more practical step that is being advocated by that very practical person, my right hon. Friend, than that of the proposals to establish these great sanatoria which I think would follow under this Bill. It cannot be said that experience has shown that the fighting of consumption should be held to be distinct from insurance, because in Germany insurance for the provision of treatment in sanatoria has gone hand in hand and covers a great part of the treatment. I am not prepared to speak upon the technical methods of fighting consumption, but I am speaking as one who is answerable for a sanatorium under a local authority how far I think that provision will go, and how far it will not go. The local authorities are having a great deal put upon them, and I think this ought to be a national undertaking, and the State ought to do its work, and not look to the local authorities.
§ Mr. WALTER LONG
I agree with the hon. Member as to the division of expenditure consequent upon the wholesale treatment of tuberculous disease between Imperial and local revenue, and I concur in what he said in preferring Imperial to local revenue for the expenditure, and also to a limited extent as to administration. But I entirely deny that he is justified in his statement on which he based his conclusions that we know all about tuberculous disease but nothing about cancer. It is exactly because I hold the diametrically opposite view in regard to tubercular disease that I cannot recognise in this speech a valuable contribution to the Debate. I am not pretending to speak on the subject as an expert or anything approaching an expert. I am very happy to think that we have in the House hon. Gentlemen such as the hon. Gentleman (Sir Philip Magnus) and the hon. Gentleman (Sir Henry Craik), who both have great knowledge of their own, and both represent a 389 large number of the medical profession, and we have opposite the hon. Member (Dr. Addison) who is a most distinguished member of the profession. We cannot raise in this House a more important subject, or one which bears more closely upon the lives of the people than this. I hope that from those who are able to speak with far greater authority than I can, we shall have some light thrown upon the position in which we find ourselves. I am not here to oppose the proposal of the Chancellor of the Exchequer that a proportion of the money which is to be found under the Bill shall be devoted to the treatment of tuberculous disease, but I am here to ask him—an Amendment which I have on the Paper has this in view—not to commit this House, as we are to be committed, if we are to take his introductory speech on this subject as expressing the policy of the Government and leave the Bill exactly as it stands, to a method of dealing with tuberculous disease in respect of which we have very little, if any, knowledge as to its real effect upon this most fell enemy of the human race.
I do not pretend to speak as an expert, but I have some small authority to take part in the Debate, because it was during the time that I had the honour of being at the Local Government Board that, on the advice of the medical experts of that Department and with, I believe, the support of the medical profession as a whole, there was appointed the Commission whose report appeared only yesterday. I regret that we should be embarking on the consideration of this question and taking what may be rather definite steps regarding it, when no Member can have read that report, and still less have grasped the important bearing it may have on the first principles connected with tuberculous disease. I venture to say that the report makes it perfectly clear that we want, above all things, more knowledge, and that in order to get that knowledge we want much more research. This is not the time to discuss that report. I have gone hastily through it, and I do not propose to hurl its paragraphs at the head of the Chancellor of the Exchequer, but I venture to say that anyone who will read it carefully will come to the conclusion that valuable as it is—it is impossible to exaggerate the value of the work done by the Commissioners—and public-spirited and self-denying though their services have undoubtedly been, if the report makes one 390 thing more clear than another it is that we have more knowledge to get and more careful research to make in order to get it. The Chancellor of the Exchequer in an eloquent passage of the speech in which he introduced the Bill said it was proposed to erect a chain of sanatoria across the country. That is the vital principle which underlies the right hon. Gentleman's proposal, and it is because I do not wish him to commit himself to that as a wholly satisfactory method for the treatment of the disease, that I now ask him to give the matter further consideration.
The right hon. Gentleman opposite (Mr. Munro-Ferguson) said he was not addressing himself to the Bill, but to the general question of tuberculous disease. That might be a good introduction to a speech on the general question outside this House, but here we are addressing ourselves to the Bill. I take a different view from that taken by the right hon. Gentleman. The Bill makes two proposals. It proposes, as I understand, to set aside a capital sum of £1,500,000, and £1,000,000 is provided in the shape of a yearly contribution. I also understand that the £1,500,000 is to be mainly devoted to the erection of sanitoria throughout the country, and that that is to be under the control of the Local Government Board. The £1,000,000 of yearly expenditure is to be under the control of the Health Committees. So far as I can find out, only £60,000 a year out of this great expenditure, either of the capital sum or of the annual expenditure, is to be devoted to research. I think I am accurate in this statement of the procedure under the Bill. My right hon. Friend says he wants all this work to be under the control of the Government. I have had the honour of serving under more than one Government, and as I was for some time president of the Local Government Board, I am the last person who would in any way disparage our public departments or belittle their great capacity, but I say if you are going to deal effectively with a great question of this kind, it is beyond the power of any great central department to do half of the work that has to be done. It is only by cooperation between the Government Department and the local authorities, the latter taking a larger share of the work, that we can hope for any possible success. The right hon. Gentleman made a remark with which I entirely agree. He said there had been successful work done in connection with this disease. Where was it done? It was done in the great city of 391 Edinburgh. That city made the first great step in this great work—the first successful step in dealing with the disease. I venture to say that the work done in Edinburgh will reflect eternal credit on the municipality and the public of that city. But the work never could have been done if the responsibility for doing it had rested on the central authority. They devoted themselves to ascertaining what is the precise nature of this disease and what is the best way of curing it. They set themselves to work to find out if they could some of the causes which contribute to it, or which create it. Then they said: "Is there anything we can do as the local government of the city to deal with these cases?"
We know something of this in Ireland. A movement marked by great public spirit and great industry was started, and the wife of the Lord Lieutenant devoted herself to it with tremendous energy. That work emanated from headquarters. What was the first difficulty that presented itself? I venture to say it was a difficulty which will occur in every case, and one which can only be met by the local authorities. It is this: When you come to deal in a radical manner with this great disease and try to stop its ravages, you come face to face with the fact that in order to do this you must check the movement of the individuals who are affected, and who may become the media of infection. What is the first result? It is that we interfere with the daily livelihood of a large section of the population. That can be done with the help and assistance in the first instance of the local authorities, but it can only be done if the central Government are ready to go beyond the mere erection of sanatoria and the mere bearing of the expense attendant on the working of these hospitals. The right hon. Gentleman opposite says that we know a great deal more about this disease than we know about cancer. That may be true, but in the opinion of Gentlemen in this House who can speak as experts on the question nobody can say that the knowledge we have of tuberculosis is in anything more than its infancy. We have now a somewhat inaccurate knowledge as to the amount of the disease, how it is spread, and the treatment which it requires. It would be very difficult for anybody to lay down dogmatically that the establishment of sanatoria all over the country would be a successful way of dealing with it. 392 It has been said very truly that this disease is one of the most terrible that affect the human race, and that it brings more misery than probably any other into our homes. I believe that on that ground there is great justification for the action which the Government are taking in giving special prominence to it at this moment, although I wholly share the view of my right hon. Friend that it would have been far better if the Government had been able to keep this subject by itself and deal with it as a part of the greater question of interference by the Government with diseases which are ravaging the population. This form of disease was made a subject of inquiry by the Commission to which I have referred. I am very sorry that that Commission was not continued. If the Government had continued it, or if some Commission of equal weight were appointed to take its place, and were now going on, I should not have been here to make these criticisms.
But we are obliged to take things as we find them, and to judge men more by deeds than words. We do not for a moment suggest that the Chancellor and the Government are not absolutely sincere in the steps which they are now taking to deal with this disease. But we are brought short up by the knowledge that they had the opportunity to renew this Commission or appoint a fresh one to continue their most valuable experiments. That opportunity was worth taking advantage of, because you had all the machinery of this Commission, experienced men, knowing what had been going on and the men who had been working under them, and if the Government had continued that Commission and were now in a position to say that that Commission would continue the experimental work from the point to which it had already been done, I should not have been here to cast any doubt upon the wisdom of the proposal now made. That proposal is to devote vast sums of money to the erection of sanatoria across the country, while only a very small sum of money is to be devoted to the work of research. I have been unable to get very reliable information as to the results obtained in these sanatoria. I think that my right hon. Friend was in error in assuming that there is difficulty in the way of local authorities getting sanatoria because they are limited to the area of the borough. I assure him that that is not the case.
§ Mr. MUNRO-FERGUSON
I did not say it was, but they are generally within easy reach of the health authority.
§ Mr. WALTER LONG
I was at the Local Government Board, and sanatoria were established miles from the area governed by the local authority, and in the districts most suitable for the purpose. One of the main guiding principles of the Local Government Board has always been to see, where local authorities proposed an institution of this kind, that everything was carried out in the manner most likely to conduce to success. I can find no reliable evidence to show that treatment in sanatoria has been really effective. I have myself visited one or two sanatoria which have been erected in this country, paying institutions for occupation by the better-off classes. They reflect the utmost credit on those medical men who have established them, and are doing their best to check this disease. But I am afraid that they are being forced to admit that the results, so far as real cures are concerned, have, so far, been very moderate. I am not sure that I would not even go further. I have been given some figures which I will quote for what they are worth. Messrs. Elderton and Perry, of the Department of Applied Mathematics, University College, as a result of their study of the "Mortality of the Tuberculous and Sanatorium Treatment," arrived at the following conclusions:—(1) Mortality of tuberculous patients treated in sanatoria, even when disease is taken in an incipient stage, is four times as heavy as general population; (2) The mortality of apparently cured (sanatorium) is twice as heavy.
I give these figures with the authority with which they come. I do not say for a moment that they can be regarded as absolutely reliable, but I do say that they point in the direction which I have been endeavouring to indicate. I do not pretend to give this statement as unanswerable, or even as one that cannot be met by others. It is, as I say, extremely difficult to arrive at accurate information on this subject. I do not think that anyone will tell us that we can be confident of the effect upon this disease of treatment in sanatoria that we ought to embark upon the plan which commits us to this great expenditure, and does not leave us any power of spending money in other directions if necessary. The proposals in the Bill, as I read them, and as I read the speech of the right hon. Gentleman, ap- 394 pear to limit this work to phthisis. I believe that if we are really going to develop the interests of local authorities in this work room ought to be left for the inclusion of some other diseases under this expenditure which in some cases are even more prevalent than phthisis, and which consequently cause more local misery and excite more local sympathy. The proposals of the Bill, as it seems to me at all events, limit our operations to the erection of sanatoria—the Chancellor in his opening speech laid special stress on these sanatoria—and it is because it seems to me that an altogether undue proportion is to be spent on these buildings and by no means a sufficient sum is to be devoted to research work, and because I believe that the limitations imposed upon those who have to carry it out, whether the health committee or the Local Government Board, are far too severe, that I ask the Chancellor to make a definite declaration that the policy of the Government is not to cover this or that field but to take the other line and to admit that possibly the language of the Bill is too limited in its character, and that he and the Government will be prepared to make it possible in the Bill to do more in the direction of research, which I believe ought to be the first work done by the Government, and that they will not embark immediately on a large expenditure on sanatoria without at all events more knowledge than we have now or than we can possess at this moment that the proposed treatment is likely to be really effective.
I would remind the Committee that the Chancellor in his speeches in this House and in the country laid great stress upon the sufferings of our people in this and other ways and the help that this Bill is going to give. We ought in this House, where we have the advantage of the presence of men who represent great scientific bodies in their constituencies or who possess themselves expert scientific knowledge, to remember that if we raise undue hopes in the minds of the people we may even lead them to a greater state of misery than they are in at present; and if they believe that the Government are going to embark on a great crusade and going to erect all over the country sanatoria, and that these sanatoria are going to relieve them of this disease, then the last position will be infinitely worse than the first. It is only right to tell this House that in pursuing such a policy at the invitation of the Government they would be acting 395 with undue haste and without sufficient knowledge. For these reasons, I support the Amendment of my right hon. Friend, moved, as I believe it was, with the object of securing full discussion on this subject and not with the object of voting against this proposal, and still less of placing an obstacle in the way of the work which the Government are proposing to do by providing what is to be the best considered method of dealing with one of the most terrible diseases with which the human race has ever been afflicted.
§ Dr. ADDISON
I am sure that the House is indebted to the right hon. Gentleman opposite for having introduced this subject in this way, because it can in any case do nothing but good. I think that no one would be prepared to argue that the somewhat wild anticipations which certain people entertained at the commencement of the sanatorium treatment have been justified by results. Nevertheless, during the last few years not only in this country but in some others we have obtained without question a sufficient amount of very reliable data which I think will more than justify the Chancellor of the Exchequer in pursuing this undertaking. I quite agree with what the right hon. Gentleman says that in the main it should be a national undertaking, and also I further say that it should be administered by the local authorities. It will be one of the main businesses I hope in a short time of the local health committees set up under this Bill. They will prove to be, I believe, an ideal machine for collecting information, for arranging for the visitation of the families, and for the inspection of those who have to be looked after while a relative or some other person is in a sanatorium. It is provided in the Bill that you may have a group of localities. For instance, in scattered districts, say in Wales, where the cases are scattered over a very wide area, that they should be sent to one particular locality for treatment. But I must say that my belief is that the point of the right hon. Gentleman the Member for East Worcestershire has been overstated. He compared our knowledge of this disease with that of cancer. I am sure that the House will not expect any technical matters to be introduced, but at the same time I think it was really a somewhat unfortunate comparison.
§ Mr. AUSTEN CHAMBERLAIN
I did not compare the experts' knowledge of the 396 two diseases. I compared the painful character of the scourge in each case.
§ Dr. ADDISON
I am coming to that, but the point I wish to make for a moment is as to the state of our knowledge as to any efficient method of treatment and the state of our knowledge with regard to the prevention of these diseases. Now, with regard to cancer, it is safe to say that we have absolutely no knowledge of the prevention of the disease. But there is no question of the fact that we have a great amount of knowledge as to how to prevent tuberculosis. The death rate of the country during the last few years, and in Germany since the establishment of these insurance schemes, has abundantly justified the carrying out of various ways and measures to prevent the spread of the disease. This does not apply in any degree whatever to cancer. We know practically nothing as to the modes of preventing it. With regard also to treatment all we have in that particular disease is the knife. It is the last resort of despair, but it is the only method. Here there is something which is very different.
The point raised by the right hon. Gentleman, which I should like to criticise more particularly, is the objection which he alleged against the Insurance scheme in connection with this disease. This scheme is to insure against the distresses arising from sickness. Here is a disease which is accounting for more of those distresses than any other one disease. For example, I see that the Ancient Order of Foresters pay on an average in 4,707,680 cases of sickness annually, and of these 941,575, or 20 per cent., was due directly to phthisis, and at least 51 per cent, to other forms of tuberculosis. A quarter per cent, of the payments of this one society are due to charges dependent on the incidence of tuberculosis from various causes. If you want to protect the Insurance fund and protect sick pay, you should at the same time undertake the preventional treatment of that disease which causes a greater charge upon the funds than any other disease. It is fair to say that a person dying from some form of tuberculosis would be a charge upon a fund of something like £14 more on the average than a patient dying from any other form of disease, because the patient has been on sick pay, of course, for a longer period. It is estimated by the Hearts of Oak that the average cost of each consumptive invalid is £41, while for other invalids it is 397 £23 each. Friendly societies at the present time spend more than a million a year in treating this disease. Can there be any fact more important than that to justify us in including this disease in a national scheme of insurance, to assist insured persons by preventing the progress of this disease. If we remove it out of the category of insurance, then we should not have the same potent influence to assist in measures directed to prevent its spread. I think that is the most important consideration of all for introducing the treatment of this disease into an insurance scheme. The inquiry to which the right hon. Gentleman, the Member for the Strand Division (Mr. Long) referred—and I am sure the country is indebted to him very much for having originated that inquiry—was, to a great extent at all events, directed towards the spread of the disease and the modes of infection —the question of food, the relation between bovine and human tuberculosis, and so forth, and it was not directed particularly to the methods of treatment. The point of this particular section of the National Insurance Bill is that it is directed to treatment. With what the right hon. Gentleman said as to the value of careful research in matters of this kind I quite agree; yet, at the same time there is no reason why we should not make the fullest possible use of the know ledge we have in regard to treatment. It is true that there are several diseases of which we know partly the cause, and that there are others of which substantially we have no knowledge whatever as to what they are really due; but it does not necessarily follow that we must wait until the time arrives when we have studied and obtained an accurate knowledge of the whole genesis of a disease before we undertake vigorous methods of treatment. That does not necessarily follow at all.
§ Dr. ADDISON
I do not wish in any way to misrepresent the right hon. Gentleman. I was referring to what was the inevitable inference from the general trend of his remarks as directed to expenditure on research. What I wish to point out is that whilst expenditure on research is thoroughly justified, that in itself is no reason why we should not have an extended method of treatment. Another 398 reason why it is more necessary to include this disease in the national scheme is the cost which at the present time is put upon the Poor Law. I believe about a million and a half annually of Poor Law expenditure goes on persons suffering from tuberculosis. If we can prevent the spread of tuberculosis amongst the people who are to be insured we should prevent them coming within the ambit of the Poor Law, and in that way we should indirectly, but none the less effectually, be reducing the burden upon the Poor Law with regard to this disease. Every Member of this House is probably acquainted with some, or perhaps many, families which have been greatly affected by the incidence of tuberculosis. It may be that a family which was previously self-supporting has gradually come down and down until it has become a burden on the Poor Law. I believe that this great scheme will ultimately provide us with the machinery for preventing this degradation of a large section of the community. As to what the right hon. Gentleman said with regard to the provision of expensive buildings, I am sure his protest to the Chancellor of the Exchequer will be exceedingly useful in regard to incurring an immense expenditure on bricks and mortar. In some districts it is fair to say that a sanatorium can be erected for £100 a bed. Apart from that, I believe the right hon. Gentleman the Chancellor of the Exchequer will be willing to accept an Amendment of my hon. Friend behind me which will introduce the words "or otherwise" or something of that kind into the Clause to meet the point—I hope the right hon. Gentleman will accept it—as to the application of this scheme to less expensive methods than an expenditure on bricks and mortar. In some districts, perhaps the right hon. Gentleman is aware, cases of tuberculosis are being successfully treated in shelters of cheap construction. What the right hon. Gentleman opposite has said with regard to the provision of expensive buildings no doubt will be very useful, but the whole thing is linked in one chain. It would be useless for the Government to set up their local health committees to inquire into cases which are in such stages that they could be overlooked or could with advantage be treated locally, unless we provided at the same time institutions for treating a considerable number of people in whose case there would be some hope of the treatment being successful.
May I say a word with regard to these sanatoria? The right hon. Gentleman's 399 figures are really based, if I may say so, upon very slender premises. According to the report of Dr. Bulstrode, of the Local Government Board, there are not in this country at the present time more than about 2,000 beds available in sanatoria for the whole community, and it is true to say that there are not more than 1,500 which are in any way acceptable to persons of small means. When you come to compare that with the fact that there are between 250,000 and 300,000 people at one time in the country affected with tuberculosis, it is perfectly evident that 1,500 beds for that immense population will not provide very reliable data. At the same time a considerable number of those buildings suffer from important drawbacks at the present time. Some of them are small, and some of them are inadequately staffed, and these disadvantages can only be removed by undertaking some such national scheme as this. What really happens in the ordinary way now? You have 1,500 beds, and a population of 250,000 suffering from this disease. A person now goes on suffering from tuberculosis until he has to give up his work, at which time treatment would probably not be so successful as if it had been undertaken earlier. Then he tries to get into a sanatorium, and he very probaly has to wait from three to six months before he can get in. During the whole of that time he is going downhill, and it is sheer waste to undertake the treatment of this disease unless we step in before that. It so happens then that the conditions are such that the large population who are suffering from this disease have to wait a long time before they can get into the sanatoria. It is, therefore, entirely useless to compare the mortality of the population infected with tubercle with the mortality of the population as a whole, especially when you select, as you inevitably do at present, the very worst cases to make your calculation upon.
Something like one in seven cases of disease are due to some form or other of tubercle, and you can have no better reason than that to introduce the treatment of this disease into a national scheme in order to prevent it from spreading. If I may, for a moment, I will now refer to what would happen under this scheme to justify it in the way it would work, and see how the chain would be constructed. There are two classes of cases which may usefully be treated in sanatoria. In bad cases, that cannot be cured; although you cannot cure them, you can do something 400 for them, and you can do more still for those with whom they live. It is perfectly true what the right hon. Gentleman said, that many patients go into these institutions and go back homo and live a little longer and die. But if you could have them for three months to teach them how to conduct themselves in their own home, so as to avoid infecting those with whom they live, we think you would in that way enormously prevent the spreading of the disease. With regard to the spread of the disease, we have a very considerable amount of most accurate knowledge. I am not speaking of the investigation by the Commission, I mean that the disease is carried by one individual who may infect another by certain channels, particularly in the sputum. Perhaps it would be well to give a case in point. In a particular instance a particular flat has been occupied for eight years with a clean bill of health. In one particular flat, as I am told, the mother was infected with tubercle, and ultimately died, and they left it after a year. Family A having left, family B, consisting of seven people, came in. They stayed for a year. After they had left the father developed tubercle and died, and the mother died and one of the sons and another child died of tubercular peritonitis. Family C came in, and their record was: one child died of meningitis, one of tubercular hip, and another of wasting disease. Later on, when they had removed, the father died of phthisis. Finally family D came in. One of the children died of phthisis, one died of tubercular meningitis, and one of wasting disease.
During twelve years in that one tenement there were thirteen cases of tubercular disease, and during the same twelve years in the other tenements they had a clean bill of health. It is perfectly evident that here you have a case where the building is infected. It illustrates what we could do if we had a scheme whereby the mother could have been removed when she was infecting her household, and if at the same time the local health committee could come in by a visitor who is a common-sense person. I do not mean by any oppressive and interfering methods, and I sincerely hope that those committees will be able to bring in a large number of useful, level-headed, benevolent persons who will, with some training, undertake this work of visiting houses rather than rely on officials, who are inclined to work on hard and fast lines. We all of us know from our health visitors 401 that there are such people obtainable. If the family had been visited and the flat disinfected and the mother removed to an institution where she could be taught how to avoid infecting her family, in all probability the result would be that families B, C and D would not have presented such a dismal record. [An HON. MEMBER: "Is it possible to disinfect a building from tubercular disease, or is it always liable once there has been that disease in it?"] As the hon. Member perhaps knows, the one thing of all others which is fatal to tubercle baccilus is sun. That, of course, would open up the whole of the housing question. But at the same time it is perfectly possible to disinfect the building, and an ordinary dwelling with fair efficiency. That is the first class of case. There is another class of case in which we have sufficient evidence to show that if taken early a large percentage can be cured, or, at all events, their duration of life can be distinctly prolonged. As it is at present the average duration of life of tuberculosis patients is probably about five years.
§ Mr. WALTER LONG
When the hon. Member speaks of a large number of cases of persons whose lives were prolonged, does he mean that that applies only to treatment in sanatoria?
§ Dr. ADDISON
Oh, no; I do not say that. I do not say it would not be possible to treat them with proper food and fresh air, say, in cheap shelters, and you might in a large number of cases obtain the same results. But it is much more convenient to have them grouped together, for the reason that where they are so grouped you are able to provide more expert treatment. If you have half a dozen cases in a back yard or garden or field you cannot provide for each group the same skilled attention as you can when you have a large number together. Of course, in the early days it is quite true to say that people had a sort of general idea that you could save them by giving them plenty of fresh air. We know that is not sufficient, and that it is a much more detailed matter than that. We have obtained much further information. Exercise, as we know now, is a very essential part of successful treatment. I am speaking of early cases, coupled with proper food, and so on. Let me give you some evidence on this particular point. I notice in the records of Hamburg that the percentage of cases taken in the first stage in 1900 was in 1905, when the average expec- 402 tation would be that they would be in their graves, 95 per cent, still at work of those admitted in the first stage, and of those admitted in the second stage 82 per cent, were at work, and of those admitted in the first stage 50 per cent, were at work. That is to say, the earning power of those people when they came, out again was enormously increased, and consequently the burdens upon their own families and upon the community were proportionately diminished. I do not say that a large number of those people might not, if they cams under unsatisfactory domiciliary conditions, contract the disease again, because, they will still have some focus or foci of infection within them. That only shows how necessary it is that we should have some provision, and there is in this Bill, for following up those cases when they go back home again as the right hon. Gentleman says, if you simply send them to a. sanatoria, pack them off home again, and finish up with them, you will have very unsatisfactory results.
It is necessary that there should be instituted groups of visitors and so on who will follow up those cases and, as the right hon. Gentleman suggested, there should be established dispensaries over the country to which those patients could go for periodical examination, advice, and all the rest of it. I believe it would be possible to establish an average dispensary for a population, say, of 250,000, and you would not require an extensive building, and you could run such a dispensary for about £750 per year. It is estimated that you could provide 128 dispensaries for England and Wales at an annual cost of about £100,000, which is merely a trifle comparatively, and the cheapest form of treatment no doubt. They are essential to the right following up of the cases which have been in the sanatoria, and they are also essential for the treatment or supervision by nurses and whoever may carry out the work of those who live at home, while perhaps someone is in the sanatorium. When the right hon. Gentleman says that the provisions here are not great enough for the carrying out of a national scheme dealing with the whole matter straight away, that is true. We estimate that for the present tuberculosis population, with the death rate of about 60,000 per year, that 30,000 beds would be required to provide for the treatment of those persons for three, four, or five months' stay in the institutions. It would require a larger sum than is provided in the Bill, but that will be one of the incentives which I 403 think will be most valuable and which will be agreeable to the right hon. Gentlemen who opened this discussion in making the insurance authorities look for cheaper methods of treatment, because the money which is provided will not allow a sufficient number of beds to deal with the present tuberculosis population. It is, I think, a valuable measure for the prevention of disease, or at all events of that disease which causes a bigger proportion of suffering and loss than any other one disease. Whilst I am sure the right hon. Gentleman wishes the economical side of it to be prominent and borne in mind, he also thought it would be made possible to have cheaper methods of treatment. I am sure it will be nothing less than a national calamity were this Clause to be deleted from the Bill.
§ Dr. HILLIER
I am sure that all the Members of this Committee have listened with great interest and sympathy to the instructive speech which we have just had from the hon. Member for Hoxton. Under this Clause in the Bill which we are now discussing the State does, perhaps for the first time, address itself to a great public health problem, and in such a way, as it seems to me, that it does take upon itself the responsibility of dealing with this particular disease. I cannot entirely agree with the closing remarks of the last speaker when he attempted to defend the policy laid down in this Bill, which is not the treating of the disease as a whole, or, as he put it, dealing with the whole matter, but merely offering a sort of palliative and making a sort of beginning. If I may refer to my personal experience I should like to inform the Committee that when I was in medical practice, not so very many years ago, I was especially associated with the sanatoria movement. I had the satisfaction of inducing the friendly societies of this country at one of their national conferences to appoint a deputation which accompanied me to Germany, for the purpose, first of all, of inspecting the sanatoria in that country, and, secondly, of acquainting themselves with the provisions of the State Workmen's Insurance Department. That deputation accompanied me to Germany and spent some nine days in learning some facts with which the Chancellor of the Exchequer has since acquainted himself. I hope he will forgive me for saying so, but he will find if he consults some of his friendly society acquaintances that their first introduction 404 to the whole of this scheme was made by the visit which they voluntarily undertook to Germany some few years ago on my advice. The result of that visit was that so far as the sanatoria was concerned they came back and they formed a committee, of which I had the honour of being one, who set about to establish what is known as the National Sanatorium for the Treatment of Tuberculosis, which is now in existence in Benenden in Kent, and has been maintained by the subscriptions of the friendly societies for the treatment of their own members. A very creditable performance it is, and a very high tribute, I venture to think, to the old voluntary spirit and system which prevailed throughout the friendly societies in dealing with benefits of this sort. I am sorry to say at that time the friendly societies did not see their way to reconcile themselves to the compulsory element in the scheme of national insurance. Arguments, no doubt, have been used since then which have had considerable weight, and they have had time to think the matter over, and I presume that at any rate in a great number of instances to-day that objection on behalf of friendly societies has been overcome.
There is a point of interest in connection with the founding of that sanatorium at Benenden. The friendly societies were convinced by their experience of sick benefit that tuberculosis made a far heavier claim than any other disease upon their resources, and it was on economic as well as humanitarian grounds that they founded that sanatorium. But in approaching this subject and in proposing schemes for dealing with it, whether those schemes can be best carried out under an insurance Bill, or can best be dealt with by different machinery altogether, of this at least I am convinced, that if the State is going to address itself to this problem at all, if it is going to undertake the responsibilities of dealing with tuberculosis, it must deal with the whole matter, and it cannot afford to deal with merely portions of it. This proposal to build a chain of sanatoria throughout the country and to provide sanatorium treatment merely for those insured under the Bill is not a statesmanlike proceeding nor a wise policy. After all, tuberculosis in its most common form, consumption as it is commonly known, is, at any rate in its later stages, undoubtedly an infectious disease, and if you are going to address yourselves to this problem you have to keep that ele- 405 ment in it more permanently before you than any other. How do the proposals of the Government, work out from that point of view? The Bill will merely provide that persons insured under it will be the recipients of sanatorium benefit. They will be removed to these sanatoria and will receive what benefit sanatorium treatment can give them, and they will, at any rate, be removed as centres of infection from the midst of their families. But what about other members of these families who contract phthisis as they must inevitably do. They continue to spread the disease, and this sanatorium treatment, unless it is supplemented by some machinery for dealing with other cases of phthisis in the country, will be nothing less than a costly luxury. You must either leave the thing alone altogether, or you must do it thoroughly. What you are proposing under this Bill is really a palliative, and not a remedy, and I think a costly palliative which can scarcely be justified. Therefore, I think, the right hon. Gentleman (Mr. Austen Chamberlain) raised a very important question indeed when he asked the Chancellor of the Exchequer whether, after all, this was a question to be dealt with by an insurance Bill, or whether it could be dealt with by some other machinery altogether. I welcome the attempt on the part of the State to grapple with this great problem, even if I do not think the whole of the efforts proposed are entirely well directed. I recognise that they are a beginning, and provided that the entire responsibility of dealing with this disease is accepted by the Government, and these efforts are carried out on scientific lines they most assuredly will have my support. The hon. Member (Dr. Addison) dwelt very properly upon the necessity for dealing with advanced cases of phthisis as well as with the early cases in sanatoria, and then he went on to say that these advanced cases, after the education they have had in sanatoria, might safely be allowed to go back to their small homes. I am sorry to say, after a considerable number of years' experience of sanatorium treatment, and a good deal of consideration of the subject, I am bound to differ from him.
§ Dr. ADDISON
I did not say that at all. They only stay for a limited time, but when they go back to their homes they will have been so trained that they will be less likely to spread infection than they otherwise would.
§ Dr. HILLIER
I am very glad to have elicited that further explanation. I am not prepared to deny that a man might be rendered slightly less dangerous as a centre of infection by this educational means, I should be sorry to do that, but I think it would be the greatest possible mistake if we were lead to believe that any amount of education in a sanatorium would prevent an advanced case of phthisis returning home remaining a centre of infection. On this point I should like to quote the last interview I had with Professor Koch, which occurred a few years before his death. I had the privilege of collaborating with him some few years ago in a small work on the subject upon which he advised me, and the thing that he impressed upon me, and it is a thing I shall remember as long as I live, as the result of his life work and investigation in this matter was that up to the present time neither in Germany nor in any other country had the really necessary measures for preventing this disease been taken. I said, "What, in your opinion, is the chief source of the spread of this disease?" He said, "I have no doubt whatever that the chief source is the poor consumptive returning and dying in a poor home surrounded by his family. Any proposal which merely regards sanatoria as places for the treatment of early cases of phthisis or places where advanced cases may be treated and then allowed to go back to the family really fail to achieve the first requirement of any great preventive measures. Therefore, I say again that if the State is going to take up this matter—and a great deal has been done by voluntary effort; but I do not deny that no one can deal with it like the State—I trust they will take it up in a thoroughly scientific spirit and will deal with it as a whole, and not in the piecemeal way which is suggested in this Bill so far as we are at present advised. The right hon. Gentleman (Mr. Walter Long) referred with justice to the wonderful work which has been done under the guidance of Dr. Philip in Edinburgh, where they have complete machinery for dealing with all stages of this disease and where they have actually had the gratification of seeing a steady diminution in the death-rate from tuberculosis. It is perfectly certain that whether it be done under this Bill or by something supplementary to this Bill, unless the State combines with its sanatorium benefit a complete machinery for dealing with cases of phthisis amongst the poorer classes more particularly, whether they be in- 407 sured or not, they will be undertaking a work which neither economically nor scientifically is sound.
With regard to the economic side, I should like to say a few words. I entirely agree with the right hon. Gentleman who has deprecated the expenditure of large sums of money on bricks and mortar. I go further and say that in my opinion admirable accommodation can be provided for the treatment of tubercular cases for less than (£100 a bed, which was the sum mentioned by the hon. Member (Dr. Addison). I think before any departure is taken in this matter the whole question should be gone into most carefully, and expert evidence most carefully collected, because I am convinced, from what I have seen of open-air sanatorium treatment, that admirable results can be obtained from what in ordinary conditions of life might be regarded as very primitive accommodation, but which nevertheless is perfectly healthy, even if it is of a somewhat Spartan simplicity, and therefore I hope that this point will be borne in mind by the Government and their advisers. The hon. Member (Dr. Addison) spoke of a flat with successive families infected with phthisis. I have no doubt he has seen a series of similar cases compiled by the medical officer of health for Manchester some few years ago, giving precisely the same sort of statistics and the same result. These cases will, I think, sufficiently emphasise the point I am making, that if you are going to deal with this subject and take on yourselves as a State the responsibility of dealing with it, the last thing you must do is to allow an advanced case of consumption to go home and die in the bosom of his family. I have considered the domestic as well as the scientific side of the problem, and there is this to be said, that in these advanced cases it is perfectly possible for relatives and friends to visit them in sanatoria with safety. They need not be deprived of the companionship of their friends and relatives in their last days altogether. But that is very different from allowing advanced cases to go home. I care not what precaution you may take with regard to the education received in these sanatorium. The conditions in the case in which a patient returns to a small cottage or tenement are such that further disaster is almost certain to follow.
A question has been raised by the right hon. Gentleman as to the advantage of 408 sanatorium benefit, and as to the percentage of cures which may be obtained by this method. I do not hesitate to say that I so far agree with him that I think the first advantage of sanatoria or of any similar institution is that you get the consumptive out of the environment in which he might continue to be a source of disease, although I admit that you also educate him into how to conduct himself if an arrest of the disease is obtained. With regard to the proportion of cures, various figures have been published by sanatoria, and various claims made, and I am quite convinced that a considerable proportion of early cases are actually cured. I am not prepared to say what is the precise ' percentage, and I do not think any one can state an exact figure, but I would say a very appreciable proportion. Then there is a very considerable number of other cases in which there is a temporary arrest of the disease, under which for a time a man or a woman enjoys good health, but beyond these there is the other class of cases, of which I have spoken, which are only too numerous, and in regard to which we shall have the greatest and the heaviest responsibilities. In conclusion, let me emphasise once more that the greatest source of the spread of this disease is to be found in those advanced cases of consumption which are allowed to go home to die, or to remain, in a narrow little home or in a crowded tenement.
§ Sir HENRY NORMAN
The speeches we have listened to afford ample justification for the Amendment which was proposed by the Member for East Worcestershire (Mr. Austen Chamberlain). My own contribution to the discussion must be without any claim to the technical authority which gave weight to the last two speeches. I think in a discussion of tuberculosis we must bear in, mind one fundamental fact, that if tuberculosis is to be stamped out in this country, there is in the last resort only one Government Department which can deal with it, and that is the Local Government Board. So long as large masses of people have to live in the conditions under which they live at present, in such, unsanitary surroundings, and under such wretched housing conditions, you will never succeed in stamping this disease out. It would be very interesting to enter into the questions of the responsibility and the causes for such conditions, but I do not 409 propose to do so. The hon. Member for the Strand Division (Mr. W. Long), who speaks with much knowledge and authority upon matters connected with local government, alluded to the new Tuberculosis Report. Of course, we have had only a moment to glance at it, but, so far as I have been able to see, it is confined, almost, entirely, to the question of the transmission of bovine tuberculosis to human beings. That touches only remotely upon the matters to which this Bill is chiefly addressed.
The object of an Insurance Bill must be, as far as possible, to combine all the agencies in the country into one great attempt to raise the standard of the health of the nation, and to accomplish that we must remove, as far as possible, the sources of infectious disease; we must either cure or segregate the infected person. To have introduced this Bill without having made an attempt to deal with these persons, either by cure or segregation, would have been to give evidence of the inability of the authors of the Bill to take a broad view of their responsibility in framing such a measure, and if they had done so, and had sought to leave to other agencies the task of dealing with this great problem I hope I should have been one of the first to reproach them with a lack of insight and foresight. It has been found, to use a phrase which I think comes from Germany, that from the economical point of view the cheapest thing you can do for a consumptive person is to cure him, and it is also the cheapest thing for the community. Every justification for the greatest efforts, and the greatest enthusiasm, in the combination of all the agencies in the country in this work, as far as possible, is found in the fact that under these circumstances tuberculosis in every form will be a constantly diminishing quantity, and therefore, though it sounds paradoxical, the more you spend the less you will have to spend in coping with it. To take one point which has not been mentioned this afternoon, we all agree that there is no doubt whatever that the sanatorium treatment is of great value in certain stages, but it is a very long treatment and a very costly treatment. I do not think it can be correctly described as a scientific treatment. Tuberculosis is, of course, a microbic disease, and such diseases must ultimately be fought bacteriologically.
Although I speak with great humility I may say that I have taken an interest in following, as far as I can. the medical 410 literature on the subject, and although I have no claim to make a prophecy it appears to me that we are now in sight, perhaps within a few years, of a time when tuberculosis will be cured by injection, on a par with the triumphant serum and similar treatment of other diseases, such as tetanus, diphtheria, and that brilliant and extraordinary treatment recently described in the medical press in regard to the treatment of syphilis. I attended by proxy a scientific lecture in London quite recently with regard to the progress of the tuberculin treatment of consumption. I am not a scientific man and I know it would be wrong to raise false hopes; nothing could be more unwise or more cruel, as the past has shown. But I am told that one can safely say that there is ground for believing that within a comparatively few years, as we are now able to diagnose phthisis at a much earlier stage than has been the case, in the past, we shall have a direct, radical and inexpensive cure, compared with the indirect and comparatively unscientific result of sanatorium treatment.
You cannot do without sanatoria, but you cannot do everything with them; you cannot, unless you work on a very broad scale, do very much. For that reason I have put down an Amendment on much the same lines as that of my hon. Friend behind me, though it is a little more definite in the wording, to add after the words "treatment in sanatoria and other institutions" the further words "or other preventative or curative treatment." I hope the right hon. Gentleman will see his way to accept my hon. Friend's Amendment or my own, which I should prefer, as it is a little more definite, because it confers upon local health committees the power to adopt other methods of treatment besides sanatoria, and, indeed, invites them to do so.
§ Mr. ARTHUR LYNCH
I wish to speak more in regard to the importance of research. It has been touched upon in some of the very interesting speeches which we have had, and although some of the hon. Gentlemen have no special knowledge of the subject they have showed the greatest earnestness and appreciation of the subject. The gravamen of my argument is not directed so much against sanatoria. Rather what I want is to have both sanatoria and research, and that of the two the far greater weight should be allowed to research. The perspective of these two things should be changed. You 411 may spend millions of money on sanatoria and ten years afterwards when you take a retrospect of what has been accomplished the answer may be almost nothing. There are many differences of opinion with regard to sanatoria, and there is a very powerful school of medicine, comprising broadly those who are in the forefront of bacteriological work, who doubt whether much advantage, scientifically, is derived from sanatoria if limited to the expectant treatment. That school is not opposed to sanatoria, or to the provisions of the Bill in other respects, because they recognise that in sanatoria not only can patients be kept under observation and capably treated, but that they can gain in these institutions further opportunities for research work. Without that facility for research I would be inclined to say that this expenditure on sanatoria would be money almost entirely wasted.
Yet I am one of those who believe that it would be possible in a few years to stamp out consumption and all forms of tuberculosis in the same degree as leprosy has been stamped out, and it is a rather curious fact that the bacillus of tuberculosis and the bacillus of leprosy resemble each other a great deal; so much so that even skilled bacteriologists are sometimes unable to make the distinction. Leprosy was stamped out not by sanatoria or other treatment of that kind. Really nothing was known of the etiology of the disease, but there was undoubtedly an incidental advantage in its treatment by segregation. I am inclined when I ask what advantage will be derived from the expectant treatment to say that the greatest of these advantages will be the taking away of the patients from their homes and segregating them from the rest of the community. And, therefore, I would like to emphasise the remark of the Member for Hertfordshire (Dr. Hillier) that so far from it being permissible to allow patients who are in the last stages of the disease to go home I would regard that as the most dangerous period of all the phases of the disease. That is the time when the bacillus has gained a triumph over the system of the patient and has begun to increase and multiply, and is given forth by him again with the greatest energy. The two months in the last stage of the life of a consumptive patient are far more dangerous to the health of the community than two years at the earlier stage. I wish to traverse one or two arguments 412 raised in the course of this Debate, and first let me say as regards cancer there is no comparison between the two diseases. We do know something about consumption; we have isolated the bacillus; we train and cultivate the bacillus; we know the methods of infection, if not all at least many of them; whereas of cancer we can only guess that it is a microbic disease, and even that point is disputed with the greatest energy by many learned men who spent years of their lives in its study.
The hon. Member for Montrose Burghs said that Scotland, for instance, would be a suitable place for the erection of sanatoria. I doubt that Scotland or England, of any place in the British Isles, is a suitable place to erect sanatoria. I knew an old lady who lived to be more than sixty years of age; she contracted phthisis in Scotland, and she was told by her physician that she had only three months to live. She emigrated to Australia, and used to see her physician about every ten years, when he invariably told her that she had only three months to live. As a matter of fact, she outlived him and even his grandson. I knew a man who in the last stages of consumption was sent to Australia as a last resort. He recovered, and lived to become a professor in one of the universities and a distinguished student of the disease with which he was threatened. South Africa is a marvellous climate in respect of phthisis. More valuable than any sanatorium treatment is a warm, dry climate, free from microbes; so I rather discourage the idea of building sanatoria in Scotland, as the suggestion arises, not so much from scientific reasons as from patriotic motive. I am not very much in favour of the famous chain of sanatoria in these countries, because England has a climate which is enough to kill an ordinary healthy man, much more a consumptive patient.
Another point is that tuberculosis is not a deadly disease. I say that with great circumspection. How can you call a disease a deadly disease which takes upon the average five years to kill its man, and very often fails to kill him at all, compared with the disease such as small-pox or diphtheria or typhoid fever, which finishes a man in a couple of weeks. Consumption is one of those diseases which is upon the border line of not being fatal at all; a great portion of every civilised community are almost immune from phthisis, that is so-far immune that their constitutions are 413 capable of resisting its attack. That vitiates statistics derived from sanatoria because it is impossible to estimate the number of cures. In accordance with this, post-mortem examinations have shown us in recent years that a great proportion of ordinary persons have been at some time of their lives attacked by tubercule bacillus, perhaps never knew they were so attacked, and survived that attack, and as post-mortem examinations more and more increase, I am inclined to think that the discoveries of the proportion of persons who at one time or another have been attacked by tuberculosis, would rise higher and higher. So that when you say a person has been in a sanatorium and has been cured it is a logical fallacy to impute that cure to sanatorium treatment, yet at the same time if that person had never been sent to a sanatorium he might easily have been cured.
Patients in a sanatorium sometimes look quite healthy; they are bronzed by the sun, they may even put on weight and feed well, and may show a high rate of improvement, but by certain scientific tests which have only recently become known, it may be found that the patient is making no headway against the disease and even perhaps that the disease is making headway against the patient. So that the proper estimate in these cases is not by statistics or by the appearance of the patients, but by what is called the opsonic index. It was a discovery made rather than invented by my most famous teacher, Sir Almworth Wright, and is one of the triumphs of bacteriological science which gives to modern bacteriology what Koch looked for in his day. There are many Members of the Committee who remembers the excitement created by Koch's announcement as to the treatment of consumption. It was a premature announcement, however, put before the public for patriotic reasons when Koch believed he had discovered a cure for tuberculosis. Hundreds of patients rushed to Koch, and by submitting to his treatment, had their illness accelerated, not that his principle was wrong, but simply because he had not the means of studying his tuberculin treatment and gauging its effects. That defect is remedied by Sir Almworth Wright in his opsonic index; it supplies the means by which we can ascertain the value of sanatorium treatment. I should like to say a word or two, if I may, which I fear may shock some of my medical confrères, namely, that there is a certain superstition 414 about the fresh air treatment of tuberculosis. Throughout the whole history of medicine one can see there have been, fashions in medicine, just as there have been fashions in spring bonnets. I believe that is the case throughout the whole world in art and science, and one fashion which prevailed throughout the Middle Ages, and from which we have not wholly emancipated ourselves yet, was that of the doctrine of signatures; so that you prescribed bloodstone to a man suffering from, hœmorrhage of the lungs, and that you treated a man suffering from asthma with lungs of foxes, and quinzy with bluebells because they have long necks. I believe that is one of the reasons why we hear so much to-day of the fresh air treatment with, regard to tuberculosis. It must be remembered that tuberculosis is not always-phthisis; it attacks many of the organs besides the lungs, but I am inclined to think that the value of fresh air in the case of any tuberculosis is just as high, or nearly as high, as it is in regard to tuberculosis of the lungs—not by acting on the bacillus, but by improving the whole system, by acting as a kind of tonic and enabling the system to throw off the disease. I am inclined to think that this is the sole benefit of the fresh air treatment even in regard to phthisis, because the fresh air, not coming in contact with the bacillus, can only act by improving the tone of the whole general system. I have the authority of Sir Almworth Wright to say this: that where he has been treating tuberculous patients, all his treatment was based upon the opsonic index, and that if children were taken on a holiday to Margate, the healthiest place in the whole of England, and so interrupted their treatment to enjoy the benefits of fresh air, he sometimes found when, they returned that there had been a distinct retrogression. The great difficulty of estimating the improvement of patients by fresh air was that they might be able to throw off the disease entirely without any; treatment whatever, or even without knowing that they had been attacked by tuberculosis.
Before sitting down I should like to propose the impossible—that is, I think all this is a case for special examination by a special committee. But for the fact that we are limited to time, I would like to see this whole question relegated to a commission of experts, who would have an opportunity, not merely of taking evidence in the ordinary way, but entering thoroughly and in the most determined way into the value of the latest treatment, 415 and especially into the value of tuberculin treatment as guided by the opsonic index. But for the question of time I think it is a matter that should be so investigated, because I believe you must look for an absolute cure for tuberculosis, and if you fail to cure it you will have done very little. As long as you leave the germs about you leave a ferment, and I use the word ferment advisedly, because the action of the disease itself is that of ferment, and ferment is something comparable to a disease. Unless you stamp out tuberculosis you accomplish very little. At the same time I am in full accord not only with the good intentions of the Chancellor of the Exchequer, but to a very great extent with his methods, because although I think a great deal of the one, and a half millions will be wasted, I think it is possibly not a bad thing to waste one and a half millions, or even ten millions, if eventually we are put upon the track of grappling with this disease. The force of ail I have said is this—that whereas sanatorium treatment must be encouraged for this reason, our great weight of attack is by tuberculin treatment guided by the opsonic index; far greater weight should be given in proportion to scientific methods of research and to tuberculin treatment, and a far greater sum of money should be allocated for these purposes, if possible.
§ Mr. BARNES
After the very able and technical speeches we have just heard what I have to say will be regarded, I am afraid—I will not say as stale, flat and unprofitable—but as severely practical. It was quite with a shock I heard this present proposition coming from the Front Bench, because I believe since the introduction of this Bill that these particular provisions were the best part of it. I rejoiced to know that a responsible Government was taking steps for making some scientific and systematic provision against the inroads of disease just as we have long ago done in regard to the prevention of fire and the destruction of property, and therefore I was somewhat shocked to hear to-day the proposition put forward from the Front Bench, though I quite appreciate the fact that it is put forward for the purposes of discussion. One argument which has been put forward is that we should cut this proposal out of the Bill because provision for the prevention of consumption should not be a charge on the Insurance Fund, but ought to be a public charge. With that argument as an abstract proposition I en- 416 tirely agree. I should like to see all the money required for this scheme coming from the Exchequer. I think it is a bad principle theoretically to charge very poor persons as the Chancellor proposes a certain moiety for the treatment of disease which is preventable, and which, in my opinion, is largely due to poverty. That has been clearly ascertained by those who have gone fully into this matter. I remember attending a conference at Glasgow and hearing figures given on this subject by Dr. Chalmers which convinced those present at the conference that this disease was very largely due to poverty.
The argument put forward is that theoretically this is not the right way of dealing with consumption. Have we ever dealt theoretically with any great question. Even in my short experience I remember that we dealt with sweated industries experimentally picking out a trade or two to deal with for the time being. In regard to education theoretically everybody will admit that free education is the right thing. Education is a matter of national concern, and an enlightened and educated people is a benefit to the whole community, and therefore education ought to be a public charge. But we did not bring about free education by dealing with it theoretically. On the contrary, we stumbled into it. First we made education more or less general, and imposed a small charge, and as the community gradually recognised that education was a national concern, the fees were abolished and then we had free education. With regard to this question the same thing will happen. We have commenced by throwing a portion of these charges on very poor people, but so far as sickness is concerned I look upon these provisions as the germ of a national medical service, which I believe this scheme will grow into. In the meantime I am not condemning a provision simply because it is not theoretically correct.
The second argument was that this provision should be knocked out, because we had not sufficient knowledge. Comparisons were made between our knowledge of tuberculosis and cancer. I cannot speak from a technical knowledge of those subjects. Several doctors have spoken, and, as usual, they have differed, and it has been left for the plain man of ordinary common sense to decide. Speaking as one not possessing expert knowledge, but as a man of ordinary common sense who tries to get to know as much as possible, I have no hesitation in saying that 417 although we do not know a great deal more about tuberculosis than about, cancer we know a great deal more as to how to treat it. I have gathered information upon this question. I was in Germany a few years ago, and we collected a great many figures, and I believe that the results showed a reduction of consumption as a consequence of the adoption of the open-air treatment. I wish to say that I prefer sanatoria to serum. No harm can come out of fresh air, but a great deal of harm can come, and has come, out of serum.
§ Mr. BARNES
I know nothing about the Gentleman to whom the hon. Member opposite referred. I know that one of my hon. Friends advocated serum. I am not going to say anything against scientific research, but I think it is something which ought to be carefully watched, and if we are going to have scientific research I want it to be safeguarded. I hope we shall not torture any more poor dumb animals for the purpose of scientific research. I do not think a case has been made out against the proposals of this Bill in regard to sanatoria on the ground of a lack of knowledge. It may be true that medical science in regard to consumption is more or less in the experimental stage. We are in the experimental stage with regard to almost all diseases. It is true that we know a good deal about the treatment of consumption, and we know that the open-air treatment has been largely justified by results. There is another reason in favour of the inclusion of this disease and making it a matter for special treatment, and it is that there is no other disease claiming so many victims. The Chancellor of the Exchequer, in introducing this Bill said that every year 75,000 victims fell as a result of this disease in this country. From that point of view alone I think there is a reason why it should be dealt with specifically to the exclusion of other diseases. I hope the same principle will be applied to the other diseases as soon as the Chancellor of the Exchequer can afford to spend the money.
It is said that this Bill does not deal with the subject thoroughly. I agree with what the hon. Member for Bow and Bromley (Mr. Lansbury) said as to the inclusion of women and children, and I voted for his proposal. I regret that this scheme does not cover the women and children. I have heard the statement made about 418 the danger of the further spreading of this disease by people being sent from a sanatorium home to die. I do not think that should be allowed. I should like to see a more liberal provision made. For these reasons it is claimed that we should not do anything at all in this matter, but that seems to me a very illogical position to take up. I want a start to be made. I think a start is being made in the good old blundering British fashion, not by academic consideration, but by blundering into it and getting something done. Afterwards I shall vote every time I get a chance for extending this principle so as to make it theoretically more perfect.
It has been said that if this 1s. 3d. were saved we might get this question dealt with on theoretical lines. I do not know whether the Chancellor of the Exchequer has an additional 1s. 3d. in the till. If I thought so I should vote for the exclusion of this Sub-section in order to have the question dealt with in another way. What I feel is if we do not spend this 1s. 3d. in this way we shall not save it. This Bill is surrounded by vested interests of all sorts, and if we do not spend this 1s. 3d. upon sanatoria then the doctors will have it, or somebody else, and I do not know any better way of spending it than upon sanatoria. For all these reasons I am, inclined to vote for the Bill as it stands. It may be said that sanatoria, as well as other things, is purely experimental treatment. At all events, there is this to be said, that fresh air can do nobody any harm, and sanatoria, if they prove to be of no use for consumption, will be very useful for something else. At present we find thousands of poor people laid up sick for weeks and months in the slums of our large cities and there they have to stop. As soon as they get well, and even before they are well, because of the pressure of economic poverty, they go to work before they are fit. If these sanatoria turn out to be no use for the treatment of tuberculosis they will certainly come in for these poor people as useful convalescent homes where these people can get what is better than physic, namely good fresh air and plenty of food.
§ Mr. LLOYD GEORGE
We have had some very able speeches, and we have also had one of the most instructive Debates I have been privileged to listen to for a very long time. In saying that, I am not reflecting in any way upon any of the other discussions I have heard. I think the Committee will agree with me when I say 419 that this Debate has been full of significance and full of suggestion in every part, and I do not regret a single minute of it, because I think it has been very valuable. The suggestion we put forward is a new one so far as an Act of Parliament is concerned and the Treasury, and therefore it is important that it should be thoroughly examined before we proceed with it. We are embarking upon a new experiment and incurring considerable financial liabilities. In fact, they are very heavy liabilities. We are incurring an expenditure of £1,500,000 by way of capital liability upon buildings for sanatoria, and we are incurring that proportion of the expenditure which the Financial Resolution and its provisions have laid upon the shoulders of the taxpayers. From all the inquiries I have made I think this experiment will be a success, and I am sure that its success will end in our extending the experiment a good deal further than we propose to do in this Bill. Therefore, I think it is perfectly right that we should examine this proposal very carefully before we proceed with it. I think the warning which has been given to the Committee not to trust exclusively to sanatoria in dealing with this question is a very timely and a very necessary one, because if we were to do that sanatoria could not possibly cover all the cases of consumption. We might, if we concentrated the whole of our efforts upon sanatoria, neglect the larger percentage of people who cannot possibly, under this system, receive treatment. I therefore not only think the warning was a timely one, but I think it was a very valuable one at this stage.
The hon. Member for one of the divisions of Clare (Mr. Lynch) was perfectly correct when he said there are fashions in cures, and undoubtedly sanatoria for the moment have got the advantage of being also fashionable, but that does not mean they are not very useful and very valuable. A good many remedies which after years of struggle have managed to secure the approval of the profession have come to stay, and the case of sanatoria is a case of that kind. It is not something which has been suggested within the last few years. It is something which was suggested a food many years ago. I forget how many, but I am not sure it is not forty or fifty years ago when an English doctor tried the experiment. It has been a long experiment, and it has 420 gone through the same stages as every other successful experiment. It has taken very many years to convert the faculty, and it is only because the experiments, extending over a good many years, have been a success that doctors have been at last convinced there is a good deal to be said for it. I do not, therefore, put it in the same category as a sort of fashionable craze. It is something tried and tested by the most severe test of all, the test of experience, extending over something, like two generations. The right hon. Gentleman (Mr. Long) said, and said very properly, you must not merely make a case showing that the ravages of the disease are very terrible, and that a good deal of suffering is involved. You must also make your case that this particular method of dealing with it deserves at least a trial. I agree with him. I do not think there is any doubt at all about the terrible injury which is inflicted upon the strength and vitality of the-nation, or the mortality which is attributable to it, or the economic devastation which is created by it. We have also got to make a case that it is desirable to try this particular experiment on this considerable scale in order to meet the ravages of the disease. The right hon. Gentleman rather cast doubt upon the success of the sanatorium experiment. He quoted certain figures. I did not quite catch the authority, but they did not seem to me for the moment to be conclusive.
§ Mr. LLOYD GEORGE
And I agree with, the right hon. Gentleman. I should like to have that authority again if he will kindly let me have it later on.
§ Mr. LLOYD GEORGE
I should like to see what it really implies. We have fortunately two or three very important facts, and facts on a very large scale, which enable us to come to a conclusion as to whether sanatoria are something more than a temporary craze, and as to whether they justify us in spending £1,500,000 of capital and £1,000,000 a year in maintenance for the purpose of trying, through that medium to cure and arrest consumption. We have got, first of all, the experience of our own country. There is a. very valuable book—I have no doubt hon. Members have seen it—by Dr. Arthur Latham and Mr. C. H. Garland. It contains a 421 good many figures showing what the effect has been in the sanatoria we have established in England. Unfortunately, there are two rival schools, and they think it necessary, in order to establish the advantage of their own methods, to decry the other. That is a great mistake. There is, of course, no rivalry like that of the advocates of special methods for remedying either body or soul. It is not merely that they insist their own specifics are the very best—they are not satisfied with that—but they will insist that any remedy suggested by somebody else is poison. There is just a little of that in the advocacy of the rival schools in regard to consumption. I think it is a mistake, because undoubtedly they are not substitutes one for the other. They can be fitted in, and one can supplement and assist the other. I hope, therefore, we shall not consider them merely in the nature of rival and antagonistic methods of dealing with the same disease. As a matter of fact, one method may be far and away the best for a man who is in a certain stage of the disease, or who is in a certain condition of life, and another may be an infinitely better one for a man who is in an earlier stage of the disease. I hope, therefore, it will not be necessary for us to advocate one method at the expense of another. I only preface that observation before I come to the figures with regard to what has happened in England. I am not sure whether the sanatorium referred to by the hon. Gentleman is not the sanatorium of the Hearts of Oak. This is the report to the Hearts of Oak with regard to that sanatorium:—All the patients with early tuberculosis did well, and left the sanatorium with the disease arrested and fit to return to work. The success of the treatment almost entirely depends on the stage of the disease when the patient is admitted.It then gives certain figures, and the result can be tabulated as follows: Fifty-eight patients treated by the society up to May, 1009; disease arrested, 34.5 per cent.; improved, 57 per cent.; unimproved, 8 per cent. That shows the vast majority of those who entered the sanatorium were cither cured altogether, or they left very considerably improved as the result of the treatment. There is another case, the case of the Post Office Sanatorium Society. In that case, they treated 168 cases, and the results may be thus tabulated: Disease arrested, 48.8 per cent.; improved, 36.3 per cent.; unimproved, 14.2 per cent. There was only one died out of the total number. That shows, at any rate so far as the experiments in this country are 422 concerned, they have been a very considerable success, and after all. as the hon. Member for Hoxton (Dr. Addison) in a speech which impressed the House, has pointed out, the experiments here have been on a very limited and small scale. We have only got 2,000 beds, and, as he pointed out, practically only 1,500 of those are available for people with this disease. In Germany I think there are 10,000 beds for the exclusive use of consumptives belonging to the working classes. The experiments have been going on in Germany for a considerable number of years, and in the cases to which I am referring, they deal, not as they deal here in many of the sanatoria very largely with better-class patients, but exclusively with the working classes. This is the result of experiments in Germany. The figures are very significant. I have got hero the statistics of the Imperial Insurance Office, and they show that every year the proportion of consumptive patients discharged from sanatoria as able to return to work increases, and that the duration of their earning capacity is more prolonged. That is the result every year. If the Committee will follow the figures they are very striking. The sanatorium treatment in Germany began in 1897. In 1897 65 per cent. of those treated were able to return to work. In 1909 83 per cent. were able to return to work.
§ 6.0 P.M.
§ Mr. LLOYD GEORGE
They generally stay about three or four months in the sanatoria. The proportion of persons treated who are able to work at the end of the first year was 62 per cent, in 1902, but it has now increased to 80 per cent. The proportion able to work at the end of the second year has increased from 44 per cent, to 63 per cent., at the end of the third year from 30 to 57 per cent., at the end of the fourth year from 30 to 52 per cent., and at the end of the fifth year from 27 to 46 per cent., so there has been an improvement year by year in the method, and, consequently, in the results, of the sanatoria treatment in Germany. In other words, whereas in 1902 one person in every four was still able to work five years after undergoing treatment, the proportion now is nearly 50 per cent. I think that is quite sufficient to justify us in embarking on this experiment. Every enquiry I have made proves to me that at any rate the 423 sanatorium treatment gives a man an increased chance in fighting for his life, and I think that stands to reason. I do not know what the effect of the open air is upon the disease, but, even if it has no effect at all, it does strengthen a man in fighting against it. You remove people from an atmosphere in small homes in towns where the air is pretty devitalised, and charged with dust, and put them in healthy surroundings. Sanatoria are generally in about the healthiest spots that can be found. You put them there for four months and see they get good food. Their habits are improved, and those indiscretions in the matter of diet, sleep, air, and ventilation which men commit unless they are really looked after are checked during that period. That in itself has a great effect on men suffering from disease of that kind, and, as far as I am able to discover, the most valuable part of the sanatorium treatment is the discipline in the institution itself. The patient leaves the sanatorium after four months' training in the kind of treatment that is best for him if he is to keep the tubercle down. He learns what is necessary with regard to diet and air, he learns what excesses to avoid in every direction, and that sort of training is really valuable for a subject who has the tubercle lurking in his or her system, always ready to spread to some vital part unless it is kept in check. That in itself is exceedingly valuable for the purpose of enabling us to grapple with this disease. I think we are justified in the course we are taking by the facts I have referred to, facts quoted not only from the very valuable work of Dr. Lathom and Mr. C. H. Garland, but also by the medical adviser of the Local Government Board (Mr. Newsholme). Analysing the figures affecting consumption in this country and giving a perfectly impartial view as to the methods of dealing with the disease the medical adviser of the Local Government Board says—I am completely convinced that sanatorium treatment is most beneficial to patients and enables a large proportion of them to resume their ordinary life.That is the conclusion he has come to, after looking into the statistics published on the subject, and that, at any rate, is one of the reasons which has prompted us to experiment in the direction of sanatorium treatment in this country. As regards what has been said about not erecting expensive and extravagant buildings I am in complete accord. One of the 424 first things I am told with regard to sanatoria—and in this matter I must not be taken as indulging in anything in the nature of uncharitable criticism, I am only conveying to the House information which has reached me—is that a good deal of money has been wasted not upon bricks and mortar but upon marble. I think it is a great pity to put up these extravagant buildings; we want our money to go as far as we can make it go. I also agree with the suggestion that, after all, sanatoria are in an experimental stage and that therefore to erect magnificent buildings is a great waste. It is not making the best use of our money; it is not by any means the best method of fighting the disease. I therefore entirely agree with the remarks which have been made on that point.
I think there are at least three advantages in supplementing our sanatorium expenditure by other methods than sanatoria. Take the case of Germany, where, since the year 1897, the sanatorium treatment has been extended and a great deal of money has been spent upon it. I think there they provide 10,000 beds and treat about 40,000 patients every year. But even that does not exhaust the whole of the demand upon them. I do not contemplate that under any conditions it will be, I will not say possible, but desirable to build a sufficient number of sanatoria to provide accommodation for all subjects in this country, and for that reason I think it is just possible some may be treated in another way. There are advantages in having other methods of treatment. Where doctors disagree I know it is rather rash for a mere politician to intervene, but, at any rate, I think I may point out three advantages. The first is, if you get some other method it helps you in your selection of patients for your sanatoria. Those engaged in sanatorium treatment well know that it is not every patient whom you can send into a sanatorium. Some, unfortunately, are too far gone, and it would simply be encouraging false hopes by taking such patients into these institutions. At the same time, you will be keeping others out who might benefit by the treatment. Besides that, these patients are apt to do more to spread infection than to get rid of it. Therefore the first thing which will have to be done under our method will be to decide what are proper cases to treat in sanatoria. The second thing is that as we cannot hope to provide sanatorium treatment for all consumptives in this country, and I believe they number from 200,000 to 300,000 at the very least, if we 425 have got other methods than sanatorium treatment, it will mean that those for whom you cannot provide treatment in the sanatoria will receive some special treatment which experience has proved to be useful in cases of consumption. The third reason is well worth considering. I am not sure, but I think it possible, if you have got other methods of treating, you can shorten the period during which patients stay at the sanatoria, and then very probably twice as many patients will be able to receive sanatorium treatment. Therefore, for all these three reasons, I think it is very desirable you should not confine your treatment of consumptives to sanatoria, and I hope I have convinced the Committee that the Government do not intend, at any rate, to concentrate the whole of their efforts in their struggle against this disease merely upon building and maintaining sanatoria.
I now come to the second point raised by the hon. Member for the Blackfriars Division of Glasgow (Mr. Barnes). His criticism seemed to amount to this, unless you can do everything you had better do nothing. I cannot conceive a more unwise policy. In this country we like to proceed experimentally; we like to pass from stage to stage, and we like to get even into the most advanced stages by easy stages. That is what we are doing here. But we are not going by very easy stages, because we are taking a very large stride in this matter. I am sure that no doctor, no advocate of sanatorium treatment, could have had it in his mind a year ago that the Government would within twelve months come down and offer £1,500,000 for the purpose of building sanatoria and would find another million towards maintaining them. After all, the real danger of a proposal like this is that it attracts attention to the disease as well as to the remedy; but the proposal which has been advanced is that instead of finding £1,500,000 we should provide at' least another £3,500,000, in order to cope with this disease. Practically, I cannot see my way to do that; it cannot be done unless we reduce the benefits all round under this Bill—at any rate, until we have tried this experiment and see how it works out. We are trying it on a sufficiently large scale to make the results much more valuable than the results we have already obtained from sanatorium treatment in this country.
I think the right hon. Gentleman the Member for East Worcestershire will agree with me it will be possible for the Exchequer to provide another three millions 426 for the purposes of this experiment. At any rate, we ought first to see what will be the result of our present proposition. It would, of course, be very desirable if we could undertake the whole responsibility of treating every man, woman and child in this country suffering from the disease, but that is not the function of a National Insurance Bill. Still we are bound to deal with this problem. It is an urgent one. I do not know one more urgent, and although it does not come properly within the sphere of an insurance Bill to provide expenditure of that kind for those who are outside the contribution, it will have to be dealt with when the general question of Poor Law reform is under discussion. Local authorities, at any rate, are beginning to wake up to their obligations in this matter. They are spending considerable sums of money, and I believe in Ireland, during the last few years, they have built no fewer than seven sanatoria, and still they are undertaking further obligations. A number of county councils in this country are also realising their responsibilities in this matter. I am reminded by my right hon. Friend the Attorney-General that Heading has done so.
§ Mr. LLOYD GEORGE
Yes, and I have some remarkable statistics from Birmingham. I was rather surprised that the right hon. Gentleman who comes from Birmingham should have ventured to criticise sanatoria treatment, and should have used Edinburgh as an example when, at his own doors, he has an illustration of the success of the experiment he is criticising. The Birmingham sanatorium is a valuable illustration of the advantage of this system. Birmingham in this, as in many other respects, has been a pioneer on municipal reform, and it is a much better authority on municipal reform than on Tariff Reform. At any rate that shows that the municipal authorities are becoming quite alive to it. I conceive that there is a good deal of hope here: that there is a possible germ in this Bill which may fructify to something even bigger than this plan. What happens? I should like to see the system extended so that families could be cured in these sanatoria. I think there is a method suggested in the Bill which when it develops will enable us to do that. In one Clause of the Bill there is a provision that the local authorities 427 "may." There is some doubt about the interpretation of the word, but it is the intention of the Government that the local authorities and the Treasury "may" each find half of the excess which is charged in respect of the medical benefits which are administered by the local health committee. That is left purely to the option of the Treasury and of the local authorities. They can make their own terms in regard to the conditions under which they are prepared to meet it. I think that provision may very usefully be extended to sanatoria.
Plainly what would happen would be this: If it is decided to have treatment for families, and make it compulsory, you must find three and a-quarter million straight away. This is to make it optional, and I have not a bit of doubt that the local health committee and the approved societies will use these sanatoria for the purpose of curing the wives as well as the insured persons. It will soon, probably, be discovered that the accommodation is inadequate. If the treatment is successful then it will be upon the local authorities in that district to approach the Treasury with a view to getting increased accommodation to be allowed to expend more money for that purpose. The Treasury will undertake half in addition and the local authority will undertake the other half. It is left entirely to the option of the local authorities. There is no compulsion upon them. It is in the interests of the local authorities to do this, because every one, like the right hon. Gentleman opposite, who has had experience of local government in this country must know that a very considerable proportion of the expense of medical benefit now chargeable to the Poor Rate is attributable to tuberculosis. The infirmaries of this country maintained by the guardians are full of patients suffering from tuberculosis. In the Homes we get tuberculous patients staying for months, and sometimes for years, with consequent expense both in medical attendance and in maintenance. I am trying to get the accurate figures—I could not get them in time for this discussion—but what I have indicated is a source of a heavy expense to the rates. This provision will be to that extent a relief to the rates—not perhaps to the full extent of the million, but to a very considerable extent. And if it were possible to make an arrangement with the local authority whereby they could extend the 428 provisions of this Bill—they can do it under the Bill itself—then I believe it will further relieve the rates, and provide a much more effective system of dealing with cases of tuberculosis in various parts of the country.
One thing I should not like. I certainly should not like to undertake this responsibility on behalf of the Treasury merely on the assumption that the local authorities would afterwards come to the rescue. I have already had too much experience of that in connection with old age pensions. I remember when it was suggested that the benefit of the Act should be extended to paupers, I stated, on behalf of the Government, that it could be done provided the local authorities contributed the amount which it cost them. When I made that offer there was a great silence. Nobody got up on behalf of the local authorities. I never even got a resolution from any of the local authorities in any part of the country. Then, being thoroughly innocent in this matter, I proceeded on the assumption that it was thoroughly understood. Immediately every local authority in the kingdom was up in arms, and said that they had never agreed to such an arrangement, and wanted the Treasury to bear the whole cost. I am not going to be a party again to that kind of thing. Therefore, before we undertake any further liabilities in the matter, I should like to have a little clearer understanding with the local authorities, and those representing them on both sides of the House.
I hope such a suggested understanding will not degenerate into an attempt on the part of those who directly represent the ratepayers merely to raid the Exchequer. It ought to be treated as an attempt to co-operate; it should be cooperation between the local and Imperial authorities for the purpose of stamping out a great disease. I believe if it is treated in that way it can be done now. We could then not merely—and I say so advisedly—make this provision; for the purpose of dealing with insured persons, but I believe that if the local authority met this advance in the spirit in which we are making it it will be possible for us to deal with tuberculosis on a thoroughly national, comprehensive, and drastic scale. That suggestion I throw out. It may not be possible within the four walls of this Bill. If it is to be an attempt merely to abstract the sum of £2,500,000 from the Exchequer for the relief of the rates, that 429 is degenerating a great crusade against consumption into a squalid attempt to relieve the rates. That is really not to the purpose. I therefore suggest that if that can be done we shall make a very great step in advance in what is really a national campaign against consumption.
I agree with what has been said by several hon. Gentlemen, one of whom quoted Dr. Koch. I believe that Dr. Koch, in one of his published works, has said that:—Consumption is a disease of small homes.I believe that is one of his greatest sayings. It is perfectly true. In the main the disease attacks those living under conditions which do not allow them to strengthen their frames to struggle against its incipient attacks. It is therefore very largely a housing question; possibly, as an hon. Friend behind me would suggest, one of ground rents. We shall deal with that housing question to a certain extent in this Bill, but we cannot make the Bill to deal with every aspect of the disease. We can no more deal with the whole problem of tuberculosis by this system than we could with the whole question of housing. I do hope the Committee will not overburden the scheme by attempting too much. After all, that is only one step towards our purpose. It is perfectly clear that we have to go on and reform the Poor Law in many respects. I hope we shall be able to do a good deal more towards the housing problem. In the meantime I have pleasure in saying that we have had an instructive and very valuable Debate that I think will bear considerable fruit. If it be that we can ensure co-operation between all the authorities of the country, local and Imperial, who are charged with the burden of looking after the welfare of the people we shall put an end for ever to one of the most terrible scourges that inflict mankind.
§ Mr. AUSTEN CHAMBERLAIN
In the concluding words of the Chancellor of the Exchequer, I think this Debate has been amply justified, and that it will be found to have been not only instructive to us, but very instructive to other people interested in this question, and ready to deal with it outside this House. My friend and I, especially my friends on these Benches for whom I am speaking now, have listened with particular interest and satisfaction to the statement which the Chancellor has made. He has amplified his previous explanations of the 430 Bill. He has given us much further light, and has told us what is really in his mind. He has foreshadowed some small but important alterations in at any rate the wording of the Bill, which have, I think I may say, entirely met the criticisms which we directed against the Clause as it stood. After all, the main point raised by the right hon. Gentleman the Member for the Strand Division was that sanatoria should not be accepted as standing alone as a remedy, nor should their merits, however great they may be, be allowed to put into the shade other methods of cambating the disease. We are quite satisfied with the statement of the right hon. Gentleman that though this experiment of sanatoria is a large experiment it is still to be regarded as only an experiment, and not only as an experiment, but as one amongst several combating and fighting this disease. That is the main point for which my hon. Friend and I contended. We are satisfied with the Chancellor's declaration on the subject.
As regards the point I specifically raised I think I am almost satisfied by what the Chancellor has said. I hesitated about raising it because I am very reluctant, as the Chancellor knows, and as the House will have seen, to do anything which would place a great new demand upon the Exchequer at a time when the Exchequer has such great liabilities to meet, and when with the general assent of the House still further liabilities for the future are being created. The House is not only agreeing to pay much larger sums in future years, but whether it be the right hon. Gentleman or I, or some other gentleman be Chancellor of the Exchequer, we will not be grateful to the House of Commons if it overlooks the fact that whilst its benefits no doubt begin immediately some of the liabilities do not mature for a long time. What I do want to acknowledge to the Chancellor is that he has acknowledged both in his speech and in his suggestion that action against consumption must be in the nature of a crusade. It cannot be purely a matter of insurance by individuals or on behalf of individuals. We are in complete agreement that for that purpose the co-operation of local authorities with the Imperial authority is necessary. The Chancellor has sketched a means by which, in harmony with the provisions already in the Bill, but in extension of those provisions, that co-operation might be brought to bear upon this problem. I do not like offhand and on the spur of the moment to 431 say more than that I am very favourably impressed with the suggestion, and that I hope that on those lines we shall be able to arrive at such a widening of our energies and of the scope of our operations as will prove a material benefit to the country. I do not at this moment ask leave to withdraw my Amendment, because there are other Members who have a special right to speak on a subject of this kind, and who would be prejudiced by my doing so. I do not want to cut them out of the discussion, but I hope that when the Debate reaches its natural termination without undue delay, the Committee will allow me to withdraw the Amendment and not insist on negativing a proposition which was never intended to be voted upon, and which has served ins purpose in eliciting the most interesting statement of the right hon. Gentleman.
§ Mr. LLOYD GEORGE
I am not at all suggesting that the Debate should come to an end, but I do suggest that we have really covered the whole field of this particular paragraph. We can deal with sanatoria from the point of view of machinery later on. This Sub-section merely settles the benefit. I hope it will be possible by general agreement to get, at any rate, Sub-section (b) before we adjourn at —say 8.30. If this is understood, it does not matter whether we debate the question on this Sub-section or on the subsequent provision.
§ Mr. AUSTEN CHAMBERLAIN
I cannot speak for others in a discussion like this in the same way that one can speak for them in a party debate, but I will do my best to facilitate that arrangement.
§ Sir RANDOLF BAKER
I wish to ask whether it would not be possible for some portion of this money to be applied to other means of fighting consumption besides that of sanatoria. There are three distinct lines on which the disease can be fought. The first is the line of research for finding out new means of cure; the second is that of extending existing methods, and the third is that of curing people already attacked by the disease. I think the Chancellor of the Exchequer is putting all his energies into the one line of curing people who have the disease already. I submit that much might be done by preventing the increase of the disease, and, if possible, minimising it. There are two methods which might have very valuable results. The first, and I would particularly press this, is the com- 432 pulsory notification of all cases of consumption as soon as they are discovered. I do not know whether it would be possible for the Chancellor of the Exchequer to introduce a provision in this Bill making, such notification compulsory. The second method is the carrying out of experiments to find out something further about the disinfection of buildings. An hon. Member quoted a case where four separate families had been infected with tuberculosis through going into the same flat. I myself know a case in which three sons of a family were infected. The father and mother had no trace of the disease before, and they were in a house which nobody had inhabited except themselves. The eldest son developed consumption and died; the second son came home, developed consumption, and died; and the third son did the same. The house was not more than ten years old at the time; but it is supposed that the three boys developed consumption through living in that house. If it were not that, the doctors are unable to find out what was the cause. If some experiments could be made in the matter of disinfecting buildings, a great deal might be done towards lessening this terrible disease. Every Member will agree that everything possible should be done with that object.
I would also suggest that instead of building sanatoria something might be done by using tents. I know one case where a man has lived for two years in a tent in his own garden, and goes to his-work every day. The expense is ridiculously small compared with building a large sanatorium. Much might be done by a system of open-air cure in the early stages of the disease if there were some means of supplying tents in country districts and small towns, in which the people might dwell and still go to their ordinary work. The Chancellor has given most interesting figures from Germany as to the number of people who have been cured and returned to their work at the end of a year. It is said that something like 50 per cent, are able to return to work at the end of the year's treatment. What we ought to try to find out is whether those people who are able to return to work still carry sufficient seeds of the disease to infect those with whom they come in contact. Obviously, it is of no use setting up a great and expensive system of sanatoria all over the country if the cures are only partial or only as regards the particular persons treated, and if it does not prevent the disease being spread again when the per- 433 sons return to their work. I think that something might be done by research in connection with this point, and I hope the Chancellor of the Exchequer will bear these various suggestions in mind.
§ Mr. LANSBURY
May I ask whether the Amendment standing in my name, to extend the treatment to the wife or children of the insured person, will be in order?
§ The CHAIRMAN
I am considering that matter, and I will reply to the hon. Member when we reach the Amendment.
§ Mr. LANSBURY
It would be a convenience if I could know your decision, because it will decide whether I speak on the present Amendment or not.
§ Mr. LLOYD GEORGE
I should certainly submit that it would be impossible to carry out the Amendment of the hon. Member without imposing a fresh charge on the Exchequer. Therefore, seeing that there is no money at all in the Bill providing for that purpose, it could not be done without a fresh Resolution, and I shall submit when the time comes that it is quite out of order to discuss a proposal which goes outside the Bill and will involve a charge on the Exchequer of at least £3,000,000. I would suggest, if I might, that the hon. Member should put his points in the present discussion.
§ The CHAIRMAN
When the Chancellor of the Exchequer submits his point of Order I shall have to ask him how he differentiates between medical benefit and sanatorium benefit as regards the Financial Resolution. The Financial Resolution says that the State shall find two-ninths of the cost of the benefits under Part I. of the Act. I cannot differentiate in my own mind between medical benefits and sanatorium benefits in the Financial Resolution, except in this respect, that in addition to the two-ninths the State finds one-half of the extra cost for medical benefit and 1d. per person in regard to sanatorium benefit. I do not myself think at present the Amendment is out of order; but that is the point I shall put to the Chancellor of the Exchequer when be raises the matter later on.
§ Dr. CHAPPLE
I think it will be generally accepted that better results in the cure of tuberculosis' have followed the erection of sanatoria than any other treatment known to medical science. That, 434 however, need not blind us to the limitations of sanatoria. An hon. Member said the other day that sanatoria had appealed to the imagination of the people. I think we should be careful that they appeal also to our judgment. We might waste an enormous amount of money on sanatoria and get very poor results. What cures tuberculosis? It is not costly buildings; it is not sanatoria as such; it is not the therapeutic treatment in sanatoria. What cures tuberculosis is the resistance of the tissues in the person who has been infected. All that sanatoria can do is to provide the so-called sanatorium conditions; that is, fresh air, open air, good food, and rest. The question for us to decide is can these conditions be provided in any other way? Because, if they can be provided in a cheaper way we must be cautious lest we spend too much money upon these buildings, and are guided too much by the imagination of the people and too little by our judgment. An hon. Member referred to the number of cures amongst those who had gone to distant colonies. Of all the treatment that has been applied to ordinary phthisis none yields such good results as the climatic, in those countries where sanatorium conditions prevail. If people go to South Africa or some of the higher altitudes where they can live in the open air all the year round they can be cured of consumption. We "know by statistics that fully 50 per cent, of the people who die from other diseases show on postmortem examination that they have, at some time in their life, been cured of tuberculosis. We must not run away with the idea that there are no other remedies except sanatoria.
The Chancellor of the Exchequer said in his very interesting speech that there would be a selection of the cases suitable for sanatorium treatment. I should like to know how the health committee will make that selection. We have to divide tuberculosis into two great classes to see how far the cases are suitable for sanatorium treatment. We have the early stage of tuberculosis and the later stage. In the early stage of tuberculosis it is not infectious. In the early stage it is curable. In the late, stage it is infectious, but not curable. Therefore you have practically two diseases to deal with, one of which is early, non-infectious, and curable, and the other of which is late, infectious, and incurable. For which of these two great classes of cases are these sanatoria to be provided? In the one case the sanatorium would be a treatment hospital, and in the 435 other case it would be an isolation hospital. Which do you provide? I maintain that it is a very difficult thing to get a man in the early stage of phthisis to go into a sanatorium. In the first place you have to take him away from his work. We are not dealing now with rich cases where the patients can go to Australia and elsewhere. It is difficult to induce a man in the early stage of phthisis to isolate himself in a sanatorium and to leave perhaps' a young family at home. If it is difficult to get the head of a family in the early stage to isolate himself for six months or a year in a sanatorium, it is even a more difficult thing to get a young married woman, the mother of a family, to leave her home and isolate herself for treatment purposes. Until there is a discharge in a case of tuberculosis it is not infectious at all. There must be a discharge of sputum, or matter from a joint, from the glands, or in some other way from the body. It is only by the escape of germs that there is any danger at all.
In the early stage of phthisis in a mother of a family it is not infectious, and there is therefore no danger to her family. On the other hand, if you are going to make the sanatorium an isolation hospital, like a fever hospital, are you going to compel patients to be isolated during the whole period of treatment? If you get persons into a sanatorium for a short time, they soon begin to tire of institutional treatment. If the disease is in a late stage, you cannot practically do anything. I think one of the great values of a sanatorium is that the patient may be taught how to destroy the sputum so that when he gets home he will take greater care and precautions. These objections may not be vital, but they are important, and the question I am going to ask is whether there is no other simpler and less expensive way by which you would be able to arrive at the same result. I think there is. If anyone who had phthisis consulted me in the early stage, the advice I would give would be that he should emigrate at once and get sanatorium conditions—fresh air, and a climate where he could live out all night as well as all day if he liked. There is nothing so effective as conditions which develop the tissue resistance to the spread of the germs. But only a rich person could emigrate and so follow my advice. If I were consulted by a poor person in the same stage of disease, I would say, "Go to a 436 sanatorium, or live under sanatorium conditions." If you are going to have the best sanatorium conditions for the curative treatment of the disease, you want the establishment in a country district. If you want the sanatorium for isolation, you can afford to have it right in the centre of the city, for the sputum can be destroyed and made non-infectious. What I have to say therefore is by way of caution in regard to the expenditure of money on tremendous buildings which fill the imagination but which cannot be justified by the requirements of prevention. I would rather follow the course of making every infected home a sanatorium, for you can provide in every home sanatorium conditions. Not long ago a woman, whose husband had consumption at Willesden, stated that she and her husband and six children all slept in one room. That man, who was in the last stage of consumption, would have been taken away from his home, not for curing, but for isolation purposes. He had left the germs in that room where there were his wife and six children, and conditions prevailed there for the supply of consumptives being kept up.
The conditions of poverty and slum life, as the hon. Member for Blackfriars (Mr. Barnes) told us, are the conditions which are the great primary cause of tuberculosis. I think the health committee ought to be given jurisdiction over all infected houses. There should be a compulsory notification of every case of tuberculosis, and the notification, should tell whether it is an infective or a non-infective case. The health committee should be empowered to see that precautions are taken to have the place disinfected, for if that is not done, the supply of consumptives will be kept up, notwithstanding that you isolate those cases which are infective. I have an Amendment on the Paper, which would to some extent empower the Health Committee to take these precautions. My criticism, therefore, is not against sanatoria as such; I am distinctly in favour of them. I simply utter this word of caution that at least a large proportion of the money should be used to provide isolation homes for individuals, so that the Health Committee shall be satisfied that sanatorium conditions prevail, namely, fresh air, ventilation, and sanitary conditions in any particular home. They should have power to have inspectors whose duty it would be to visit the homes, to give instructions and directions, and to report to them that such 437 conditions do prevail. I think the Debate has been extremely interesting. I hesitated to speak at all, because those who had already spoken seemed to be so well equipped on the points which bear on this important subject.
§ Mr. SHERWELL
I am extremely reluctant to even appear to prolong the discussion, which may seem to have reached its legitimate limits in the speeches already addressed to the Committee; but I would like respectfully to submit that the Chancellor of the Exchequer, in the extremely sympathetic and within certain limits comprehensive speech that he made recently to the Committee, did not appear to me and to some of my hon. Friends around me to meet the vital considerations which were raised by the Amendment now before the Committee. The right hon. Gentleman the Member for East Worcestershire (Mr. Austen Chamberlain), whether by deliberate intention or not, did unquestionably raise considerations of great importance in suggesting that the benefits proposed to be conferred under this Sub-section might be more properly, and probably more satisfactorily, conferred under some other machinery than that proposed in the Bill. I may say that with that general proposition I and some of my hon. Friends emphatically agree. We have already submitted to the Committee that in the judgment of some of us the particular benefit which is proposed to be conferred on a certain set of persons by this Sub-section is a benefit which, by its very nature and because it is a great benefit, is probably one which should be proposed in some other connection than in intimate connection with this insurance scheme. I have listened this afternoon to some attempts to deal with what to me are the very strong arguments advanced for the suggestions of the right hon. Gentleman the Member for East Worcestershire that the provision of sanatoria benefits for the cure or arrest of tuberculosis is a provision which concerns matters of public arrangement rather than the private machinery of a State insurance scheme. I have listened very carefully to the whole of this Debate in the hope of hearing these arguments met. Although I recognise that the Chancellor of the Exchequer interposed an argument, I might say an almost all-conquering objection against the right hon. Gentleman's proposal when he raised the strictly financial objection. I quite recognise that it is not in the power of a private Member 438 to persist in a proposal involving the expenditure of considerable sums of public money if the Chancellor of the Exchequer gets up and says that the state of the national finances will not allow him to provide the necessary sums. But the Chancellor of the Exchequer said that this proposal was, in its very nature, experimental, and that we were not right in suggesting that because the whole community would not participate, therefore we should not deal with this provision in a tentative and partial way. That is not the position taken up by myself and my hon. Friends.
We quite recognise that financial necessity may involve some restriction of the methods, but where we are inclined to differ from the Chancellor of the Exchequer is in the assumption that the class who will benefit under his scheme are the class who most need the benefit in reference to the community at large. I recognise that the selective principle must be adopted, but I think that when the scheme is in actual operation we may find that a great force of public expectation has been disappointed, and that the very section of the community which this House would most desire to benefit may be largely left out of the scheme. My hon. Friend the Member for Hoxton (Dr. Addison) did suggest certain arguments for including this benefit under the insurance scheme rather than providing for it by the authority of the State or the duly elected local authority. The first argument he adduced was that tuberculosis is a disease which plays a most important, indeed a paramount, part in determining the claims made upon the sick benefits of the friendly societies. That may be true, but I think my hon. Friend forgot to mention the other fact that whilst tuberculosis is responsible for greater claims on the funds of the friendly societies than any other disease, there is probably no other disease which is more strictly related to industrial and domestic conditions than tuberculosis. There is no other disease more closely related to questions of housing, sanitation, factory arrangements, and factory conditions than tuberculosis. But the very problems with which it is related are problems which are of public concern. So far is it recognised in the provisions of this Bill that tuberculosis is closely related to the social arrangement and industrial conditions that you proceed at once to appoint a nominative local health committee who are expected to speed up and more or less coerce the local 439 sanitary authority. The existence of this special authority to coerce the local authority who are charged with public health and sanitary arrangements, seems to suggest most powerfully that the provision of benefit for this particular disease, of cure for this disease, is properly a matter of public and social arrangement, and should not properly find a place in an insurance scheme of this character.
The other argument of my hon. Friend the Member for Hoxton was this: In giving to the House details of expenditure of Poor Law administration, he is aware how large a part this disease plays in expanding this expenditure upon Poor Law administration. Surely that was an argument in the opposite direction to that for which my hon. Friend adduced it. The very fact that so much of the expenditure for Poor Law administration is provoked by this disease does suggest that the arrangements for the cure of this disease or the benefiting of it are properly arrangements which should have a public authority and public sanction behind them. What is the general consequence of introducing this sanatorium benefit for the cure of tuberculosis in connection with this insurance scheme? It is that you have to limit the possibility of the proposed benefit to certain persons, and you do not open up the possibility of that benefit to the community as a whole. My hon. Friend below me, in the very informing speech delivered just now, seemed to suggest further the argument that this is properly a duty devolving upon the State and the local authority acting in co-operation. He pointed out that you may divide tuberculosis into a non-infective class and an infective class. Under the scheme which the Chancellor of the Exchequer quoted it is by no means certain that more than a small proportion of persons in the infective class will be embraced in the benefits proposed by this Bill.
I confess I would much rather cut out this sanatorium benefit from the Bill as it is, with the view of making public arrangements for the public treatment of this disease, where the State should act in conjunction with the local authorities in providing the necessary treatment than persevere with this benefit in its present condition and thereby run the risk that those who most need the benefit may be excluded from the possibility of getting it. It is perfectly true that the Chancellor of the Exchequer did in the most sympathetic 440 way just now suggest that in connection with Clauses 14 and 15 it might be possible to extend this benefit, by the co-operation of the State and the local authorities. But Clauses 14 and 15 restrict the possibility of the benefit to insured persons. In hoping to extend the benefit to others who are non-insured persons under the Clauses of this Bill he may find himself face to face with this difficulty, which to my mind is insuperable, that he will be asking insured persons to devote their funds to the benefit of persons who are not insured and are not contributing under this scheme.
I agree that when you are setting up machinery to deal with the benefit in such a great public scheme of importance as this you ought to erect it on a basis which, however necessarily limited and restricted in the first instance, is such as to make development and extension easy. I am afraid that, owing to the way in which the benefit is proposed under this arrangement, the possibility of extension and development may be found not to be easy but difficult. I am greatly afraid in connection with the sanatorium benefit that one defect of the Bill which characterised other proposed benefits under this scheme is that you are in danger of devoting the resources of the State to the less needy classes of the community rather than to the classes who most properly can plead for aid from the State because they need it most. I hope in the course of the discussion for a modification of the scheme in reference to sanatorium benefits, as also with reference to other proposed benefits, and that it may be possible still to undertake such a scheme of reconstruction, as shall throw the greater part of the weight of the benefit on the side of the necessitous and poor rather than on the side of the respectable and more or less prosperous artisan.
§ Mr. COOPER
I was rather disappointed with the speech of the Chancellor of Exchequer, for one particular reason. He did not enlighten the House in the slightest degree as to the general principles on which the administration of the crusade against consumption is to be carried out. Up to the present we know only that sanatoria are to be provided, that in Germany they have been very successful, and that it is hoped that by providing them for this country they will have the same beneficial results. The Chancellor of the Exchequer said he hoped that we should in future deal with this great 441 subject on a more national, comprehensive, and drastic basis. If that is the case, surely the step we are taking at the present time should be the first great step in a comprehensive and carefully thought out scheme. We have no idea how this great benefit is going to be administered. Presumably by the Local Government Board in connection with the Local Health Committees. I think it is of some interest to point out that there is already one phase of this question dealing with consumption which the Government are making no effort to deal with. It is not, perhaps, the most important, but it is a very important point. They are taking no steps to deal with the milk supply—
§ The CHAIRMAN
We really must not go too widely at this stage. The hon. Member cannot go into that matter.
§ Mr. COOPER
All I want to say, in conclusion, is that we are left to hope that the administration of this benefit, which we do not at all understand at the present time, will, if it goes to that Department, be carried out with very much more success than has been the case in other directions where good that might already have been done has not been done for this country in tackling the disease of consumption.
Mr. MacCALLUM SCOTT
If I understand him aright my Friend the hon. Member for Huddersfield (Mr. Sherwell) has introduced an element of reality into this Amendment which was never intended to be pushed to a Division. I understood him to say that he would vote for the Amendment if he got the chance, and I certainly want to vote for it; and if I can do anything to secure that a Division shall take place I will do so. The reason for which I am supporting this Amendment is to a large extent different from that which was brought forward by the right hon. Gentleman who moved it. I agree to a very large extent with the considerations which he adduced and which the hon. ember for Huddersfield emphasised. If I understood him aright his argument was chiefly based upon this consideration, that to deal with this national scourge of consumption and kindred diseases was a national task which ought to be undertaken by the Nation at the charge of the Treasury, and it was not a suitable thing to be tacked on as an incident to an insurance scheme, which is subject to most arbitrary limits and applies to a comparatively small number 442 of people, excluding at least two-thirds of the population. Obviously the question is one which should be treated on a national scale and not on a partial and limited scale. By the treatment under this Bill you are trying to empty a trough of water with a dipper and all the while the tap is on. The women and children have practically nothing done for them in this matter of consumption. While you are emptying the trough the tap is on to its full extent and you can only keep the water down to a certain level. But that consideration alone, in the absence of some alternative national scheme, and in the absence of other considerations to which I have alluded at the beginning, will not induce me to vote for this Amendment. I believe that half a loaf is better than no bread. I am not one of those who would say that because the scheme does not do everything, therefore it must do nothing. The consideration to which I alluded at the beginning, and which has decided me to support this Amendment, is this. It follows from a remark which dropped from the Chancellor last evening. This sanatorium benefit does not apply to married women living at home, and it does not apply to children. We had this question raised in a previous Clause. The answer of the Chancellor then was, "I would be only too anxious to extend this benefit to women and children, but I have not the financial resources. I put the obligation upon you to show me where the money can be found." I think I can point out to the Chancellor the golden bridge, the royal road, by which he can extend those other benefits which we have been previously discussing to women and children. Let him omit this sanatorium benefit altogether. He will then set free the money which would have been expended upon it to be spent upon extending those other benefits which are so necessary to women and children. I put this with all seriousness and earnestness. The manner in which married women are being treated under this Bill is a foul blot upon the measure. It is a harsh and cruel injustice, and, by multiplying other benefits which will go to one class only, at the expense of married women, you are intensifying the hardship. I wish to get some of this money to be expended under the Bill on sanatoria used for extending other benefits to married women at least, and possibly to the children. Before you multiply benefits for men, at least secure that the 443 other benefits which are already passed are extended all round. Let us at least do justice to all before we are generous to some.
The question we are discussing is one which requires a great deal of consideration. If we are going to spend a, million and a-half of money in building capital, and a million a year in expenses, I think we ought to see that we get the best value we can for that large amount of money. I thoroughly agree with some Members of this House that it will be very much better if we can bring married women and children under the Bill. We have, however, to face the fact that the Chancellor of the Exchequer has so much money to spend, and the greatest care should be taken to get good value for that money. My experience of medical practice in this country has brought home to me one important fact, namely, that the most difficult thing we have got to deal with in consumptive patients is that it is almost impossible, in a great many eases, to get them to leave their homes. If you had everyone looking at the matter from a scientific point of view, and not going in for the idea of wishing to die at home amongst relations, and so forth, you might then try a large and gigantic plan of huge sanatoria in the country. What you have got to face is that in a great many cases doctors do not see the patients until the disease is well advanced and has come to a stage in which it is utterly impossible to effect a cure. We are going to spend this money on the building of huge sanatoria all through the country. They will have to be well staffed, and there will be enormous expenses attending them. I do not say that a few large sanatoria would not be beneficial. I think if you can get cases in time, cases which are curable, and not highly infectious, and send them to sanatoria, in such circumstances the patients might be benefited; but it must be remembered that it would be a wicked and iniquitous thing to send a person in the primary stage of the disease to a sanatorium where there are advanced cases. If the Government are going to have sanatoria throughout the country they must first of all make up their mind on two questions. They must not compel a curable case to go into some place where there are incurable cases. The next principle they have to consider, if they wish to work this scheme properly, is this: They will have to provide for those 444 cases in which the patients will not leave their homes under any consideration, and for cases when they come out of the sanatoria, when the patients are sent home in a dying condition, and spread the disease from the time they return until they die. I think that the method which they should take into consideration is the provision of some very small pavilions, which could be moved about from one place to another— which could be sent to a locality and where the doctor of the locality, who is treating the case, could see the patient, should he refuse to go to a sanatorium. It would be for the benefit of the patient that he should be able to obtain the use of such a pavilion, an actual house, which he could use as his home, which would have a south or south-west aspect, and which could be placed outside his home—where he could sleep at night, or could live during the daytime if he could not go to work, and where he would not be the focus of contagion the whole time to the family with whom he lives. Take the case of a man working for a £l or 30s a week in some manufactory of one of the numerous small towns in Lancashire. A man may be found to have consumption in the first stage. The doctor tells him to go to a sanatorium, but it is impossible for that man to go unless you give him 30s. a week to support his family. In nine cases out of ten the man with premonitory symptoms of phthisis absolutely refuses to leave his wife and children, and he takes the chance of getting well at home. An hon. Member suggested that a small tent might be suitable for the use of a man suffering from symptoms of the disease when he came home at night. I can assure hon. Members that phthisis does not increase during the day time in anything like the way it does during the night. Men are out working in the open air; but they come back at night and sleep in a room where the window is perhaps only a foot square, and where the wife and three or four little children also sleep. If we are going to make any real, honest, and straightforward attempt to meet this disease we must consider not only the sanatoria, but the treatment of patients in their own houses. My experience during the last twenty years or more in this country as a medical practitioner is that the workman loves his home, and he will not leave it except he is absolutely compelled to do so by the law of the land.
I would ask the Chancellor of the Exchequer not to spend his million and a-half in large buildings, which may be utterly 445 and completely useless within a few years, but to spend a good deal of it in research, in order to see whether some discovery cannot be made in this country, and not leave us to look forward to Germany, France, or some other continental country finding out a cure for consumption. I would appeal to the right hon. Gentleman to give a good deal of the money to research, and to be careful about entering upon the building of these large sanatoria. I appeal to him to try and do something at the homes of working people and help them to go on with their work during such time as they are being treated for this disease, something might be done by way of giving them these huts or pavilions which I suggest, where they will have fresh air, and, if necessary, some compulsion should be exercised in making them use those places. In that way, a person suffering from phthisis would cease to be a focus for the spread of the disease to wives and children, and some value would be got out of the million and a half of money which is going to be spent, enabling men to work, and possibly cured while he is continuing his work. Even if some better means of treating the disease be discovered in the future, there will be the advantage that large sums have not been tied up in huge buildings which might possibly not be suitable for convalescent homes, a use to which it has been suggested they might be put. I hope the Chancellor of the Exchequer will take into consideration the treatment in some way of persons in their homes. After all it is only the open air treatment that is obtained at the sanatoria. Experience of the plan of sanatoria is that a person goes to one of these institutions believing that he is going to get well, because he has got the disease in the first stage; he comes back to his home and after a very short time dies. We have really nothing definite to go upon, and any man in general medical practice in this country during the last twenty-five years must be deeply despondent at the results which have been achieved. I trust the Chancellor of the Exchequer will see if something cannot be done to continue the open air treatment at the houses of the people themselves.
§ Mr. AUSTEN CHAMBERLAIN
I think I ought to ask leave to withdraw the Amendment. [HON. MEMBERS: "NO, no."] There are other Members who have Amendments on the Paper, and it is desired by the Chancellor of the Exchequer 446 that at any rate they should deal with this Sub-section. I now ask leave to withdraw the Amendment.
§ Mr. LLOYD GEORGE
We have had a discussion of three and a half hours on this Amendment, which it is not at all intended to press to a Division, and was brought forward purely for the purpose of a general Debate on the subject. We are just at the beginning of Clause 8, and there are other Amendments which I think ought to be considered. We only want to take a further small paragraph.
§ Mr. ROWNTREE
As one who has had some experience in trying to stamp out this scourge of consumption in a large works, I confess that I am somewhat uneasy at leaving the matter exactly where it is at the present time. I am grateful to the right hon. Member for East Worcestershire (Mr. Austen Chamberlain) for raising the question in the way he has done. The fundamental difficulty that I feel is that we want a system whereby this treatment which we have been speaking of shall easily be extended, not to one class of the community, but to all classes. I do think the Chancellor of the Exchequer will not feel, in what I am going to say, that I am in any way hostile to what he has in his mind. There is no part of this Bill which has appealed more to the imagination and sympathy of the nation than this proposal as to sanatoria, and I am anxious that the arrangements should be such that their use can be extended to the right people. For instance, I am sure, when we begin to deal with this question in the way which has been suggested, if we intend to insure persons, then we must extend the benefits to the wives of insured persons.
§ The CHAIRMAN
This point is specifically raised, and I think we ought to leave the general discussion now and deal with the specific Amendment.
§ Mr. ROWNTREE
I accept your ruling entirely, Sir, but I do not think I can raise the two or three points to which I desire to call attention at any other stage. Anyone who has tried to do anything to stamp out consumption in any class of the community knows perfectly well that there are cases in which maintenance is necessary. One of the most important things in consumption is to try and keep the patient in an easy state of mind.
§ The CHAIRMAN
The question with which the hon. Gentleman is dealing does not arise on this paragraph at all.
§ Mr. ROWNTREE
I am sorry, I did not think that I was travelling further than other hon. Members have done. My point is this. I am sure the Chancellor will see that directly he has introduced this scheme public opinion will demand extension in one direction and another, and the difficulty some of us feel is that directly we suggest that certain extensions should be made that hon. Members will say, and I think with perfect force, "that is all right, but it is not insurance." The difficulty some of us are in is to see how under the system that the Chancellor has suggested you can readily get that extension to those other classes who are so in need of it. I cannot help feeling, after some of the arguments that have been advanced to night as to the way in which the municipal authorities have already begun to work in connection with sanatoria, that it would have been very much better if this could have been done on a national basis, and probably done through the local authorities. It seems to me also on the evidence that is before Parliament at the present time that the position of the children who have been inspected in our schools is of vital importance. We know that there are over 6,000 cases of tuberculosis found out in the 68,000 children that have been examined. Those children are not being treated, and those children should—
§ Amendment negatived.
§ Mr. LANSBURY
I beg to move, in Subsection (1), paragraph (b), after the word "treatment" ["Treatment in sanatoria"], to insert the words "for such insured person, or the wife or child under sixteen of such insured person."
Everything that we have heard this afternoon proves quite conclusively that consumption and tuberculosis are very terrible diseases, and that they attack all persons, young and old. We have also heard that, not only is it absolutely necessary, but that it is incumbent to treat it in its very earliest stages. I have listened to the whole of the Debate this afternoon and to the speeches of the very eminent doctors who have given us their opinions and advice on the subject. Every one of them agrees that the best thing to do is to tackle it at the earliest possible moment. As the Bill now stands there can be no sanatorium treatment or no treatment at all for the children of insured 448 persons or for the wife of an insured person. We have just practically decided that sanatorium benefit is to stand, and I think anyone who has listened to the Debate must agree with me when I say that we ought to include the women and children. The only objection there can be to that is the objection that is made against every extension, and that is that we cannot do everything at once. I venture to put against that that we ought at least to do the right thing at once, and the right thing is certainly to deal with the young persons and prevent them growing up with this disease and so being much more difficult to deal with. The other point is that the women are the mothers of the children and have to take care of the children, they have to be with the children all the time, and if there is this danger of infection, and we are told on all hands there is, then the one thing to do is to save the mothers from infecting the children. You are proposing to take away the fathers, while in their case they are only at home during a limited number of hours and can be isolated and can sleep in a room away from the children and means can be taken to prevent them infecting the family. But with the mother it is an entirely different thing. The mother must be in the home and must attend to the children if she is there, and in my judgment, and I give it very humbly to the Committee, she is more likely to infect the children than is the man, therefore to rule her out and to say that she shall not have this sanatorium treatment or any treatment at all for this disease is, I think, not starting on right lines.
I would have preferred to have gone without some other benefit under this scheme so as to have brought the women and children in. If I am asked what evidence there is as to the absolute necessity for bringing in the women and children, I can only give my own experience in the district where I live and the experience I gained in visiting practically every part of industrial England, Wales and Scotland when a member of the Poor Law Commission. In the right hon. Gentleman's own country of Wales I visited at least 100 cases where the people were suffering more or less from phthisis and tuberculosis. In every one of those cases either a child or a woman was really infecting practically the whole household. It is true that they were getting some kind of relief under the Poor Law, but the relief and the treatment that was being given was so miserably inadequate that the 449 money just as well might not have been spent at all. I saw families, not merely one or two, but scores of families, suffering from phthisis and the whole family getting infected. When we are asked to leave out of account, as we are under this Bill, the women and children, I do very respectfully put against the Chancellor's plea of not doing everything at once the plea that the children and the women are of even more importance than the man in this connection for the reasons I have already given. There is a perfectly easy method by which this could be done. The Chancellor of the Exchequer does not seem quite to realise the difficulty we are all going to be landed into with the competing authorities for dealing with children and women on public health lines. I mentioned them last night, and I repeat them again because I am determined continually to put to this House what the whole of the Poor Law Commission, both Majority and Minority, laid express stress on, and what every expert witness laid stress on, and what every chief officer of the Local Government Board laid stress on, that the one thing we were doing in England was wasting public money on so many different public services for doing the same thing, with the result of a frightful waste of public money and time.
§ Mr. LANSBURY
I want to show how to get the money for paying for the women and children. I was going to ask the Chancellor if he would consider the matter, and he hinted in his speech just now of devising some means under this Bill. I at least, as a twenty-year old administrator in local affairs, know the difficulty of making local authorities pay, but I venture to suggest to the Chancellor that it would be much better worth making an effort to do what he suggested in his speech by some revision in his Bill, so that the local health authority, together with the National Exchequer, could make such provision that every poor person shall have at their disposal all the means for getting rid of consumption that will be at the disposal of the well-paid artisan and well paid people. I do beg of the Committee to give this proposal their very earnest consideration.
§ Mr. LLOYD GEORGE
The hon. Gentleman has appealed to the Government to give this matter their very earnest 450 consideration. I can assure him that we have already done so. I had a suggestion which I outlined in the speech I made earlier in the afternoon, and I think I may respectfully suggest to the hon. Member that that would be a practical way of approaching the subject. If this Amendment is incorporated at this stage, it means committing the Government to three and a half millions before we get any kind of arrangement with the local authority. That I frankly say I could not undertake and could not proceed with. On the other hand, if the hon. Member for Bow and Bromley withdraws his Amendment that does not dispose of the question of providing sanatorium treatment for the wives and the children. On the contrary, I should then proceed with the suggestion I made originally: I have always thought it would be very desirable that the sanatoria should be used for the purpose of curing the wives and. children of insured persons. I have already made my suggestion in the matter—that we should insert the words "sanatorium benefit," when we come to deal with the local authorities, and introduce words that would make it optional out of the funds at their disposal to cure the wives and children of insured persons in those institutions. That would mean that the local authorities, I have not the faintest doubt, would do so. Under the Clause I have indicated, it would then be open to the Treasury and the local authorities to say: "Very well, we will come ofrward, and we will pay half of the excess." That I am prepared to face, but to force me now without any preliminary talk upon the matter, and without my being able to say, "If you put in £l,000, I will put in another," to force me, at this stage, to take the whole responsibility, that is an impossible undertaking, and I cannot face it; therefore I could, not go on with a matter which completely disarms me when I come to deal with that of local government. I am sure that is not the wish of the hon. Gentleman. I sympathise entirely with his object. He has asked me to make an effort in the matter. I propose to do so, and I have suggested what I think is a more practical way. I not merely sympathise with the hon. Member, but I am prepared to take a practical step towards the object that he has in view. I hope, therefore, he will not force us now to a Division, which would prejudge the question and perhaps make it out of order to deal with the matter later on.
§ Mr. HUNT
This is a very reasonable Amendment. You are not doing nearly as much for the children as you are for other people under this Bill. The women, too, have to pay until they are married, but when they are married they get no sick pay. Therefore I think it is a very small request that they should have sanatorium benefit. This is really more important to the children than to the husband, because if a child is infected with consumption you have nowhere to send it; you cannot prevent it from going to school, where it may give the disease to other children. It is the same with the wife. You have nowhere to send her. She has to stay in the house, and may very likely give the disease to her children. I think, therefore, the hon. Member is quite right in asking the right hon. Gentleman to accept this Amendment. If you send people away in the early stages of the disease, and they get better, there is a way of putting up outside shelters where they can continue the treatment. In that way I think you can do a great deal to prevent the spread of consumption.
§ Mr. CLYNES
The hon. Member for Bow and Bromley (Mr. Lansbury) may take his own course in regard to pressing his Amendment to a Divison, but if he goes to a Division I shall readily support him in the Lobby. I do not think that a sufficiently persuasive or hopeful statement has been made by the Chancellor of the Exchequer to justify the withdrawal of the Amendment. We heard in the right hon. Gentleman's speech earlier in the evening an account of his experience with the local authorities on a substantially similar question of financial arrangements. He expressed his keen disappointment at the attitude adopted by the local authorities in regard to bearing some share of the cost in the matter of old age pensions, and he told us that he had learnt a great deal from that experience. We also have learnt something. Speaking for myself, the conclusion I have come to is that we may intelligently anticipate the answer of the local authorities when this question is put to them. They will tell the Chancellor of the Exchequer that it is a matter of national responsibility, and not one in regard to which any financial liability should be thrown upon the local authorities. The Chancellor of the Exchequer's speech, to my mind, gave the mover of the Amendment the best possible reason for pressing it. There will be no difficulty in the way of negotiating with 452 the local authorities should this Amendment be incorporated in the Bill. All the appeals to them may still be made with equal force, even with the safeguard and precaution involved in the incorporation of the Amendment in the Bill. Every argument used last night in support of extending medical treatment to women and children in cases of ordinary disease apply with redoubled force to the particular ailment here concerned. Much has been made in the country and in speeches of Ministers with regard to all that is to be done with a view to dealing with the great scourge of consumption. But if we do not now deal with the position of women and children, it means that in the working of the Bill we shall have many years to wait —at least three or four—before these extended or additional benefits can in any sense come into operation. I am convinced that no more popular or useful act could be done by the Chancellor of the Exchequer than that he should now declare that he is prepared to accept even the financial responsibility of immediately providing for the treatment of this scourge of consumption in the case of women and children.
§ Mr. LEES SMITH
I had an Amendment on the Paper a good deal narrower in scope than that of the hon. Member for Bow and Bromley. I merely proposed that sanatorium benefit should be extended to the wife of the insured person. That would cost only £400,000 a year.
§ Mr. LLOYD GEORGE
(who was very indistinctly heard): The hon. Gentleman has another Amendment on the Paper, which I propose to accept. For purely sanatorium treatment, I agree it would be £400,000, but the moment you extend it it becomes a very serious charge indeed. For that reason I could not face it except in the way I propose.
§ Mr. LEES SMITH
There is power in the Bill to withdraw from the moneys of each insured person 1s. 3d. a year, to which the Government will add 1d. The right hon. Gentleman now tells us that he will accept from me an Amendment making the whole scheme more expensive. I should like, before proceeding further, to have some indication as to where the extra fund will come from?
§ Mr. LLOYD GEORGE
If the hon. Member wishes to make it impossible for me to accept his Amendment I can understand his question.
§ Mr. LEES SMITH
In any case, the statement the Chancellor of the Exchequer made just now and the new statement which he has added make it a little difficult to think out the whole position as it will be when this Amendment is accepted. I should like the right hon. Gentleman to give us an undertaking that when we come to Clause 14 we shall have an adequate opportunity to discuss the whole subject.
§ Mr. LLOYD GEORGE
(who was very indistinctly heard): I propose to add the words "sanatorium benefit" to "medical benefit," and there will be another Amendment somewhere to include women and children. If necessary, I will even recommit the Bill, with a view to getting a full discussion upon the inclusion of women and children in reference to Clause 14. I will certainly take any steps necessary to do that.
§ Mr. LANSBURY
Does the Chancellor of the Exchequer mean that in Clause 14 he is going to introduce a provision to bring in all the women and children of insured persons?
§ Mr. LLOYD GEORGE
What I said was that that would be done in reference to Clause 14. I cannot for the moment say where the actual Amendment will be, but I know it is on the Paper. I will undertake to recommit the Bill if necessary to enable an Amendment to be introduced, making the charge permissible to the Treasury in the conditions I have stated.
§ Mr. SANDYS
If the hon. Member presses his Amendment to a Division, it will be with great satisfaction that I shall support it. This question of dealing with consumption is entirely a national matter, and not in any way one to be divided with the local authorities. There is great justice in the demand that women and children shall receive adequate treatment under the Bill in connection with this disease. It is beginning at the right end. If we look after the children early in life it is probable that the demands made upon the fund in respect of them will not be nearly so great later on as they might be if they had not had a good start. Therefore, looking at the question merely from the business point of view, I shall support the Amendment.
§ 8.0 P.M.
§ Mr. RAMSAY MACDONALD
There is a doubt in my mind as to which is really the better method to pursue. The hon. Member opposite (Mr. Sandys) says that 454 he will vote for the Amendment because the charge for sanatorium treatment ought to be imposed on the State. That is precisely what the Amendment does not do. The Amendment, with the intention of which I am fully in accord, would put the charge for the treatment of the wife and children on the sanatoria fund. That fund is got together by the 1s. 3d. per head of the insured person plus the 1d. of the State. If the difficulty that will arise between the Treasury and the local authorities under Clause 14 did not exist, I would accept the Chancellor's suggestion with the greatest alacrity. If sanatorium treatment is put under Clause 14 that would relieve the insurance fund to a much larger extent than if it was put under Clause 8. I think the hon. Member for Bow and Bromley (Mr. Lansbury) would be well advised to withdraw his Amendment and let us have time to see what the effect would be. I think it is quite possible, if we carefully consider the matter between now and when we come to Section 14, we might come to some arrangement by which we could minimise the danger of an obstructive local authority or enable us to put the whole charge upon the State.
§ Mr. LANSBURY
As I do not understand the rules of procedure, may I ask the Committee to allow me to describe it as I understand it. It is that on Clause 14 the Chancellor of the Exchequer will allow some Amendment or other to be made, so as to bring in the women and children, or if necessary he will recommit the Bill to enable us to have a later opportunity of discussing any proposal with regard to them. If that is so, I am prepared to withdraw my Amendment and willing to postpone any further discussion.
§ Mr. LLOYD GEORGE
I want to be perfectly clear. I am not saying it will be necessary to do it, but if it is necessary I undertake to do it. The hon. Member for Leicester (Mr. Ramsay Macdonald) has pointed out that we are putting a charge upon the fund which perhaps it will not bear. I am afraid that only means in reference to Clause 14 that the Treasury and local authorities may take upon themselves in equal proportions any additional charge that may be involved. I still say, if we insist upon a division now the question is decided, and I cannot do what I said afterwards.
§ Mr. LANSBURY
What we wish to be able to discuss is whether it shall be "shall" instead of "may," which is really the crux of the matter. I do not want the Chancellor of the Exchequer to pledge himself, but I should like him to say whether it would be in order to discuss that.
§ Mr. LLOYD GEORGE
I should have thought the Committee would be free to give them a complete option of deciding. It lies also within the power of any hon. Member to more that it shall be compulsory.
§ Mr. LANSBURY
We know it is better to put in "shall" when dealing with the local authorities. After the Chancellor of the Exchequer has met us in this way, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Amendment made: In Sub-section (1), paragraph (b), after the words "other institutions" ["Treatment in sanatoria or other institutions"] insert the words "or otherwise."
§ The CHAIRMAN
The hon. Gentleman asks me a question which is not quite within my province. I should say it covers a good deal of it.
§ Dr. CHAPPLE
I understood from what fell from the Chancellor of the Exchequer that the words "or otherwise" cover treatment in a sanatorium or other kind of treatment, but my Amendment applies not to other treatment but to other buildings.
§ The CHAIRMAN
I had better call upon the hon. Member for Northampton (Mr. Lees Smith) to move his Amendment.
§ Mr. LEES SMITH
I beg to move, in Sub-section (1), paragraph (c), to leave out the word "Weekly" ["Weekly payments whilst rendered unfit."]
§ Question proposed, "That the word proposed to be left out stand part of the Clause."
§ Mr. LLOYD GEORGE
That is a question about business, which should really be addressed to the Leader of the House. It will be taken on Monday, I think.
§ Committee report Progress; to sit again upon Monday, 17th July.