NATIONAL INSURANCE ACT (MEDICAL RELIEF).

HC Deb 24 March 1914 vol 60 cc301-35

Sir HENRY CRAIK

I beg to move, "That, ire the opinion of this House, Medical Relief under the National Insurance Act is open to objection as regards some of its principles, inadequate in many respects, and likely to lead to serious difficulty; and that the supply of Sanatorium Benefit is greatly defective."

In rising to move the Motion which stands in my name, I have no intention of making any tirade against the Insurance Bill. I wish to approach the matter as moderately as possible, and in no party spirit. If I have faults to find it is not in any party spirit, but from a sincere conviction that there are dangers involved in them. I am ready to admit all the good intentions with which this Bill was introduced. I am quite ready to admit that the Government carried the National Insurance Bill with good intentions, and also that they knew from the way we received it from the first that it had the cordial assent of all parts of the House. I am quite aware also that the Bill has been carried into operation with a great deal of energy on the part of the National Commissioners and the officials. I am ready to admit that when you are distributing to 13,700,000 persons 25,500,000 in sick pay, and £5,500,000 in maternity benefits, that much good is conferred and much benefit is done, and much light is thrown on dark places where it was necessary that light should be thrown. But the extent of your work and the goodness of your intentions do not absolve you from the necessity of careful consideration and of wisely weighing the difficulties. I am not going to repeat any of the stale arguments about the necessity of licking stamps and interfering with individual liberty, or the various tirades that have been made upon the Bill on behalf of mistresses and servants.

There is something far more deep-reaching and important I wish to deal with. I confess myself that I am opposed to the principle of compulsion, and I think you could have got all the benefits of the Bill without that violent interference with the habits, customs and feelings of my countrymen involved by the adoption of this principle of compulsion. I am not going to open up that question, except to say that it operates worst in that part of the Bill with which I am concerned, namely, medical relief. The lack of consideration is the ground fault which I lay to the charge of the Chancellor of the Exchequer in the carrying out of this Bill. If he had carried it out calmly after consideration, after duly weighing all the difficulties, and after taking into account the experience of those who had moved in the fields where he was about to move, he would have made use of what was an enormous chance for himself and, what is still more important, of an enormous chance for the future of this country. He neglected to do so, and by that neglect, by that hurrying through of a Bill of its magnitude and difficulty without discussion and without giving the opportunity for weighing the various different opinions, he was led into error in principle and led into mistakes that cause infinite disappointment with regard to details.

It is no part of my business to consider the solvency of the scheme as a whole. That has been to my mind proved as a pressing and impending danger. I only want to touch upon that because it is in large measure put down to something that immediately has to do with the aspect of the Bill with which I am concerned. Insolvency is in large measure put down to malingering, and that, most unjustly, is laid at the door of the doctors. Let us look at the essential difficulties which this want of consideration has introduced into the principle of the Bill. You have determined to work your system mainly through societies hitherto free and self-managed. You have established a compulsory system where formerly there was a voluntary system. You have given proportionate State aid. You have assumed power of examination and of prescribing rules. But, in adopting this instrument of the voluntary societies to carry out a State work, you have not guaranteed their solvency, and you have not been able and you are not able by the nature of things to make all societies equally well managed. You do not, and cannot, take the management of these societies into your own hands. You have changed their character. From being a body of selected persons, you have practically, and as far as you can, made them universal. Then comes the crux of the situation in connection with that part of the subject to which I want to call attention. You can hand over your work of national insurance to these free and voluntary societies, but you cannot, with any justice as a nation and as a State, hand over the supreme object of this Act, the health of the nation, into the hands of any voluntary society. That is a business which you have taken upon your own shoulders, and, if you have done it rashly or without consideration, you have done a great wrong to the nation, and you have built up what may be a great impending danger. You may trust societies in the national work of insurance, but you cannot shift on to them the supreme duty and responsibility that rests upon you of providing for the health of the people.

Let me for one moment call attention to what this really means We have had great talk about this national insurance business, of the ripe and fresh fruit that was to be poured into the laps of the people, of the great benefits that were to be given, and of how you were to raise poverty into comfort. What is the one greatest difference of all between one man and another in his course through life? Is it not, above all differences in wealth, in station, in rank, in privilege, and in power, the difference in the health of the body, and, if you neglect that, how can you make it up by any advantages or solaces you bring by trying to give a few additional comforts, or by a little more levelling of the ranks? The real difference between man and man, far greater than any other difference between the wealthiest and the humblest in this land, is whether the one is in possession of health and the other in a state of weakness and frailty. You must attend properly to and build up the health of your people, and you cannot hand over that duty to any ironbound system of State insurance in the hands of friendly societies. In whose hands was this work previously? I say without hesitation that it was in the hands of the great medical profession of this country, and its record is one to which it may with pride appeal. In what quarter of the nation can you see more works of charity, more works of benevolence, more unselfish labour given for their fellow creatures, than among the ranks of our medical profession? Have they not by difficult and long processes gathered a knowledge of the difficulties that they have to meet? Is there any class that has a chance of knowing the working class and other classes in this country in the deepest and most. intimate relations of their lives equal to that possessed by the medical profession? You had there a source of knowledge and a mine of experience that the Chancellor of the Exchequer would have done well to have used more fully than he did in regard to this Bill.

I am not going to revive the old contest that existed as to whether the doctors were to refuse or not to come within the scope of the Act. They were reasonably anxious as to their own position, but I may safely say from long intercourse with them that they were not mainly anxious as to their own position; they were anxious for the welfare of the people among whom they had laboured. They were afraid that their patients with whom they had had personal relations of the most intimate kind were henceforth to be nothing but numbers on cards, treated with all the sordid details that belong to contract practice. They came and gave you their help freely and fully. You have got, I think, 16,300 doctors on the panel. I have not a word to say against them. I am ready to believe that many of these doctors are among the best of their profession, read to do honest work for their fellow creatures. But while 16,300 doctors look a very fair number for 13,700,000 people—something considerably less than. 1,000 people per doctor—it does not quite represent the reality of the situation. A good many of these are duplicate names on the panel. It is impossible to say in how many cases that occurs. Besides that, they are not equally distributed throughout the country. There are a large number of places in the large centres where the population is so large that there is less than one doctor for every 3,000 inhabitants. I do not think that that is a quite satisfactory condition of affairs, and I do not believe that hon. Members below the Gangway who support this Bill, and hold it to be absolutely right, will be prepared to say that one doctor for each 3,000 is adequate. I admit we have got a very fair number of doctors, high in their profession, honest in their endeavours, and thoroughly loyal in their efforts to work this Act. But the Act says you are to give "adequate medical service." What are the rules laid down as to that? I should like to call attention to what they call adequate medical service:— The practitioner is to give to all persons, who are for the time being entitled to obtain treatment from him, such treatment as is of a kind which consistently with the best interests of the patient can be properly undertaken by a general practitioner of ordinary professional competence and skill. If the condition of the patient is such as to require more than this, what is the step to be taken? What does one expect when he is himself ill? Is it merely an ordinary casual visit from an ordinary medical practitioner? What about operations? What about skilled diagnosis? Is there time to obtain such front a man who has to attend 3,000 patients? What about consultations? What about nursing and appliances? I will not refer to drugs, because that question will be dealt with by others. Let me call attention to what was said by the Chancellor of the Exchequer in interpreting "adequate medical attendance." The right hon. Gentleman made a speech to the Advisory Committee on 13th January, 1913, in the course of which, by way of illustration, he showed how money might be used at Bradford. They were to have a certain number of consultants and specialists; one was to be an oculist; at the head was to be a consulting physician at a salary of £1,200 a year; then there was to be a specialist surgeon at £1,000 a year, and in addition the Chancellor of the Exchequer said something as to the provision for exact diagnosis which pathology and bacteriology had placed at the disposal of modern science. Is that what is given now by "adequate medical service" as defined by the rules sent out by the National Insurance Commissioners? Is it a short visit of a few minutes, or a case of being treated with a crowd after waiting for a long time at the door of a humble consulting room? Is that diagnosis, consultation, appliances, drugs, and all that may come from the science of bacteriology? What provision is there for the nursing which the Chancellor of the Exchequer said was to be part of the "adequate medical treatment"? I am old enough to remember the time when the nation hung with anxiety on the life of a young man, our late King Edward VII., when Prince of Wales. That was in 1872. I happened to know his doctor, Sir William Gull, and I remember his own description of his work; "it was no skill of mine, but it was simply that I nursed my patient, and my nursing did much more than medical skill." Nursing is one of the essential parts of adequate medical treatment, and you have got none of it provided by this Bill in many parts.

Mr. J. SAMUEL

We have it provided in litany counties.

Sir H. CRAIK

What was the old state of affairs? When a special operation, a special consultation, or a skilled diagnosis was necessary, where did the poor man go in former days? Was it not to the hospitals—the hospitals served by doctors gratuitously, and was it not there that he found the help which he absolutely needed, and which cannot be denied consistently with giving adequate medical service. But you have increased the difficulties of the hospital, you have crippled their resources, and have you supplied adequate compensation in their place?

I have complained of the action of the Chancellor of the Exchequer in hurriedly dealing with a question of enormous complexity, setting aside much of the real expert medical opinion which he might have had. Still, the doctors have come in and have given loyal work, but have they in all respects been fairly treated I am constantly having brought before me cases of hardship, not arising merely from petty technical rules, not merely due to the grinding pin pricks of officials, not merely an outcome of the confused and contradictory instructions—and that they are confused nobody can deny. I myself, by personal experience can vouch for it, for I have tried to study them and have hopelessly failed in my attempt to understand many of these complicated and multifarious rules. But there have been real difficulties which doctors have had to meet, and I will give one specimen in connection with a matter which has been going on for some time in the London Committee. As regards that committee, the doctors have a considerable grievance. Section 15, Sub-section (2B), of the Act requires the Commissioners to see that arrangements are made by the local committee to provide for the personal allocation to doctors on the panel of insured persons who have not selected their doctors. A Regulation of the 15th December, 1912, requires that that Regulation shall be carried out, and a Regulation of the 10th January, 1914, seems when first read adequately to carry out the Regulations which are provided by the Act for the allocation of patients. But I find there was a Memorandum issued in November, 1913, which practically sweeps away this question of personal allocation. This Memorandum says that experience has shown that it is difficult for the committees to bring their index register up-to-date with sufficient accuracy to enable it to be utilised for the purpose of existing personal allocations, and that the Regulations have accordingly been modified so as to relieve the committees of the obligation to attempt such allocation. Is that carrying out your Act? [An HON. MEMBER: "Yes."] Is it, indeed? When the Act says that an allocation is to be made, is it carrying it out to say that the committee are entirely relieved of the duty?

Substantially, the purposes of the financial provisions of the 1912 Regulations have not been followed, but a new method has now been adopted with regard to doctors. What has been the result? For months past large sums paid in respect of medical relief to the London Committee have not been allocated to the doctors; they have been funded, and some doctors have been subjected to very severe straits in consequence of the action of the National Insurance Commissioners, who have chosen to reverse the dictum of an Act of Parliament, in order to relieve the committee from a duty placed upon it. That is only one instance out of many. The doctors have a much more serious complaint to make in the charge that is brought against them of conniving at malingering. Nothing, I do not only say could be more false, but could be more dangerous, than to permit the growth of such an idea. Sickness charges have increased because in your haste in pressing through this Act you accepted insufficient data as to the amount of sickness. In the old days, when societies were free and mutual, men often held back from making a claim. It was a matter of pride and interest to them to swell the funds of their society. Do you expect, with a system of national insurance, that these people should be any more generous than any one of us would be if we were insured in an ordinary company. Do we say, "I do not think we require this insurance benefit; there are many people who require it more, and therefore I will not claim"? Do you expect that they will still show that quixotic generosity?

There is even a far greater danger than that. You made a mistake because you went upon insufficient data, but you will make a far greater mistake if you make it more difficult for the doctor to grant a certificate where illness exists by reason of the suspicion of his conniving at malingering. The doctor has no interest in sickness allowance. No man visits a doctor or takes the doctor's dose from pleasure. He goes because his health needs it, and as a consequence of that he receives a sickness allowance. The first, the foremost, I would say the overwhelming duty of the doctor is not to friendly societies or to any financial considerations, but to his patient, and to his patient alone. The legal profession has been proud of the fact that their first duty is to their client. Far more true is that of the doctor. His first duty is to his patient, and in comparison with the interests of his patient he is not ready to consult or think of the interests of your funds or of the solvency of your system. Is the doctor to take the risk of declaring a man incapable of work because you hold that "incapable of work" means "incapable of carrying on his ordinary work"? If I were a doctor and knew that any friendly society interpreted "incapable of work" as being incapable of any work whatever, however light, I should pronounce a person incapable of work even though I knew he or she to be capable of doing a little household work or attending to some light duties. The phrase "incapable of work" was adopted recklessly and thoughtlessly, I believe without any discussion, by a change in the Act, and it has been productive of the very greatest hardship. I will read only one letter which I have received from a doctor, who is a Constituent of my own in Lancashire. His words ought to burn in upon the hearts of those who have the great sense of the importance of the health of the country. He says:— As to malingering in women, this is a detestable business. The women of Lancashire are the white slaves of Europe. In no other country has a woman to work as they do in Lancashire. They weave all day, get scrappy breakfasts and dinners, come home often to light the fire, cook, wash, Lake bread, or put their children to bed. They are up at 5 a.m. and take the baby out to nurse, leaving it to be guarded for them during the day. It is grind, grind, grind! In time she gets run down by dyspeptic anæmia, no matter how high her spirit has been. She requires a rest, and I shall give her that rest, in spite of the friendly societies and of the charges that are brought against me. That is only one specimen out of many. By the skimpiness, scantiness, and inadequateness of your medical relief, which was carried out in a hurry and in defiance of the experience of those who were experts and who readily came in and gave their services, and by the heart-breaking criticisms that have been passed upon the doctors, you have made it a matter which stains your Bill, however good were your intentions. We want to guard against the danger that is looming ahead in regard to this unwholesome competition between financial interests, between the solvency of your Act, between the solvency of particular friendly societies and the vastly more important interests of the health of the people, which should be independent of sordid financial thought. That is entrusted to the medical profession, and I trust the medical profession will stand firm, loyal, and unmoved against attacks. We do not want any State system. We do not want a system under which the working classes and insured persons should be a drilled regiment acting under the orders of State officials. The truth is that the Chancellor of the Exchequer took too hasty a view. He has risked a great deal. He paid no heed to remonstrances which were well weighed. He listened to them for a time—I know it from my own experience in dealing with him; he dealt with us fairly and reasonably at first, but when it became convenient to consult us no longer he then insinuated charges against the profession. He paid no heed to the remonstrances or to the experience of those who had to perform the work. The very essence of the matter, as we told him, is free choice of doctors and cordial personal relations between the doctor and the patient. I do not like this plan of forcing a man to choose a doctor on the panel and making him write himself down under that name. I ask hon. and right hon. Gentlemen on the Front Bench opposite whether any one of us would like to write our names on the list of any particular doctor and pledge ourselves always to attend that doctor?

Mr. BOOTH

We do.

Sir H. CRAIK

For my own part, I do not think of the doctor for one moment until I am ill; then I choose my doctor according to my mood, according to the illness, and according to my need. [HON. MEMBERS: "Oh, oh!"] Would hon. Members like to be pledged and bound during the whole of the year to consult and attend only one doctor?

Mr. BOOTH

It is the usual thing.

Sir H. CRAIK

It is not usual in our own life. You had the key to the position in developing on wider lines the old intimate relation. There were many of the better-to-do working classes who were ready to arrange with their doctor. All they asked was, "Give us the fair amount due to us from the Insurance Fund, and let us make our own arrangements." You would have done it much cheaper, and you would have had an enormously larger fund in your possession to deal with the lower part of society which hitherto, till your insurance-Act came into force, was dealt with by charity and very largely by the gratuitous work of the medical profession. You have broken down all that. You have chosen to ride rough-shod over the habits of the people. You have chosen to bind yourselves to nothing but a compulsory system, compulsory not only in its principles, but in all its details, and now in return for that you find yourselves buried in a mass of machinery, forced to give often contradictory and undecipherable instructions. I admit that an enormous expenditure must necessarily bring great benefits, and the enormous work which has been done by many agents must lead to benefit, but instead of a perfect system slowly growing in accordance with the habits and wishes of the people, you have established an inadequate system, a system involving many dangers and many evils, and one which may before many years require complete and entire recasting. When that day comes I believe you will be glad to follow more closely than you did before the experience and advice of the medical profession.

Mr. GODFREY LOCKER-LAMPSON

I beg to second the Motion.

I should like to show how in other directions the expectations of the public are being deceived. It is rather difficult to discuss the Insurance Act in this House, because whenever we comment upon this defect or that defect in the Act, whenever we ask the Chancellor of the Exchequer to redress a grievance here, or to fulfil a pledge there, we are nearly always told that we are slandering the National Insurance Act. If we tried to get the pledges carried out which were given to consumptives, we are told we are vilifying the noblest legislative work of the last 100 years. If we point out that chemists are being swindled out of their money we are told that we are planting yet another arrow in the breast of St. Sebastian. In fact, the Chancellor of the Exchequer looks upon the National Insurance Act as a sort of Ark of the Covenant which the ordinary man really cannot touch at all without profanity. It may be convenient for him to pretend that it is, but I do not think that any of us are in the least bound to take the same view. The Insurance Act is not a, holy legislative enactment, and it certainly was not recommended to the country in at all a holy manner. Many hon. Members on this side of the House have done their best to act fairly by the Insurance Act, and they have done their best to suggest improvements whenever the opportunity has arisen, but I do not think that in the least binds us to shut our eyes to the defects of the Insurance Act, or to refrain from pointing them out, when we have the opportunity, to the Chancellor of the Exchequer and other Members of the Government. I think the Chancellor of the Exchequer would have had a great deal less to complain of if he had made in the past fewer glowing promises in respect of the Act. His promises, for instance, to tuberculous people will not very easily be forgotten. I do not in the least suggest that he intended to take people in, but I think he has deceived himself. In the exuberance of his imagination hard facts have very little place; but though the oratory of the Chancellor of the Exchequer will pass away, hard facts will come home to roost before very long. What really is the case of tuberculous persons under the Act? It is no use telling us, as the Chancellor of the Exchequer did the other day, that several thousands of insured persons are being given satisfactory treat- ment, if an equal number of insured persons who are paying the same full contributions under the Act can get practically nothing out of it. The Government, to my mind, have really got to deal with these cases, and at once, for every day that goes by they will be taking these poor people's money under what are really grossly false pretences. Everybody remembers the pictures which were painted not so very long ago by the Chancellor of the Exchequer in order to tempt people to come into his scheme. The poor consumptive man who paid his full contribution was to be saved from the jaws of death. No place and no treatment was to be too good for him. A first-class hotel was to be at his disposal. That was a vision conjured up before the eyes of consumptives when the Chancellor of the Exchequer wanted to get support for his Bill, but the vision has proved an unsubstantial pageant and such stuff as dreams are made of. It is possible that the Chancellor of the Exchequer still believes in the first-class hotel, but if he does I think he is the only man in England who does.

Mr. BOOTH

No.

Mr. G. LOCKER-LAMPSON

I should like to give the hon. Member a few instances of what I mean. The Chancellor of the Exchequer took 6d. a year per insured person from the funds of the sanatorium benefit and gave it to the doctors for domiciliary attendance on consumptives, and the result has been exactly what might have been expected, and what was pointed out, that nearly all the insurance committees throughout the country have been short of money ever since, and unable to give proper sanatorium treatment to those who have come before it. There has also been a very great shortage of beds. In some cases insurance committees have got sufficient funds for treating their patients, but there is an absolute lack of accommodation for the patients they want to treat. The bulk of the committees throughout the country are short of money, and the consequence is that instead of treating all suitable cases in sanatoria, they are only sending a selected few, the others being generally jobbed off with dispensary or, even more commonly, home treatment. An instance of this was given the other day at a meeting of the Barnstaple District Insurance Committee, where a man was shown to have been recommended for sanatorium treatment fifteen months ago and was still living in a cottage absolutely unfit for such a case. Some insurance committees make no disguise of the fact that they have been giving institutional treatment not in accordance with the needs of the patient, but simply in accordance with the amount of funds at their disposal. I have a return of the Kingston-upon-Hull Insurance Committee, where what I have just stated is practically stated in black and white. In Aberdeen, again, the insurance committee is short of funds, and will very soon have to refuse many deserving cases for sanatorium treatment on their own showing. The Essex Insurance Committee is in the same position. That committee only a few days ago, according to their own report, had twenty-three insured consumptives on the waiting list for institutional treatment, and at the last meeting of the committee they called attention to the urgent necessity for the provision of a sanatorium by the county council.

Mr. BOOTH

Hear, hear.

Mr. G. LOCKER-LAMPSON

That is my point. Sanatoria do not exist. The Kent Insurance Committee are also experiencing deficiencies, and at the same time they have cut down the nourishment for their insured consumptives. The hon. Member opposite (Mr. Wedgwood Benn) made the matter clear in regard to the Kent Committee. He said:— In the case of individual insured persons, who have already been in receipt of special nourishment for the full period for which Grants are ordinarily given, the committee, while continuing the treatment recommended, have in some cases postponed the question of any further grant of special nourishment in consideration of the immediate claims of other applicants, and with the object of securing the employment of the funds at their disposal to the greatest advantage. It is perfectly obvious that that is merely a Parliamentary way on the Front Bench of saying there is not enough money to go round. I could multiply instances showing that there are far more insured persons in want of sanatorium treatment than there is accommodation for. The sanatorium sub-committee of the Southampton insurance committee have reported that there are far more insured persons in the sanatorium than they can possibly afford to pay for. The West. Hartlepool Committee have reported that the funds available for sanatorium benefit are not sufficient to allow the best results beng obtained. In all there cases the same difficulty has occurred-deficiency of funds—and the same thing is taking place all over the country at the present moment. Added to the want of sanatoria and proper nourishment, there is also a very great shortage of beds in the sanatoria. For instance, in the area of the Bristol Insurance Committee there are twenty-four consumptive insured persons who are waiting for beds, and this after two years for the making of proper arrangements for this kind of case. It is quite clear, therefore, that in the administration of sanatorium benefit contributions are being deducted week by week from the wages of poor people for proper sanatorium benefit, and that proper sanatorium benefit is being withheld. I do say that it is the duty of the Government to do something in this matter. In the face of facts like these, it is really no use for the Chancellor of the Exchequer merely to reply that we are slandering the National Insurance Act. It is his duty, when he is extorting contributions week by week from the wages of poor people, to see that they receive the proper benefits they are paying for.

Mr. BOOTH

You are in favour of sanatorium benefit?

Mr. G. LOCKER-LAMPSON

I am in favour of the proper benefits being given for the contributions, and so long as the Chancellor of the Exchequer continues not to do this so long will he find that he will receive the condemnation of those who have to pay, and who remember the glowing promises he made when he wanted support in the country. In my opinion, if the Insurance Act is ever to be made a tolerable Act among the population, you must give equality of treatment to those persons who pay their contributions. The administration, to my mind, of medical benefit is also extremely defective. My hon. Friend has referred to the want of proper methods of exact diagnosis. These methods are provided in Germany, and the Chancellor of the Exchequer before he introduced his scheme had been studying the German system. But when he introduced his scheme he provided no money for those methods of exact diagnosis. In many parts of the country absolutely nothing has been done in the matter. Only the other day, in his last annual report, the chief medical officer of the Local Government Board stated that scientific diagnosis was practically inaccessible over the greater part of England, and he went on to point out the great delay in proper treatment, and the great amount of sickness that necessarily results. Sir John Collie only a few days ago gave an address before the Faculty of Insurance, and warned his audience of the gravity of this question. I think anybody who really studies the question must come to the same conclusion.

There is a graver question than this. I refer to the absence of facilities for conducting serious operations. The Insurance Act is rather contradictory on this subject. Section 15, Sub-section (2), says that insured persons shall receive adequate medical attendance and treatment, but paragraph (c) of the same Sub-section only gives the right to an insured person to be attended by the practitioner selected by him, and such selection can only be made once a year—that is to say, insured persons can only demand the treatment his selected doctor can give, even although it may be quite inadequate for the particular illness from which he suffers. In practice his position is even worse, for he is not even entitled to all the treatment his own selected doctor can give. According to the Regulations of the Commissioners, he is only entitled to treatment of the kind which can be given by a practitioner of ordinary professional skill. In other words, if an insured person is suffering from an ordinary illness, he can get more or less proper attendance, but if he requires a major operation, and the panel doctor refuses to perform it, he has either to secure it for himself in some hospital or make some payment for it outside of his insurance contribution—that is to say, in the hour of his greatest need he gets nothing at all. To my mind this is very bad, socially and economically. If operated upon, that man might be able to go back to his work. He is probably out of work, and there is a loss to the labour market, and there is a claim of 10s. a week on the society. He cannot afford to pay for a specialist, and the hospitals have long waiting lists. The board of management of the Birmingham Hospital recently reported that there were 180 to 200 cases awaiting admission during the greater part of this year. While the board regretted that it was necessary to wait in many cases which needed treatment, it was quite clear that a considerable increase was necessary in the number of beds, and that the income did not justify the board in dealing with that matter at present. Birmingham is only one instance out of a great many I might adduce which are in this position all over the country. A very unsatisfactory state also exists in another branch of medical benefit. I refer to medicines and appliances. This unsatisfactory state exists especially in the industrial districts. Medical benefit is defined by the Act, as

"Medical treatment and attendance, including the provision of proper and sufficient medicines and such medicines and surgical appliances as may be prescribed by Regulations to be made by the Insurance Commissioners."

"Medical treatment and proper and sufficent medicine" would seem to be a kind of unrestricted term under the Act. Unfortunately for the insured person, it is not at all unrestricted. For instance, the Bolton Insurance Committee have sent out to all the panel doctors a circular prohibiting the prescription for ordinary patients of extract of malt, oil, cod liver oil emulsion, and petroleum emulsion. I have also got here the drug tariff of the London Insurance Committee, which allows these medicines. Therefore the Bolton patients, who need building up in order to avoid the possibility perhaps of consumption, cannot have the necessary malt and cod liver oil, while the London patient can. What is this difference of insured persons under the Act I It is quite clear. I have here a copy of the "Druggist, and Chemist" for this month. It is shown there that in Bolton there is an estimated dificit of 24 per cent. in the Bolton Drug Fund—that is to say, there is a sum of only £7,200 available to pay £8,950 due for chemists' bills during last year. The hon. Member for St. George's in-the-East the other clay repudiated the suggestion that the Bolton restriction arose out of any deficiency in the chemists' account; but it is rather curious that this restriction should have been imposed in the January of this year, after the state of the chemists' account at Bolton was made known. Why did the Bolton patient get malt and oil in 1913, and why cannot he get it now? The reason is perfectly obvious. The Act in this respect is bankrupt. There is not enough money to go round.

10.0 P.M.

If I had time I could show that exactly the same thing is taking place in the case of the Southampton Insurance Committee. This question of medicine is of twofold importance. First, there is the restriction of getting medicine for insured persons, which is extremely grave, and which is absolutely illegal, because the Act says that medicines must be proper and sufficient; and second, where the medicines are not restricted, and where the drug fund becomes insolvent you have got unfair treatment of the chemists who have supplied the medicines ordered by the doctors, and cannot get their bills paid for last year. The Chancellor of the Exchequer told us the other day that nearly all the deficiencies in the drug fund were in areas where the payment per-attendance system had been in operation. In these, as in other matters, the Chancellor of the Exchequer was misinformed. The hon. Member for St. George's-in-the-East stated a few days ago that the only insurance committees in whose areas the doctors are now working under the per-attendance system are Manchester and Salford. He went on to say:— In the following areas, however, that system was originally adopted, either in whole or in part, and discarded at the end of the first quarter of medical benefit:—Blackpool, Canterbury, Cambridgeshire, Dorsetshire. Eastbourne, Kent, Stoke-on-Trent, Suffolk West, Wallasey, and Zetland. That is to say, excluding the first quarter, which is a very short period, and does not very much matter, the only areas that have been working on a per-attendance system are Manchester and Salford. But there is an estimated de-ficiency in the drug fund in no fewer than eleven areas in Lancashire alone. There are deficiencies in Manchester, Blackburn, Bolton, Burnley, Bury, Oldham, Preston, Rochdale, Salford, Stockport, and Wigan. I have got a letter, written three or four days ago, by a Manchester chemist, who says:— I have worked day and night for the success of the Act. Personally, I have been tied up to work every Sunday for the last twelve months, and had to give up my holiday last year. The Commissioners owe me £800 for drugs and appliances supplied. There is no use disguising the fact that deficiency spells ruin to many of oar men. The script sent to me in January this year have only brought 50 per cent. In Yorkshire there is also a deficiency. I have here a report. of the Leeds Insurance Committee, showing that, they have only got a couple of hundred pounds to pay chemists' bills amounting to £4,000. The Scottish Commissioners have just addressed a letter to the Pharmaceutical Committee of Insurance for Scotland, stating that there is a deficiency in at least one area in Scotland. In Birmingham the chemists have only been paid 40 per cent. of last quarter's accounts, and there is no question of excessive or unreasonable or extravagant prescribing by the doctors owing to the per-attendance system, because the per-attendance sys- tem does not exist in these areas, and the capitation system has been in operation throughout. But, in spite of this, the clerk to the Birmingham Insurance Committee has sent out a circular to the chemists intimating that a full settlement of their accounts cannot be made.

In. Bradford nearly £1,000 is still owing to the chemists for the two last quarters of last year, and they say that even greater deficiencies are expected this year. In Stoke-on-Trent also the chemists have not been paid. It has been suggested that some of the chemists' losses should be made good out of the Sanatorium Benefit Fund, and some by putting in operation Clause 40 of the Medical Benefit Regulations. By Clause 40, if any doctor has been guilty of extravagant or unreasonable prescribing, he may be surcharged to that extent for the benefit of the chemist. But the machinery is extremely complicated, and very unpleasant, and there is no suggestion that there has been any extravagant or unreasonable prescribing by the doctor. As for the Sanatorium Benefit Fund, it is already mortgaged up to the hilt. The real cause of the trouble is not unreasonable prescribing by the doctors, but excessive sickness in many of the industrial areas, and the result will be that in those areas where there are very few non-industrial workers panel chemists will be liable to be underpaid. The Insurance Act in this respect is bankrupt so far as chemists are concerned, and it is the duty of the Government to step in. In the second place, there is the second question of surgical appliances. The medical and surgical appliances for insured persons are supplied, I think, by the Insurance Commissioners. The Commissioners zip to now have refused to allow various necessary appliances, such as trusses and other necessary articles, and possibly think that the approved societies ought to supply them, and that the drug fund would stand the expenditure. Certainly the chemists cannot afford it, and neither can the approved societies afford it. They have got absolutely nothing to spare, and even if local approved societies could supply them it could only be by stopping a certain amount of benefit for their members.

What happens in practice is that the insured person does not. get the article he needs, and he remains on the sick fund, and continues to occupy the doctor's time. I have tried to show what I believe are very serious defects in the administration of medical benefit. The real case is that there is more sickness and longer continued sickness than the Chancellor of the Exchequer ever expected under his scheme, and, in any event, a great economic loss is the result, quite apart from the humanitarian consideration that it is for the benefit of the State that the insured persons should get well as soon as possible. But what happens in existing conditions? Insured persons are kept from work, and are suffering pain. Doctors are unnecessarily worked, and their surgeries are overcrowded. Prescriptions are increased, and the chemists cannot get the money due to them. Sickness claims are multiplied, and the solvency of particular societies is threatened. That really is not all, for if the doctors are overworked it is admitted that they can give less attention and time to sick persons. If chemists are unpaid they will be tempted to demand that less costly drugs be prescribed, or that certain medicines shall not be prescribed at all. They have been doing that, as I have shown, in Bolton, Southampton, and else-where. The approved societies are threatened with deficiencies, and they will be tempted to treat patients harshly. Therefore I do say the Government are bound to do something in the matter. Contributions are extorted week by week for certain food benefits under the Act. [MR. BOOTH: "You agreed to it."] We agreed to it, but it is the duty of the Government to see that the full minimum benefits shall be given to those who pay full contributions. Really it is because I feel that the Act is on its trial in this matter, and that there will be an inevitable collapse unless the Government realise the gravity of the situation, that I beg to second the Motion of my hon. Friend.

The PRESIDENT of the LOCAL GOVERNMENT BOARD (Mr. Herbert Samuel)

I desire to intervene in this Debate to deal only with one aspect of the question, that with which the Local Government Board is directly connected, the provision of sanatorium benefit. Other aspects of the question will be dealt with by the Member for St. George's-in-the-East (Mr. Wedgwood Benn). who represents the Insurance Commissioners. As the time is very short, I shall compress my remarks within the smallest possible compass, and will occupy the attention of the House for a very few minutes. Let it be remem- bered, in the first place, that "sanatorium benefit" as used in the Insurance Act does not imply that every consumptive person must necessarily be attended and treated during the whole period of his illness in what is ordinarily known as a sanatorium, namely, an institution especially erected to provide for the treatment of tuberculous cases. The cases in their earlier stages are sometimes of very doubtful diagnosis, and it is necessary for them to be watched either at a tuberculosis dispensary or in hospital, and after they have been to the sanatorium, if the disease is arrested, the patient resumes more or less his ordinary life, and such treatment as he receives is domiciliary treatment. If, on the other hand, the cases, unfortunately, grow worse, so as to be incurable, then during the last stages the only treatment left to be given is hospital treatment. This is clearly stated in the report of the Committee over which the hon. Member for Plymouth (Mr. Astor) presided. One paragraph of the Report runs as follows:— 'Sanatorium benefit' in the National Insurance Act, 1911, means treatment in sanatoria or other institutions or otherwise. The expression is not used in the restricted sense of a course of treatment carried out in-an institution called a sanatorium. Similarly the expression 'sanatorium treatment' has an equally -wide significance. The principles of treatment. which have been elaborated for the most part in sanatoria., have a wide application outside these separate institutions. The advantages of this form of treatment can, in many instances, be given to patients who are living in their own homes or in shelters. In sonic of these cases it may be desirable to secure that the patient should be provided with additional food, or a separate room or bed, in order to ensure efficient treatment. And as suitable conditions, especially if the treatment is being carried out under the advice of a medical man with special knowledge of modern methods, home treatment may be, in all essentials, sanatorium treatment. That paragraph comes with the unanswerable weight of the most authoritative body of medical men and others who have been appointed in this country to examine this important subject, and it comes also with the imprimatur of the hon. Member for Plymouth, the chairman of that Committee. I think that fact ought to be borne in mind by hon. Members when they quote the number of tuberculous cases in this country and assume that every one of those cases ought properly, during the whole period of the disease, to be housed in sanatoria. That is not so. There is no such obligation. I think no medical man would say that such a course of treatment is either necessary or proper. The hon. Member's Committee had to estimate the number of persons who ought to have sanatorium treatment in the strictest sense of the term, and the number who ought to have treatment in hospital. Those two forms of residential treatment are suitable to different classes of cases. They had to form the best estimates they could. The field was quite untrodden, and there was no knowledge as to the number of tuberculous persons present. Let hon. Members opposite remember, and those who now criticise so harshly my right hon. Friend the Chancellor of the Exchequer and the administration of the Insurance Act, that during the ten years they were in office they never lifted a single finger even to touch the fringe of this question. Therefore when we came to deal with it the field was untrodden, and the best estimate had to be formed of what the extent of the disease was. The Committee of the hon. Member reported that so far as the number of insured persons was concerned, it would be necessary to provide beds in sanatoria, on that basis, for 2,100 persons in proportion to the population that they reported, and an equal number in hospitals, being 2,100 in each ease.

The number of beds approved by the Local Government Board in England, which is the only part of the United Kingdom for which my Department is entitled to speak, for the 2,100 insured persons who might need those beds, and for any others of the population for whom accommodation may be desired, was 5,145. The number of beds in hospitals for tuberculous people was 2,580, and, in addition, 571 children, or, altogether, 8,300. In the middle of last month, dealing with insured persons alone, there were actually in sanatoria receiving treatment for tuberculosis, not the 2,100 estimated by the Committee but 3,215, and in the hospitals the number of cases suitable for hospital treatment was 1,658. At that time there were 265 vacant beds in sanatoria, and 344 vacant beds in hospitals. Up to the present date, I am informed by the Insurance Commissioners, that in England alone—they have not yet got the precise figures, but they give me the approximate figure—over 20,000 persons have received treatment for tuberculosis either in sanatoria or in suitable hospitals. The hon. Member for Salisbury (Mr. G. Locker-Lampson) quoted cases where there has been deficiency. It may be that particular insurance committees have not in their own districts provided adequate accommodation. That is their fault. The accommodation is available. The beds are there. If they are not able to arrange for the use of them it is their duty to do so. If the hon. Member would furnish me with specific particulars, which he has not quoted in terms, of the cases to which he referred, I shall be most grateful to him, and will certainly make it my immediate business to look into each particular case. The London Insurance Committee has now over 750 insured persons in sanatoria or in hospitals. The Metropolitan Asylums Board alone has provided them with 500 beds in Downs Sanatorium and the Northern Hospital at Winchmore Hill for tuberculosis patients. In addition to all those, there are being erected further sanatoria at the present time with 2,894 beds, and sites have been approved also for sanatoria for 940 beds. So that when these additional over 3,000 beds are provided, we shall have a total of about 12,000 beds available for persons unfortunately suffering from tuberculosis in this country.

But that is not all. The Government is going beyond the requirements of the terms of the Insurance Act, and we, for the first time, are endeavouring to make provision for the whole of the population. I agree that at the moment our measures are only for the most part in the preparatory stage, but work has been begun, though it is far from being complete. There is adequate accommodation now in the sanatoria for all insured persons suffering from tuberculosis. There is not yet adequate accommodation for the rest of the population suffering from tuberculosis, but that we trust will be provided. One and a half million pounds has been voted by this House for the buildings—and the Treasury have undertaken to find half the cost to provide treatment for the non-insured persons suffering from tuberculosis. Out of fifty county councils all but six have already submitted to the Local Government Board schemes for the provision of tuberculosis officers, dispensaries, sanatoria, and hospital treatment. Of the seventy-six county boroughs, all but seven have submitted already to the Local Government Board schemes for the treatment of the whole of their population who are suffering from tuberculosis. The Local Government Board are pressing forward with the utmost rapidity the approval of those schemes. Most of them have already been approved. The Board are stimulating the remaining small number of authorities also to complete the necessary arrangements. Eighty per cent. of the population of England are already covered by the schemes that have so far been submitted. At the present time £800,000 per year in England is being devoted for tuberculosis treatment of insured persons alone, and we believe when all the arrangements of the county councils are completed a further sum of £1,500,000 from the rates and taxes will be spent annually for the treatment of these persons. There has been, as the House knows, for some time the general desire floating in the minds of great numbers of the people that there should be a national campaign against tuberculosis. Many eminent people, medical men and others, were most anxious that this should be undertaken. But everyone felt that the task was a hopeless one until the State intervened and brought in the strong arm of the law and the deep purse of the taxpayer to assist in this object. That has been done; the work is now launched and is being completed with rapidity. When hon. Members opposite have succeeded in accomplishing one-tenth of the good social work which has been done in this and other matters by the Chancellor of the Exchequer, then, and not till then, let them cast the first stone.

Mr. H. W. FORSTER

The right hon. Gentleman ended on a rather controversial note. My hon. Friends were singularly uncontroversial in the way in which they put their case before the House, and I thought the right hon. Gentleman would have devoted rather more attention to the matters which they unfolded than indulged in the form of words with which he ended his speech. After all, we are not here tonight to deal with these party questions at all. It seems to be one of the extraordinary things about this Act that we are called upon to deal with and discuss it at times when party feeling is stirred to its depths by other questions. Hitherto we have endeavoured to do all we could to keep party bias out of our discussions of this matter in this House. One thing that ought to take it out of party politics is the fact that we are discussing matters that vitally affect an enormous number of people who are compelled to come within the ambit of this Act whether they like it or not. The question which has been raised to-night is whether or not the treatment which was held out to them is being actually received by them. My hon. Friend (Sir H. Craik) had something to say about the adequacy of the medical benefit. He pointed out that the benefit laid down in the Act is undefined. It is described generally and broadly as "ade- quate," and the whole question whether or not insured people are getting the benefit to which they are entitled turns on the meaning of the word "adequate." This House did not define it The Chancellor of the Exchequer defined it outside the House in some of the picturesque speeches that he made. He said that insured people were to get the best of doctoring, the best of drugs, and the best treatment suitable to their particular case.

We all know that they are not getting the best doctors, the best drugs, or the best treatment suitable to their case. Why? It is not the fault of the doctors; it is not the fault of the Insurance Committees; it is not the fault of this House; it is not the fault of the Insurance Commissioners. It is the fault of the Chancellor of the Exchequer, who did not provide enough money to give these people the best doctoring, the best drugs, and the best treatment suitable to their case. The Chancellor of the Exchequer called the tune, but he refuses to pay the piper. I think my hon. Friends have done well to raise the question in the House, in order that this aspect of the matter may receive some consideration. I have been interested in reading a report. which I suppose nearly every Member of the Committee has seen, an interim report issued by a committee of the Fabian Society. Many hon. Members may agree with, while others will disagree from, the Fabian Society. Some will agree with the conclusions of the report; sonic will not. But I think there can be only one question as to the ability and impartiality with which the inquiry appears to have been conducted, and the clearness and ability with which the report has been written. What does the report say in reference to the question of medical benefit? The report says, as a result of an inquiry which has been carried out in every county in the Kingdom, that we see no reason to doubt that for the most part the insured persons who are on the doctor's list are getting under the Act the same sort of medical attendance and treatment that used to be obtained by the average club member, except in so far as the crowding of the doctor's surgery has in many cases become greater, the demand on his time more incessant. and the trial to his nerves and temper sometimes unbearably sharper. Do not we all remember the way in which the Chancellor of the Exchequer used to refer to the club member and to club practice, to the evils of the contract system? Cannot we almost see him now standing at that box and, with all his- eloquent gestures, driving home to the minds of Members all the evils that attended the old system of club doctors? Do we not also remember the enthusiasm with which he held out the hope that all this inadequate medical treatment was to be banished by the passing of the Insurance Act, and that there was opening out a bright future for all these insured people in regard to medical treatment? The result of this impartial inquiry of the Fabian Society only confirms what every one of us can, from our own private experience, say, that the kind of medical treatment which is being given to insured persons now, through no fault of the doctors, through no fault of the insurance committees, is not that adequate treatment which was promised by the Chancellor of the Exchequer, which was aimed at by the House of Commons, and which was provided by the Act. itself! I do not want to labour these points. My hon. Friend the Member for Salisbury alluded to the question of the inadequacy of the medical treatment, and commented upon the absence of modern methods of exact diagnosis. These were specifically insisted upon by the Chancellor of the Exchequer at the time he made his arrangements with the doctors. He laid it down as one of the conditions of giving the medical profession the extra grant that they should employ modern methods of exact diagnosis. The Insurance Commissioners have been unable to arrange for the provision of consultants without whose aid and assistance modern methods of exact diagnosis are absolutely impossible. I say that the administration of this Act falls very far short of the intentions of the House of Commons when the Act was passed.

I have only one word to say in regard to the question of the second part of the Resolution, that of sanatorium benefit. The right hon. Gentleman has given us some very interesting figures as to the progress that is being made since the Act became law as to the provisions of accommodation in numerous institutions, and as to the number of people who have received sanatorium treatment. He was good enough to read us a little lesson upon what we ought and ought not to expect with regard to the provision of sanatorium treatment. He said that we ought not to assume that every consumptive ought necessarily to go into a sanatorium. We do not assume that every consumptive ought to have the right to go into a sanatorium. We were led to expect it by the Chancellor of the Exchequer. The right hon. Gentleman opposite has forgotten the speeches of his colleague. He did not talk about the question of domiciliary treatment. He led a large body of people to believe that if a man was suffering from consumption he would pass almost automatically within the four walls of a kind of first-class hotel. That was promised by the Act. The right hon. Gentleman said that £1,500,000 was provided by the Act to create and bring into being these sanatoriums. Now the right hon. Gentleman tells us, and I listened with some surprise, that there is adequate accommodation now for all insured persons in institutions. Then what is the use of setting aside £1,500,000? If there is adequate accommodation now, we do not want to spend £1,500,000. If there is adequate accommodation why do we hear such complaints from every county with regard to people on the waiting lists of institutions who have been waiting for months and are likely to be waiting for many months more? He told us there were 20,000 people in England who received sanatorium benefit within institutions or within their own home.

Mr. HERBERT SAMUEL

Not all in institutions.

Mr. FORSTER

And a great many more who received domiciliary treatment in their own home.

Mr. HERBERT SAMUEL

Ten thousand.

Mr. FORSTER

And a very large number receiving sanatorium benefit either in or outside institutions. The question is whether the treatment they receive is the treatment they ought to get. Is the treatment given to them, either in these institutions or in their own homes sufficient for the purpose? What is the purpose? To cure their disease and restore them to health. I do not know if hon. Members saw a very interesting lecture given the other day by a man who speaks with great authority on this matter—Dr. Sutherland, the tuberculous officer to St. Marylebone Dispensary. It was by no means an attack on this Act, or on sanatorium benefit, but he said he felt it incumbent upon him to point out from his own experience as a tuberculous officer, that sanatorium bene— fit given under the Act as now administered is not sufficient. He quoted figures to show that the average duration of treatment amounts to only just over twelve weeks. Comparing that with the treatment given to tuberculous patients, subjected to almost identically the same kind of treatment by the Charity Organisation Society, he pointed out that as the result of the longer period given to patients treated by the Charity Organisation Society, a larger proportion of them are being restored to health than under the provision of this Act.

We ought to make this Act as perfect as possible, and if there is any society dealing perhaps with a difficult class of patients and obtaining better results because it gives a longer treatment than that given under the Act, we ought not to be content with the administration of the Act as it is now being carried out. I hope that, as a result of this Debate, something more may be done. Let us look at what Dr. Sutherland has to say with regard to the institutions which bring such comfort to the heart of the right hon. Gentleman opposite. He points out that it is not enough to call an isolation hospital or a fever hospital a sanatorium. You do not make it into a sanatorium by calling it one. He also points out that the buildings provided are unsuitable and overcrowded. I think the mere statement of numbers given by the President of the Local Government Board loses some of its charm when we find in the mouth of one of the tuberculosis officers a statement to the effect that these institutions are overcrowded and are losing some of their efficiency. Dr. Sutherland calls attention to the tendency to limit the extent of the treatment which insured persons get either to a certain period of time within an institution or to a certain amount of money spent in domiciliary treatment. I agree with him that the thing to aim at is the cure of the patient, and not the mere passing through institutions of the largest possible number of patients.

I wish hon. Members would keep in the very front of their minds that unless we are giving these people the best kind of treatment we are not dealing fairly by them under the provisions of this Act. There is one criticism which Dr. Sutherland makes which I hope all insurance committees will take note of. He says that it is absolutely fatal to mix those who are just beginning and who are just found to be suffering from this awful scourge with others in the same ward who are in an advanced stage of the disease. I believe you are really doing far more harm than good by sending these newly infected people and mixing with those in a far more advanced stage of the disease. I hope that the insurance committees, the Insurance Commissioners, and the right hon. Gentleman will do everything they can to discourage this practice on the part of the insurance committees, which is carried out merely with a view to showing the very large number of people who have been in receipt of benefits? I only want to recall to the mind of the House the statement which my right hon. Friend began the discussion with to-night. He said he was not attacking the Insurance Act and that he was not raising this question in a spirit of irreconcilable hostility to those charged with the administration. He has brought this matter before the House of Commons in order that attention may be drawn to the most important branches of administration of the Act, in which we believe there is room for very considerable improvement. I think the Government have no right to complain of the line and temper in which this matter has been brought before the House of Commons. I hope that they will pay attention to what has been said, and do their very best to see that this state of things is remedied.

Mr. WEDGWOOD BENN (Lord of the Treasury)

The Debate has been a very short one this evening, and I am sorry that it is necessary that I should have to speak at this moment. I apologise to my hon. Friends behind me, who are much better qualified to speak than I am and who will not have an opportunity of doing so. The hon. Gentleman who has just sat down charged us with treating this subject in a party manner. I must say that anyone who has taken any interest in the subject of the National Insurance Act must have noticed a marked difference between the way in which the subject is treated in this House by hon. Gentlemen, and the way in which it is treated in the country. We are told that they do not vilify the Act. I have not the slightest complaint to make of the line of the mover and seconder of this Motion, but unfortunately they are not the persons we have to deal with in the country. Will the right hon. Gentleman whom I see opposite, and who lately was Lord Advocate, say that he has never vilified the Act?

Mr. SCOTT DICKSON

Never, I have told the truth about it. It is the best electioneerer we have got in Scotland.

Mr. BENN

That is precisely the point. Hon. Gentlemen who speak in this House say that they never vilify the Act. They send other people into the country to vilify it. The right hon. Gentleman says this: He agreed with the friendly societies which characterised it as a monstrous Bill. There never was such a monstrous Bill. The electors are entitled to it and they want it. That seems to me to come very near vilifying the Act. How are we to administer the Act when the official party opposite go up and down the country telling people that they are paying 4d. in stamps in order that salaries may be paid to Members of Parliament. [An How. MEMBER: "Who has said that?"] I will read a pamphlet issued by an organisation called the National Union of Conservatives and Constitutional Associations. These are the only words in the pamphlet: The Radical policy: Four hundred a year in their own pockets; 4d. a week out of the workers' pockets. What does that mean if it does not mean that the stamps are used to pay the salaries of Members? Take the hon. Member who sits below the Gangway (Mr. Worthington Evans), and who knows the Act, and who ought to be able to talk fairly about it. He goes up and down the country telling people that twice the benefits would be given if the thing were properly managed. There was the South Manchester by-election, one of the glorious victories for Tariff Reform and anti-Home Rule. This is a pamphlet, "Unionists and the National Insurance Act," by Mr. Herz, prospective Unionist candidate for East Manchester. There is a great deal in the pamphlet, and it concludes: With the same money Mr. Worthington Evans. M.P., states that well-managed friendly societies would give twice the amount of benefits granted by the Government. How can you hope to get people to work with a will, and make the Act a success, when people who know the Act, and speak with authority, go up and down the country making statements of that kind? Hon. Gentlemen who have spoken tonight have pursued the same policy they have pursued on previous occasions. They have said: Why do not you give this or that benefit? Why do not you give a second opinion? Why do not you pay for an operation? Or why do you not do a great many things which the Act cannot and does not give because the money is limited? One of their favourite methods at by-elections has been to point out all the Amendments which they moved to this Act, and which a wicked Radical Government refused to agree to, amendments which would have cost an additional £13,000,000 a year. Their other line of criticism was to come to the House and press the Chancellor of the Exchequer to say whether the Act was not really insolvent—two lines of criticism which cannot be made to agree. All those things that have been said to-night that might be done, and as to the appalling state of affairs as revealed among the married women of the country, we admit. But hon. and right hon. Gentlemen opposite when they had the power did not find out, and did not attempt to remedy them. If there are things which are not within the scope of the National Insurance Act it is not because it is a bad Act, because we are doing the best we can with the money at our disposal. The important thing we can discuss to-night is what hon. Gentlemen who are criticising us are proposing to substitute for the Act. They are proposing to substitute the voluntary system. The right hon. Gentleman who sits for the Walton Division started by saying that no desire of party interest would persuade him to abuse the main principle of the Bill, which is universality of compulsion. The Noble Lord at the other end of the scale said he would make it voluntary, and he added, "You would win more elections by that than by any other policy you can adopt."

It is not the slightest use to show defects unless you propose a remedy. Their remedy is making it voluntary. I want to put a few questions to those who advocate voluntary insurance. In the first place, What about the sanatoria? The House knows at the present moment insured people of all kinds can be treated by-county councils under what is called the "Hobhouse Grant." Into that fund the insured population only contribute 9d. per capita for that purpose. Suppose you made the insurance voluntary, anyone who likes can go out and only those who wish need stay in. The result would be that a very much smaller number of persons would contribute in respect of the sanatorium benefit.

Viscount HELMSLEY

Is the Act hated so much?

Mr. BENN

If many hated it, not so many would be left in; you would not have the same number of ninepences, and consequently it would not be possible, if you had the voluntary system, to continue the sanatorium contribution by insured persons. What does that mean? It means that the whole cost would fall on the county councils. Fourteen million ninepences per annum would fall on the rates, so that the first result of the voluntary system would he an increase of the rates by £500,000 a year. Take the second point in their remedy. The people who are left out would still have to pay taxes for the people who remain in. That is perfectly clear. Moreover, one of the arguments used by the Noble Lord the Member for Hitchin (Lord Robert Cecil) was that one of the bad effects of the Act was to lower wages.

Lord ROBERT CECIL

Can you quote?

Mr. BENN

In the by-election in which he was returned, the Noble Lord said that one of the probable effects of the Act would be to lower people's wages.

Lord ROBERT CECIL

I do not remember using that argument, but I do remember saying that a good half of the ninepence would come out of the wages.

Mr. BENN

The argument used by the Noble Lord was to the effect that the fact that the employer had to pay three pence would influence him in the rate of wages he paid, quite independent of the four-pence. Consequently, if you had the voluntary system employés would suffer a reduction of wages for the benefit of those who had come under the Act, and employers would pay, not in respect of their workpeople—for the right hon. Gentleman opposite (Mr. Bonar Law) said that they would pay whether their men were in insurance or not. What is the result? The reason that the employers accepted the Act was twofold—first, because they believed it would improve the tone of their workpeople; and secondly, that it would make them feel that they were themselves doing something for those who co-operate with them in their business. If under a voluntary system the employer's workpeople do not come in he will be paying not for his own workpeople, but for the benefit of those of his rivals, and his own workpeople will still be entitled to come to him and say, "Here I am, I have worked for you for many years; you have contributed for the benefit of somebody else. Now, help me in my time of distress." So the inducement to the employer would be entirely removed. What about the health of the community, of which the hon. Gentleman who moved this Resolution made such a deal? Fourteen million people have now access to proper medical attention. If a large number of those who detest the Act, as the Noble Lords says they do, go right out, a large number of them would lose the right to the medical help they have at present. Hon. Members will remember that in the Act of 1013 provision was made that exempted persons, who number over 50,000, should have the right to a doctor, and of those over 35,000 have already selected a doctor. Moreover, all deposit contributors, or the vast majority of them, become entitled to medical benefit. You hazard the health, and the attention to the health, of all those people if you make the Act voluntary and give them the right to go out.

Who is going out, and who will be left in if the Act becomes voluntary? Experience has shown that in Belgium and Denmark that it is not the rich people who are left out, but the poor people and the young people who had not much money, and who feel that it would be cheaper for them not to come in. It is not the ill people who will be left in, not the people we hear of by question and answer in this House who have received £13 6s. for their contributions and only had thirteen weeks' treatment when they think they might have had it longer. What is going to be the effect of this upon the finance of the Act? Can you continue to charge people a flat rate which they pay at the present time? Even with the present sickness experience for the whole of the fourteen million people, men of fifty-five have to pay 1s. 4d. to get the benefits of the Act. What will the right hon. Gentleman do in his voluntary insurance scheme with these people? When they subsidise a society what sort of examination are their going to make? Are they going to say, "What benefits are you going to give, because on that will depend the rate of the subsidy?"

Lord ROBERT CECIL

It will depend on the age of the members.

Mr. BENN

That will govern the rate of the subsidy. If they say, "We will give you, as we do now, a reserve value equivalent to the age of your members," what will be the result? That a person will say, "Why should I go into insurance now? I will wait until later on in life, and then get the subsidy promised under the new scheme." The result of that would be that the whole finance of the Act would be absolutely wrecked. Then about societies. We have heard a great deal about their position and about the guaranteeing of the benefits, and the fact that people are paying for their stamps but are not being guaranteed their benefits. I ask the hon. Member if the scheme were voluntary, does he think there would be any guarantee of benefits? What about the independence of societies? I notice that the hon. Member for Colchester made a speech the other day, in which he complained of all the red tape and all the interference with societies.

Mr. WORTHINGTON EVANS

Hear, hear!

Mr. BENN

Exactly. Suppose you made the Act voluntary and the man pays his contribution, the State its contribution, and the employers their contribution. Is not the State going to inquire into the way in which the society administers the money? Is there to be no control? The fact of the matter is that experience shows, both in Belgium and in Denmark, that. under a voluntary system you must have complete State control and complete supervision of the societies. For the hon. Gentleman to pretend that voluntary insurance means independence for the societies is to make a statement which I do not think can be substantiated. In con-elusion, I would ask the hon. Gentleman who moved this Resolution in a speech of admirable tone, Does the profession for which he speaks authorise him to say that they wish to leave this system and go back to a voluntary system, because, if they do, what are they going to charge the patients? Are they going to be content to deal with a population in which all the well people have gone out at the same rate that they deal with a population which contains an average sickness experience? Of course, they can do nothing of the kind.

Mr. G. LOCKER-LAMPSON

May I ask the hon. Gentleman, who has not referred to a single argument advanced on this side, whether lie is going to see that the chemists shall be paid or not?

Mr. BENN

I will ask the hon. Member this question in return: Is he authorised by any body of chemists in Manchester or Salford to complain that money is owing to them?

Mr. G. LOCKER-LAMPSON

I ask the hon. Gentleman once more whether, on behalf of the Government, he will give a pledge that the chemists will be paid the money that is due to them under the Act?

Mr. BENN

When I have reason to suppose that the chemists through authorised channels are making the demand, au answer can be given to that question. I will ask the hon. Member these questions: Under his voluntary system how are you going to pay the doctors, and what control are you going to have over societies?

Mr. G. LOCKER-LAMPSON

Is the hon. Gentleman in order in discussing the question of a voluntary scheme?

Mr. BENN

The Motion says the Act is based on wrong principles. I am endeavouring to examine other principles on which it might be based.

Mr. SPEAKER

The hon. Gentleman is examining other principles on which he thinks it might be based.

Mr. BENN

I will ask the hon. Member these questions: Under his system what is he going to pay the doctors? Is he going to pay them more or are they going to do their work for the same capitation Grant? Is he going to promise less control over the societies? What, rate is he, going to charge the insured persons? What benefits is he going to give insured persons, and what guarantee will he give them?

Mr. ASTOR

The hon. Gentleman has asked my hon. Friend a series of questions which it is quite impossible for him to reply to in three minutes. The hon. Gentleman has, as far as I could see, not directed his attention to a single argument which was put to him by the Mover or Seconder of the Motion. He dealt with by-erections in Hitchin and Manchester, he dealt with leaflets, he dealt with voluntary schemes, but, as far as I could hear, he did not attempt to meet a single one of the arguments which were put forward by the Mover and Seconder. I wish to say a word about the speech of the right hon. Gentleman (Mr. Herbert Samuel). He said it was all right about sanatoria and institutions. All the institutions and all the sanatoria were there for insured persons. I want to put before him a statement which he made at Question Time only a month ago. An institution for the purpose of sanatorium benefit is not merely a sanatorium. There are also other institutions. In answer to a question from this side of the House, the right hon. Gentleman said: In some districts there is insufficient accommodation at present for advanced cases of tuberculosis. The councils are taking steps to provide full accommodation.

Mr. HERBERT SAMUEL

Advanced cases.

Mr. ASTOR

But they are insured persons. The Insurance Act does not restrict sanatorium benefit only to early cases, therefore the right hon. Gentleman has no right to say there is accommodation in institutions for all insured persons. The Labour party claim to represent particularly the insured persons. On these occasions there is hardly a speaker for the Labour party to deal with questions of insurance. If hon. Members really had the interests of the insured persons at heart they ought to bring more pressure to bear upon the Government to give adequate treatment, whether medical or sanatorium treatment.

It being Eleven of the clock, the Debate stood adjourned.