- (1) No payment shall be made in respect of sickness disablement or maternity benefit to any insured person during any period when he is an inmate of any workhouse, hospital, asylum, or infirmary, supported by any public authority or out of any public funds or by a charity, or of a sanatorium or similar institution established under this Part of this Act.
- (2) During such period as aforesaid any such benefit which would otherwise have been payable to such person—
- (a) shall be paid to or applied in whole or in part for the relief or maintenance of his dependants (if any) in such manner as the society or committee by which the benefit is administered think fit; or
- (b) if such person is an inmate of a sanatorium or similar institution in which he is receiving treatment in accordance with the provisions of this Part of this Act, and has no dependants, shall be paid to the local Health Committee towards the general purposes thereof.
- (3) For the purpose of this section, the expression "dependants" shall include such of the following members of the insured person's family as are wholly or in part dependant upon the earnings of such person at the time when he became an inmate of any such institution as aforesaid, that is to say, his or her wife or husband, father, mother, grandfather, grandmother stepfather, stepmother, son, daughter, grandson, granddaughter, stepson, stepdaughter, brother, sister, half-brother, half-sister.
- (4) The society or committee by which the sickness disablement or maternity benefit of any insured persons is administered, may enter into any agreement with the proper officers or authorities of any convalescent home or sanatorium, admission to which is conditional on the payment of the whole or any part not less than one half of the cost of maintenance, for the payment thereto of any sickness disablement or maternity benefit which would, apart from this section, be payable to or in respect of any such person who becomes an inmate of such home, during any period for which he remains an inmate.
§ The CHAIRMAN
The Amendment in the name of the hon. Member for West St. Pancras is an alternative Clause, and cannot be moved unless the Clause in the Bill is left out. The Amendment of the hon. Member for the Oswestry Division of Shropshire to leave out Sub-section (1) seems to me to raise the question of the whole Clause, and, if so, is not in order. I may also add that I think that the discussion of this Clause will be conducted more conveniently on specific Amendments than on the Motion to leave out Subsections.
§ Mr. AUSTEN CHAMBERLAIN
I gather from what you said, Sir, that it is out of order to move the omission of Subsection (1) for the purpose of raising a discussion on the whole position of hospitals in regard to this Bill, but I should have thought that it would perhaps be the more convenient course before we go to particular Amendments.
§ The CHANCELLOR of the EXCHEQUER (Mr. Lloyd George)
I suggest that the point which I think the right hon. Gentleman wants to raise can be raised much more conveniently on his own Amendment.
§ Mr. CASSEL
On the point of Order. What is the position of the Member who wants to have Sub-sections (1), (2), and (3) omitted, and Sub-section (4) to stand? I should like to know the proper time to raise that point.
§ The CHAIRMAN
The hon. and learned Member does not propose to leave out Subsections (1), (2), and (3), but proposes to insert something in their place which is an alternative Clause.
§ Mr. CASSEL
My position is that I should like Sub-section (4) alone to remain. I have moved alternatively to omit each of those Sub-sections, and, assuming that they stand, to amend them. If you look through the Paper you will see my Amendments. I am quite ready to take up the matter at any time or at any point it would be convenient.
§ The CHAIRMAN
The Amendment as to Sub-section (1) practically raises the question of the whole Clause. The hon. and learned Member has put down an enormous variety of Amendments to this Clause which makes it impossible to make out what he desires. I have to take the matter as it stands, and his Amendment did seem to me to amount to a new Clause altogether, and that is the reason I say it is not in order.
§ Amendments made: In Sub-section (1) leave out the words "in respect" ["in respect of sickness"], and insert instead thereof the words "on account."
§ After the word "to" ["benefit to any insured person"] insert the words "or in respect of."40
§ Leave out the word "insured" ["any insured person"].
§ Leave out the word "he" ["when he is an inmate"] and insert instead thereof the words, "the person to or in respect of whom the benefit is payable."—[Mr. Sherwell]
§ Mr. POLLOCK
I beg to move in Subsection (1) to leave out the words "or by a charity."
I desire to move this Amendment in order that we may have further information given to us by the Chancellor of the Exchequer. It is not easy, as the matter stands at present, to understand why these words should be in the first Sub-section which provides
"No payment should be made in respect of sickness, disablement or maternity benefit to any insured person during any period when he is an inmate of any workhouse, hospital, asylum or infirmary, supported by any public authority or out of any public funds …."
That obviously appeals to one's common sense, but the question that is raised is somewhat different when we come to the words, "or by a charity," because if the insured person is fortunate enough to secure the support of a charity during the time when he is, or ought to be, enjoying the benefits which his payment of his insurance premium earned for him, then it is not quite easy to see when public funds are not being used for his maintenance, and when he is not in any asylum, or infirmary, or sanatorium, or any institution which is carried on by public funds, why he should lose the benefit which he has contracted to receive for the contributions he has paid. The words "or by a charity," I submit to the Committee ought to be left out unless some justification is given for them. I know that Sub-section (2) provides
"during such period as aforesaid any such benefit which would otherwise have been payable to such person (a) shall be paid to or applied in whole or in part for the relief or maintenance of his dependents (if any) in such manner as the society or committee by which the benefit is administered think fit, or (b) if such person is an inmate of a sanatorium or similar institution in which he is receiving treatment in accordance with the provisions of this part of this Act and has no dependents, shall be paid to the Local Health Committee towards the general purposes thereof."
41 4.0 P.M.
I understand the Chancellor of the Exchequer intends to submit some Amendments to deal with this position, and that he is prepared and intends to make it possible that during the time the insured person is in receipt of the benefits of a charity that some of the money which would otherwise go to dependents would go to the charity. If that be the arrangement then the charity is to a large extent in the same position as other institutions in which an employed person may be for the time being an inmate, and if so, it may be that harm would be done to the charity or to the employed person. If that is so the vast charitable resources of this country which are expressed in the form of hospitals and other institutions, and the employed persons are suffering. Many of us are anxious on all sides of the House as to what the position of the hospitals would be when the Bill is passed. All of us must realise that a great many of those noble and charitable institutions are carried on upon small funds which are received from persons who are in the category of the employed persons who would be receiving benefits under this Bill. If these sources of income were taken from them they would be in a very perilous position. What we fear is that the position of the charitable hospitals might be undermined, and if we do not see what the future of the hospitals is to be, I think we shall deservedly raise the point in this House in order that it may be dealt with by the Members of the Committee, many of whom are deeply interested in hospitals and their management, and all of whom, I am sure, are deeply concerned with their welfare. I move the Amendment in the hope that the Chancellor of the Exchequer will make plain what he intends by not only the first Clause but by the whole Clause after his Amendments have been incorporated. I think I have said enough to show the importance of the matter and the importance of having a clear indication from the Chancellor of the Exchequer.
§ Mr. AUSTEN CHAMBERLAIN
I assume that the Chancellor of the Exchequer will prefer to have the Debate developed before he replies. In very few cases have I put down Amendments in addition to those appearing in the names of hon. Members, but in this case I felt so strongly that I took that course, this being one of the points to which I called the attention of the House when the Bill came up for Second Reading, and one, I think, to which 42 the House should give its serious consideration. The Chancellor of the Exchequer said on that occasion, I think, and certainly he has said since in reply to a deputation, that we should be encouraged by the example of Germany, which had dispelled our fears that any misfortune or injury will happen to the hospitals in consequence of the passage of this Bill. I have to admit I have no knowledge about the German hospitals, and I have not even known where to go in order to get it, and therefore I am not at all prepared to deal with the point as regards that country. But I was under the impression that the great bulk of the German hospitals were rate-supported hospitals, largely maintained by public funds, and only partly, and to a small extent, dependent upon private subscriptions and donations, Whether that be so or not, I really do not think that in a matter of this kind the example of Germany gives us either light or guidance as to what would happen in this country. Our voluntary hospital system is an old-established one, it has been of slow growth, it has gradually developed, and it has been largely encouraged by private effort in recent years, whether taking the form of Hospital Saturday and Sunday collections, or in the case of London, King Edward's Hospital Fund, which has done so much for the institutions in the Metropolis.
I think it must be clear to anyone that these institutions, which have been largely dependent upon the voluntary subscriptions of the workers and employers and the like, cannot expect to receive, at any rate, to the same extent, that class of help in future, when the State steps in and taxes both the workman and the employer in order to provide that which hitherto the workman has had to provide for himself, or to receive from these voluntary institutions. I think it must be clear that, not only they cannot expect to receive the same amount of support from the public in future, but that individual hospitals will be very differently hit by the results. Where they are in the main supported by endowments they will have much less to fear. In those places where the Hospital Saturday collections have been largest they may expect to lose more, for when you have compulsory levied a charge of 4d. per week upon every workman it is hardly to be expected that he will voluntarily devote an additional 1d. per week, as he has been accustomed to do in the works of many of our large towns, to the support of institutions of the character 43 which we are now discussing. I have received information showing that the probable effect of the Bill will differ in the case of different institutions, and very likely in different parts of the country. I have received some information from a meeting which represented, I think, forty-four hospitals in the Midland counties. They calculated, averaging out the whole of these institutions, that over 50 per cent., I think I might put it at 60 per cent. —I am sorry I left the exact figures behind me—but, at any rate, over 50 per cent. of their entire income was liable to be adversely affected by the Bill, and in many individual cases of hospitals, within that area, the proportion so affected rose up to 75, 80, and even 90 per cent. If you take the average it is already sufficiently serious. All these institutions have difficulty in maintaining their activity and keeping the number of beds open to the public, which are required by the communities whom they serve. There is a difficulty of getting subscribers, especially new subscribers as the old ones pass away, and that has undoubtedly increased of late the tendency under the imposition of other burdens, for both subscriptions and legacies to fall off.
In these circumstances it is not to be surprised at if the managers of these institutions view their prospects under the Bill with something like dismay. But I want to remind the Committee that, quite apart from the immediate beneficent work done by the hospitals for people who have gone there to be treated by the careful nursing and surgical skill and the services which they receive, there is another great service to the public which these institutions fulfil and which cannot be fulfilled by anything but them, and that is the training of the whole medical profession of the country. They are dependent upon the experience which they get in the hospitals for their training, and we are dependent on the experience they get in the hospitals for the progress of medical and surgical science. If anything goes wrong with the hospitals in consequence of the passing of this Bill and the resources at their disposal are insufficient for their work, it is not merely individual institutions or a great number of institutions that will suffer, it will be the whole community, directly or indirectly, that will be losers by the loss to the hospitals. I had suggested, and, in fact, proposed by an 44 Amendment of mine, that where an insured person became an inmate of one of these institutions supported by voluntary contributions—by which, of course, I intended to mean supported partly by voluntary contributions, and not necessarily wholly, because most of them have some little endowment or other resources— where an insured person became an inmate of one of these charitable institutions that if he had no dependent the whole of the money due to him as sick pay should go towards his maintenance in the hospital, and if he had dependents the money which was due to him as sick pay should be divided between the hospital and the dependents. I think that that is the very least it is possible to contemplate if we are to maintain those hospitals in their present position. I am sure also it would be natural to suggest that the medical benefit due to the insured person should be payable to the hospital. But, as I understand the scheme of the Bill, the medical payment would be due to the doctor who first certifies him as ill, and will not be available for the hospital to which he may be sent by that doctor.
Without a very large alteration in the scheme and without knowing what arrangements are involved in the remuneration of the doctors by the patients out of hospital it is quite impossible to put down Amendments dealing with the medical benefit. But there is another alternative. The Chancellor of the Exchequer has reserved a large lump sum from the contributions of the insured which he proposes to pay for treatment in sanatoria. Though it may eventually develop so as to include treatment for other diseases it is quite obvious that in the framing of the Bill it was intended to be treatment of consumption and tuberculosis only. I had expressed before now a strong doubt whether that is the best way of spending such a large amount of money. I believe a much less sum spent in close connection with the local authorities in home work would go a great deal further than this vast sum lavished on sanatoria, and, in any case, I think it would be a fair thing, if the Chancellor is unable to find more money for this purpose, to take a portion of the money which is now allocated for sanatoria and allow it to be allotted to hospitals whose need is proved and whose efficiency is proved, by some impartial central authority. What I had in my mind in making a suggestion of that kind was some such committee and some such regulations as were framed for the 45 administration of grants to university colleges. I was extremely sorry to see that the Chancellor of the Exchequer had consented to hand over these grants from the Treasury, which had administered them extremely well, to the Board of Education, in which I have not the same confidence as I have in the Treasury.
§ Mr. LLOYD GEORGE expressed dissent.
§ Mr. AUSTEN CHAMBERLAIN
You have not. I am very glad to hear that. I read it in the papers, and rashly concluded it was a fact. The manner in which that fund was administered by the Treasury was primarily on the advice of a committee which was appointed to see that these university colleges are doing work of a university character, looking to their needs and looking to the extent of the local effort which is being made in support of them. The grant from the Treasury is awarded and allocated among them having regard to these facts. I think it would be possible to do something of the same kind for the hospitals, and to take a lump sum out of the money which is at present allocated to sanatoria and entrust that lump sum to a committee for allocation amongst the hospitals, a small committee which would allocate it on certain definite lines, taking into account the need of the institution and the value set upon that institution in the locality in which it was placed, as evidenced by the contributions which are locally paid to its support. That would, I think, help to encourage local support, instead of stifling it, and would put these institutions on a secure basis. If that be not done, and done on a generous scale, the only other plan is that for each man sent to a hospital for hospital treatment, there should be a payment out of the National Insurance Fund. The Chancellor of the Exchequer has spoken as if the hospitals would be relieved of much of their expenditure. I do not think that that will be so. You may possibly, and I hope you will—though many good hospital authorities do not share that feeling very profoundly—eliminate from hospital cases a certain number of out-patients who never ought to go to hospitals at all, who are competent to find for themselves the kind of treatment they require and are not fit objects of the charity of hospitals. But you will leave the hospitals with a vast amount of work, and you will probably have under the medical system to be established by the Bill not fewer, but more, 46 cases sent by the doctors to the hospitals for treatment. The moment you insure all these millions of people, and have a small per capita contribution for the payment of the medical officer who has to give medical treatment, the tendency in any case of a serious or prolonged kind will necessarily be to send that case to a hospital. In any event, the more serious cases will still go to hospitals. The resources of the hospitals under these circumstances will be taxed quite as heavily in the future as they have been in the past, and they will not be able to expect to discharge their duties on less funds than they have hitherto had.
I submit to the Committee and to the Chancellor of the Exchequer that the Hospital Saturday Fund, mainly contributed by working men, producing in the City of Birmingham something like £20,000 a year, not all of which goes to the hospitals, some going to sanatoria and convalescent homes, but of which something like £10,000 goes to hospitals; the Hospital Sunday Fund, contributed largely by employers; the subscription lists, again in the main the result of contributions from employers, will all be adversely affected when you compulsorily tax both employers and employed in order to secure medical treatment. You cannot expect these people, if they are compulsorily taxed for these purposes, to maintain their voluntary subscriptions at the same rate as in the past. I have made certain inquiries and I find that hospitals are already receiving letters announcing a diminution of the support they have hitherto had I have spoken to several people connected with hospitals in the difficult and thankless task of bogging for them, a task which has always to be renewed, because old subscribers fall off and new subscribers have to be found to take their places, and all have told me that it has been increasingly difficult to fill up the places of old subscribers within the last few years, and that under this Bill they think it will be absolutely impossible to do so.
There appeared on Saturday in the name of the Chancellor of the Exchequer an Amendment dealing with this subject. I do not renew my protest against the late hour at which the Amendment has appeared on the Paper. It is better to have an Amendment on the Paper on Saturday for discussion on Monday, than to have it only on Monday or to hear it for the first time when it is read from the Chair. But between Saturday and now there has been 47 no opportunity for most of us to confer with those with whom we have hitherto been in. correspondence on these subjects, or to take their advice. I only say for myself, therefore, that the Chancellor of the Exchequer's proposal seems to me absolutely inadequate for the protection of the hospitals. Whether they are to get anything or not depends, under the Chancellor's proposal on whether the persons have any dependents of any kind—not merely whether they have a wife and children of their own, but whether they have any dependents however remote. If they have any dependents, however remote, they are to get nothing out of the insurance fund. It is only if they have no dependents at all that they will get any payment from the insurance fund. I think that that is wholly inadequate, even when coupled with the proviso which appears in Clause 17 that an approved society may make a voluntary contribution to such hospitals. You cannot leave this matter to the voluntary action of the societies. You are disturbing an arrangement which has worked well, thanks to the ceaseless efforts of the men who, as governors of the hospitals or as medical officers, or consultants of the hospitals, have given a vast amount of unpaid and unrewarded public service to their fellows, in this particular form. You upset that arrangement, you jeopardise the fund on which they have already drawn, and I think you are bound in the interests of the institutions, in the interests of the medical profession, and in the interests of the progress of medical science, to make adequate provision in the place of the funds which are now to be withdrawn.
§ Mr. LLOYD GEORGE
The right hon. Gentleman opposite has made a very valuable contribution to the discussion of a very important part of the great problem of national health. It is quite obvious that no system which has for its object the promotion of the national health can possibly be complete if it impairs the vitality or the efficiency of the great hospitals of the country, and it is of the first consequence that in carrying through a scheme of national insurance we should do nothing that would have that effect. I think I shall be able to satisfy the Committee not merely that in the Bill as it is there is no real justification for the fear in the minds of a great many of those who are engaged in hospital work, but that by the Amend- 48 ments of which we have given notice the slightest shadow of fear has been dispelled. I will give the Committee, first of all, the reason why I think the alarm generally and naturally felt by those who are engaged in hospital work has no foundation in fact.
What will happen under the Bill? The first thing that will happen is that hundreds of thousands—I am not sure I should not be right in saying millions—of outpatients will be transferred from the charge of the hospitals to the charge of the Insurance Fund. I had an important deputation last week from the hospitals of this country, and Mr. Holland, who has done a vast amount of excellent work in this sphere, who has really devoted his life to it in the most self-sacrificing way, was telling me that there were about a quarter of a million of out-patients in connection with the London Hospital alone—I think the number was 220,000. I asked him as to the class from which they were drawn. He told me that they never took them from the class who would naturally resort to Poor Law relief to begin with. Therefore they were not undertaking the work of the medical officers of health, the workhouse infirmaries, and the parish doctors. On the other hand, they were not undertaking the work of those who, in the judgment of the hospital authorities, are so well off that they could well afford to pay a doctor themselves. Therefore, the out-patients are drawn either from low paid or very moderately paid labour, or from well paid labour with a heavy family charge, who in the judgment of the hospital authorities could not pay the ordinary medical charges. That is the very class affected by this insurance. It is just the class outside the six million friendly society and trade union members who make provision for themselves now, and who consequently would never become hospital out-patients, and the pauper class. What would happen under this Bill? Every one of these would be entitled to a doctor. It is true that they may prefer the hospitals. I was told that they go to the hospitals very often because they prefer the hospital doctor. But in that case I think the hospital authorities would be entitled to say, "Are you insured? Have you not got provision for medical attendance under the Bill"? I think they would be entitled to rule them out. Where there is a free choice of doctors they cannot complain. That will relieve the hospitals of a very heavy charge which is now cast upon them.
49 The second thing I would point out is that a very heavy charge is incurred by hospitals in connection with the cure of tuberculosis in various forms—not merely consumption, but other forms of tubercular disease. That represents a very heavy charge. The hospitals have to keep these patients a very long time, and the charge is out of proportion to the number of patients. Under the Bill you have, first of all, £1,000,000 provided for that specific purpose—a purpose which at the present moment is very largely a charge on hospital funds. The right hon. Gentleman (Mr. Austen Chamberlain) says very properly, "I hope you will not confine that provision to sanatoria." As he knows, in a recent debate—one of the most useful debates we have had in the course of the Committee stage of this Bill—the measure was altered in such a fashion as to apply to the cure of tuberculosis, not merely by sanatorium treatment, but by other methods of treatment as well. That makes it still more useful as a relief of the charge on the hospitals. The right hon. Gentleman himself made a very significant and interesting statement. He said that out of £20,000 collected by the friendly societies in Birmingham—I understand that they undertake the organisation of the collection, but the point does not really matter—only one-half went to the hospitals, the rest going to sanatoria. That shows what a very important relief this provision must be in the future to the charge at present borne by funds of that kind.
§ Mr. AUSTEN CHAMBERLAIN
I am afraid that when I spoke of sanatoria in connection with the Birmingham fund I misled the Chancellor of the Exchequer. I did not mean merely consumption sanatoria, but convalescent homes and institutions of that sort.
§ Mr. LLOYD GEORGE
To that extent at any rate, it would be a considerable relief; and even in regard to the other part, there is a provision for convalescent homes in the Bill as well. Really, I think the hospitals, if I may say so, are taking rather too one-sided a view of the matter. They are looking only at the increased charges and the possible diminution of subscriptions; they are not looking, on the other hand, at the diminution of charges and the new sources of revenue that will be opened up. The treatment of consumption will undoubtedly represent a great diminution of charge. I will come to the other point. I do not see why the work- 50 men should subscribe less in future. The subscriptions in the main come from those who are members either of friendly societies or of works clubs, because although friendly societies do give a man some sort of medical treatment they do not make any provision or hospital treatment. Accident treatment is outside the ordinary medical treatment provided by the friendly societies. Therefore friendly societies have got to make some effort to provide hospital treatment in addition to ordinary medical treatment. That is exactly what happens —with this exception—and the same thing applies to works. Take an ordinary works' club. The men pay 3d. or 4d. a week for the family doctor, but they collect an extra penny for the hospital. What happens in the future under this Bill? The man who is paying 6d. will in future pay 4d. for benefits. Sometimes those who pay 7d. and 8d. will pay 4d. At any rate, they pay less in the future.
What I want to point out is this: that at any rate there is no reason why the man who is now paying the extra 1d. towards the hospitals when he is paying 6d. for medical treatment should pay less in future towards the hospitals because he is a member of a friendly society. On the contrary, there is every reason in the world why he should pay more. As a matter of fact I do not think he will pay less, but that he will pay more. The same thing applies to those who are in work, referred to by the right hon. Gentleman (Mr. Chamberlain). In most of those works they have a works doctor, and this in addition to helping to keep up the hospitals. There is a reason for that. When you come to accidents you have to resort to hospitals. Therefore they have to make provision for accidents, and for operations, which cannot very well be performed in a man's own house. They are also paying that now in addition to medical treatment. The same thing will happen in the future —with this difference: that the man will have to pay less for his friendly society, and therefore will have more to give to the hospital.
When you come to the employer, I agree with what the right hon. Gentleman says, that the employer is paying something for the first time that he was not paying before. "Therefore," ho says, "he will subscribe less." He will not! That is the very thing which is always put forward in this connection, but it is one which never works out like that. I will take the case of a Bill piloted through the House by the right hon. Gentleman's distinguished 51 relative, that of Workmen's Compensation. I was a firm supporter of that Bill. I voted for it. I never made a single speech on it. I considered it a very valuable measure. What happened under that Bill? There were enormous charges cast on the employers, especially those who owned collieries. Many colliery owners at one time really firmly believed that that measure meant ruin to them. They believed it. They said so. Many Radical Members thought so, and if they thought so what on earth did the others think? I can well understand their feelings, because it increased for the moment their charges very considerably. They said: It will damage the infirmaries. I do not believe there is a single colliery infirmary throughout the kingdom which received a smaller contribution from a colliery proprietor since that Bill became law than before, although since that time colliery owners have paid hundreds or thousands a year in respect of the working of that measure. So that really there is no danger that the employers this time will not discharge what they regard as a very fair obligation to their workmen by subscribing in the future to hospitals.
The right hon. Gentleman the Member for St. George's (Mr. Lyttelton) is very anxious that I should refer to what he said as to pointing out new sources of revenue. I will tell hum what the new sources of revenue are. But first of all, there is consumption. I do not rule out the suggestion of the right hon. Gentleman that there might be some sort of committee to dispense that sum of money in some sort of way. I think the Local Government Board will see to that. I do not express any opinion as to whether their protection will be adequate. I will come to the other sources of revenue. The first is the subscriptions by the approved societies. I think that should extend to the local health committees as well. I think they also should be in part subscribers. Of course there is no power of compulsory levy. Still the power of subscription in itself will be a valuable one. If the hospital funds are going down, and if there is a danger of that hospital being closed, or any number of beds being closed, or not being used, I think it will be in the interests of the societies in that district to subscribe. I know it is said they generally subscribe very liberally; that perhaps, on the whole, we should not depend too much on the 52 number and volume of these subscriptions. But I attach much greater importance to the Amendment of the Government than the right hon. Gentleman does with regard to the payment of sick pay to the hospital of those who have no dependents. It means that in the case of the vast majority of bachelors who happen to go to a hospital 10s. a week will be paid for the first three months. It means in respect of others who go that there will be a considerable contribution to the funds of the hospital, and this is a perfectly new source of revenue which the hospitals have never been able to look to before. The right hon. Gentleman says: "Well, but in the case of those who have got dependents you ought to levy a certain contribution on those as well." I have got quite an open mind upon that subject, and I would rather express no opinion upon it until we come to the Amendment. For the moment, at any rate, I may tell him what is in the mind of the Government, which will just bear out what is said upon the subject. In Germany that is the arrangement. Whenever a man goes to the hospital there a certain contribution goes from the sick fund.
§ Mr. LLOYD GEORGE
That is the arrangement made, I think, with the approved society. I have not got that in my mind at the present moment. I am on another point now. I am on the point of something being paid when a man has dependents. In Germany they have divided the contribution, and half goes to the hospital. I do not know whether the right hon. Gentleman has not got the German plan in his Amendment. All I want to say is this: I think those who are in charge of the hospitals are exaggerating the danger. Certainly they are overlooking very considerably the diminution of the charges. They are at the same time overlooking the possible new sources of revenue. Therefore, there is no real reason to suppose that the hospitals will be worse off. On the contrary, I think the hospitals will be very much better off than in the past. Above all, for this reason: everything is to be gained by exciting a new interest in national health. For the first time you organise national health; 53 you get fifteen or sixteen millions of people who join societies for considering the best method of promoting national health. Hospitals, which are an essential part of any system for promoting national health, must necessarily improve their position by this new interest which is thus excited.
As I have been somewhat concerned in hospital management in London for many years, and am the treasurer of the Hospital Saturday Fund, perhaps I may be allowed to say a few words on this question. The Chancellor of the Exchequer will forgive me if I say that he is very greatly under-rating the hospital grievance. The State is not only knocking at the door of the hospital. The State is entering the door, and is forcing far more work upon the voluntary hospitals, for which it refuses to pay. In fact, under this Bill as it stands our voluntary system of hospitals, I verily believe, becomes impossible to work. I will take the Chancellor of the Exchequer's arguments one by one. He says that there is no reason to believe that the subscriptions and resources of hospitals will be diminished. That is not the opinion of the King's Fund. It says in the report—the right hon. Gentleman has had it in his hand— most distinctly that the governors of that fund, representing the whole of the hospitals, and, to a certain extent, controlling them in the Metropolitan area, believe that the resources will be considerably diminished. It is not the opinion of those who actually work the hospitals. The right hon. Gentleman quoted Mr. Sydney Holland. He might also have referred to officials of the hospital who have not been quoted, and who come to one conclusion. As he wants facts, perhaps he will allow me to read the copy of a letter received by one of the London hospitals from one of the larger employers at the East End. In reply to an application for a subscription, they say:—We have this morning received your letter asking for a subscription to the London Hospital. We are sorry to say that we are considerably reducing our subscription list, and we are unable to undertake fresh burdens in this way.After referring to the Income Tax and the rates, the letter proceeds:—We are now faced with further burdens under the proposed Insurance Bill. We regret we are unable to help you. We think other manufacturers will feel as we feel.That is only one out of many letters received, and the truth is——
Yes. This application was for a continued subscription, and this letter was supplied to me by the secretary of the hospital. That is only one example, and there are others I could quote; but I will not weary the Committee with them. The right hon. Gentleman should recollect that this is not only a question of the subscriptions of employers, but, as he has mentioned, the subscriptions of workmen. In London the working classes do not bear a large proportion of the expense for the upkeep of the hospitals. [An HON. MEMBER: "Oh, yes."] No, not in the Metropolitan area. They only bear, perhaps, 12 per cent. of the whole. Outside London it is different; the figures, the proportion, are reversed. It is utterly impossible to imagine that the same amount that is coming to the Hospital Saturday Fund out of the urban districts round about, which is now collected and forwarded to the hospitals, will be the same as in the past. The hospitals do not believe that there is going to be any great relief in one way suggested by the right hon. Gentleman. The King's Fund say that the sanatoria benefits will not relieve the hospitals to a large extent. The London hospitals are of that opinion too. They do not think that the means of dealing with consumption under the Bill will have much say in reducing hospital expenses. In fact, all the authorities who are able to judge are of opinion that the funds are bound to fall.
I quite admit that the London hospitals have other resources. There are large endowments and landed estates which make the subscriptions of the majority of them of less importance than in the provinces. The London Hospital, which is the greatest of all, and which ministers not only to the whole of the East End of London, but to the contiguous counties, and is really a national hospital for the eastern part of the country, draws as much as two-thirds of its income from voluntary subscriptions. The Chancellor of the Exchequer anticipates that something substantial will be gained from the permission given to the friendly societies and to other bodies under the Bill to subscribe. But there the proof is against him. Those powers, of course, exist now. Out of £85,000 sent every year to the London Hospital only £50 came from the friendly societies. That is a fact worth a great deal of theory in the matter; and it shows how little the mere permission given to approved societies under the Bill 55 will come to. The right hon. Gentleman very much underrates the amount of the work which will be put upon the hospitals under the Bill. He says: "You are going to relieve the out-patients' department of a vast amount of expense." He knows very well that the out-patients cost comparatively little compared with the in-patients; that the amount is something like 2s. 2d. compared with £5 10s. That is about the proportion, and therefore it is not a very great significance, but even then the figures given by the London Hospital, which is the biggest, shows that only 36 per cent. of those who come as out-patients are within the four corners of the Bill. The rest are women, children and persons out of employment who are not brought in under the Bill. I do not know whether the right hon. Gentleman has considered these figures. Only 36 per cent. come under the Bill at all. If that is so, we have only that margin to draw on. Then you must allow for those who prefer to go to the hospital because of the superior treatment given there, and it is doubtful whether even in regard to the out-patients department there will be a very great saving. In late years hospitals have appointed almoners, who make it their business to go into each department and see that persons who have the means to pay and who ought not to claim sick relief, do not have the advantage of public charity. Those almoners have not been at work very long but they have achieved good results, and in that respect they are doing a great deal to make it unlikely that the burden will be very much lighter in respect of outpatients.
When you come to the in-patients and serious cases, I am convinced that the work of the hospitals will be enormously increased under this Bill. My opinion is worth very little, but that is the opinion of the King's Fund and the Central Hospital Board. You are proposing to doctor the whole community. You are going to treat the whole people for the first time, and for the first time you are going to recommend women to have the sort of operations that have been only possible, or at any rate have mostly been attempted, in the case of the well-to-do as a rule. And there is no doubt that the number of serious operations will vastly increase in consequence of the increased care and solicitude given to the health of the people. I am all with the right hon. Gentleman; it is a great thing that it should be, but why should you behave in 56 so stingy a way; and it is not so much a question of stinginess. Why should you diminish the help to the hospitals when you increase the amount of work placed upon them? The Chancellor of the Exchequer will feel that the general practitioner will hasten to refer all serious and doubtful cases to the hospital. If he has a case of any difficulty he will send it to the nearest hospital for treatment, and the fact that you are going to increase the area of medical attendance to such an extent and the fact that you are going to see so much more closely after the health of the people makes it certain that the expenditure thrown upon the hospitals will be increased, and you provide no means whatever to meet that.
The Chancellor of the Exchequer has already told us that in Germany that matter is dealt with by clubs and associations formed under their scheme; they make, so far as I understand, their own arrangements with the hospitals and pay for the work done, and that is what I recommend with great diffidence to this Committee—that for work done payment should be made to the hospitals. This is not a Bill to subsidise doctors or any other class; it is a Bill to secure national efficiency, and if you are going to use the hospitals to a greater extent for that purpose why refuse payment? I quite admit it is not a question whether you behave with generosity. That hardly matters. The question is: Are you not going to diminish the means of the hospitals while you are making a greater call upon the devoted skill of the surgeons and the doctors? Are you not going to make it more difficult for people to be treated? The diseases that afflict mankind are not fought in the homes but in the hospitals, and the experience gained in the hospitals goes to abolish them.
The right hon. Gentleman will be the last to underrate the work of the medical schools. That work has to be maintained. There never was better work done than is being done now; inquiry was never so fruitful as to-day, and there never was a time when we were so close to the threshold of great discoveries for the benefit of mankind as now—and (hat now should be the last moment to choose for crippling hospitals in their work. The doctor deals with the individual man, the hospital deal with mankind and the diseases of mankind at large. The right hon. Gentleman may say that is rhetoric, and he will want to know what practical proposals I have to lay before the Committee for deal- 57 ing with the matter. I say you should make it obligatory on the Health Committee to pay for the work done in the hospitals, and if you like, of course, to adjust the burden as between them and the general practitioner. I am well aware that the right hon. Gentleman has great difficulties with the general practitioner.
There is a well-founded belief that hospitals do take away a good deal of the work that might be done by the general practitioner and that would bring well-deserved earnings into his pocket. The hospitals have dealt with that themselves. The fact that they are employing these almoners of whom I have spoken has diminished the undeserved relief given by hospitals at the expense of the general practitioner, but even though the general practitioners do object—and I have nothing to say against those who labour with such zeal and such sacrifice among the poor in the East End of London and in the working-class districts—I do not think you ought to sacrific the public advantage and benefits to the interest of any particular class of people. I believe the difficulties are capable of adjustment, but if the voluntary system of hospital management and hospital relief is to go on and to increase and fructify, and I believe on the whole it is the best ever devised from the point of view of public health and scientific research, then you are bound to make some other arrangement than that under this Clause of the Bill. I venture to lay these arguments before the Committee because they are founded upon facts and are known to every Member who has studied the problem, and I hope the Chancellor of the Exchequer will not say he has given a final answer in the words he used in his reply just now. I trust that the principle may be payment by results for work done by the hospitals as it is to others concerned with the public health.
§ Mr. AUSTEN CHAMBERLAIN
I understand from the Chancellor's speech that he would be favourably disposed to consider an Amendment of mine on line 37, page 28, of the White Paper. I want to know if it will be possible for me to move that Amendment if the Amendment now before us is negatived?
§ Mr. LLOYD GEORGE
I think it will be quite possible. I should think it would be quite in order for the right hon. Gentleman to move an Amendment providing that half the money should go to the hospitals.
§ The CHAIRMAN
I do not see why the right hon. Gentleman's Amendment should not be moved, even if this was negatived.
§ Mr. JONATHAN SAMUEL
I do not know whether the present Amendment is to be withdrawn, but it raises a very important matter which ought to be considered before the right hon. Gentleman (Mr. Austen Chamberlain) moves his Amendment. I listened very attentively to the speech of the right hon. Gentleman opposite, and I think he is under a misapprehension with regard to our hospitals. I am not speaking now of London, because if we are going to legislate for London we must have a separate Clause in the Bill for London. I am speaking more on behalf of the provinces. Practically speaking, we have three classes of hospitals in the provinces. We have a fever hospital and a small-pox hospital dealing with infectious cases, and we have a surgical hospital. With regard to the first two they are maintained out of the rates, and they are for insured persons as subscribers for the maintenance of those hospitals, and if such subscribers become an inmate of these hospitals for typhoid fever, scarlet fever, small-pox or anything of that kind they are entitled to benefit under the Bill. I contend, therefore, that nothing should be deducted from their benefits towards the maintenance of these hospitals. Such deductions cannot apply to a person suffering from infectious diseases.
With regard to surgical hospitals it does not apply to that, for this reason. I have the honour of representing a town where, unlike London, the workpeople for thirty-five years have contributed to the maintenance of the surgical hospital by subscriptions out of their wages. The employers also subscribe, but the bulk of the subscriptions come out of the wages of the workers. These people have a right to go into the surgical hospitals in cases of accident or of operation. They will not get any benefit under this Bill in cases of accidents; that has been decided; and, if they do not get any benefit under the Bill in cases of accidents, why is it suggested, as is suggested by the right hon. Gentleman the Member for East Worcester, that half of the benefits derived by the workpeople under this Bill should go towards the upkeep of the hospital when they are in it. The fact is that hon. Members upon the other side of the House have exaggerated very much the probability of any reductions in the subscriptions towards the hospitals. The 59 only hospital that could possibly suffer is the surgical hospital; the fever hospital, the smallpox hospital and the sanatorium cannot suffer. With regard to the surgical hospital, it is bound to be maintained in the future as in the past, because it is there to meet accidents incurred in the works. They are contributed to by the workmen, and therefore they do not come within the province of this Bill.
§ Mr. J. SAMUEL
So far as the north of England is concerned we know of no such thing as a general hospital in a sense apart for ordinary operations. The hospital is one where people go for ordinary operations, and in that case if a person is a subscriber to the hospital he is maintained free of charge.
§ Mr. J. SAMUEL
In the case of medical wards in a hospital to which a person is not a subscriber he has to pay for maintenance. I know that is so. I know there are a large number of cases where private patients have paid. The people who go there can afford to pay, and I contend there is no necessity for the alarm which is created by the right hon. Member for East Worcester with regard to these hospitals. I believe the workmen will continue, especially in the provinces, to contribute their mite and their share towards the maintenance of the hospital, and I do think it is a cruel thing to suggest, and the right hon. Gentleman opposite has suggested, that 5s. a week of the benefit should be deducted from these people towards the maintenance of the patient when ho is in that institution. I hope the Committee will not think of accepting such an Amendment as the Ron. Member has suggested.
§ 5.0 P.M.
§ Mr. CASSEL
As the Amendment I have on the Paper was framed after consultation with those connected with hospitals, perhaps I may be permitted to say a few words on this question. The point upon which the difference has really arisen is this: The Chancellor of the Exchequer is prepared to go so far as to say that where a person has no dependents the sick pay shall be paid to the hospital, therefore the difference between us really only applies to the case of a person who has got de- 60 pendents. We have to remember that the insured person is the person entitled to sick pay. He has paid his contribution, and he is entitled to his pay as a matter of right. That is a proposition which ought not to be lost sight of. Whether the person has dependents or no dependents, he is the person who is entitled to the sick pay as a matter of right, and at least there ought to be a power to make a contract between the sick person, the society, or the health committee and the hospitals to meet the expenditure actually incurred by the hospital authorities for maintenance and treatment. The hospital should be paid, either the whole or part of the man's sick pay, for providing him with maintenance or nursing care. The effect of this Bill is to deprive a man of the right of making that contribution, and it is in this respect an injustice to the man entitled to the sick pay.
If the hospital says, "You must pay 5s. per week," you have not the right to do it because the money must go to the dependents. It does not go as the man himself determines, but to those whom the health committee or the society determine for him. In a case where there are no dependents, I think it should be open to the man or to his society to contract with the hospital that part of his benefit may be, not shall be, paid to the hospital, and I think it may be left to the hospital to act fairly, leaving it open for contracts to be made that either the whole or the part of the sick pay should go to refunding the hospital the expenditure it has incurred. I do not think that arrangement would be unfair at all, let us assume the man is in his own home. The first charge upon the fund would be his own maintenance, and the dependents would only come in after the maintenance of the bread-winner and the cost of his sickness had been dealt with. The result of the Bill is that the dependents score at the expense of the hospital, and the dependents get the benefit of the expenditure which the hospital incurs.
I do not see why, if a man who is entitled to the 10s. a week benefit, if he likes to have certain extra comforts, should not have them before the dependents come in. What I object to in this proposal is that the Bill makes it absolutely compulsory for the man to pay his sick benefit to his dependents and no one else. There is no opportunity of having for himself any extra comforts, and actually the Bill leaves the selection of the particular dependents who are to have this privilege not to the man 61 himself, who is the person insured, but to the society or the health committee. On those grounds I submit that in cases even where there are no dependents—and as I submit where there are dependents—it ought to be possible to make a contract for some portion of the benefit to go to the hospital. Although my main Amendment has been ruled out, I think later on I shall be able to give effect to my views in another way. My Amendment does not prejudge this question. It may be found that the hospital revenues will be seriously affected, but I think it should be left open to them to make such a contract as I have mentioned, and the insured person should not be prevented from entering into such a contract.
§ Captain CLIVE
I wish to ask whether it would not be possible, no matter what Amendment the right hon. Gentleman puts in later, to accept this Amendment. I do not think the workman who is made to contribute under this Bill should be deprived of all benefits under certain circumstances if he goes into the hospital. This Bill is one to provide for the cure of sickness, and the ordinary place for the cure of sickness is the hospital. Why should it be declared when a beneficiary goes into the hospital that he should be deprived of all benefits? Many of our hospitals are largely supported by the contributions of working men themselves. In my own county our hospital was at one time at a very low ebb, and it was only put on a sound basis by the establishment of a penny-a-month fund from the workmen, which raised £800 a year, and that amount has been practically maintained ever since. The men receive hospital tickets in proportion to the amounts collected, and there is always a ticket available for those who have occasion to go into the hospital. Under this Bill the working men are going to contribute, not one penny a month, but Yd. a week, and in spite of that large contribution the workman, if he goes into the hospital, is to have no means of paying his way when he is in the hospital.
The ordinary hospital ticket does not cover the cost of the man in the hospital. One of the objects of this Bill is to make a man independent, and if he has his benefits under the Bill he will feel in a much more independent position. He will be able to contribute to the hospital, and instead of being an object of charity, he will be able practically to pay his way. I ask the Chancellor of the Exchequer to consider whether he cannot put down an 62 Amendment in a less detailed manner as to the conditions under which this benefit is to be obtained? One of the conditions put down is that if one man has no dependents and another has, an agreement may be made for the purpose with the hospital or with the infirmary. Why cannot all be left to the friendly society to arrange with the hospital, because the conditions are different all over the country. I believe the Chancellor of the Exchequer is desirous of interfering as little as possible with the independence of friendly societies, and I think he might allow them to draw up rules for dividing the benefits between the dependents and the hospital, and permit them to give it all either to the hospital or the dependents, as they think fit. In the meantime I urge upon the hon. Member now representing the Chancellor of the Exchequer (Mr. Masterman), whom I congratulate upon his return to the House, to put before the Chancellor of the Exchequer the views I have expressed in favour of this Amendment being accepted.
§ Mr. LANSBURY
I wish to call attention to the case of infectious hospitals which are affected under this Clause. At the present time in the Metropolis a man or woman, whether single or whether they have dependents or no dependents, can go to these hospitals perfectly freely, and they are not expected to pay, whether they are rich or poor, or whatever their position. I think it will be an injustice if, under this Bill, you levy a contribution on a man merely because he has no dependents. I hope that in any amended Clause, at any rate in the case of services now given at the hands of the community, payment will not be insisted upon. If you take the case of a woman earning very low wages indeed, she will need her money after she has been to the hospital to get herself back to health and strength again. Even fever hospitals do not keep patients too long, and very often they come back and have to have more convalescent treatment. If it is stipulated that a man or a woman shall pay for treatment in a fever or infectious hospital, I think that will be a retrograde step, and that is something which the Chancellor of the Exchequer has declared this Bill does not do. With regard to hospitals, I think their maintenance should be a public charge, but until we get that, all of us who have to do with people who are sick are bound to acknowledge the very splendid work done by voluntary hospitals up and down the country, especially in the metro- 63 politan area. I wish to point out to hon. Members opposite that we ought not to grant public money to these institutions unless we have some sort of public control I hope the Chancellor of the Exchequer and those who are acting with him will stick to the old-fashioned principle that wherever there is a grant of public money, there must be public control as to how it is spent. I am in favour of something of this kind being done so long as there is public control to see that the money is spent in the most efficient manner. I am not at all sure all the conflicting and competing appeals made to us in London is quite the best method of running public health in the Metropolis; in fact, I know it is not, but I am looking at things as they are and as they will be if this Bill becomes law, and I am perfectly certain men belonging to the society of which the hon. Member for Mile End and I are members will not contribute twice over, and the hospitals will lose a considerable amount of money. Personally, I am willing that should be made up in some kind of way, but not without the safeguard of some public control as to how the money is spent. We hear so much of Germany in this House that I wonder we do not bring their laws and plant them down here for good and all; but very often we have them misreported. I consider Hamburg provides one of the finest examples as to how the public health should be dealt with, and there the hospitals are under State control. There is no question of voluntary hospitals, in the sense of the London hospital, and there is an elaborate system of payment from the Poor Law authority right up to the Insurance authority. There is, however, at the bottom State control, and I hope the Government, when they draft this Amendment, will not draft it in such a way that they will be giving public money to the hospitals to spend as they please, but that they will put them either under the control of the Public Health Committee of the district in which they are situated or under the control of the Central Health Authority of the whole country.
§ Mr. HUME-WILLIAMS
I am entirely in agreement with the hon. Member who has just spoken, that as long as things remain as they are at present it is desirable the hospitals, supported as they are by voluntary contributions, should freely give their services to those who enter their walls; but we are initiating an entirely new condition of things. The 64 hospitals at present are intended for, and provide their services mainly to, the very poor, and they are supported by voluntary contribution in order that they may take in time of sickness those who have not the means of providing for themselves. You are altering all that. You are providing that in future a person who is sick shall have made some provision for his own sickness. You are providing that the doctor who attends him outside hospital is to be paid for the services he renders. By what logical process can you arrive at the conclusion that a doctor attending a patient outside the hospital is to be paid and the doctor attending him inside the hospital is to give his services free? I do think, and in this I am in entire agreement with the Chancellor of the Exchequer, this is a question of supreme importance, because it touches the lives of the very poor people. It is desirable in the interests of those of whom I speak, that you should do your very utmost to increase the scope of the hospitals. I do not think I am putting the percentage too high when I suggest that in not less than six cases out of ten where sickness occurs among the poor and among the working classes the chances of recovery are much better in the hospital than in the private home. The conditions of sanitation are better. They have at their disposal the highest skill in the land, for our great surgeons very often nobly devote their services to the poor. Antiseptic conditions prevail in the hospital, and they have every appliance required. It is therefore desirable that as far as possible the scope and utility of the hospitals should be improved.
I confess I share the fear put forward by the right hon. Gentleman who spoke first on this side of the House. The employers and workpeople are going to have compulsorily placed upon them that which they have hitherto done voluntarily. The employer subscribes to the hospital because it is there his people may go when they are sick, and the workpeople subscribe because it is there his friends go, and it is there he may go himself one day when he is sick. The moment you put compulsion upon them to provide for sickness it is only human nature they should say, "Why should I subscribe?" I fear the employer will say to himself, "If I have got to pay this large subscription to provide for the sickness of the people whom I employ, at any rate, I cannot afford to do it twice over." A fact came to my knowledge only this morning concerning a large hospital 65 in the North of England. An official of one of the large railway companies said to my informant, "This Bill will place an additional burden upon my company to provide for our working people of about £35,000 a year, and all we shall save is £5,000 which at present we give to the hospitals." If that is a condition which prevails, and if that is a justifiable sentiment, it is indeed a painful outlook for the hospitals.
I was not myself convinced by the obviously bonâ fide, and indeed, enthusiastic attempts of the Chancellor of the Exchequer to provide for the hospitals in future, because I cannot see what the new sources of income provided by this Bill are to be. He relies chiefly upon the fact that those suffering from tubercular complaints are in future to be provided for elsewhere. I think I speak that which is common knowledge when I say that excepting a few special hospitals provided for that complaint our hospitals are not filled now with those suffering from tuberculosis. There is not room for them, unfortunately. Then he says, the sick pay which will be received by the insurer will largely diminish the number of people who go as out-patients to the hospital. The attendance and medicine provided for the out-patients of the hospital are but a small portion of the expenditure incurred and the duty performed. What they are fighting for is the maintenance of the beds in the hospital and the enlargement of the hospital to meet the ever increasing needs of the sick poor of the community. This Bill gives to that class of hospital no relief whatever. On the contrary, if the suggestion of the hon. Member, or something of the same kind is not accepted, it will place upon the hospitals the burden of giving for nothing that for which the person they are attending is receiving payment. He has insured to meet that specific thing which has occurred, namely, his treatment in sickness. He is receiving it, and he is not paying for it. I submit that is not common sense, and is an injustice. I have put down Amendments suggesting that when a man receives sick pay and is in hospital the contribution should go to the hospital. I should be quite content to withdraw that Amendment if some reasonable assurance were given by the Chancellor of the Exchequer that he is going to provide that, at any rate some of the contributions should go to the hospital. It appears to me to be common sense, and I hope, as the result of this discussion, the Chancellor of the Exchequer will see his way at any rate 66 to accept in some form an Amendment which will not leave the hospitals to do all the work and to receive none of the pay.
§ Mr. O'GRADY
The hon. Member for St. Pancras suggested that a certain amount should be paid by those who receive treatment in a hospital.
§ Mr. O'GRADY
I know the Bill provides for sick pay, but the workman joins for the purpose of having some income during the time he is sick. It provides 10s. per week during the time the man is sick, plus medical attendance. It seems to me if that is so outside the hospital you ought to provide for the case inside the hospital as well. There are other points also to be considered. Some kind of hospitals are maintained out of the rates, and the workmen contribute as ratepayers. That being so, it seems to me very hard to have an agreement by which a man will be compelled out of his 10s. per week to pay a certain amount towards the hospital. Personally, I do not think the contributions of the workmen to the hospitals will be diminished to any great degree as a result of this Bill. They have always risen to the occasion hitherto. I know in Birmingham over and over again we have not only paid contributions out of our weekly wages, but on the usual Hospital Saturday paid extra. I think that system will go on still. I feel the workman—I want to put this point as strongly and as clearly as I can—if there is the slightest possibility of danger that the treatment in the hospitals will depreciate because of loss of revenue will rise to the occasion and see to it that the hospitals are made effective again. I hope the Chancellor of the Exchequer will not listen to the suggestion that agreements may be made whereby a man who goes into the hospital shall give a certain proportion of his 10s. a week to the hospital. I urge it on the ground that for the first time in the history of this question we are now considering the matter of national health as a national asset. We are dealing with the thing from a broad national point of view, and I do not think we ought to do anything in the way of decreasing the amount of money a man gets under the Bill. I feel that would do harm to the Bill. It would harm the individual, and I believe it would also harm the dependents a man might leave at home. We ought in this matter to be generous. If the hospitals them- 67 selves are in danger, and if my prophecy respecting the make - up of revenue is not fulfilled, then, taking into consideration the point of view of the utility of the work done at the hospitals on behalf of national health, the policy of the Members with whom I am associated on these benches must be to urge in season and out of season that if the income of the hospitals should be endangered those institutions should be municipalised. That seems to be the logic of the position if there is to be a decrease of revenue as a result of the passing of this Act.
§ Mr. A. LYTTELTON
I do not propose to make any reply to the hon. Member who has just spoken beyond pointing out to him that it is not the scheme of this Bill to municipalise hospitals, I would like to ask the Attorney-General if he thinks the words as they now stand are a sufficient safeguard for the hospitals, and whether they meet what I take to be, in different degree, the opinion of the entire House. If the words "or by a charity" are left out the clause will read:—
"No payment shall be made in respect of sickness disablement or maternity benefit to any insured person during any period when he is an inmate of any workhouse, hospital, asylum, or infirmary, supported by any public authority or out of any public funds, or of a sanatorium or similar institution established under this Part of this Act."
Is it not desirable to add the words "or supported by voluntary subscription" in order to bring hospitals within the purview of the Amendment which we all desire to pass in some form or other? If that is agreed then we come to the question of to what extent and in what way a subsidy will be made for the services that may be rendered by the hospitals. I take it that the general opinion of the House is that nothing shall be done to diminish the efficiency or position of the voluntary hospitals. We all start from the same principle. It is only a question of method. The Chancellor of the Exchequer anticipates there will be great relief to the service which hospitals hare to render by reason of the operation of the tubercular and sanatorium provisions and by the relief he anticipates will be given in the matter of out-patients. In one large hospital alone we are told no fewer than 220,000 out-patients are 68 treated in the course of a year. But on the other hand only 36 per cent. of these 220,000 will be dealt with by this national insurance scheme at all, and, therefore, it is extremly doubtful whether, as regards out-patients at any rate, there will be much substantial relief. Next there is a question which I myself cannot answer, and on which contrary opinions are expressed by hospital authorities, namely, whether the sanatorium provisions of this Bill will relieve these institutions to any considerable extent.
Hospital experts who have been consulted say that the finances of these institutions will be seriously depleted by the operation of this Act. I do not think, if I may respectfully say so, that the anticipation of the Chancellor of the Exchequer that employers will continue to subscribe as much as ever is really going to be justified. The right hon. Gentleman told us that because employers under the Workmen's Compensation Act anticipated a great burden and their anticipation was not generally fulfilled, therefore they are not likely to decrease their hospital subscription in anticipation of the effects of this insurance legislation. Personally, I do not think the effect of the Workmen's Compensation Act can have much bearing on the argument. In this case you have to consider not colliery owners or other very large employers, but you must bear in mind the position of the small employers who have in the past been willing to make a contribution to the hospital, but who, in my opinion, in view of the burden placed upon them by this measure. may not be so inclined in the future. Therefore, the possibility is that in days to come hospital revenues from that source will diminish.
With regard to the doctors they have a magnificent record in the past for the non-remunerated services they have rendered with such wonderful generosity. But if you place on a man the duty of attending for a small payment relatively more patients that he can fairly be expected to attend to, the natural and inevitable tendency will be for him to send to the hospital patients who otherwise would continue to receive attention in their own homes. My general impression is, therefore, that the hospital revenues will be diminished and that an increased burden may be cast upon these institutions in regard to the services they will be called upon to render. On both sides of the account, in fact, there will be something adverse to the hospital. The Chancellor 69 of the Exchequer made a very sympathetic speech, and intimated some intentions of giving way on subsequent Amendments, and of making certain concessions. We have to consider which of the three schemes before the Committee is the more desirable. There is the scheme of my right hon. Friend the Member for St. Pancras (Mr. Cassel), the scheme of the Government, and the scheme of my right hon. Friend the Member for East Worcestershire (Mr. Austen Chamberlain). The Government propose to make the subscription to the hospital contingent entirely upon a man having any dependents; therefore, if a man who is in hospital, say, for a period of six weeks should have any single person—say a nephew—dependent upon him, he would have to be gratuitously treated by the institution, and would not be required to make any contribution. I do not think anyone can say that that is just. On the other hand my right hon. Friend (Mr. Chamberlain) proposes in his Amendment to place it in the hands of the local authorities to decide in what proportion the subscriptions shall be allocated between the hospital and the patient.
§ Mr. JONATHAN SAMUEL
Would you do that in the case where a workman subscribes to the hospital regularly? Would you in that case deduct halt his benefit?
§ Mr. LYTTELTON
I am inclined to think it would be very difficult to prescribe arbitrarily on the face of the Bill what sums should be paid. The ideal thing is that there should be some contribution. I do not think the House is yet in a position to say what that proportion should be, but possibly the best and most sensible arrangement we could make would be to submit the case to some impartial authority to decide what amount the hospital should receive, and how much should go to the patient. I think it will be impossible, without some agreement of that kind, to come to a satisfactory arrangement. Between the different plans I rather like that of my hon. and learned friend (Mr. Cassel). His proposal is to leave it to the hospital to agree with the man or his society what the proportion should be. That seems to be a reasonable suggestion. I think the hospital might fairly be left to settle the matter with the man. The Chancellor of the Exchequer has promised to deal with this Amendment in a spirit of concession, and I certainly hope we may approach it with a 70 fair amount of justifiable hope that he will recognise the undisputed claims of the hospitals.
§ Mr. HARWOOD
This discussion has brought us face to face with the very great and pressing national problem. I hardly think the Chancellor of the Exchequer was quite right in what he said about the subscriptions not being diminished and in the analogy which ho drew with what has occurred under the Workmen's Compensation Act. I think the right hon. Gentleman pressed that point a little too far, because employers under the Workmen's Compensation Act almost invariably were liable for the damage done. That consideration will not arise under this Act. I hope the Committee will realise that in the country generally —it is the case in the town which I have the honour to represent—our hospitals are not endowed, and are really supported by the community, the workmen's subscriptions being a very important element. Another point which was stated by the Chancellor of the Exchequer was that the work of the hospital would be diminished, because people will not go to the hospital, but will prefer to be treated by the doctor at home, especially as they are not called upon to pay his fees. I think that any relief which may be gained in one direction will be much more than counterbalanced by the increase of work which will be thrown upon the hospitals in other directions, because the tendency will be on the part of the doctors to send patients for treatment in the hospitals who are now usually treated at home. I am quite convinced the Government will have placed on it the duty of putting the hospitals on a sound basis in regard to national requirements. The position is ridiculous as it is now. There is a growing tendency on the part of the public to believe that they can get better treatment in the hospitals than at home. People more and more are learning that you are better doctored in hospitals than at home, therefore it would be a cruel thing to say to people, "You see, so much is paid for you for doctoring, go back home and call in your medical man." The public will not accept that. More and more the tendency is quite in the opposite direction, therefore the Government must face that. The present position, that these hospitals should have to be maintained out of private sources, is really quite unreasonable. They are frequented more and more by all kinds of people, and it is a few people who have to carry them 71 on, and when a greater work is thrown, upon them it will really be necessary that they should be put upon a logical basis. For example, the very doctors who doctor in the hospitals doctor your patients outside, and you say to them, "If you doctor them outside you get so many shillings a year, but if you doctor them inside there is nothing to pay." That is evidently illogical, and therefore I hope the Government, if they are going to shape an Amendment, will realise that we are really brought up against a very serious proposition as we shall have, whether we like it or not, to face the fact that we must put the hospitals upon a logical basis and to make them national institutions in some way or other is the sound line to take.
§ Sir ROBERT FINLAY
It seems that the Clause as drawn would enable a man who is being treated voluntarily in a hospital to receive some sickness benefit at the same time. If that is the effect of the Clause what becomes of the second Subsection, which proposes Amendments with regard to applying the money for the benefit of hospitals? The second Subsection says:—
"During such period as aforesaid any such benefit which would otherwise have been payable to such person."
And it is proposed to amend it by saying it shall be applied in whole or in part for the benefit of the hospital. Surely it is obvious that you ought to put in words in the first Sub-section which shall make it clear that if a man is being treated in a hospital maintained by voluntary subscription he shall not be entitled to receive the sickness benefit. The words as they stand I do not think will have that effect: "Maintained by a public authority or out of public funds or by charity." Those words are not adequate to denote the case of a hospital which is maintained by voluntary subscription. I beg the right hon. Gentleman to consider the necessity of amending the first Sub-section in the sense which I have indicated. There is one aspect of the necessity of seeing that hospitals are not damaged by this Bill, which I should desire to emphasise. Not only do hospitals supported by voluntary subscriptions bring the highest possible medical and surgical care to the service of the very poorest class who can be brought to the hospital, but in doing that they achieve inestimable benefits for the cause of medicine, surgery, and science. Our hospitals are great medical and sur- 72 gical schools, and anything that diminishes their efficiency would inflict a severe blow upon medical science in this country. It is the unanimous opinion of those who are familiar with the working of hospitals that this Bill as it stands would most seriously prejudice them.
§ Sir R. FINLAY
It is very nearly unanimous. The apprehension is very widespread, and I think the reason given for it is very sufficient; it is believed that, while the work of the hospitals will be augmented, their subscriptions will be diminished. That is a state of things which no one can contemplate without dismay, and which must lead to the consideration of the question whether it is not necessary to subside these great institutions out of public funds. I was somewhat struck by the observations of the Chancellor of the Exchequer. There was a certain optimistic tone about them. He seemed to think all would come right, and those interested in hospitals need not be alarmed. I wish he had been able to say something more solid for the purpose of removing these apprehensions than he did say, and I feel very sure those who have given a great deal of work to hospitals will not have their minds very seriously relieved when they read what the Chancellor of the Exchequer said on the subject. The matter is of such vast importance that I hope it will receive the attention of those in charge of the Bill, and that the Committee will see that such Amendments are made as will secure that adequate contribution shall be made to hospitals which will have increased work thrown upon them under the operation of the Bill.
§ Mr. HAMAR GREENWOOD
I think while we are formally discussing the Amendment to leave out the words "by charity" we are really discussing the merits of the Clause moved by the right hon. Gentleman (Mr. Austen Chamberlain), and the alternative Clause to be moved by the Chancellor of the Exchequer. I rise to support the Amendment of the right hon. Gentleman (Mr. Austen Chamberlain). In the first place, a person who insures under this Bill insures for certain specific benefits set out in the Fourth Schedule, and generally they are sick benefits, disablement benefits, medical benefits, and, in case of necessity, sanitorium benefits. No-insured person insures for a hospital up to the present. He pays his premium, his 73 employer pays his, and the State pays its contribution, but not for hospitals at all, In a normal case it is presumed that the insured person is taken sick in his own house and is attended by a medical man, and gets his 10s. for the first period and 5s. for the subsequent period and keeps himself and his dependents out of that money in so far as he can. If he goes into a hospital he gets medical attendance, he gets his food supplied, and he gets his 10s. and 5s. a week just the same. The amending Clause of the right hon. Gentleman (Mr. Austen Chamberlain) throws the responsibility as to whether or not those who go into hospitals and who have dependents outside will contribute towards the support of those hospitals on the health committee. This committee is the best judge as to whether or not the money should be given to dependents outside the hospital, or whether there should be a fair and just payment to the hospital. That is an extra benefit given to a man who may, or may not, be financially able to pay for it, and, as there is doubt as between the dependents of the insured person who takes advantage of a hospital for which he has never paid, the amending Clause should apply, and the responsibility should be thrown upon the health committee. But that Clause should be further amended, so that in the case of those, like the vast majority of working men in the constituency which I represent, who now subscribe, and I believe will continue to subscribe 1d. a week, in spite of all this pessimism about the hard-heartedness of the working man, the health committee should take cognisance of the subscriptions of these working men, and, of course, if they subscribe for the hospital while they are well, they are entitled to the benefit of a hospital while they are ill, independent of any National Insurance Bill whatever. We are all agreed that hospitals must be supported at all costs, and it is no use for the Chancellor of the Exchequer to call out that hospitals in the future are to be supported by the weekly allowance of those who are dependents. He seems to suggest that we are a nation of orphans or bachelors without anyone dependent upon them. The number of that class who go into hospitals is an infinitesimally small portion of those who receive the generous benefits now given by hospitals. I shall certainly support the Amendment if amended as I suggest.
§ Dr. HILLIER
I should like to ask you, Sir, on what lines this debate is going 74 to be continued. The hon. Member (Mr. H. Greenwood) has made an admirable speech in support of an Amendment later in the Paper in the name of the right hon. Gentleman (Mr. Austen Chamberlain). I desire to ask whether we are at liberty to discuss that Amendment now, and if so, whether we shall discuss it again when the Amendment is before the House?
§ The CHAIRMAN
A good deal has been said about subsequent Amendments which are connected with this question. It may be a general convenience to the Committee that they should be able to refer to those Amendments. When we come to the individual Amendments we shall have to take some one and deal with it, but I hope we shall not have a lengthy discussion on the Amendment. Therefore, I do not propose, after the discussion that has taken place, to prevent hon. Members from saying something about these Amendments.
§ Sir HENRY CRAIK
The discussion has wandered over a very wide area, I have no doubt with advantage, but I think it has somewhat obscured the actual Amendments before the Committee. I think the range of discussion was really largely due to the misapprehension of the effect of this Amendment in the mind of the hon. Member (Mr. Jonathan Samuel) and the hon. Member (Mr. Lansbury). Let us see exactly what this Clause ordains at present. The first Sub-section of Clause 12 does not give anything, but takes away what might otherwise have been given. The Sub-section as it stands prevents a contributor from receiving any sickness or disablement benefit if he is in a hospital. What we are seeking to establish is that if he receives such treatment in a charitable hospital he shall have re-established for himself all the rights that ho would otherwise take, but there is nothing to be taken away from him. The money is to be there disposed of in respect of him by some means or other.
§ 6.0. P.M.
§ Sir H. CRAIK
The Amendment that we are now discussing, moved by the hon. Member (Mr. Pollock) which we have wandered very widely away from. We say that where a man is in a hospital supported by the rates or out of public funds the money that he would otherwise receive 75 might fairly pass into the credit side of the insurance fund. That is a benefit he has been providing for by a payment of public rates. It may be that the stability of the fund will be guaranteed all the more by this sum, which would otherwise go to him, passing into the fund. But if he is dealt with, not by a public fund, but by a public charity and by the voluntary labours of the medical men who attend the hospital and who are absolutely unpaid by the charity or by those who are subscribers to the hospital, is it not reasonable, I would ask, to say that we must make a clear distinction between that case and the case of the man who is dealt with by public funds, and that we should say in that case the money shall not pass into the Insurance Fund, but shall be the property of the man, and shall be disposed of in fairness between him and those to whose kindness he has been indebted for his treatment in a voluntary hospital? That is all we are seeking to do by the Amendment proposed by my hon. and learned Friend. We can do no more until we strike out these words in the first Subsection of the Clause. If we leave charity institutions exactly on the same footing as institutions supported by public funds, then the subsequent Sub-section assigning sickness or disablement allowance either to the man himself or to his dependents will be absolutely useless, and we shall have to slump together the charity and the public funds in one Clause. It would be absurd to try to go back upon that. I hope my hon. and learned Friend will take his Amendment to a Division if that should be necessary. I trust the Government will accept the Amendment as a preliminary to any further alterations in Clause 12. Unless we separate charity institutions from other institutions which are kept up by public funds, we cannot introduce the Amendments of which the right hon. Gentleman has given notice, but I may say here that in my opinion these Amendments do not go far enough in justice to voluntary institutions.
§ Mr. C. BATHURST
There is a small point which has been lost sight of in the course of this discussion. The Clause appears on the face of it to apply to the allocation of sickness, disablement, or maternity benefit. It does not refer to ordinary medical benefit. That is to say, the benefit to which it does refer is the benefit which represents the cost of maintenance of the individual in these institu- 76 tions. But surely we ought to consider the matter in reference to the question of the allocation of medical benefit to those persons housed for the time being in these institutions, because it appears to me that unless the equivalent of medical benefit goes to some extent to the hospitals—I think that it should all go to the hospitals —the hospitals will have to do a large amount of work which would otherwise fall on local practitioners and friendly societies. That being so, the medical benefit which would in the ordinary course go into the pockets of the ordinary medical practitioner will go to the State, to swell the unapplied balance, because that work is being done for them. Surely that is an additional reason for making a considerable allowance to the hospitals, because they will be doing a great deal of the work proposed to be done under this Bill by the independent practitioners outside the-hospitals.
§ Mr. BAIRD
I think there is one more reason why this Amendment should be supported. In his speech the Chancellor of the Exchequer did not say he was going to oppose this Amendment, but he seemed to think it was unneessary. He did not use the one argument he is in the habit of using—namely, that the State could not afford the money. Even if funds were not available, that would not be an argument for resisting this Amendment. An hon. Member below the Gangway said that medical attendance was provided under the Bill, and he contended that whether a man got it in a hospital or in his own home, did not make much difference. I would point out that a man gets a very great deal more in a hospital than in his own home. He gets sickness benefit which is designed to pay for what is required at home. If it is defrayed out of the rates, it is reasonable that that should make it unnecessary for any further contribution to be given. If he is going to benefit through a hospital supported by charitable subscriptions, and which is not supported by the public rates, it is right that he should contribute according to his own means to the funds of that institution. I do not think it is possible to resist this Amendment on logical grounds. The right hon. Gentleman did not advance any argument in support of his view to show that those who think otherwise than himself are wrong.
Nothing could be more regrettable than the suggestion that hospitals which axe at present supported by voluntary subscriptions could be put under the municipalities. 77 That would be doing a thing which has been found undesirable in other countries. It would take away the distinctive character which our hospitals possess as compared with the hospitals in other countries. The hon. Member for Bow and Bromley (Mr. Lansbury) referred to the hospital at Hamburg. I have very little doubt that if the officials of the hospital at Hamburg were here to-day they would tell us that they are unable to conduct there the experiments and researches which are necessary for the advancement of medical and surgical knowledge in the same manner as can be done in the voluntary institutions of this country. I think it would be an unfortunate thing to take away the voluntary character of our hospitals, as was suggested by the hon. Gentleman. What is the alternative? What do we propose to do by the Bill, supposing this Amendment is not accepted? In the first place this Amendment is desired by every one of the hospitals. It has the support also of the Manchester Unity of Oddfellows, one of the societies best entitled to speak on the subject. If you turn to the only other section that deals with hospitals, namely, Section 17, you find it provides:
"It shall be lawful for an approved society to grant such subscriptions or donations as it may think fit to hospitals and other charitable institutions, or for the support of district nurses, and to appoint nurses for the purpose of visiting insured persons who are members of the society, and any sums so expended shall be treated as expenditure on such benefits under this Part of this Act as may be prescribed."
That is a Clause which all the hospitals desire to see excised from the Bill. They find it quite unsatisfactory because they think it most undesirable that they should be called upon to deal with cases on a contract basis. They desire to be paid pro rata as cases come into the hospital, and unless the words which this Amendment seeks to omit are omitted, it will be impossible to move Amendments subsequently to meet the case. I do not think the Chancellor of the Exchequer's proposed Amendment meets the case at all. Why draw a distinction between a man who has dependents and one who has no dependents? There is no reason why a man who has a grandmother dependent upon him should have his expenses paid, while another who has not a grandmother dependent upon him should not have his expenses paid. That cannot be affected 78 by the Chancellor of the Exchequer's Amendment. The right hon. Gentleman did not offer any very determined resistance, or say that the Government would not accept this Amendment. In view of the very small amount of opposition which the Amendment has produced, and of the very strong arguments adduced in its favour, I hope the Government will see their way to delete these words from the Bill.
§ Mr. PETO
There is no doubt that what we are concerned with at present is the question to what extent the cutting out of these words would cause voluntary contributions to fall off in future. The Chancellor of the Exchequer took the usual rosy and optimistic view, and seemed to think it would be all right for the hospitals in future. An hon. Member stated that in a case he knew the amount of a railway company's subscriptions to the hospitals along the line amounted to £5,000. I should like to give the Committee an illustration on a smaller scale. I would remind the Committee that companies and firms throughout the country contribute to hospitals, convalescent homes, and institutions of a kindred nature in their neighbourhood, and it is perfectly well understood that the contributions of the employers are to be used for the benefit of their employés. In the case of a company in which I am concerned, I have just ascertained that the annual subscriptions amount to £130 a year. The company has only 500 to 600 workers, and that sum works out at just under 5s. a year, or a penny per week per worker. It is one-third of what will be asked as the employer's contribution under the scheme. It is only a little adjunct of the sickness benefit scheme which has been in existence since 1859, and which practically costs the workmen nothing, for the employer's contribution is placed at ½d., which pays for the sickness benefit. We go on the system of sharing out what remains at the end of November. I quite agree with several hon. Members who have touched on the subject that sanatorium benefit is hardly going to affect this question of convalescent homes and other institutions at all. It is perfectly true that among many of the institutions which have been subscribed to we may have occasionally to send one of our workmen. One hon. Member referred to the fact that when a workman is in a hospital he gets a great deal more than medical treatment. That still more 79 applies to convalescent homes. It is not quite clear to me whether convalescent homes are intended to be included or not. The words are: "Workhouse, hospital, asylum, or infirmary, supported by a public authority or out of any public funds, or by a charity, or of a sanatorium or similar institution established under this part of this Act."
When the Government have introduced a great scheme of national insurance, which, is absolutely obligatory not only on workmen, but on employers, is it reasonable, especially when you exclude from the benefit of the Act any workman while he is in hospital, in addition to putting a large compulsory weekly levy on every workman and on every employer in the whole country to expect confidently charitable contributions, certainly voluntary contributions, as I have shown in what I consider a fair average case, amounting to a penny per week per man to continue on exactly the same scale as before? If you are going to give the workman in time of sickness a sum which I cannot regard as excessive, 10s. a week as a maximum, if you are going to make him support as best he can his dependents out of that, when he is in his own house, and he has got to provide all his own maintenance during his time of sickness, then, why, if he is subject to some illness which makes him a suitable applicant for admission into a hospital or similar institution, do you suddenly decide to pay nothing at all to the hospital and to pay to his dependents the entire sum which in another case would have had to keep him as well as his dependents? I think that there ought to be some more equitable treatment. I entirely agree with the hon. Member for Glasgow and Aberdeen Universities (Sir H. Craik), that the first thing you have got to do is to cut out those institutions supported by charity altogether and settle how you are going to deal with such cases in future. You will not be able to deal with their case under the old system. I hope sincerely for myself that it will not result in putting all these great institutions on a basis of being supported out of the rates, as was suggested by the hon. Member for East Leeds. He said, in addition to that, that we must be generous and that we must not take any part of the payment that would otherwise be made to the workman and pay it to the hospital. Then he went on to say there would be no need to do so, for he was sure that the working classes of this country would see 80 that the subscriptions to the hospital were kept up.
I have endeavoured to show that there is an enormous amount of money paid to these institutions every year on behalf of the working classes, and I ask is it reasonable to say that, because we must be generous and take nothing back out of the sickness pay, we are going to put the working class to the loss of not only keeping up their own penny a week subscription, but of keeping up the whole of these enormous contributions to maintain these institutions which are provided by the employers? I do not think that that would be generous to the working classes. I think it would be infinitely better to recognise the fact that a man has better treatment and attendance in hospital than out of it, and that it is only reasonable if he gets the whole of that for nothing that he should not receive the whole of his sickness benefit for his dependents. I think that a more equitable scheme will have to be found. I am sure that if the right hon. Gentleman will make an investigation, as could easily be done by asking a certain number of employers, he will find that my figure is not very far wrong. They do it now quite voluntarily, without taking any special credit for it, simply as part of the arrangements made, resulting from the good understanding between the employers and employed, and because it is in the interests of the employers to look after the health of the workmen in times of sickness. In many cases it would be found that more than a penny a week per man is paid as a voluntary contribution into these institutions. Under the provisions of this Clause how is that going to be made good? I am quite sure it is not by asking the working classes to take the whole burden upon themselves. A reasonable, arrangement might be if some portion of the money were paid for the maintenance of the man while he is in the hospital. I would also like the right hon. Gentleman to tell me quite clearly whether this Clause as printed will apply to convalescent homes or will not?
§ Mr. ELLIS GRIFFITH
I think we are all agreed that if the insured person is in an institution supported out of public funds, he should not get all the money for his dependents. That is, he should come under Sub-section (1) of Clause 12. If, on the other hand, he is in an institution which is not supported out of public funds, I think that we are all agreed that the private institution should have some part; of this money. If we are all agreed about 81 that, there should not be very much difficulty in arriving at some form of words that would embody in the Bill the general conclusion at which we have arrived. But I would point this out. I am afraid that the result of omitting these words "or by a charity" would have an effect the opposite to that intended by hon. Members, because if you omit these words the man will get the money himself. You really want these words in so that you will not have the money paid to the individual himself, in order to get a contribution to the hospitals. I think that the Attorney-General might tell us what is his opinion about this form of words? My own opinion is that is does not matter much whether you keep these words in or take them out. If we keep them in and amend the Bill, we arrive at the conclusion I have just stated. If we keep them out we can arrive at the same conclusion. In order to get the subsequent Amendment these words "or by charity" would have to be knocked, but if that be so Sub-section (2) with this Amendment will not secure the case at all, because Sub-section (2) does not apply to hospitals, if you once strike these words out, because it is limited to Sub-section (1), which is limited to institutions which are of a public character.
§ Mr. AUSTEN CHAMBERLAIN
I think if perhaps the hon. Member had been here at the beginning of the procedings before this Amendment was moved——
§ Mr. AUSTEN CHAMBERLAIN
Then I am afraid that the hon. Member, like a good many others of us, did not know exactly what we were doing at that moment. As the hon. Member is generally pretty quick in matters of drafting, he might have perceived, had he been here, the effect of the Amendments which were accepted by the Government as mere drafting Amendments. Had they not been put in I think there would be a great deal to be said for the argument of the hon. Member, but as they are put in we ought now to leave out these words, because we have altered the Sub-section, and it now reads— I am omitting unnecessary words—"that no payment shall be made on account of sickness to or in respect of any person who is an inmate of a workhouse hospital, asylum, infirmary, etc." I do not want the whole contribution to go to the hospital. My Amendment proposes that part of it should go to the dependents and part of it to the hospital.
§ Sir RUFUS ISAACS
With regard to the Clause which we are at present discussing, there are only two points of criticism that have been directed against these words. One was, as the right hon. Member for Glasgow and Aberdeen Universities suggested, that the words "or by a charity" could not apply to convey what is meant, which was the case of a hospital or institution supported by voluntary subscription. The further criticism is that by the uncertainty of the words in the early part of the Clause it was made necessary to bring in other words in order to give effect to what is the general view of the House as to what is the particular way the proposed Amendment should be carried out. By the general view of the House something should be done with regard to hospitals, and that would be precluded if these words "or by a charity" were left in. With regard to the first point which was raised by my right hon. and learned Friend, I do not quite agree with the criticism which he addressed, but I do in part, probably in a way which would meet his view. When you take the words "or by a charity" to cover the case of a hospital which is being supported not out of voluntary subscriptions, but in some other way out of charity, which may not be public funds, I do think that there is justice in the comment that "or by a charity" are words which leave a doubt as to whether the hospital is supported by voluntary subscriptions. We met that by having after the words "or by a charity" (if these words are kept in) the words "or by voluntary subscriptions." I think that meets the criticism as regards the first point. With regard to the second, I think we are in no difficulty as to taking a technical view of the words "or by a charity," and of the sub-sequent words which follow under this Sub-section (2), because, as I submit to the Committee, there is no difficulty at all in discussing the general question which we are all specially discussing under Sub-section (2) either under the Amendment of the right hon. Gentleman the Member for East Worcestershire or the Amendment proposed by the Chancellor of the Exchequer. Notwithstanding any alteration made in the earlier words there would be no difficulty in dealing with this Amendment under Sub-section (2). The words "or in respect of any person," in the earlier part, were merely required so that we might deal with the case of a woman who is the wife of an insured person, but not herself 83 an insured person, and who received maternity benefit. For drafting purposes it became necessary to introduce those words, which in no way alter what has been already decided. When you come to Sub-section (2) there are the words "which would otherwise have been payable." What you say first of all is that the payment shall be made under certain circumstances; then "during such period as aforesaid," any payment that would otherwise have been made shall be dealt with in a particular way. In that way, I submit, you can deal with the Amendment of the right hon. Gentleman the Member for East Worcester, or the Amendment proposed by the Chancellor of the Exchequer, or any Amendment which deals with a proposal of this character. We are not in any way estopped by the earlier words, and therefore I suggest to the Committee that it would be better to keep in the words "or by a charity," and add the words I have suggested to carry out the views of hon. Members opposite, namely, "or by voluntary subscriptions." Then you can deal with specific Amendments raised hereafter, and no one will be prejudiced.
Sir GILBERT PARKER
Would the words proposed by the Attorney-General cover all the cases? In my constituency there is a hospital which is partly supported by voluntary subscriptions. It combines the two things—it is a charily, but it is also supported by voluntary subscriptions. I wish to know whether the words proposed cover that instance.
§ Sir RUFUS ISAACS
I think the words would cover that case. "Charity" would cover endowments, and "voluntary subscriptions" would cover the funds from other sources. I can assure the hon. Gentleman I am quite clear that there is no difficulty or ambiguity in these words, but if there should be any doubt, though I cannot see why there should be any, I will certainly consider the introduction of words which will clear up the matter.
§ Mr. LANSBURY
I wish to ask whether, under Clause 12, the word "hospital" includes hospitals which are under the control of the Metropolitan Asylums Board? Is the Attorney-General aware that the treatment of persons in those hospitals is absolutely free, and, seeing that the insured person is rated for their upkeep, is it intended to make him pay twice over for the same benefit?
§ Sir RUFUS ISAACS
It is quite clear that the words, "Supported by a public 84 authority out of public funds" would include the hospitals mentioned by the hon. Gentleman. The hon. Member has put to me a question which I have answered, but it arises on an Amendment which is to be brought forward later for decision. The hon. Member will bear in mind, in receiving my answer, that we have not yet carried the Amendment.
§ Mr. CASSEL
Would a convalescent home be included in those words? It would not be a workhouse, a hospital, an asylum nor an infirmary. The words are "Sanatoria or similar institutions" established under this part of the Act.
§ Sir RUFUS ISAACS
I agree that the words "Sanatoria or similar institutions" would cover convalescent homes of a similar character to Sanatoria, but I do not know whether the words are wide enough to meet the point my hon. Friend makes. I understand him to mean a convalescent home supported in some way by public subscription or out of public funds. I will consider whether words can be introduced in order to clear the point up.
§ Mr. LEIF JONES
The word "approved" might be substituted for "established," making it any institution "approved."
§ Sir RUFUS ISAACS
In connection with an Amendment of that kind I am not quite sure whether the other point could be raised.
§ Dr. ADDISON
The discussion has ranged over a very wide field with respect to hospitals, and the point of Order on which I ask the ruling of the Chair is this; Will the Committee be quite in order on Clause 15, for example, or Clause 17, to discuss the general position of hospitals and institutions in relation to this scheme, or would that discussion not be in order?
§ The CHAIRMAN
I could not possibly answer a question of that kind. I do not know what the hon. Gentleman means by a general discussion on the position of hospitals. We could not a second time, traverse ground already covered. Anything relevant to the Clauses which the hon. Member has mentioned unquestionably would be allowed.
§ Mr. JOWETT
The discussion on the Amendment has gone far outside the particular terms of that Amendment, and, therefore, I consider I shall be as much in. order as any other member of the Committee in following the lines laid down by 85 other speakers in the discussion. The Amendment, with its consequential Amendment proposed later on by the right hon. Gentleman the Member for East Worcestershire, becomes more and more hateful. The fact of the matter is, when stripped of its verbiage, it is a further plan, in addition to all that has been done in times gone by, to put working men compulsorily under contribution for hospitals which are not under public management, and over which they have no real control. These so-called voluntary hospitals are most of them voluntary only in name, so far as a large part of the country, at any rate, is concerned. Already they have lost their voluntary character to the extent that the foremen in factories collect week by week contributions. How, in the name of Heaven, can they be called voluntary hospitals? But on the top of all past experience of these outrages on the so called voluntary principle, it is now sought to give power to the local health committee in certain circumstances to deprive insured persons who have paid for their insurance of the benefit to which they have acquired a title. The hospital system of this country is in a transition stage, and the question is rapidly forcing itself upon the public as to what is ultimately to be the position of hospitals. Voluntary subscriptions tend to diminish rather than increase. Sooner or later some Member of a Government, sitting on that Bench, will have to face the question of the hospitals of the country, in order to put them on a sound basis, by frankly making them a public charge and placing them on the public funds. If it is insisted upon that contribution shall be forced from insured persons, and from working people, I for one will go into the Lobby against the proposal if a Division be taken.
§ Mr. POLLOCK
I wish to explain the position I take upon this Amendment, which was moved in order to obtain further information from the Chancellor of the Exchequer as to what was intended by the Clause. I said it was quite impossible to understand the Clause unless we had from the Chancellor of the Exchequer what was his intention as to the Sub-section before the Committee. The question has now been fully debated, and it has now been made clear that what I said seemed possible is not so-namely, that during a certain period a man who was entitled to benefit under this Act would lose the money to which he was entitled by contract, and that it would go into the scheme 86 for the benefit of the Insurance Fund. As that is not so, a supplementary scheme will be provided in later Sub-sections which are to be moved which will enable the money to be applied to the many purposes to which it is important that it should be applied. The words the Attorney-General has suggested do not seem to cover the case where an infirmary or hospital is supported by endowments. Some of my hon. and learned Friends around me have some doubts whether the words which the Attorney-General proposes are sufficient. Perhaps the right hon. Gentleman will let us have the opportunity of considering the words he proposes to insert, having regard to the very wide alteration that has been made in the first Sub-section. On the grounds I have indicated, and feeling that the Clause does not in any way deal with the point that has been suggested by the hon. Member for Bradford, and also feeling that the point I brought forward has been fully dealt with, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Sir RUFUS ISAACS
I beg to move, in Sub-section (1), after the word "charity" ["or by a charity"], to insert the words, "or voluntary subscriptions."
§ Mr. C. BATHURST
I desire to put a case to the Attorney-General as to an hospital with which I am connected. It is a case where a large portion of the fund that supports the hospital is not raised either by charity or voluntary subscription. At the time the hospital was built, as I believe is rather common in various districts, a fund was raised by the employer and the employed, and the people in the district subscribed over a thousand pounds, which was invested, but is not subject to any charitable trust. The interest upon it forms the nucleus for the annual contribution which supplements it. I do not think that the words of the Attorney-General include a case like that, where there is no real endowment, but where there is a fund out of which the hospital is supported other than by annual contributions.
§ Sir RUFUS ISAACS
It is not quite easy when the Clause is amended to see the exact effect, but the words seem to mo to cover all the cases. My mind, however, 87 is quite open on the matter. What I am anxious to do is to carry out the intention of the Committee. I shall consider any other form of words which may be suggested, or any other case which hon. Members put before me.
§ Mr. W. THORNE
If this Amendment is carried, will any of the insured persons who will be compelled to go to a hospital kept up by voluntary subscription lose their benefits?
§ Sir RUFUS ISAACS
That question arises on a later Amendment. I do not think that this commits the Committee to anything.
§ Question, "That those words be there inserted," put, and agreed to.
§ Mr. LEIF JONES
I beg to move, in Subsection (1), to leave out the word "established" ["similar institutions established"], and to insert instead thereof, the word "approved." This is a drafting Amendment.
§ Mr. AUSTEN CHAMBERLAIN
Perhaps the Attorney-General will be good enough to tell us what is the exact effect of describing an institution or putting in the words "approved" under this part of this Act?
§ Sir RUFUS ISAACS
If the right hon. Gentleman will look at Clause 15, Subsection (1), he will see that there is provision made for the purpose of administering sanatorium benefit, and that the Local Government Board have power to approve of sanatoria or other similar institutions. Therefore it is better to use the word "approved" rather than "established."
§ Mr. AUSTEN CHAMBERLAIN
I think that is doing the very thing that I was anxious to prevent, and I understood that the Chancellor of the Exchequer expressed sympathy with me, that is confining the proposal and the consequent benefit to institutions, either existing or established in the future for the purpose of sanatorium benefit. Sanatorium benefit is consumption benefit, tuberculosis benefit, and we do not want at all to confine this to treatment in institutions which are set up for tuberculosis diseases alone.
§ Mr. AUSTEN CHAMBERLAIN
If it is similar it must be an institution for the treatment of the same kind of disease and subject to the same limitations. That is my whole point. I read the word "similar" as saying for the same purpose as sanatoria, which will be established for consumption only.
§ Sir RUFUS ISAACS
I think the right hon. Gentleman will find that on Clause 15 we deal with the specific point in order to meet the criticism of the right hon. Gentleman.
§ Mr. HARRY LAWSON
May I point out to the Attorney-General that nearly all the great hospitals in London have convalescent homes. They are, of course, of a general character, and are not limited to phthisis. It is quite clear that this Clause does not touch them.
§ Sir RUFUS ISAACS
I do not suggest that it does. The point that was raised by the hon. Member for St. Pancras was a point I thought well worthy of consideration. That has nothing whatever to do with what I just said in reply to the right hon. Gentleman the Member for East Worcestershire. This is a criticism really directed to Clause 15, as to which we have Amendments on the Paper.
§ Mr. FORSTER
I only want to make sure that we are proceeding on safe lines. The approval which may be given under Clause 15 by the Local Government Board is, I understand, limited to those institutions which are designed to give to insured persons sanatorium benefit.
§ Mr. FORSTER
Then the Amendment which the Attorney-General has foreshadowed really will have the effect of extending the area of approval which the Local Government Board can give. We on this side do not want to limit the benefits to those persons who are deriving sanatorium benefit only.
§ Sir RUFUS ISAACS
I am sure the hon. Gentleman will find that we have dealt with that in the Amendments we propose to Clause 15 on which this point will come up for consideration.
§ Mr. FORSTER
I only want to make sure that there will be no misunderstanding, and that the Local Government 89 Board will be enabled to approve of institutions for the treatment of persons in addition to those receiving sanatorium benefit. If that is the object of the Amendment I see no objection to it.
§ Mr. LEIF JONES
I had no intention in moving the word "approved" to limit it in the sense suggested. I really want to extend it, and I move the Amendment because it seemed to me that the word "established" did seem to limit it.
§ Sir P. MAGNUS
If we adopt the word "approved" we do certainly seem to limit the matter to a greater degree than by the word "established." I would venture to suggest that in the meantime it might be better to leave out the words until we come to discuss the matter afterwards.
§ Sir RUFUS ISAACS
There is a complete misconception with regard to this Amendment. Whatever is desired in the way of extension or the approval of the Local Government Board is not being dealt with in this Clause and is unaffected by this Clause. It will be affected by Clause 15, where the specific point comes up for discussion. Here all the Committee is asked to do is to accept the word "approved," which is a better word than "established," and the matter comes up afterwards on Clause 15.
§ Sir P. MAGNUS
I take it that the word "approved" will not be limiting what is proposed in Clause 15.
§ Sir RUFUS ISAACS
That must entirely depend on what is done in Clause 15. We do not really change anything now except that it is better drafting to have the word "approved."
Hon. Members will see Clause 8, paragraph (b), that treatment is not limited to treatment in sanatoria, but also includes "such other diseases as the Local Government Board, with the approval of the Treasury, may appoint." So I think the point some of my friends are afraid of does not arise here, and it seems to me that "approved" is better than "established."
§ Mr. RAWLINSON made some observations which were inaudible.
§ Amendment agreed to.
§ 7.0 P.M.
§ Sir RUFUS ISAACS
I beg to move, in Sub-section (2), to leave out the words "any such benefit" ["as aforesaid any such benefit"], and to insert instead thereof the words "the sum."
90 This is the first of a couple of drafting Amendments. When they have been accepted the Sub-section will read: "During such period as aforesaid the sum which would otherwise have been payable on account of any such benefit to such person." This would agree with what was done earlier, and would enable us to discuss the various questions as we make progress.
§ Amendment agreed to.
§ Sir RUFUS ISAACS
I beg to move, in Sub-section (2), after the word "payable" ["payable to such person"], to insert the words "on account of any such benefit."
§ Amendment agreed to.
§ Mr. SHERWELL
I beg to move, in Sub-section (2), after the word "to" ["to such person"], to insert the words "or in respect of."
§ Amendment agreed to.
§ Mr. AUSTEN CHAMBERLAIN
I beg to move, in Sub-section (2), paragraph (a), after the word "shall" ["(a) shall be paid"] to insert the words "if he be an inmate or patient of a hospital or institution supported wholly or partly by voluntary subscriptions be divided between that hospital or institution and his dependents (if any) in such proportions as the local health committee may determine, and in all other eases shall be."
This Amendment to a great extent expresses the general opinion of the House, as was gathered by the Government in the previous discussion. It is quite true that one or two hon. Members objected. The Member for Stockton (Mr. Samuel) raised a decided objection, and the Member for Bradford (Mr. Jowett), and one or two-others, also objected. As summarising the discussion we have just heard, as collected by the Attorney-General and expressed by other speakers on that side, there was a general consensus of opinion that where a man was in an institution which was wholly or partly supported by voluntary contributions and was an insured person, part of the money due to him, if he had dependents, and the whole if he had no dependents, should go to the institution which gave him not only treatment but board and lodging as well. The hon. Member for Stockton opposing this idea in the earlier stage of the proceedings, spoke of hospitals in a way in which I am quite unable to follow him from my experience. He said there was no such 91 thing in his part of the country as a general hospital, that they were always surgical hospitals.
§ Mr. AUSTEN CHAMBERLAIN
I should doubt very much whether the number of beds for surgical cases exceeded the number of beds for general cases. In particular cases situated in places where accidents, owing to the nature of the trade, happened to be peculiarly numerous and where hospitals were especially provided for the purpose, there might be such cases, but in ordinary cases of the great hospitals in the towns they are general hospitals with a general side and a medical side, and the treatment of the surgical side covers accidents which are brought into them and which could not be treated at home, but they do certainly the same thing for medical cases. The hon. Gentleman seemed to talk almost as if working men had no need for hospital treatment unless a man who had broken a leg or had to undergo a surgical operation, but there is an enormous number of medical cases where the prospects of recovery depend absolutely upon the conditions under which he is nursed and the skill and care with which he is nursed, and he could not get that in his own home. He could not get either the proper physician or the skilled nursing which is necessary. Certainly there are cases in which the medical side of the hospitals is not less necessary to the working man than it is in those cases which go to the surgical side. The Member for Bradford put forward a different view. He said that in this country now there was no such thing as voluntary hospitals. I think he went as far as that. At least, he said they were considered voluntary but had ceased to be voluntary, and why? Because you make the working man contribute to their maintenance.
§ Mr. JOWETT
Hon. Members know that the influences under which they are given deprive them of their voluntary character.
§ Mr. AUSTEN CHAMBERLAIN
I decline to accept that on behalf of the working men of Birmingham, that they have not independence enough to express their own opinion even though they are canvassed. The hon. Gentleman said the 92 working man was canvassed by the foreman to subscribe, and therefore his contributions ceased to be voluntary.
§ Mr. AUSTEN CHAMBERLAIN
What if he were canvassed by the same foreman for his vote? [HON. MEMBERS: "He is."] Some of these gentlemen would not be sitting where they are.
§ Mr. LANSBURY
Better speak for yourself. [HON. MEMBERS: "Order, order."] You know more about it than we do.
§ Mr. LANSBURY
You do not know anything about us. [HON. MEMBERS: "Order, order."] He should not make offensive remarks.
§ Mr. CHIOZZA MONEY rose to a point of Order.
§ The CHAIRMAN
I am dealing with the point of Order. We cannot all speak at once. Hon. Members had better speak in their turn.
§ Mr. CHIOZZA MONEY
The right hon. Gentleman told my hon. Friends they would not be in their places but for certain considerations. Remarks of that kind are of a personal and offensive character.
§ Mr. AUSTEN CHAMBERLAIN
The Member for Bradford said that if a working man was canvassed by a foreman for a contribution to an hospital it ceased to be voluntary.
§ Mr. AUSTEN CHAMBERLAIN
And then I inquired what happened if he was canvassed for his vote by a foreman. Did it cease to be voluntary then?
§ Mr. AUSTEN CHAMBERLAIN
Did hon. Gentlemen opposite ever discourage canvassing in their interests by a foreman?
§ The CHAIRMAN
That is not a point of Order. It seems to me to be an explanation. The right hon. Gentleman is, however, travelling a little wide of the subject before the House.
§ Mr. AUSTEN CHAMBERLAIN
I will come back to the question of the Bill. The experience of hon. Gentlemen is that working men subscribe hundreds and thousands of pounds to hospitals against their will and therefore their subscription ceases to be voluntary. I do not think that is so. I myself am most anxious that they should not cease to be voluntary. The hon. Member would be glad to see them put upon the public money. I do not know whether ho means the rates or taxes. I am most anxious they should be kept off both as much as possible; I think it will be a bad thing for the medical society, bad for the hospitals, and bad for the progress of medical science if you introduce in these hospitals the kind of inspection and control and rules and regulations which necessarily follow upon direct aid from the taxes. I am most anxious that should be avoided; I have before my memory the considerable support given to an observation which the Chancellor of the Exchequer made this afternoon. He rested his case that the hospitals would not be injured mainly upon the German example. He has told us throughout that the effect of insurance in Germany was to improve, and not to weaken, the position of the hospitals. To-day, for the first time, he has told us the reason why that is the case. It is because the German system has adopted the practice embodied in my Amendment. I quite understand why the Chancellor of the Exchequer is absent; but he was sympathetic towards this idea, and had so open a mind upon it that I hope those who represent him in his absence will not be more unwilling in regard to it than he showed himself inclined to be.
94 The Government agree that where a man has no dependents the money should not go to him, and the Committee have already embodied in the first Sub-section the provision that no money is to be paid to a man while he is in hospital, but there is no provision for paying it to anyone else. The original proposal was that it should go to swell the general insurance fund. The Amendment of the Chancellor of the Exchequer provides that where there are no dependents it shall go to the hospital. I propose that where there are dependents it shall be divided between the dependents and the hospital in such proportions as the local health committee think fit. We must set up some tribunal to decide what the proportions shall be. I am not wholly satisfied with the local health committee, but I do not see any better tribunal that we can provide, or one which would have greater power to obtain knowledge of the conditions and needs both of the hospitals and of the dependents of the individual whose money was at stake. There is only one other thing I would say, though it does not really arise on this Amendment, and I do not wish to complicate the Amendment with it. I think it will be found desirable that the hospitals should be represented on the local health committee, and no doubt it will be still more desirable if an Amendment of this kind is carried.
§ Dr. ADDISON
I hope the Committee will not agree to take money for the sake of the hospitals from the dependents of persons in hospitals. We all thoroughly agree with what has gone before in this Debate as to the urgent necessity of maintaining hospitals in a proper manner, but I do not agree that the sick fund which would otherwise assist dependents is the right place to get the money. If a man has no dependents there can be no serious objections to the money going to the hospital; but if a man has any dependents at all the main purpose of this Bill is that they should be prevented from becoming impoverished during the sickness of the breadwinner. The hospitals must be entitled to be paid for the services they will render to the insured person. The only question before us is where the money is to come from. I think the right hon. Gentleman indicated some time ago that before this scheme has been established long we shall have forced upon us the necessity of organising proper standing relations between the hospitals and the insurance scheme. At the present time—and I daresay this is the reason why 95 the right hon. Gentleman has selected this particular fund for a raid—there is really no permanent arrangement for properly contributing to the hospitals. The health committees have their maternity benefit, their medical benefit, and their sanatorium benefit all earmarked, but it will be necessary at the very first stage of this scheme coming into operation that some insured persons should receive treatment in a hospital as soon as possible, in order that they may be prevented from coming on the sick fund. I did not intrude earlier in the Debate, and I will not press my views on the Committee at this stage, but I think that an organisation working through the local health committee is the proper way to deal with the hospital part of the scheme.
It will be necessary that we should have a proper organisation for maintaining the hospital portion of the scheme as an insurance scheme. As a matter of fact, it is impossible to have an insurance scheme unless we have institutions attached to it for the treatment of patients. The Amendment simply suggests that the money shall come from the sick benefit of the insured persons. Nothing would be more deplorable than to mix up business with charity. We know that the lay members of the boards of the hospitals devote many hours every week to the collection of subscriptions—a wearisome and miserable business it is—to keep the hospitals going, and the medical staffs for the most part are entirely voluntary. There is no question whatever that very soon after this scheme is established there will be a great addition to the in-patient work of our hospitals. No doubt there will be, as the Chancellor of the Exchequer said, some relief to the out-patient department. A large number of people go there who are perfectly well able to pay for themselves; they are a burden to the hospitals and a nuisance to the deserving poor who go to be attended to, because the latter are kept much longer than they ought to be. It will be a good thing for the hospitals altogether if this evil is abated. I am afraid that I cannot agree with an hon. Member opposite that the establishment of a system of inspection would in any way touch the disease. We have only to go to the out-patient department of any large general hospital to see that it is perfectly easy to pick out a considerable number of people who have slipped through the very wide mesh of the sieve which has been provided by the system of 96 inspection. It is almost impossible, in a large hospital with a great many people coming into the out-patients' room in the early morning, to sift them out with justice. But when we have the domiciliary treatment that we shall have under this scheme, they will be sorted out for us to a great extent. So far as the wards are concerned, we must of necessity have an increase in the work of the hospitals almost at once. A large number of cases will be diagnosed at an earlier stage, and treatment will be called for at an earlier period. Many cases which are now not treated at all, or which are curable only by operations, will, when this fund becomes established, be sent into the hospitals as soon as possible to be treated, and the pressure upon the hospital part of it will become very much greater.
I feel confident that it will be imperative for us to establish, under proper health authorities, standing relations between the existing hospitals and, let us say, for example, as I hope will be the case, the existing Poor Law infirmaries brought properly up to date and devoted to their proper use. All this means that we shall have before us the great problem of how properly to finance the hospitals and dispensaries, and to bring them into working relation with this great scheme. Therefore I hope the Committee will not prejudge the issue by playing with the question—for that is all that this proposal will do—by extracting from the dependents of insured persons some small portion of their sick pay in order to devote it to these purposes. That will be no adequate way of dealing with the question. It will create a great deal of prejudice against the scheme, and serve no useful purpose. For these reasons I sincerely hope the Committee will not agree to the Amendment.
Sir GILBERT PARKER
The hon. Member opposite (Dr. Addison) has really supported the statement made on this side of the House that in the future increased burdens would be laid on hospitals. The Chancellor of the Exchequer wound up a very careful speech by saying that when this Bill was passed there would be established a wider spirit in favour of preserving the national health, and that that would make the work of hospitals easier. But the hon. Member opposite has shown us the true facts of the case as presented by every hospital in the kingdom, namely, that as soon as this Bill is passed the result of that, earlier diagnosis to which he referred will be to send the cases to the hospitals sooner. The medical men will 97 naturally transfer to the hospitals for additional treatment and also for the relief of their own heavy responsibilities a great deal of the work which otherwise they would have to do themselves. I do not agree with the hon. Member for Bradford (Mr. Jowett) that the working man who is insured ought not to pay anything at all. For instance, it is quite clear that the sickness benefit of the insured pays, as it were, for the insured person's board and lodging and for the hundred little things that are necessary for the care of a sick person. But if he goes to a hospital to which he has contributed nothing—it may be he goes with an in-patient's ticket, which someone has paid for by heavy subscriptions—he gets the benefit, and no one begrudges it to him. On the contrary, the hospital is established for that purpose. But in that case the sick benefit goes to the man's dependents alone. Those dependents may be in great need, or they may be, say, two sons who are partly earning their own living. It would seem reasonable that there should be detached from that full benefit a portion for the hospital from which the insured person receives treatment and care, more things than he would receive in his own home, better and more constant attendance, and probably a better class of food and everything else.
What I am suggesting is this. That if he were in his own home he is going to benefit under the Bill—which is considered a benefit, at any rate, such as can be given with the fund at the disposal of the Chancellor of the Exchequer. That money covers his own expenses in connection with his own sickness, and covers, also, the expenses of his family. He is then very much better off if he goes to a hospital and leaves the whole of that money for the support of his family, because nothing of it goes to pay for, say, accessories of medical attendance and things which are not directly medical attendance, for a hundred smaller things which must be paid for, and which would have to be paid for out of the sick benefit if he were in his own home.
§ Mr. O'GRADY
Does the hon. Member consider the train fare and the hundred and one little things that have to be paid for?
Sir GILBERT PARKER
I do not think that quite meets my point. There may be an occasional train fare, but this sum represents a great deal more. The margin between what he will have to pay if in his own home and what he receives for nothing 98 in the hospital is considerable. I think, without putting any pressure at all upon the working man, that it is a thing which ought to be taken into account by the Committee. Take a hospital in my Constituency which is supported by a few people who are fairly well to do. On the whole it is a poor constituency. It is supported by the working men. When the yearly deficit occurs they combine, go out into the streets, and gather money. That money, together with the proceeds from the hospital fête, or something of that sort, tides the hospital over from year to year. But now the governors of the hospital say that they are absolutely certain, that once the working man has to pay compulsorily into the fund provided by this Bill, and once the employer has to pay, you will get a general diminution of the subscriptions. The working man will not take the same interest in supplying the yearly deficit of the hospital, and therefore the hospital will get less. The employer, having to pay into this fund will naturally say: "The State is doing so much and compelling me to do so much, I cannot afford to give so much to the hospital." Rightly or wrongly that will be the tendency. Private subscribers, who are neither employers nor workmen, will also say: "The State has a great scheme of sick benefit," and their attention will be directed away from these voluntary hospitals, with the result, I am absolutely certain, that throughout the country the general funds of the hospital will suffer. I cannot think that any working man, seeing the thing as I see it, will hesitate to say: "I am perfectly willing if that sick benefit is coming, that a certain portion of it shall be detached to help to pay for, in however small a degree, the attendance which I am receiving in this public hospital, supported by voluntary contributions." In that view I very strongly support the Amendment of my right hon. Friend. I am absolutely certain that if the workmen had the matter explained to them that they would have no hesitation is supporting the Amendment, and that really hon. Members opposite have no right to say, as they have said, that this is an extra burden upon the working men. It is only the subtraction of a small amount of benefit for the double benefits which he receives.
§ Mr. CHIOZZA MONEY
May I beg the Committee to bear in mind as to why we pay sickness benefit. The theory of sickness benefit is this: When a man is ill his dependents need some maintenance, and 99 the maintenance provided by the Bill is 10s. per week for thirteen weeks, and 7s. 6d. thereafter. I ask hon. Gentlemen to reflect as to what right have we, because a man is seriously ill, and therefore taken to hospital, to deny his dependents the sickness benefit which he would receive if he were not seriously ill, if he merely had a small complaint and were at home? For there he would not only be enjoying the society of his family, but the 10s. sickness pay. May I ask the right hon. Gentleman to think of the matter from that point of view, and ask himself very seriously whether it is not the fact that this Amendment would deny the family in their destitute condition—because it is a destitute condition—the small amount of benefit which this Bill provides. I do most earnestly hope that the Government will on no account agree to this Amendment. I can only say that, desirous as I am of supporting the Bill in this connection, I shall be compelled to vote against them if they accept the Amendment.
§ Mr. HAMERSLEY
We have been told that the burden of the hospitals will be very much increased. In fact every speaker is absolutely agreed that the work thrown on the hospitals will be enormously increased. A second factor that we have been told in this connection is that the income of the hospital—it seems to be unanimously agreed—will be diminished by the operation of this Bill. Therefore we are in this position so far as the hospitals are concerned: Anyone, I think, who has listened, as I have, carefully, to this Debate will not, I think, demur to these two propositions: the enormous increase of hospital work, and the diminished revenue by the operation of this Bill. In Sub-section (2) the Bill provides that the committee or society can say—it is a duty cast upon them—in the case of an insured person going into one of the hospitals, how much of the sick benefits shall be paid to the dependents and how much shall go to the general fund of the hospital. We find in a later Clause a definition of what "dependents" are. They cover nearly everybody. They may be a stepson, a half-brother, or a half-sister. I should like the Attorney-General to inform us how much, say, shall be paid where the stepson is the dependant, out of the 10s., and how much to the general fund? Suppose the committee say that under the circumstances 5s. of the 10s. shall go to the dependent. Then, 100 by the operation of the Act the committee will hand the other 5s. over to the hospital, which is taking care of the insured man, giving him medical attendance, food, etc. Instead of going to the hospital, the balance, it appears, may be paid over to the general fund.
The right hon. Gentleman, in his Amendment, in which I heartily agree with him and will support him, simply desires to extend the operation of the Bill a little further, and leave it to the health committee to say how much of the money shall be paid to the "dependent"—stepson, for instance—and how much shall go to the hospital. It is proper to do so, because the hospital is providing for the insured man. There is a hospital in my Constituency that I am particularly interested in. The governors have appealed to me on this particular point. In this hospital there are no tuberculosis cases at all. It is a county hospital, operating in three counties, and entirely dependent upon voluntary subscriptions and charity. Three counties send all their accidents there, and the cases that need operations. A very large portion of the community that that hospital serves are poor people. Nearly all those men who go there will be insured. Further work will be thrown upon the hospital, whose funds will get less. All that is asked by this Amendment is that the health committee shall have the powers already given by the Bill extended, and be able to decide how much will be paid to the dependents and how much, if any, to the hospital.
§ Mr. KEIR HARDIE
There are two aspects of this Amendment that the right hon. Gentleman who moved it cannot have considered. The first is that this Amendment proposes to worsen the position of members of friendly societies. At the present moment the members of friendly societies who are receiving sick benefits, and who require to go to an hospital or infirmary, are not thereby called upon to forfeit any part of the benefit. If this Amendment be carried, if they have no dependents, they have to forfeit the whole of the benefit. If they have dependents they have to forfeit a portion of the benefit. Thus the position of friendly society members is going to be worsened if this Amendment be added to a Clause already sufficiently vicious. The second point is this: the right hon. Gentleman was frank enough to admit that a very large proportion of the funds, especially in the industrial centres, for these 101 hospitals and infirmaries, are drawn from the working classes. I will not enter upon the disputed point as to whether the workmen pay voluntarily or under a system of semi-compulsion. That is beside the point for the moment. The point is beyond dispute that the working classes in industrial centres—whatever the case in the country districts—are the main supporters of these charitable organisations. There are districts like Sheffield where every workman employed in the big works pays a penny per week towards the maintenance of these institutions. In the mining districts the contribution is usually a shilling a year. No one who knows the fact but is aware that anything from 60 to 75 per cent. of the total income of these so-called charitable and voluntary institutions comes directly from the working classes. So what would happen? The workman at the present time is a member of a friendly society. He is also paying 1d. a week towards infirmaries and hospitals. He meets with an accident. Is he going to be deprived of a part of his sick pay which is to be paid over to the institution which he is already paying to maintain? That is to say, you make a workman provide the money for the building of the institution and then you penalise him by taking away part of his insurance money. I am sure the right hon. Gentleman and his supporters cannot have considered that aspect of the question. Even in the case of a man with no dependents there is always house rent, which is going on, and there are all sorts of items of expenditure when a man is in hospital or out of it which are being continually incurred. I agree entirely with the final argument of the hon. Member for Hoxton, that a fund would be required to maintain the hospitals in the future to a greater extent and higher degree of efficiency than they have been in the past, but some other source must be sought for that purpose than the sick pay of the persons insured.
§ Mr. HARRY LAWSON
Speaking in the interests of the hospitals, I am rather inclined to agree with hon. Members opposite, that the Amendment of my right hon. Friend, although not unjust in principle, is not a satisfactory way of meeting the hospital difficulty. The truth is the authors of the Bill have forgotten the hospital problem. What we want to do is to establish a true and vital arrangement between the scheme and the hospitals. Money will have to be found, but I do not think it is satisfactory to take it out 102 of the sick pay. The hon. Member opposite said it is against the common practice at the present time. As he pointed out, those in receipt of sick pay who are members of friendly societies are not asked to pay to the hospitals to which they go, and therefore it would be objectionable, not perhaps from the hospital point of view, to introduce this new feature. If the Government would only face the point, it is just as necessary to deal with the hospitals and perhaps more so than with sanatoria without shirking the problem because of any difficulty and unpleasantness that surrounds it. They are a little afraid of the doctors, and they are not willing to increase the burdens under the Bill. At the same time I do not feel inclined to support a proposal which is represented with some reason as interfering with the custom now prevailing, that the workers should have access to the hospitals without any change on the sick pay which they receive. But I must take exception from the point of view, not only of London, but of the whole South of England, to the charge that at present workmen generally are forced to subscribe to hospitals. Take the Hospital Saturday Fund. Thirty-five thousand pounds a year of that is devoted to hospitals in London, and the workmen manage this fund through their elected representatives upon the fund, and they have a voice in all questions as to how it should be raised or spent. The workmen of London subscribe to the fund, and they would resent as much as anybody else the charge that they are compelled to subscribe to it. That is not only true of London, but it is also true of other towns such as Dartford, where 65 per cent. of the money for the hospitals is found by the working men, and where they have their own representatives upon the Committee, and take part in the management of the hospitals. So far as the South of England is concerned they refute that charge, and I venture to think that they recognise it as the best form of thrift and the highest social duty that they can perform. They do this, and do it in a large degree, not so much in London as elsewhere. The hon. Member for Merthyr Tydvil knows that in London the proportion contributed by the working classes is very small in comparison with the total amount—it does not go beyond 10 per cent. of the total charge for the upkeep of the hospitals. Whilst that is so I am not prepared personally to support a proposal to take money from the sick pay, 103 The Government will have to face these difficulties like men, and they will see that they must deal with the hospitals in a fair spirit from the national point of view. They will learn that before this Bill is through, and I hope the effect of this discussion will not be wasted.
§ Sir RUFUS ISAACS
I have listened to the discussion and to the arguments put forward with considerable interest, and I agree there is a desire to come to some agreement, if possible, with regard to this matter. I think the Chancellor of the Exchequer said that to a large extent he rather agreed that something must be done with regard to the hospitals and some provision made to meet any possible deficiency that would arise in the future after this Bill comes into operation. But I do feel, after listening with the closest attention to everything that fell from the right hon. Gentleman opposite and those who supported him, that the Government cannot accept the Amendment which the right hon. Gentleman moved. I am impressed myself with two views against that Amendment which I will submit to the Committee. The first is, I think the Committee should hesitate long before it would consent to take the money which this Bill provides as insurance benefit from those insured, and so deprive them of it and pay it to the hospital which hitherto has not been in receipt of it. I quite understand the case made that if what you were doing by the Bill was to take away something from the hospitals which they have hitherto been receiving you must make the working classes pay to make good that amount. But you do not take away a contribution which the working classes were paying hitherto. The working man has paid, and is paying, to them. Six millions of people have been subscribing to friendly societies up to now, but they have also been subscribing to the hospitals. This is not the case of where a man is a member of a friendly society and has not been a contributor to the hospitals.
I may mention a personal incident that happened to the Chancellor of the Exchequer and myself in the country the other day. We were met, almost as if it was intended as an object lesson, when going through a country district, by a collector who was collecting from members of friendly societies or others money for an hospital. We believe that will continue, more especially having regard to the very important benefits which we are conferring upon the working classes. The man who 104 has to pay in order to get certain benefits from the hospital will now be able to pay not less, but more, for he will have more money and not less to contribute to the hospitals, and, notwithstanding that you make him insure, for benefits that he did not previously have, he will still have more money in his pocket than before. I am giving full effect to the criticism of Mr. William Watson, the actuary to the Manchester Unity, in reference to a speech which I made some time ago. Even allowing that Mr. Watson is right, and he is a very great authority, but making all due allowances for his authority, I say there will still be a surplus in the hands of the working man which he will be able to distribute.
The second point is also very important. The right hon. Gentleman's Amendment gives the allocation of the proportion of this fund between the insured person and the hospitals to the health committee. But what is to become of the friendly society? Why is not an approved society to have right in determining how much shall go to one and how much shall go to the other? That is a very serious blot upon the Amendment which the right hon. Gentleman has proposed. There is no provision made for that at all, and the result would be that you would be taking it out of the hands of the approved societies and putting it into the hands of the local health committee, which would then be dealing with the benefits of members of approved societies. I submit that the last thing we want to do here is to impair the working of the friendly societies We do not want to take this matter out of their hands and put it into the hands of the local health committee. I agree that there is a great deal that may be effected, and it seems to me there is admirable ground here for arriving at some agreement. There is the Chancellor of the Exchequer's Amendment, which, of course. I cannot discuss at the present moment, but I think under that Amendment you have a clear scheme by which the hospitals would get benefits which hitherto they never had, but they will not get them at the expense of the insured person.
§ Mr. POLLOCK
The Amendment of the Chancellor of the Exchequer does not deal with the friendly societies.
§ Sir RUFUS ISAACS
I think the hon. and learned Gentleman is wrong. What is intended, and it can be made clear, is that an agreement can be arrived at be- 105 tween the friendly societies and the local health committee and the hospital or infirmary. I do not want to take up time now on that point, but if the Amendment does not clearly do that it can be made right. The intention is for an agreement between the friendly society and health committee, and the hospital or infirmary under which members shall be taken by the hospital, and shall receive certain payments, if there are no dependents; the money can be dealt with either as a whole or in part, as the Amendment provides by the approved society and the local health committee. That is the way we submit to deal with this, and my suggestion is that the we might dispose of this Amendment now, and later on get on with the Amendment of the Chancellor of the Exchequer, upon which Members can express their views. I hope that, having discussed the matter, I will not say at undue length, because it is an important matter, the Committee will come to a conclusion now, before we adjourn for the private Bill.
§ 8.0 P.M.
§ Dr. HILLIER
The right hon. Gentleman the Chancellor of the Exchequer in his speech this afternoon based his objection to this Amendment, or any Amendment on the lines of that now before the House, on the ground that the burden of the hospitals would under this Bill be considerably lightened. The hon. Member for Hoxton, who is an authority on this subject, has completely demolished that argument, and he has made it perfectly clear that the effect will be precisely the contrary to what has been set forth, and that the burden thrown on the hospitals will be greater than it was before. As the hon. Member pointed out, there will be a great increase among the number of in-patients in the hospitals, and it is the in-patients that cause the expense and not the outpatients. I agree with the Chancellor of the Exchequer that in all probability the out-patients' department will have a smaller attendance in the future, but we should bear in mind that in all great hospitals the services rendered in the outpatients' department are generally given gratuitously by the medical profession, and add very little to the expenditure of the hospital, in fact it is a mere bagatelle. In future that expenditure is likely to be very materially increased. I hope the Committee will take note of that fact. We must remember that the expenditure of our great hospitals in the future will be 106 increased rather than diminished, and we must consider how that increased expenditure can be met.
I confess that on this point I find myself in agreement with the hon. Member for Mile End. I know the proposal contained in the Amendment is an arguable position, but it is sure to be misrepresented and misunderstood, and after all it will not satisfactorily meet the difficulty. I think as an alternative it would probably be wiser to bring an Amendment to Clause 17, which does provide for contributions to hospitals. Apparently the one shred of the old voluntary system to be left is that on which the Government are going to rely for the maintenance of the great general hospitals. That is a very inconsistent attitude to take up when we bear in mind the attitude they have adopted in this Bill. There are various other points which were made by the Chancellor of the Exchequer, which in view of the very admirable rejoinder made by the hon. Member for Mile End, who has shown great expert knowledge on this question of hospital administration, I will not take up any further time dealing with. I think when the Chancellor of the Exchequer relies upon the sanatoria movement relieving our hospitals to a great extent in regard to tuberculosis patients, he is as unduly sanguine as he was in regard to the effect of this Bill upon the expenditure of our great hospitals. The women and children suffering from tuberculosis in our great cities will, unless further machinery is provided, continue to attend the out-patients' department of those hospitals. I think the Chancellor of the Exchequer was unduly sanguine when he imagined that the sources of revenue of the hospitals would not be diminished by this Bill. I think that when you once get State intervention in a matter of this sort you will inevitably find a disposition on the part of those who have supported the voluntary principle in the past to think twice before they continue their subscriptions to any considerable extent in the future. Although I have come to the conclusion that on the whole it would not be wise to press the Amendment of my right hon. Friend, I am convinced that some provision will have to be made in the direction I have indicated, and I hope that when we come to Clause 17, which deals with the provisions for the upkeep of our great hospitals, the Committee will approach the question in an unprejudiced way.
§ Mr. WALTER M'LAREN
I am pleased the right hon. Gentleman is going to with- 107 draw his Amendment, because I believe it would prevent the maternity benefit being paid, because it has to be divided. If a man is laid up in a hospital while his wife is confined, I cannot see, under the wording of the right hon. Gentleman's Amendment, that the wife would be able to get the whole of the maternity benefit. That is one of the legal effects of the Amendment.
§ Mr. AUSTEN CHAMBERLAIN
I do not think my Amendment is capable of being construed in that way, and in the case mentioned by the hon. Member a woman would not be deprived of maternity benefit at the time of her confinement.
§ Mr. AUSTEN CHAMBERLAIN
I do not think it would be the legal effect of my Amendment, although that may be the legal effect of Sub-section (1) as altered. The Government, however, have promised to consider the form of words to be adopted. After all, my Amendment would leave the matter to be decided by the health committee.
§ Mr. AUSTEN CHAMBERLAIN
The maternity benefit need not be divided. The benefits to which the man is entitled are to be divided only in proportion as the health committee think fit, and they might give a small part of it to the hospitals and the rest of it to the man's dependents. They would not refuse to give the maternity benefit to the man's wife if he was eligible at the time. I put this Amendment down here as being the earliest place at which I could raise the question of the hospitals, and I was anxious to have a general discussion on the Sub-section rather than upon the Amendment. I certainly do not want the case for the hospitals to be tried on this Amendment only. I do not wish to put the Committee to the trouble of a Division, and I ask leave to withdraw my Amendment. I wish to observe, however, that the Attorney-General has been much less sympathetic in this matter than the Chancellor of the Exchequer, whose attitude at the beginning of the afternoon was one of great sympathy with the hospitals. The right hon. Gentleman said that the hospitals have done so well in Germany on the lines suggested that they must do well here. The 108 discussion has revealed the fact that the treatment of cases in the hospitals under this Bill is not the same as it is in Germany, where a contribution is made to the hospital for every patient sent. You are bringing a vast number of men into your net who have never been in a friendly society, and if that is a fatal objection to my Amendment it is also fatal to the Amendment of the Chancellor of the Exchequer.
There is the strong, sentimental argument of the picture which has been so luridly drawn of a heartless health committee getting everything they can for the hospital, and not thinking of the man who is sick and his dependents. I do not think that is a very likely case to arise. If you put it on the principle that a man is entitled to have what he is insured for, namely, 10s. per week whether he is maintained and boarded in a hospital or not, that applies equally to the man outside the hospital as to the man inside, and from that point of view the Chancellor of the Exchequer's Amendment is as unsatisfactory as my own. It is unsatisfactory from my point of view because I do not think it gives sufficient compensation to the hospital, and if the Government reject this Amendment, which has been put down in conformity with their own scheme, they ought seriously to consider the granting from some central fund of compensation to hospitals for loss of revenue incurred in consequence of the passing of this Bill, whether by the falling off of the subscriptions of workmen, or of employers, or either. It would be a disastrous thing for medical science in this country if we did not adequately provide for our hospitals. I do not think the Chancellor of the Exchequer's Amendment, as it, stands, will do that, and I do not think it can be done under the Financial Resolution unless it is altered. I have been most reluctant to press any Amendment upon the Chancellor of the Exchequer which would increase the expenditure provided by the Bill, but I wish to say I should be sorry to try the case of the hospitals upon an Amendment of this kind.
§ Amendment, by leave, withdrawn.
§ Mr. CHIOZZA MONEY
I beg to move, in Sub-section (2), paragraph (a), to leave out the words "in whole or in part."
This Amendment has arisen out of the subject-matter we have been discussing. I would point out that, after all, the highest benefit provided for is 10s. for 109 thirteen weeks, at the end of which period it falls to a smaller sum. I believe that such a sum ought not to be divided in that manner, and it ought to go wholly to the dependents. I put the case that if a man is not seriously ill, his dependents get 10s. If he is so seriously ill as to be in the hospital, why should he——
And, it being a Quarter past Eight of the Clock, and there being Private Business set down by direction of the Chairman of Ways and Means, under Standing Order No. 8, further proceedings were postponed without Question put.