§ Sir CLEMENT KINLOCH-COOKE
I beg to move to leave out from the word "That," to the end of the Question, and to insert instead thereof the words "in the opinion of this House, the working of the National Insurance Act shows that, while the cost to the State increases, the benefits held out to insured persons are, in many instances, not forthcoming, and there is reason to believe, in the near future, that the situation will become more acute and a still larger number of insured persons will suffer."
I propose to divide my remarks into two parts, cause and effect. The first indictment I propose to prefer against the Government is that every working man and working woman is forced to contribute to the cost of an undertaking, the advantages of which, whatever they may be, were never properly explained to the persons who have to pay. No Bill touched so many interests or interfered so much with the liberty of the individual as did the National Insurance Bill when it was before this House, while I think, for inquisitorial methods, nothing like it was ever submitted to this Assembly. Given sufficient time, the Bill might have been framed into a system of national insurance which would have been a real boon to the nation, but by rushing it through as the Chancellor of the Exchequer did, at the instigation of the Government, instead of a measure, to use his own picturesque language, of justice and mercy, we had thrust upon the country an act of tyranny and oppression. This, in my opinion, is the main cause of the present unfortunate position. Important Amendments, representing the interests of every class of the community, were never discussed at all, and thirty-three Clauses, together with five Schedules, which dealt with contributions, which were to be paid by insured persons, were driven through the Committee without debate of any kind at all. 585 By the time we came to the Report stage, the Bill, which in its original form occupied seventy-eight foolscap sheets of paper, had extended to 124 pages. Naturally, one expected, as one had a right to expect, that some time would have been given to the consideration of the extra pages. Notwithstanding that 700 Amendments appeared on the Paper, of which 470 were Government Amendments, hardly one of them was discussed at all, and 93 Clauses were never even debated, and when we came to the Third Reading, that was a mere matter of form.
I now come to what I describe as a trick on the part of the Government. I trust that expression will not be thought unparliamentary. Notwithstanding all that the Prime Minister had talked about the Second Chamber being a Chamber to revise hasty legislation—and surely if ever a Bill was hastily passed through this Parliament the National Insurance Bill was—and in spite of the further statement that after the Parliament Bill had been passed, there would be left with the House of Lords duties and responsibilities neither small nor unimportant, the Government sent up the National Insurance Bill together with three other important Bills with the demand that they should all be passed through the House of Lords within ten days. This is what they call democratic government How was it possible to pass through the House of Lords and adequately discuss the Bill in the time which was allotted to it? Why even Lord Beauchamp who represented the Government, and who ought to have explained the Bill on behalf of the Government, said he did not know how to do so, as he was not sure whether he understood the Bill himself, and he was quite certain that not half a dozen others understood it at all.
Why was there this hurry? It was not on our part. We desired to have the Bill recommitted to next Session. We desired to see some of the regulations that were about to be drawn up, and some of the plans which were about to be submitted to the country for the working of the Act. Up to that time nothing was known as to how the Act was going to be worked. All that we were told was that it was going to be worked by a system of regulations. What was the result of our suggestion? That suggestion was not even considered. Why not? Not because the Government themselves had not the opportunity, if 586 they choose, to recommit the Bill to next Session, but because they were not in a position to do so. This is what I want the country to understand, and after what I say to-day, I think they will understand. The reason was simply this—the desire of the Government to keep the pledge which they had made to the hon. and learned Member for Waterford (Mr. J. Redmond). A Member of the Cabinet has confessed that they were under an obligation to the Irish Nationalist party, and this was one of the ways in which they wished to repay the debt. The Chancellor of the Exchequer insisted upon passing the Act through the House of Commons, and he used the whole force of the party machinery for that purpose. In doing this he knew, as indeed all Members of this House knew, that the whole scheme depended for its efficient working upon the co-operation of the medical profession, and yet even when the Bill passed, he could not say that he was in a position to secure that co-operation. In fact, he made 13,000,000 working men and working women begin to pay 3d. and 4d. a week in direct taxation on the promise that he would give certain medical benefits which were to begin six months later. He laid a similar burden on the industries of the country on the basis of the same promise. What did we find? Within a fortnight or three weeks before the promised benefits were to begin, the right hon. Gentleman had failed altogether to secure the co-operation of the doctors, and without that co-operation his scheme of insurance could not be worked. Further than that, in order to secure that co-operation, he had to come down to the House of Commons and demand an extra sum of £2,000,000 which has to be paid by the British taxpayers. Until that £2,000,000 was voted the Chancellor of the Exchequer had no possibility whatever of working the Act which he himself had brought into force. This was not the only additional cost to the tax-payers. Writing to a correspondent, the Secretary of the Literature Department of the Insurance Committee said:—I am sorry to gather from your letter that you think the Insurance Act will be a burden to you as a small employer. Generally, I suppose, employers will be able to pass on their share of expenses to their customers in the way of increased prices, and I sincerely hope that your case will not prove an exception to the rule.That is the great National Insurance Act which was to bring health and happiness into the homes of the poor, and fill the 587 cupboards of working men with "rare and refreshing fruit." What does it do? It taxes food, clothes, coal, and house rent, and this in spite of the assurances which have been given to this House from time to time, not only by the Chancellor of the Exchequer, but by the Prime Minister, that taxation should be placed upon the shoulders of those who are best able to bear it. But notwithstanding the extra taxation to pay for medical benefit, the choice of doctors is limited. Hon. Members will remember that one of the inducements held out to the people of this country to become insured persons was that they should have the doctor of their choice. On 14th October, 1911, the Chancellor of the Exchequer, speaking at Whitefield's Tabernacle said:—Under this Bill any insured person can have the doctor of his choice. That is the doctor for you, and under the Insurance Act you can get him. What a fine thing it is to get a doctor you want, and get somebody else to pay for it.Can an insured person get the doctor of his choice? I submit that he cannot, and I say also that somebody else has not to pay for the doctor you get. I shall be told by the hon. Gentleman who represents the Chancellor of the Exchequer that an insured person can have the doctor of his choice. That may be possible after he has gone through a great many preliminaries, presented a number of papers, if his story is believed, and if he happens to be alive when that process has been concluded; but that is not what the Chancellor of the Exchequer told us at the Tabernacle—and, after all, that is a place where one expected, at least, the truth—No!—the broad fact is that under the Act an insured person does not get the doctor of his choice, and, with all due respect to the right hon. Gentleman, it is not true to say that somebody else is paying for him. I am informed upon reliable authority, and I do not think it will be disputed by the Chancellor of the Exchequer, that a considerable number of persons who pay for these benefits get nothing whatever in return. I believe their names may be placed upon the lists of some panel doctors, but I am told that they have never made any application to be placed on the list. I believe this number is something like 1,000,000. That represents a considerable amount of money. It represents something like £500,000. Where is that money? I believe it is in the hands of the insurance committees, and that in some cases it has 588 been claimed by the doctors. I do not object myself to the doctors getting it, although I do not quite see what claim they have to it, seeing that they have done nothing for it. At any rate, it should not lie idle. There are many matters to which it could be applied very well. I should like to ask the Chancellor of the Exchequer if he will tell the House what he proposes to do with this very large sum of money which stands in the name of the insurance committees.
§ Mr. BOOTH made a remark which was inaudible in the Reporters' Gallery.
§ Sir C. KINLOCH-COOKE
I hope the hon. Gentleman will not interrupt me with a fire of conundrums, none of which I can understand, and some of which, he does not understand himself. Another matter to which I wish to refer is the number of patients on the panel doctors' lists. I understand that in some cases these extend to thousands, and I do not think that any doctor, however hard he works, can attend to so many patients. Some of the doctors cannot give sufficient attendance to their patients, and that, I believe, is because of the number they have to see. The doctor finds it necessary sometimes to send some of his patients to hospitals, but unfortunately there is no provision, so far as I am aware, for payment to the hospitals for receiving these patients. I admit that the hospitals are very generous in the matter, and that we seldom hear of a patient not being received in a case of necessity. I think power should be taken by a clause in an amending Bill to provide for some payment to hospitals for looking after insured patients.
Another matter in connection with doctors to which I wish to call attention is that under a Section of the Act itself it is provided that a man shall only have disablement benefit of 10s. a week if he is incapable of work. I have had a great deal of experience in this matter of incapacity for work. In the dockyards, we know, that when a man meets with an accident he has to go before a doctor, who has to certify whether he is absolutely disabled, or only disabled to such an extent that he can do something to earn his own living. What do we find? We find that in the majority of cases a man is never certified as being incapable of work, and the result is that he goes about the seaport town hardly able to crawl, with little money to himself, and, 589 if he is married, with no money to support his wife or family. The matter is an absolute disgrace and scandal to the country. I see under this Section the possibility of something of the same kind happening with regard to people under the Insurance Act. We find some doctors saying, "This man is not exactly incapable of work; he can do a little," and the result is that disablement benefit is graded down until only a small sum is paid to the man who is certified as not exactly incapable of work, but who can do some light work. I see the possibilty of disablement benefit being brought down until the man gets hardly anything at all. According to the Chancellor of the Exchequer, this Act was designed to make the poorer classes strong and healthy. If that was the case, surely an effort should have been made to give benefits to all alike, but, instead of that, we find the very poor left out altogether; while in cases where they are not left out, they are forced to pay the same contributions as others, although by the very nature of their employments the benefits they receive are illusory or confined to the amount which they pay in as Post Office contributors. Were we not given to understand when the Bill passed through the House that all contributors would be insured? I ask the Chancellor of the Exchequer, Are the Post Office contributors insured? As to the moneys paid in on their behalf, these people might as well pay into the Savings Bank, because they only get out the amount of money they pay in. Then there are the claims of the casual labourer and the outworker. Up to the present these have passed absolutely unnoticed, if we except a Clause in the amending Act which perhaps touches one or other of these classes indirectly. With regard to the Post Office contributors, the Chancellor takes refuge in what I might almost term a boast. He boasts that the number of Post Office contributors is less than he expected, and so he puts back their case until he can make other arrangements. He was asked the other day as to when those arrangements were going to be made, but we could get no satisfactory answer from him. He refused to give us any date, and told us that the matter was still under consideration.
Surely we ought to know when these other arrangements are going to be carried out. Nor does the Chancellor tell the public that the condition of the Post Office contributor, if it is to be altered, 590 can only be altered by further taxation. Further taxation means further levies on wages, and further burdens on trade. That is the remedy which the Chancellor of the Exchequer proposes—to rob more hen-roosts, those hen-roosts being the wages of the working classes. Students of the Chancellor of the Exchequer's speeches who go back some time will not fail to observe his great anxiety to help orphans and widows. I hardly remember a speech up to the time that the Bill became an Act in which we did not hear of his great anxiety for these orphans and widows, and what the Act was going to do for them. I must omit any reference to orphans. That is a matter into which I cannot go now. With regard to widows, I cannot see that the Act does anything at all for them. The Chancellor said that it would, and the First Lord also said so. I remember the First Lord telling us that while the Estimates are exceptional, that is no reason why we should delay the system of national insurance, which would make the provisions so urgently required for the widow and the orphan. Yet you find them left out in the cold. The promises of what the National Insurance Act would do for the widow and the orphan have not been fulfilled, nor was it ever intended that they should be fulfilled.
§ Mr. BOOTH
On a point of Order. I wish to know whether we are entitled to criticise the National Insurance Act for what it did not contain? I submit that the hon. Member is now complaining that the Act was not comprehensive enough in its scope when it was actually passed, and that his Resolution deals with the administration of the existing Act, and therefore he cannot bring in any complaint that it does not include benefits which do not come within its scope.
§ Mr. SPEAKER
The Resolution states that the working of the National Insurance Act shows that the benefits held out to insured persons are in many instances not forthcoming, and that the situation will become more acute, and that a still larger number of insured persons will suffer. That seems to refer to benefits which are not now being given under the Act. If the hon. Member says that the Act ought to have given more benefits and further benefits, he is going beyond the words of his Motion.
§ Sir C. KINLOCH-COOKE
I am endeavouring to show the House that the Act 591 does not give the benefits which were promised by the Chancellor, and I can hardly do that without pointing out the benefits which were promised and not given.
§ Mr. BOOTH
I do not object to the hon. Member complaining that it does not give benefits which were under discussion. The hon. Member, as I understand, is going beyond the present Parliament and referring to the public advocacy of the Chancellor, and saying that the present Bill does not agree with some speeches which were made by the right hon. Gentleman before this Parliament sat. His criticism must be confined to the benefits given by the Act.
§ Mr. R. GWYNNE
The words of the Resolution arc "benefits held out to insured persons." One has only got to refer to the speeches of the Chancellor of the Exchequer before the Act was passed.
§ Mr. SPEAKER
The words should be taken in their ordinary meaning, namely, "held out by the Act." I suppose that if the hon. Gentleman meant "held out by somebody else," he would have put in "by the Chancellor of the Exchequer" or somebody else.
§ Mr. GWYNNE
The benefits as explained by the Chancellor of the Exchequer in his speeches, when he was explaining the actual benefits, have not been carried into effect, and I think it quite fair to infer that this Resolution does mean the benefits as explained by the Chancellor of the Exchequer.
§ Mr. SPEAKER
I do not think that that is quite correct, because the proper course then would be for the hon. Member to bring in a Bill to amend the present Act in order to confer those benefits which were so held out. I think the words "held out" must mean "held out by the Act."
§ Mr. GWYNNE
Could the hon. Member bring in a Bill giving fresh benefits under a State contribution?
§ Sir C. KINLOCH-COOKE
Look at the poverty of some of these insured persons who are supposed to be deriving benefits under the Act. Taking the Board of Trade Returns for 1913, I find that there are 1,175,000 persons in the textile trade earning 17s. 6d. per week; 1,500,000 persons in 592 the clothing trade earning 15s. a week; 1,250,000 persons in the building trade earning 27s. 6d. a week. Suppose we knock off the odd numbers as representing young persons, we have at least 3,000,000 persons who are supposed to be insured under the Act who are earning only £1 a week. We have the authority of the Financial Secretary to the Admiralty for saying that £1 a week is not a wage which the Admiralty desire to pay their labourers, and is not an amount on which any man can live and bring up his family in a respectable manner. Yet we find the Chancellor of the Exchequer passing an Act imposing upon these people a reduction in their wages of fourpence and threepence a week; that in itself is a burden which ought never to have been inflicted. It would not have been done had it not been for the way in which this Act was thrust upon the Statute Book. As the hon. Member for Colchester knows very well—
§ Sir C. KINLOCH-COOKE
I have already said that I have applied the odd numbers to young persons. I think that that is about fair. If the hon. Member thinks not, he can tell me what I should have done; but I do not think that it matters for the sake of the argument. All I want to say is it was possible for the Chancellor of the Exchequer to have taken advantage of the opportunity given by the hon. Member for Colchester, who did propose that the whole matter should not rest on a flat rate. And I would remind the House not only are these poor persons mulcted in fourpence and threepence a week, but there is the rural labourer. I need not remind the House of the picturesque description of the Chancellor of the Exchequer who in one of his speeches told us that the rural labourer only received 12s. a week, and he added this meant a gradual but sure progress towards the pauper's grave. Why should he put another nail into these poor men's coffins by adding fourpence a week to be paid out of their wages for benefits they do not want and may not get?
§ Sir C. KINLOCH-COOKE
I am only quoting the words of the Chancellor of 593 the Exchequer. Of course, in order to meet the point raised by the hon. Member, I should have added the additions which are always given to rural labourers. That would bring them within the scope of the Act. I pass on now to the question of sanatoria. In the celebrated speech of the Chancellor at Whitefield's Tabernacle, he said:—A man goes to the doctor. He is examined. The doctor discovers at once that he is attacked by tuberculosis, awl he says to him, 'You must knock off work at once; you must go to a santorium.". The workman says to him, 'You are mocking me; how could I go to a sanatorium? I cannot pay.' To go to a great building in the country where he gets the best nursing, the best doctoring, the best food for his case, open air, and lives practically in a sort of consumptive first-class hotel. The doctor will then say, 'Haven't yon heard why the Government are finding one and a half millions, by the Insurance Bill, to build sanatoria throughout the country?'Nor did the Chancellor forget to mention the payment of ten shillings to the family of the, patient undergoing the cure. Over and over again I have asked the Chancellor, and the Gentlemen who represent him from time to time, how many foundation stones of these buildings have been laid by him or on behalf of the Government, and I cannot find up to the present that there has been any foundation stone laid for a sanatorium. The Chancellor of the Exchequer takes refuge in the statement that he never meant that the Government were going to provide sanatoria, that what he meant was they were going to assist local authorities to found sanatoria. That may be perfectly correct from the Chancellor of the Exchequer's standpoint. I am not here to say that he did not mean that, but he did not say that; he certainly did not give the audience at the Tabernacle, nor hon. Members of this House, to understand that it was the intention of the Government not to build sanatoria, but to divide the expense with the local authority. What do we find with regard to the number of people who are treated for consumption? We find that only one-fifth of the consumptives in this country are under the National Insurance Act, but even then they cannot be treated, because there are not sufficient sanatoria for them to be treated in. We find that the benefits are confined to insured persons, and those insured persons are only entitled to such benefits as the insurance committees recommend. That is not what the Chancellor of the Exchequer led us or the country to believe. Moreover, what is the treatment that they may receive? The Chancellor of the Exchequer said distinctly that they would go to sanatoria, to first- 594 class hotels, where they would receive the best of doctoring, etc. The insurance committee say nothing of the kind. They determine what shall be done with tuberculous persons. They may or may not be sent to sanatoria, but may be treated at home, and the patient may get a couple of bottles of cod-liver oil, or the Committee may consider that a sun-chair in the back garden is sufficient.
§ Sir C. KINLOCH-COOKE
Of course, the doctor. These were not the inducements held out to the country when the Bill was going through the House, nor are the promised sanatoria benefits carried out by the rules and regulations which have been formulated for working the Act. I should like to ask the Chancellor of the Exchequer where is the one and a-half millions? What has become of it? We hear nothing about it. We hear from time to time, or we see letters in the newspaper, about some county or another making application to the Local Government Board, or to the Insurance Department, about some Grant to assist them in building sanatoria, but we do not see any money spent. I think I am right in saying that only about £87,000 of the one and a-half millions has been spent. I submit that that is altogether wrong, and if the money is not spent, what has become of it, what is it being applied to? The Chancellor of the Exchequer at the Tabernacle said that one and a-half millions would be spent on sanatoria for the treatment of tuberculous people. He has that money. He has not spent it. Where is it? What is he doing with it? Then there is the important question of minimum benefits. We were told over and over again by the Chancellor of the Exchequer that every insured person was to get minimum benefits. There are no minimum benefits, and there cannot be any, because there is no State guarantee. But that is not what the Chancellor of the Exchequer led insured persons to expect. They were told by the right hon. Gentleman himself in the book to which his name was attached that:—My first principle is, that every friendly society must be passed as sound before it can be guaranteed by the State. That is essential, otherwise the State might be in a position of defrauding its citizens. In place of the insecurity of the present societies, in place of the number of lapsed insurances, the workmen will have behind them always security. The societies through which we shall work will be guaranteed by us. We shall have a valuation of the societies, and we shall not work through any society which is not solvent and sure.595 That is the statement of the Chancellor of the Exchequer himself. The conclusion drawn from it, and the natural conclusion, by insured persons and by the country—at any rate, by nine people out of ten—was that when a society became an approved society, the financial soundness of that society would be guaranteed by the State, and also that the minimum benefits would always be paid. Further than that, if from any cause those benefits were not forthcoming, then the State must be regarded as defrauding the citizens.
We know now there is no State guarantee, because the Chancellor of the Exchequer has told us so. The contributors have no security behind them, and approved societies are not what the Chancellor of the Exchequer represented them to be. Neither is provision made for their valuation, except, of course, at stated intervals, and accordingly there are no minimum benefits, and there is no guarantee of solvency. That position was not represented to the country, it was not represented to the insured persons. And, more than that, we are within a measurable distance of the State being placed in the unfortunate position of defrauding its own citizens. The Chancellor of the Exchequer was very angry with some critics of the Act who spoke of it as a fraud; but as the hon. Member for Colchester (Mr. Worthington Evans) said, what would have happened if these statements had appeared in a company's prospectus, and, a year or two afterwards, when the company was working and got into difficulties, the chairman of the board of directors said that what he had put in the prospectus was altogether a mistake, and that, in fact, it was untrue. I am very much afraid he would find himself involved in an action for fraud. I submit this Act to be an absolute fraud, and that view is endorsed by no less a person than Sir James Barr, at one time chairman of the Medical Association, who publicly stated, and perfectly correctly, that it was the most gigantic fraud ever perpetrated on the public since the South Sea Bubble.
The approved societies, fearful lest they should lose their customers, suspended medical examination, and in this they were aided and abetted by His Majesty's Government, who were only too glad to take advantage of the opportunity to lessen the number of Post Office contributors. As a logical result, what followed? Of course, the natural sickness 596 rate went up higher than ever it did in the time of the old friendly societies. More than that, hundreds of members who, under the old conditions, would never have come upon the books of the society at all, now began to put in claims, and that is one of the unfortunate results of compulsion. Now that a man or woman is compelled to pay 4d. or 3d., and have that sum deducted from his or her wages, and now it is known that the first three days of illness are cut off, he or she is determined to come upon the books of the society, and the members of the societies are doing so in increasing numbers. They say, and very properly, "We have paid our 4d., the Chancellor of the Exchequer promised us 9d., and why should we not get it?" Who can blame them? Hon. Members would have done the same thing. You can find no fault with them for that. In his address to the Manchester Unity, at Scarborough, the Grand Master said:—There had been a growing tendency to discourage individual effort, to lower personal obligations, and create a sense of dependence on the community, not only among the very poor, but also among the fairly well-to-do persons in regular employment, who would have shuddered at the idea of old-time pauperism.The hon. Member for Colchester mentioned the other day that we have no complete returns available, and that probably some years would elapse before actuarily certified figures are forthcoming, but the fact remains that the sickness pay has largely exceeded the sum available for distribution. In the near future they will have to call a halt, and then the bubble will burst. Those discrepancies are especially noticeable in women's societies. The Chancellor of the Exchequer admitted this the other day. I do not want to detain the House with the figures, but I would like to call attention to the fact, which cannot be emphasised too often, that Mr. Cross, of the Amalgamated Weavers' Association, with its 65,000 women members, says that they have overspent the actuaries' estimate in the first half-year by over £10,000, and in the second half-year by much about the same sum. Mr. Ormerod, of the National Amalgamated Approved Society, a very large society, tells us that the financial position is becoming weaker day after day. The secretary of the General Federation of Trade Unions states that the sickness amongst women at Cradley was about three times the estimate. I submit that that is a very serious position. The president of the National Conference of Friendly Societies tells us that some societies show from 10 per cent. to 70 per 597 cent. increase in sickness claims, and that, unless drastic steps are taken, this spells absolute financial ruin to the friendly society movement. That is a still more serious position. Again, the Associated Foresters' Court last year, at their meeting, unanimously voted that—Unless the Act is promptly and drastically amended, the financial existence of the friendly society, and, indeed. their future existence, would be seriously imperilled.Just look for a moment at what this means to the contributors. I am told, and I believe I am correct in saying, that in a society of men an excess of 50 per cent. sweeps up all the margin and all the money provided for the disabled, and that an excess of 80 per cent. means that the society has not only to reduce its rate of sickness pay, but to subject its members to a continuous levy great enough to cover all the cost of all its other benefits. Has the Government intervened in any of these societies? Do they propose to hold an inquiry as regards the solvency of these societies? Not at all. They say, "We have not the time; we must put it off to some other time; some more convenient time, perhaps a time after the General Election." That may be to them a very convenient time. We have been told by the First Lord of the Admiralty that "this Act is now settling down into its stride." Judging from the statements made by Liberal candidates at by-elections, one can hardly say that the Act has settled down into its stride. So far as I can gather, and I have attended a great number of by-elections, the Liberal candidates have been endeavouring to make excuses for the administration of the Act. They have been tumbling over one another in their desire to cry out that there would soon be an amending Bill before the country, and, if that amending Bill was not sufficient, other amending Bills would be brought in until at last we had a perfect Act. I submit that that is not the kind of legislation that this country has been used to, and, if that is the kind of legislation we are to expect from the present Government, it is no wonder that the Acts which they have placed on the Statute Book, espcially the National Insurance Act, cannot be properly administered. There is one very warm supporter of this Act—the Financial Secretary to the Admiralty. I wish he were in his place, because what I am going to say would appeal to him. He tells us that it is quite a mistake to suppose that the National Insurance Act is a new thing. "Oh, no," he 598 says, "there is nothing new under the sun." He may be right there. He goes on to say:—It might be said that the Navy anticipated the Insurance Act by over 400 years. After the defeat of the Armada in 1588. there was established the Chatham Chest into which every sailor was compelled to pay 6d. per month from his wages to provide pensions for maimed and wounded seamen.That is quite correct, but the Financial Secretary did not mention what I will tell the House, that in the case of this money compulsorily taken from these seamen for the purposes named, the State itself during the last century has taken away the greater part of that money, and the greater part of that money has not been applied for maimed and injured sailors. It strikes me that is very much the same sort of thing that we may expect from the administration of the National Insurance Act. What we want and what we ask for is that there should be an inquiry not by partisans, not by political people, but by experts, and that those experts should inquire into the working and into the administration of this Act, and to see possibly not only what are the defects, but also whether there is any way by which those defects can be remedied. That is what we should like to see, and I have no doubt, if that inquiry was properly and efficiently carried out, we should find that it would not be altogether impossible to substitute for the compulsory insurance principle a voluntary principle. I beg to move.
§ Mr. CHARLES BATHURST
I beg to second the Amendment.
I regret the absence on this occasion of the Chancellor of the Exchequer, especially as the Chancellor of the Duchy of Lancaster is unable nowadays to grace us with his presence here. I have no doubt that the Chancellor of the Exchequer is attending at the present moment to high matters of State at a time of great national crisis, and, under those circumstances, it would not be fitting for me to criticise his absence. I do not pretend to possess the robust eloquence of my hon. Friend who has moved the Motion, nor if I did possess such eloquence would it be quite fitting for me, under the peculiar circumstances in which I find myself, to indulge in it to any considerable extent. Not through any choice of mine, I was two years ago appointed chairman of one of the large associations of approved societies, representing something like five to six millions of insured persons, and I only venture this afternoon to participate in this Debate 599 because I should like, I hope in a nonpartisan spirit, to bring to the attention of the House some of those grievances which are not always voiced in this House, but to which expression is given at the various conferences of those large organisations which from time to time take place. It must be admitted that benefits, very considerable benefits, must result from the application of a sum of money amounting to about £20,000,000 per year. The question is not whether benefits result from the National Insurance Act, but surely it is rather as to whether this large sum of money is being economically expended, and equitably distributed, and is actually producing the benefits for which the Act purported to provide.
I should like to refer, quite shortly, to certain respects in which both medical benefit and sickness benefit do not, in my opinion, and in the opinion of those with whom I work in insurance matters, come up to the expectations formed at the time of the passing of the National Insurance Act. As regards medical benefit, the complaint is threefold. There is, first, the inadequacy of medical treatment, owing to the Regulations of the Commissioners; Secondly, the inadequacy of treatment owing to the lack of proper organisation of the medical service; and, thirdly, the total failure in certain cases to obtain medical benefit owing to the complexity of administration. It was mentioned last Thursday night, and I may, perhaps, remind the House again, that medical benefit is defined in the National Insurance Act of 1911 to be medical treatment and attendance, and there is no qualification anywhere in the Act of that definition, nor is there any power vested in the Commissioners or anyone else to alter or restrict the scope of that benefit. By Section 8 of the Act, there are limitations placed upon the surgical and medical appliances to be provided under the Act, and, possibly also, upon the provision of dental treatment, because it is included in one of the Schedules as being a sort of benefit that is to be included as an additional benefit., assuming that hereafter the surpluses of the approved societies permit; but so far as medical attendance and treatment are concerned, not only is it not limited by the Act, but it is expressly stated in Section 15 that every insured person shall receive adequate medical attendance and treatment.
600 It is quite clear and obvious that the insured person is legally entitled to adequate medical attendance and treatment, and to all the assistance that medical science can provide. This, indeed, has been repeatedly amplified and emphasised by the Chancellor of the Exchequer in expounding the Act. Quite recently a Regulation of the Commissioners has been issued to the effect, that medical benefit shall include only such treatment as is of a kind which can, consistently with the best interests of the Patient, be properly undertaken by a general practitioner of ordinary professional competence and skill. I venture to suggest that that regulation is quite ultra vires the National Insurance Act, and goes quite beyond the powers which the National Insurance Commissioners are entitled to exercise under that Act. Their powers to make Regulations are strictly stereotyped. and defined by the Act itself. They are confined to headings under which they are given specific powers, and this is not one of them, or to matters necessary to bring the Act into operation. The effect of this, as I suggest illegal, Regulation of the Commissioners is that only the simplest form of medical benefit can be provided by the panel doctors, and anything beyond those simple forms of treatment are treated as extras, which either have to be paid for by the patient or obtained through charitable institutions. I may instance the case which was repeatedly referred to when the recent amending Act was passing through Committee, the case of simple affections of the throat or nose or ear or eyes. Many of them involve quite simple treatment, or quite simple surgical operations, but in most cases, in fact in all cases, as I believe, except as a concession on the part of the panel doctor, those are treated as outside the scope of medical benefit and involve a special fee in order that such treatment may be obtained. Such cases, for instance, as affections of the tonsils, adenoids, inflammation of the eyes, and the like, if a special fee is not asked for such treatment, are directed to go to hospital.
I think the House must realise now that the hospital accommodation, particularly in the country districts, is proving wholly inadequate to meet the requirements of insured persons who are recommended to seek hospital treatment. It is all very well in the larger towns or in many of them, where sufficient hospital accommodation is no doubt available, but 601 in those other districts it is increasingly difficult, largely as the result of the passing of the National Insurance Act, to maintain the hospitals as they should be maintained, and in those districts patients have to wait, sometimes for several weeks, in order to receive the hospital treatment which their panel doctor recommends. That, of course, involves a concomitant charge, and sometimes a very serious charge, on the sick fund of their approved society. Then of course, as we all know, there is no proper provision being made for diagnosis. All those cases which are not simple cases ought undoubtedly to be dealt with as the result of consultation between one medical man and another. Such additional diagnosis and consultation would verily, I believe, result in an enormous saving of national money, both by way of medical benefit, and also by way of sickness benefit. It is not at all an unusual experience, especially where a doctor has a very large number of insured persons on his panel, for persons to remain in a hot, overcrowded waiting room sometimes for as long as two to three hours, and then eventually to be told, after explanation of their symptoms that they are suffering from dyspepsia, colic or gastritis, when in fact, it is proved on a more complete diagnosis that they are suffering from it may be appendicitis, or gastric ulceration, or similar complaints, requiring much more drastic treatment. For those reasons, as the result of that lack of diagnosis, and as the result of this bustling system of dealing hastily with much too large a number of persons, by the panel doctor, an increased and very heavy charge is being thrown upon the finances of the approved societies. Now I come to the organisation of the medical service. The proportion of doctors to the population is in many areas notoriously much too small The case of London is perhaps the best known. By way of illustration I may say that in Hoxton, Shoreditch, and Poplar, there is one doctor to every 5,000 or 6,000 of the population, whereas in Hampstead there is one doctor to every 476 people, and at Bath the proportion is one to every 521. It is, in fact, estimated that in many populous towns, owing to the present system of selecting panel doctors, one-fifth of the doctors are treating, or purporting to treat, something like half the total cases of sickness arising amongst the insured population. In 602 any case it is no unusual state of affairs to find from 2,000 to 3,000 insured persons on the list of a single panel doctor. In the year 1913, in many districts, from 60 per cent, to 80 per cent. of the insured persons upon those lists actually visited the doctors and required treatment. On the face of it it is quite impossible for one man, in the absence of proper assistants, to deal with anything like from 2,000 to 3,000 persons, of whom something like 60 per. cent. or 80 per cent, visit him in the course of the year. I am not referring to cases where there are assistants; in such cases. the numbers upon the panel doctors' lists run much higher than 3,000. Every day in such areas consultations are being given and so-called treatment provided for hundreds of insured persons who are seldom able to remain with their medical advisers for more than two minutes at a time, during which period it must be quite impossible for even a thoroughly skilful doctor, with full knowledge of diagnosis, to, ascertain the nature of their maladies, and decide upon the course of treatment.
Then I come to the complexity of the administration, and the occasional vacciliation of the administrators as represented, by the National Insurance Commissioners. Perhaps the most flagrant case of this vacillation occurred in the course of last autumn, when, as the result of an Amending Act, persons out of employment and in arrear with their contributions were authorised to pay a single contribution—that is, their own contribution, and not the employer's contribution as well. That made a difference, in the case of men, as between 7d. and 4d., and in the case of women, as between 6d. and 3d. What actually happened? No Regulation was issued by the National Insurance Commissioners until the month of December, although, in fact, the Act came into operation—I am not sure whether it was in July—
§ Mr. C. BATHURST
Although the Act came into operation in January, and during the period between the passage of the Act and its coming into operation, a large number of insured persons were paying up their arrears. The result of that was that a large proportion of the more honest and thrifty insured persons, at great sacrifice to themselves, were paying up arrears for which, in fact, if they had not paid them, they would never have been asked, whereas their less scrupulous 603 and less thrifty friends were in default with their contributions, and eventually as the result of the regulation of the Commissioners, were necessarily let off those arrears altogether.
§ Mr. C. BATHURST
I mean that portion of the aggregate arrears referable to the employers' contribution. What I suggest in that particular case is that if the Commissioners had been a little more alert and a little less vacillating—because they withdrew their first regulation, as I understand, and issued another in place of it—they would have caused a great deal less embarrassment to the approved societies, and fairer treatment would have resulted to those who were most scrupulous in paying up their arrears. What I want particularly to refer to is the system of the card index, and, in connection with that, the use of the various medical tickets. It has proved to be a most cumbrous and, to the approved societies, a most laborious scheme, and has involved insured persons in an immense amount of inconvenience and, in some cases, loss of the benefits that the Act was supposed to provide.
§ Mr. WEDGWOOD BENN (Lord of the Treasury)
Does the hon. Member mean the existing system or the old system?
§ Mr. C. BATHURST
I will explain quite shortly what I mean. In the first place, colossal labour was involved in getting 14,000,000 insured persons card indexed. I have always doubted, as the result of my experience on an insurance committee, whether that enormous labour, both to the approved societies and to the insurance committees, has been justified in the result. These cards were written out by the societies and sorted out amongst the various insurance committees. But the card index was doomed to failure ab initio, because it was clearly impossible to keep it up to date as an indication of the present address of the persons to whom it referred. The card index in the case of every county and borough in the country is, I believe, quite incorrect, and it is absolutely impossible to keep pace with the changes of address of insured persons. No change of address has, in fact, been reported by the insurance committees since the 1st 604 January last. Moreover, the method of application to doctors for medical treatment has changed no less than four times in the course of thirteen months. Can you imagine anything more confusing, both to the approved societies and to the insured persons? During that period there have been in use what is known as the red ticket, the buff ticket (which is now in use), Form 32, and Form 50, involving four entirely different and conflicting sets of instructions to insured persons. Every insured person should have been in possession of a buff ticket as his medical voucher on the 12th January last. Those tickets are only now being distributed by the insurance committees on the basis of this card index, which is hopelessly inaccurate, and has involved unparalleled confusion in insurance administration. Those who have not received their buff tickets, probably owing to a change of address, are being told by the doctors that they cannot be treated by them until their cards are presented. These are only obtainable from the insurance committees, and in all cases, I think, the lapse of at least a month, and sometimes longer, is involved before the card is available, and therefore before medical treatment can be obtained. The result is that many insured persons when they fall sick are having to pay out of their own pockets for the medical attendance and treatment which the Act purported to provide for them. There is also an undoubted confusion of ideas amongst both doctors and insured persons as to the arrangements for a change of doctor when an insured person changes his address. I hope that something will be done by the Commissioners to avoid the frequent embarrassment and often injustice that results owing to the impossibility of obtaining medical benefit on a change of address by an insured person.
I want next to ask whether the Insurance Commissioners cannot do something to provide skilled nursing for insured persons. I had the privilege last autumn of presiding over a largely attended conference, at which delegates were present from approved societies all over the country, from insurance committees and from various nursing organisations. At that conference a resolution was unanimously adopted in favour of the provision of skilled nursing as a part of, or in addition to, the medical benefit, on the ground that it would undoubtedly effect 605 the more speedy and more certain recovery of sick persons, and thereby result in a large saving of money which is now being expended upon medical benefit and more particularly upon sickness benefit.
§ Mr. BATHURST
I am trying to point out that, so far from costing more money, it would result in a saving of money. There are a large number of cases about which doctors are quite prepared to give evidence, in which, if proper nursing was forthcoming, recovery would be more speedy and the doctors' work would extend over a much shorter period than is the case in the absence of any provision for nursing. The hon. Member opposite asks me how the money is to be provided. May I suggest one method by which, if any additional money be necessary, it can be provided? By Section 1 of the Amending Act of 1913, the Commissioners constituted a special mileage fund in order to make medical benefit more complete. This is at least as important as a special mileage fund, and I suggest that a special nursing fund could similarly be provided under this Section. It would, I think, result in a great saving of the national expenditure upon health insurance. To sum up the suggestions which I have to make with regard to medical benefit: they are, first of all, that there should be the provision of surgical treatment in all simple cases, and also where necessary of the more complex medical treatment as well as nursing, in place of, as now, the provision only of the simplest possible medical treatment in many cases without effecting the recovery of the insured person. In the second place, there should be the provision of facilities for confirming doubtful diagnoses and assisting the panel doctors with a second opinion in difficult cases. Thirdly, there should be the better organisation of medical service, and the provision of more doctors in congested areas. Fourthly, there is needed the provision in such areas of convenient and sanitary dispensaries, in place of the small, often overcrowded and stuffy waiting rooms in which persons have to wait in some cases for hours before they receive attention. Last, but by no means least important, we need the simplification of the present somewhat complex administration of the National Insurance Commissioners and above all, less vacillation in dealing with matters of serious importance to insured persons 606 seeing that the present occasional experience of doubt and delay may result in financial loss to the insured persons.
Just shortly I want to refer to sickness benefit. I want to admit in speaking of sickness benefit, that in most cases the sickness benefit provided by the Act, and promised by the promoters of the Act is, in my opinion, being provided. There is, however, undoubtedly an excess of sick pay, which has to be paid as the result of the uneconomic administration of medical benefit to which I have referred. May I say, in passing, that conditions would be immensely improved if larger hospital accommodation could be provided. There are exceptions to the general rule, and the chief exception is the case of the small society which has a large number of married women, and to be found, I think, mainly in the textile districts of Lancashire and Yorkshire, though such are also to be found in other places. We know this, from the case of Cradley Heath and certain societies which comprise the women workers in the boot trade of Leicester and its district. The Government actuaries with little or no experience to guide them, have wholly underestimated the sickness experience in the case of the women's societies; particularly of those women who are employed in factories, and particularly at times of pregnancy. The Government advisers seem to have entirely overlooked this latter matter in their actuarial estimates. In these cases it is all very well to provide maternity benefit. But we are all aware that prior to confinement a woman, particularly if she is employed in a factory, is bound to have a period of rest. That period of rest may amount to two or three months. In the case of hard work in a factory I myself hold that three months is none too long a period.
During that period the sickness benefit has to be provided by these women's societies, and that sickness benefit cannot be provided on the basis of the Government actuarial estimates, with the result that these societies, in order to save themselves from extinction, quite improperly, but necessarily, are reducing the benefits which are being given to their members in the case of what they consider as the more trifling or temporary ailments, such as influenza, bronchitis, anæmia, and such-like. They are limiting their sick pay in these cases to periods of two or three weeks, and then declining to give any more sick 607 benefit after the lapse of that period. I do not know how the Chancellor of the Exchequer and his advisers are going to deal with this problem. It is a difficult problem which was not foreseen at the time of the passage of the Act, but, in fairness to these societies and these women, something has got to be done. Of course, it may be that it was wrong to allow them to become segregated in small local societies, instead of being brought together in a large central society or fund, as, I believe, is the case in Germany, and some other Continental countries. In any case, the sickness experience is very alarming in connection with some of these societies. There was a case which was brought to my notice quite recently in Leicester where the sickness experience is 300 per cent. of the estimate. I am not sure that in that case these restrictions were being put upon the period and the amount of the sick pay, but if not it only shows that where such restrictions are not being made in the case of the benefits to which insured women are entitled the alternative is the financial breakdown of the society.
What is going to happen after the valuation of 1915? It is common knowledge that the valuation of 1915 will show a large number of women's societies and some men's societies to be insolvent. Let me just ask hon. Members to consider what is going to happen when it is found as a result of that valuation that certain societies have a surplus and that a very considerable number of societies have a deficit? There will be a transfer of an enormous number of persons from the societies with a deficit to the societies with a surplus. The result will be that the present position from a financial point of view will become seriously aggravated. Another result will be that all your good lives will become aggregated in one class of society, and all your bad lives will become aggregated in another class of society. In other words, as has often been said in this House in other matters, you will find yourselves with one law for the rich and another for the poor. I do not want to burden the House with any further observations, except to suggest that the doctors—we are all so afraid of the doctors in this House, and I cannot see why!—the doctors want their administration tightening up as well as the Insurance Commissioners. It surely is not fair to the approved societies that the doctors should issue certificates contain- 608 ing as a description of the complaint from which the insured person is supposed to be suffering such terms as "debility" or "catarrh." They ought to make it perfectly clear what is the actual ailment from which the insured person is suffering. We, in this House, suffer from debility as a result of the atmospheric condition of the House. We sometimes have catarrh for the same reason. That does not necessarily prove that we are incapable of work. In fact, some of the most active Members of this House undoubtedly suffer from catarrh. I have noticed it amongst the most assiduous Members of this House; those who have most ability and attend most of our deliberations. But I hope that the Insurance Commissioners have realised that this system of vague description of maladies is not fair to the approved societies, and that a more specific description should in every case be given upon the medical certificate.
It is worthy of note that some of the societies comprising persons engaged in hazardous or unhealthy occupations, such as the Steel Smelters' Society, have had a different sickness experience in one part of the United Kingdom to what they have had in another part. In the case mentioned, Scotland has a far more favourable record than Wales, or even than England, which indicates that possibly the housing conditions are rather better in one part of the United Kingdom than another, but which also indicates that the administration by the Insurance Commission for that part of the Kingdom is more effective, possibly more drastic, than that of our English or possibly our Welsh Commission. I have reason to think that the Scottish Insurance Commission is about the most capable Commission of the four Commissions who administer the Insurance Act. Possibly they are not subject to the same influences as those to which the English Commission is necessarily subjected by carrying on its operations so close to the Palace of Westminster. However that may be, if it is possible to tighten up the administration in Scotland, surely it is quite possible to tighten it up in other parts of the United Kingdom! In conclusion, I would suggest that quite apart from the provision of additional money, it would be the truest economy on the part of the Government to provide further hospital accommodation, to provide skilled nursing for insured persons, to include surgical treatment in medical benefit, and to 609 provide a diagnosis and consultation in all such cases as have not received adequate treatment in consequence of inadequate diagnosis or ignorance on the part of the panel doctor.
§ Mr. ASTOR
I gather that we are able this afternoon to discuss the adequacy or the inadequacy of the benefits under the Insurance Act. I notice that right hon. and hon. Gentlemen on the other side, when they are discussing the benefits, put forward this argument: They say that because some insured persons are getting adequate benefit—and for the moment I propose to deal with sanatorium benefit—that because some insured persons are getting some sort of sanatorium benefit therefore everything is all right. We have very often to listen to that sort of argument. It is not put so concisely, perhaps; but the point we have to consider is whether all insured persons ought, or ought not, to get the adequate benefit which is held out for them under the Act, but which has not been given. Insured persons are paying for treatment they are not getting. They are paying, that is to say, for inadequate benefit. I realise fully the difficulties the Government have in promoting treatment in institutions on a big scale, and bringing it within the sphere of all the local authorities. I realise that there is immense difficulty, and that there must be delay. But it is because hon. Gentlemen are apt to claim, and do claim, too much that I am here this afternoon to say that, in my opinion, insured persons are not getting that form of benefit which they were promised and which they are paying for. I am referring now to the sort of speech made the other evening by the President of the Local Government Board as typical of what I have in my mind.
The President of the Local Government Board, when dealing with sanatorium and other institutions, gave the House the impression that everything was all right. I think he used the expression "the beds are there in institutions and in sanatoriums," and he certainly conveyed the impression that there was an ample supply of beds for insured persons, who ought to go into those beds. Similarly he dealt at some length with domiciliary treatment, and explained how valuable it was, and he laid very great stress upon its value. That is the type of speech I refer to as a speech which claims too much. If he had claimed that the Government had done their best, that they had encountered 610 enormous difficulties, and that they Were making the best use of their money, and if he admitted that in some cases persons were not getting the benefits they were entitled to, I should not be speaking here this afternoon. The point I want to put before the House is that all insured persons under the Insurance Act should get adequate benefit, and by adequate benefit I mean adequate in the medical sense. Insured persons were promised adequate sanatorium benefit. As the House remembers, the definition of sanatorium benefit is very wide. It means treatment in institutions or otherwise. That is a blessed word, "otherwise." It has stood the Government in good stead during the last few months. I do not know if hon. Gentlemen opposite ever read the sporting papers. If they do they will see that in a race So-and-so is placed first, and another second, and another third; and then there is a long list of those who "also ran." It seems to me there are a certain number of persons who get treatment in sanatoria and other institutions, but the large bulk for the last few months have come under the terms of "also ran" and of the treatment "otherwise."
There is no limit, no restriction in the Insurance Act to the time which should be given for the treatment in institutions of insured persons. As I said just now, sanatorium benefit may mean treatment in institutions or at home. Without wishing to disparage dimiciliary treatment, and for the purpose of being brief, I may refer to it as "the cod-liver oil treatment." There are some people to whom the President of the Local Government Board referred at some considerable length who derive great benefit from and ought to get domiciliary treatment. There are certain cases where people are better treated at home than in institutions. Therefore domiciliary treatment is the best for some, but, on the other hand, while domiciliary or cod-liver oil treatment is the best for some, treatment in institutions is essential for others. The point I wish to put before the House is that some persons who ought to have treatment in institutions, and are paying for it, have to have domiciliary treatment because there are not enough beds or the beds are not ready. Therefore, some people are not getting the treatment promised, and are not getting the full value for their money.
The other day, as the result of a question and answer, the President Of the Local Government Board announced that at 611 the present moment, out of £1,100,000, in round figures, which was evidently earmarked for England out of £1,500,000 capital Grant, only £40,000 had been actually given to the local authorities for the building of institutions. And he went on to say that £120,000 had been earmarked and promised to local authorities for the building of institutions. That leaves £950,000 still unallocated, and if we deduct £100,000 for institutions for children, it leaves over £800,000 still unallocated and unspent. If everything is all right, as the President of the Local Government Board claimed the other day, why bother to go on spending this £800,000? If the institutions are there, why should the ratepayers and the taxpayers go on spending money on institutions. Insured persons only form one-third of the population of this country. Nowhere near one-third of the £100,000 has been spent in erecting institutions. We have not nearly enough accommodation in sanatoria, hospitals, or other institutions for insured persons.
What do we mean by "adequate treatment?" First of all, diagnosis, and then treatment in sanatoria, in hospitals, and domiciliary treatment. Look at the question of diagnosis first of all. The President of the Local Government Board admitted that he did not know the facts in connection with the examination of sputum. One of the first essentials is the provision for the adequate examination of sputum. It is one of the first essentials in the diagnosis of tubercle. Next, the Departmental Committee on Tuberculosis said that the whole keystone was the tuberculosis officer. There are thirty-seven local authorities that have not yet appointed tuberculosis officers; therefore I think it is fair to claim that insured persons are not getting the first-class diagnosis they are entitled to. Here I come to the treatment in sanatoria, and I would like to refer to replies to questions given mostly in this House by Mr. Masterman. I do not want to go through all the replies he has given, but when I mentioned one or two cases on previous occasions, when I took it for granted that it was admitted there were gaps in the treatment, the statement was not challenged when I made it, but whoever replied took it that I had not given proof of the inadequacy of the treatment. Mr. Masterman, in reply to one question, said there were 263 persons recommended for treatment in sanatoria receiving domiciliary treatment. That is to say, they 612 were not getting that form of treatment promised to them, and which they are entitled to, and for which they pay.
§ Mr. ASTOR
Yes, these are for England, and this was some months ago. I am dealing with the position as a whole Again, Mr. Masterman said:—I am informed that the insured persons referred to and recommended for sanatorium treatment will be admitted into sanatoria as soon as possible The number of cases in the area awaiting removal to sanatoria is 105, and I am advised they are receiving domiciliary treatment.If you are put on a waiting list instead of sent to a sanatorium, you are not getting the form of treatment you are entitled to.
§ Mr. ASTOR
I have not got the area, but the date was 30th June. I have got numerous other instances proving the same thing, but it would be mere repetition to go through them. There was another case this month which my hon. Friend the Member for Salisbury referred to, where eighty-three persons are on a waiting list in Dublin. The hon. Member for St. George's-in-the-East (Mr. Wedgwood Benn) did not deny that there were eighty-three persons on that waiting list. His reply was that in the interim they were getting other treatment. Nobody suggests that they should not get interim treatment; but was that the treatment their medical advisers thought best for them? Next comes the case of advanced tuberculosis. The right hon. Gentleman said beds were available in institutions; but I would remind him of his reply to his question last month, and in that reply he said that in some districts there is insufficient accommodation at present for advanced cases, but that the councils are taking steps to provide additional accommodation. I brought that forward as evidence that he was not justified in saying there was ample accommodation for insured persons. The right hon. Gentleman interrupted me, and said these were advanced cases. The Insurance Act does not say that insured persons who are so unfortunate as to have tuberculosis in an advanced stage are not to receive sanatorium benefit. I should rather think these unfortunate persons who have advanced disease are in a less favourable position than others; and I should think it would be rather for those insured persons paying their money weekly, like anybody 613 else, that the right hon. Gentleman would have tried to provide institutions. Not only have we to consider these people themselves, but there is also the danger to the community and to the family and neighbours of infection in advanced cases of tubercle. The right hon. Gentleman therefore—and I think he will probably admit it on consideration—was not entitled to say without qualification that the beds were there. It would be more accurate if he used the phraseology he used on the 19th of February, and said that in some districts there is insufficient accommodation at present.
§ The PRESIDENT of the LOCAL GOVERNMENT BOARD (Mr. Herbert Samuel)
I did say that.
§ Mr. HERBERT SAMUEL
No, I said it the other night; I said, taking the country as a whole, there was ample accommodation, and the number of beds were sufficient, though in particular districts they might be short, but that was because the local insurance committees had not made adequate arrangements; but, taking the country as a whole, I said the beds were there.
§ Dr. ADDISON
The 263 persons referred to are those recommended for sanatorium treatment which are receiving domiciliary treatment in England.
§ Mr. ASTOR
I rather thought the figures given by me referred to London. At any rate, in another area there was a waiting list, on the admission of Mr. Masterman, of 105. On this question of going out from one's own area to an- 614 other, does the right hon. Gentleman suggest that if there is a restricted amount of money the insurance committee is spending that to the best advantage in railway fares? If an insurance committee is not able to provide a bed and an institution in Kent or Surrey, for instance, and has to pay railway fares and send persons to the other end of England, it is evident that those limited funds are not being used to the best advantage. When the right hon. Gentleman tells us that there is only one insurance committee in the whole of England which is able to give institutional treatment within its own area, it becomes evident that a large amount of the money available is being spent in railway fares, and would be of much greater advantage to the insured persons if the institutions were nearer at hand. I do not wish to suggest that every area ought to have its own institution, but I know there are a large number of counties and county boroughs which could run their own institutions. The hon. Gen-man in his reply said there was only one area, the Isle of Wight, which was able to supply full institutional treatment within its own area.
§ Mr. ASTOR
The hon. Member for St. George's-in-the-East said that in reply to a question that I put to him. My point is that sanatorium benefit is restricted and limited. There is always great confusion when people think in terms of sanatorium treatment when they should be thinking of sanatorium benefit. A large number of persons whom doctors think ought to be in a sanatorium or institution are now receiving domiciliary treatment, which is not best for them, and so they are getting inadequate treatment. A large number of insured persons who go to institutions do not remain there as long as they ought to. I know they are instructed and taught how to be non-dangerous to the public and their families, and then they go home, but they are not kept in those institutions for the full period which is necessary. The other day I referred with some grief and surprise to the attitude taken up by the Labour party on the whole question of sanatorium benefit under the Insurance Act. The Labour party claim to represent the insured persons, but when we are here discussing the Insurance Act and the value of the benefits, and the adequacy or inadequacy of those benefits, they do not take the trouble to be present 615 and join in our discussion or criticise the Government. I do not suggest that the Members of the Labour party ought to vote against the Government, but there is nothing in their action in the past which makes me believe that, after having criticised the Government, they would be deterred from voting for the Government. They sit silent and do not take their share in criticism. I think we are entitled to say that they are not representing labour or directly representing insured persons, but they are more like representatives of that association that is known as Our Dumb Friends' League. [An HON. MEMBER: "Where are the Conservative Members?"] They are here. In dealing with sanatorium benefits, those of us who have studied it know that one of the great difficulties was that in preparing the Insurance Act the Government actuaries had not sufficient data. It was very difficult to know how much money would be required to provide full and adequate sanatorium benefit. Mr. Masterman, in June of last year, said:The experience in the sphere of tuberculosis before the passing of the Act was too limited to be of much practical value in arriving at an estimate of the amount required for sanatorium benefit:That is to say, Mr. Masterman practically admitted, by the reply which he gave to a question put to him, that there was not enough money to deal satisfactorily with sanatorium benefit. I do not blame the Government. We are all prepared to admit that there was not sufficient experience and that we had not enough data, but the Government have no right to come here or go to the country and say that there is enough money to deal with full sanatorium benefit, and claim that everything is all right, and that insured persons are getting that first-class treatment that was promised them and which they are paying for. With regard to the money available for tubercle treatment, the Insurance Act provides 1s. 2d. Sixpence of this was given to the doctors, and then the Chancellor of the Exchequer, in a letter of 31st July, 1912, to Mr. Hobhouse, the chairman of the County Councils Association, promised to pay out of the Treasury half the cost of treating the population, irrespective of whether they were insured or non-insured dependants. But for the Hobhouse Grant the insured persons would be getting less satisfactory benefits than they are receiving at the present time, and it is only 616 because a certain number of local authorities have agreed to meet the treatment of insured, as well as non-insured, persons out of the rates, that the insured persons are getting in many districts as good benefits as they are now obtaining. On this point of the inadequacy of the funds, may I point out that Section 17, Sub-section (2), says:—If there is a deficit the local authority and the insurance committee may agree to meet that half out of the rates and half out of the Treasury.The hon. Gentleman the Member for St. George's-in-the-East told me the other day that in Scotland, in twelve areas, twelve authorities had agreed to meet this deficit half out of the rates and half out of the Treasury. That is to say, in twelve areas it has been proved that the funds were not sufficient to give full sanatorium benefit to insured persons. The mere fact of there being a deficit shows that the money is not enough to go round and give full and adequate treatment. I would just like to ask the right hon. Gentleman one question for information. The dependants of insured persons may receive sanatorium benefit, which may be extended to them. Or else they may get treatment under the Hobhouse Grant as members of the population. I take it that if they came in under the Insurance Act they would get the full sanatorium benefit given to insured persons—that is, treatment in an institution or domiciliary treatment—but if those dependants come in under the Hobhouse Grant and get treatment only under that Grant and not under the Insurance Act, I want to know whether I am right in believing that those people do not get domiciliary treatment? The hon. Gentleman said that a certain number of local authorities had applied for extending sanatorium benefit to dependants, and that it had been decided not to give them treatment under the Insurance Act, but under the Hobhouse Grant. I want to know whether by that decision the Commissioners or the insurance committees or local authorities have, as a matter of fact, deprived these people of domiciliary treatment?
I realise the difficulties which the Government have been against, and it is only because in my opinion that hon. and right hon. Gentlemen opposite claim too much, and will not admit the inadequacy of the treatment given to a large number of insured persons, that I have been tempted to speak here. I realise the difficulty, but hon. Members opposite have no right to come down and 617 say everything was all right, and that the insured persons are getting that form of treatment which they are paying for, and which they are entitled to by Act of Parliament.
§ 6.0 P.M.
§ Dr. ADDISON
We all recognise the value of the criticism of the hon. Member who has just spoken on the subject of tuberculosis, because we know he speaks from a close examination of the subject. If his criticisms had been confined to that subject we should have had less to complain of. The hon. Member for Salisbury (Mr. G. Locker-Lampson), who spoke the other evening in connection with sanatorium benefit, described the treatment as something that was fobbed off on a large number of insured persons. Those are the kind of criticisms which evoke a defence of the Act which does not commend itself to the hon. Member who has just sat down. The hon. Member's main complaint seems to be that there are some insured persons who are not getting in a complete measure that form of treatment which, under ideal conditions, would be considered right and proper for their case. I have no doubt that that is a perfectly correct statement in regard to a considerable number of cases. We have been referred to a speech of the Chancellor of the Exchequer, which, I think, is referred to almost in every Debate in this House on this subject, in which the expression "first-class hotels" comes in. I find nothing in that speech to suggest that every insured person within two years of the commencement of benefits was promised all those things which the hon. Member opposite complains are not forthcoming. Let us take the statement which the hon. Member has made. He says, quite rightly, that sanatorium benefit is described as treatment in institutions, "or otherwise," and he suggests that the majority of the insured persons are like those who "also ran," and some within the description "or otherwise." Generally, the "also ran" applies to more horses than those who actually win, and it was fair to assume that the hon. Gentleman's metaphor suggested that the "or otherwise" applied to the larger number of tuberculous persons than those treated in sanatoria. I am glad to think that he did not mean that; and it is well to correct any misapprehension on the point, because the facts are entirely against it. Those treated in sanatoria of one sort or another are more numerous than those who have not had 618 that treatment in any form or other. I have not the figures by me at this moment, but it is a very large majority. Let me take this case and look at it entirely apart from trying to get a dig at the Chancellor of the Exchequer for any speech that he has made. Let us look at it as practical men in the light of what has been done within the time that sanatorium benefit has been made available. That really is the fair test. It is not fair to complain that the Government within the two years, or whatever it is, have not provided for every insured person everywhere the most perfect and up-to date treatment for tuberculosis in all respects without delay or difficulty. That would not be fair. You might as well complain that after all these years of elementary education you have not provided for every child in the country the most perfect and up-to-date system of education. That would be an equally fair criticism of any particular Government. Everybody knows that it takes a long time to perfect machinery on this gigantic scale, and you have not got your machinery perfect in the matter of education after you have been going twenty times as long as you have been in the case of sanatorium benefit for insured persons. Personally, I am exceedingly surprised that the number of beds is so great as have been provided already.
I quite admit, as the hon. Member suggested, that in some places they are to a great extent regarded, and frankly regarded, as make-shift arrangements. Of course, they are. They had to take what beds there were, and make the best of them until the proper organisation could be got in order. Take, for instance, the hon. Member's criticism that the amount of money which has up to the present moment been actually spent in the provision of institutions is small in comparison with the £1,500,000 available for the purpose. It is quite true. He knows something about local administration, and he knows perfectly well that what was required was, and is, that the local authority should prepare a scheme. That scheme has to be negotiated with the insurance committee, and in many cases with various sanitary authorities within the county. After all these difficulties have been removed and got over, the scheme is brought to the Local Government Board and is criticised and discussed there, and then is finally brought back to the county council. After a long time it gets through the various committees and is approved 619 by the county council. Plans have then to be got out and criticised and arranged before any money is spent on the buildings. Anyone who knows anything about administration knows quite well that kind of thing takes a long time.
The only point of criticism of the Government is this: Have they done their best in the time sanatorium benefit has been available to provide treatment for insured persons in this way to the best of their ability throughout the country. I think nobody, looking at the facts without prejudice—and I am quite sure there is no one who looks at the facts in this respect with less prejudice than the hon. Member for Plymouth, whom we all know is really interested in this kind of thing, and looks at the matter fairly—and considers the large number of schemes which have already been approved, remembering the difficulties which have been got over in many areas, will deny that what we have already done in treating about 20,000 insured persons in institutions is a most remarkable achievement. It is not, of course, a perfect system such as may he evolved in the course of years. He himself was chairman of the committee of tuberculosis, and I am quite sure that he knew then, as he knows now, that that committee was largely responsible for advising the Government on this machinery; but the committee never pointed out, nor were the Government in adopting their regulations, or the public led to believe that the whole of this vast organisation could be brought into existence and into full working order in eighteen months or two years. I shall be very pleased myself if we can get it in a reasonably efficient condition from one end of the country to the other in five years.
Then we are asked: What about your man who was going to the first-class hotel? I need not defend the Chancellor of the Exchequer, and I will not go over old ground again, but of course the description was of the sanatorium to which a man was sent, and 20,000 people at the very least have been to these institutions already. I do not know that they are first-class hotels in the sense that they are the most perfect thing in sanatoria which has yet been devised. We know that fashion changes a good deal, and it is quite likely that what is now regarded as the best thing in sanatoria may not be so regarded in five years' time. In this connection, as it seems rather fashionable nowadays to 620 quote letters in Debates, I may refer to a letter which I received from a medical man the other day. He has been twenty-six year in practice, and, when I inquired about him, I found that he is a man of high quality. The interesting thing in his letter is that he has been a member of a Unionist Association, and that at the last General Election he seconded the nomination of a Unionist candidate for one of the divisions of Cambridgeshire. I will not not say whether that gentleman was elected or not. I would like to spare his feelings. The writer goes on to say that at the beginning he disliked and distrusted the Act, butI have gradually come to have a warm interest in it, and my dislike and distrust are now transferred to the Party which is working up this wretched campaign against the Act.Then he goes on to give his experience of the sanatorium benefit. It seems that in his practice there are a considerable number of military men connected with a large military camp in the neighbourhood. He says that a great deal of nonsense is talked about the sanatorium benefit, but there lives near him an ex-guardsman, and he found him to be tuberculous. He got him into the Banstead Sanatorium. He was there six months, and is now home again and uncommonly well. The following day he sent me a letter about another man in the Army. This man is employed in the Army Aircraft Factory. That rather locates it. He has been in the sanatorium, and here is a postcard (exhibited) from him giving a photograph of the sanatorium, which seems to be a good deal better than some first-class hotel. Incidentally, the man says that he is getting on real well and adding to his weight. I quite admit that is an isolated case. The hon. Member has quoted cases of people who are kept waiting, and have not yet got into any sanatorium. One must regret that they have had to wait, and no doubt the local authority, if they are doing their best in that area, will do all they can to reduce the waiting period as much as possible. The hon. Member knows that the difficulties with local authorities are not confined to the machinery of the Insurance Act. We have had difficulties with local authorities of which we know something in London, and they are not confined to the machinery of the Act by any means. The London County Council hitherto, for reasons which I need not go into, have not gone out of their way to do anything to help forward the Insurance Act. It seems a very shortsighted and small-minded way of looking 621 at a big question of this kind, seeing that there are 50,000 persons within the London area affected with tuberculosis. The insurance committee have made arrangements with the Metropolitan Asylums Board, which has beds at the present moment to spare, and which are at the disposal of the London Insurance Committee, so that, notwithstanding their difficulties, they have done uncommonly well in London.
There is another effect of sanatorium benefit, which, I think, we ought fairly to mention, and it is its effect upon the Poor Law. The Hobhouse Grant is, of course, available for all persons affected with tuberculosis in any area, whether they are insured or not. That means, for example, that in Middlesex practically all the tuberculous persons will very soon be treated under the schemes which are being arranged. It will mean that they will be gradually removed—at all events to a great extent, though I do not say completely—from out of the charges which fall upon the Poor Law. There was an investigation of 4,000 cases of tuberculosis in workhouse hospitals some time ago, and it showed, as far as you could see, that 60 per cent. of them were in the workhouse because they were tuberculous. The Poor Law Commission found the same kind of thing. The effect of the Act upon the charges which fall upon the Poor Law in respect of tuberculosis will be very profound. They are a very large proportion of the charges which fall upon the Poor Law, and, if hon. Gentlemen opposite would devote their very great influence in the country to urging local authorities to push forward comprehensive schemes for the provision of sanatorium benefit in their area, instead of picking up tag-ends of speeches of the Chancellor of the Exchequer, I must say that they would be rendering greater service to the community. I am not applying that particular remark to the hon. Member for Plymouth. He knows very well that I am not. It does not apply to anything that he has said, either here or elsewhere. The hon. Member commented on the lack of provision for advanced cases. I quite agree, and everyone must agree, that it is of the first importance that full provision should be made for such cases, particularly in London, and in crowded centres, where they are more likely to infect other members of the household. But do not blame the Government for a fault which is not theirs. The Government and the Insurance Commis- 622 sioners have work enough. The administration of this particular portion of the Act has been entrusted to the local authorities; the insurance committees have no power to provide institutions at all, and can only make arrangements with the authorities to do so. The London Insurance Committee has no power to provide institutions for advanced cases on its own account. That is the present position with regard to a large number of advanced cases. The way to remove the difficulty is not to cast stones at the Chancellor of the Exchequer, but it is to point out their public duty to the London County Council.
I should like to say a word with reference to the question of the medical benefit. I was glad to notice the other evening that the Member for Glasgow arid Aberdeen University (Sir H. Craik) seemed to have changed his tone. In a speech which [...]e delivered earlier in the Debates upon this Bill, he spoke of "mere panel doctors." The change in his tone is a welcome change. He pointed out, quite rightly, that in many districts there is a shortage of medical men. In some parts there is only one to 3,000 persons. That is not the fault of the Insurance Act. It is not a criticism of the Insurance Act. What the Act has done has been to bring men into these overcrowded areas, and in places where, before the commencement of the Act, there was only one medical man to 5,000 population, more men have been introduced. This has been one result of the working of the Act. We know well enough, as practical men, that one has to work with the men and material which are available, and hon. Members are not entitled to complain of that Act merely because it has not done the impossible. The hon. Member for Glasgow and Aberdeen University suggested that nowadays people waited in queues in the street outside the doctor's surgery, whereas formerly they went to the hospitals. He seemed to suggest that that was a bad thing. I agree it is a bad thing, for a person who is ill, to wait in a queue in a street, but I do not think that often occurs, and it is more a subject of journalistic imagination than of fact. I have been round to many of these places and have not found these queues to exist, and I should say there are very few instances of it. The old system under which the industrial population were driven to the hospitals was the very worst thing for the medical service. It meant that the men practicising in an 623 industrial district shelved their responsibilities on to the hospital. We want them to be stirred up in order that they may become more efficient professional men. Anyone who has studied this question knows that one of the great complaints made against industrial practices, as they existed before the Insurance Act came into operation, was that they encouraged medical men to send their more difficult—and sometimes their ordinary—cases to the hospitals, and they lost the stimulus which such cases provided to becoming more efficient.
The hon. Member went on to say that the Act had crippled the resources of the hospitals. I should like to know on what he bases that statement. We know that at the commencement of these Debates all kinds of dismal prognostications were indulged in. But, as far as I have been able to ascertain, the effect has not been to cripple the resources of these institutions. It may be possible that in some cases where the income of the hospital was largely derived from workmen's contributions there may have been a falling off since the Act came into force. I am glad to see that the hon. Member for Durham (Mr. Hills) shakes his head. That is an indication, to my mind, that working men are more public spirited than the Jeremiahs to whom I have referred would have led us to anticipate. I was pleased to gather from the Debate the other night that hon. Members opposite had at last been reading a serious criticism of the Act—one issued by the Fabian Society. That criticism was clearly reflected in some of their speeches, and some of the phrases used by hon. Members were familiar to my mind. One complaint they made was as to the number of minor cases treated. If that is a complaint against the Insurance Act, I must say it was one of a very flimsy and unsubstantial character. It means that people who have a right to medical benefit, and to have their cases treated early, have gone for such treatment while their cases were minor cases, instead of allowing them to drag on until they became seriously ill. Instead of that being a discredit to the Act, it is about the best testimonial that could be given to it.
The hon. Member for the Wilton Division (Mr. C. Bathurst) suggested that certificates were granted on frivolous grounds and in a loose manner. At 624 various times there may have been some substance in that complaint, but you must give people a little time to put their house in order. This is a matter to which medical men and medical committees are turning attention, and they are making it uncommonly uncomfortable for anyone who is not carrying out this duty with proper care. The General Medical Council has issued a serious warning that the issue of certificates in an improper manner will be considered as a serious ground of complaint against a professional man. It is easy to cast a stone against a roan who issues these certificates in regard to the terms in which they are couched, but it would be well if hon. Members who raise this point would put themselves in the position of the person who is ill, especially if it is a woman who is not particularly anxious that the full description of her ailment should appear on the medical certificate. Plenty of women said to be suffering from dyspepsia are, no doubt, suffering from something else as well, and they do not want it described in full on the certificate. I think it might be an improvement if some central machinery could be created whereby, while a proper disclosure were made, it could be so arranged that the certificates could be dealt with in such a manner that the medical man would feel quite free to put everything without reserve upon the certificate. As to the amount of malingering, I should say that the number of deliberate cases is relatively trivial. It had been stated that a considerable number of cases of anæmia—long dragging cases—exist among members of women's societies. That is one of the things which has been brought to light by the Act. It is quite a good point for the hon. Member for Wilton to suggest that more provision might fairly be made to deal with sickness associated with pregnancy.
Complaint has been made that provision for proper treatment is not complete in all respects. I quite agree that there is much still lacking in the matter of special services and in the necessary arrangements for making diagnosis. It is fresh in our memories that the Government were assailed from one end of the country to another; they were faced with immense difficulties; they had to work with the men on the spot, and I say it would have been impossible for any Government, with the best will prevailing from one end of the country to the other, to have established all these special services by this time. To ask the Government to set up a 625 wholly perfect machinery of laboratories, with special facilities for consultations, and so on, would be to simply ask the impossible. The complaint is that these special services have not been provided. The point I made with regard to the sanatorium benefits applies equally to these other services. The system has to be built up. You cannot bring the whole thing, cut and dried, as a machine perfect in every detail. It takes many years to do that. I quite agree that we need laboratories, special services, and consultants. In due time they will no doubt be provided, but, as a matter of fact, there are not enough medical men in the country to provide those services at the present time. If you could establish from one end of the country to the other laboratories for making all the different examinations, with all the necessaries for our complicated methods of diagnosis, if you could establish all these laboratories to-morrow, you could not find trained men in the whole length and breadth of Great Britain to staff them. It takes years to train a man to do this kind of work. Everyone who has any real interest in this Act is fully alive to all these considerations. I wish we could have a little more assistance from hon. Members opposite in helping to improve and perfect our machinery. We have plenty of criticism, and I think we have good ground for complaining that we do not get much help. I have here a leaflet issued in the recent election in South-West Bethnal Green, in which this description is given of the Act:—It puts the working classes under the heels of prying officials, whose salaries are paid for out of the hard earnings of the poor.That is a description of the Act used in the course of the election on behalf of the hon. Member who was elected. Is it likely to facilitate the provision of the benefits which hon. Members complain are not provided in full? Is there anything in this world more calculated to prejudice that provision or make it difficult to make the arrangements to provide the benefits than descriptions of the Insurance Act of that kind? We are entitled to know, when criticisms are brought against the administration of this Act that it does not do more than it does at the present time, who the prying officials are. The only prying officials who are paid out of the earnings of the poor—that is, the contributions under the Act—are the officials of the societies. The officials of the Insurance Commission are paid for by the Treasury. Therefore we can take it that 626 the description I have quoted is the Unionist description of the officials of the approved societies. When we look at this criticism, and I have heard plenty more like it, it is impossible to come to any other conclusion than that this Act has experienced a campaign of obstruction and misrepresentation which is almost unexampled in the case of British Acts of Parliament, and, to my mind, in the case of London certainly, it fully explains why, with regard particularly to sanatorium benefit, we have not got along quicker than we have done. While you have this atmosphere of suspicion and obstruction from one end of the country to the other, it is not reasonable or fair to expect that the Act will work smoothly and quickly.
The only real contribution by way of suggesting an improvement has been that we should place the Act on a voluntary basis. On the Motion before us it would not be in order to go into that proposition, and therefore I do not propose to do so. Those who know anything about the matter know that it would not mean an improvement in the administration of the Act or an increase in the benefits it is to provide. It certainly would not insure those who most need insurance; it would certainly do nothing for the casual labourer or the deposit contributor; it would probably wipe out the whole disablement benefit, and in a very short time it would ruin one-half of the societies. So far as I know, that is the only real suggestion which has come from the official Opposition with regard to the improvement of national insurance and the work of making the benefits more-accessible to the insured persons. I sincerely hope that on some future occasion we shall have an opportunity of going fully into the suggestion advanced by the Opposition as to the possibility of placing insurance on a voluntary basis. I shall welcome the time when the Committee which we are told is going to be set up to inquire into this subject is appointed, because I have a feeling at the back of my mind that the fate of that Committee would be very much like the fate of the Committee appointed by the Unionist party to inquire into the subject of old age pensions. That Committee reported that none of the schemes presented to it were practicable. It would not require a very far-seeing man to suggest that that would be the result of the Committee which is to inquire into voluntary insur- 627 ance. Those who father it and suggest its appointment will afterwards, perhaps, be more glad than anyone else if it recedes with very welcome expedition into the twilight of oblivion.
§ Mr. FORSTER
I have listened very carefully to the speech of the hon. Gentleman who has just sat down for some fruitful suggestion as to the method in which we might improve the administratoin and the effect of the Act or the benefits which the Act gives—benefits that are admitted on all sides to fall somewhat short of what the House expected or what was promised. While the hon. Member had a good deal of criticism to direct against his political opponents, I am glad to think that that criticism was a little milder than it has been hitherto. He made no suggestion. He invited suggestions from us. We have made a good many in the past, and a good many of the suggestions we have made found expression in the amending Act passed last year. If the hon. Gentleman, with all his friendliness towards the present Act, would do a little something now and again to make suggestions for its improvement, he would really do a greater service to the insured persons than he does merely by making attacks upon his opponents. If I cover again to-day some of the ground I traversed only a couple of nights ago, it is because the hon. Member for St. George's-in-the-East, who was put up to reply on behalf of the Government, studiously avoided any reference whatever to the questions that had been raised in the temperate and very careful speeches of the two hon. Gentlemen who had moved and seconded the Resolution. I do not say anything about my own speech, because I do not know whether it was temperate or not. I want an answer, if I can get one from the Government, to the points we ventured to put forward the other night, because they are points of importance. It is not at all sufficient for those who speak on behalf of the Government to get up and content themselves by making a strong personal attack upon their political opponents. I confess I should have thought that on an occasion of this kind we might have had, in the enforced absence of the Chancellor of the Duchy of Lancaster, the presence of the Chancellor of the Exchequer—the author of the scheme, the pilot of the measure, the man who conducted the negotiations with the various interests involved, the man who 628 raised and subsequently wrecked the highest hopes with regard to the usefulness of the Insurance Act. I am sorry that he cannot be here; I am also sorry that the President of the Local Government Board cannot be here. I do not want to be too hard on the hon. Gentleman the Member for St. George's-in-the-East, because I can assure him that we on this side of the House sympathise with him in the difficult task he has to perform. I do not know whether we may express the hope that he may find himself discharging it on a more permanent basis before very long.
I want to turn for a moment to the question of sanatorium benefit, and very briefly say what our complaint is. It is that people who are recommended for sanatorium benefit, for treatment in institutions, do not get it. I do not say that all the people do not get it. Of course, there is a very large number of people who do; but there is a number of people who are recommended for treatment in sanatoria, who have paid for the benefit, but who do not get it, or are subjected to long delay before they get it, with disastrous consequences to their own health. How are we met when we make that statement? The Chancellor of the Exchequer takes one line, the President of the Local Government Board takes another. The Chancellor of the Exchequer says, "How unreasonable you are to adopt that line of criticism. You cannot expect all these sanatoria to be built in a day; you cannot expect accommodation to be provided for these thousands of insured people who are suffering from this awful scourge all in a moment." We sympathise with him when he takes that line. The hon. Member for Hoxton (Dr. Addison) also took that line. I sympathise with him when he says that you cannot expect provision to be made for all these people in a day. That is not the line taken by the President of the Local Government Board. He says there is ample accommodation for all insured persons who are suffering from tuberculosis. I confess I was astounded when I heard two nights ago the President of the Local Government Board give expression to that opinion. I took a careful note of it at the time, and I have confirmed my recollection of what he said by reference to the OFFICIAL REPORT of the following morning. Here is what he said:—There is adequate accommodation now in the sanatoria for all insured persons suffering from tuberculosis, … 1,500,000 has been voted by this House for those buildings—and the Treasury have undertaken to 629 find half the cost—to provide treatment for the non-insured persons suffering from tuberculosis."—[OFFICIAL REPORT, 24th March, 1914, col. 322.]If there is adequate accommodation now for all insured persons suffering from tuberculosis, what is the object of spending any portion of the £1,500,000 which has been set aside to provide buildings by the provisions of the "People's Budget?" If there is ample accommodation for every insured person who is suffering from tuberculosis, how comes it that all the people who are recommended for treatment in institutions are not getting it? The President of the Local Government Board told us the other night that since the Act came into operation 20,000 people had been treated in institutions, and I think he said that 10,000 people had received domiciliary treatment. Would those 10,000 people have received domiciliary treatment if there had been room for them in the institutions? The President of the Local Government Board will tell me that that entirely depends upon the medical advice. Bearing upon that, I noticed a rather interesting paragraph in the Report of the meeting of the Scottish Association of Insurance Committees, which wits held in October of last year. There was an attack upon the adequacy of the funds for the provision of sanatorium benefit, and Mr. Johnson, who was one of the delegates, in reply to the discussion, said that during the whole course of treatement in this country, they had not had a single application on behalf of an insured consumptive for domiciliary treatment. They had not had a single doctor order that treatment for any case. Every recommendation which was made in respect of these consumptive insured persons was a recommendation that they should receive treatment in an institution. If there is ample accommodation for the insured people in institutions, why do they not get it? The right hon. Gentleman in another portion of his speech said:—It may be that particular insurance committees have not in their own districts provided adequate accommodation. That is their fault.The right hon. Gentlemen is not satisfied with the efforts which the insurance committee have made. He blames them for not having provided ample accommodation for all the insured people within their area. I think the insured person and the Government owe a very great debt of gratitude for the efforts which the insurance committees have made—efforts which have not been attended with com- 630 plete success. I know that the insurance committee for Kent has been unsparing in its efforts to provide accommodation, to provide proper treatment, and to do everything they can to see that this Act is properly and beneficially administered. I do not think it is fair for the right hon. Gentleman opposite to bring such a charge against insurance committees. It is not their fault that accommodation is not forthcoming for all the insured persons.
What does the right hon. Gentleman say with regard to the amount of accommodation which is necessary? He says there are in existence now something under 5,000 beds in sanatoria and hospitals in England—he was only speaking of England—for the accommodation of tuberculous insured persons. It is rather a pity that we cannot find someone who will tell us something about the whole of the United Kingdom, but I suppose we must be content with the modicum of information that we are able to extract in regard to England alone. The 5,000 beds, according to the right hon. Gentleman, are ample accommodation for all insured persons suffering from tuberculosis. Is that the information that he has at the Local Government Board? What becomes of all the estimates which were made by the Chancellor of the Exchequer when he told us that there were between 400,000 and 500,000 people in this country who were suffering from tuberculosis. The right hon. Gentleman will say, of course, that they are not all insured persons. Of course they are not all insured persons. We brought into our scheme of national insurance about a third of the population. The people that we have brought in are subject, I am afraid, more than any other section of the community to the ravages of this particular disease. The proportion of the population affected by the disease increases the lower down in the scale you go. People who live in the slums and the congested areas of our great cities, suffer more from consumption than do those who live under healthier conditions. Even if you put the number of insured persons suffering from tuberculosis at no more than 100,000, are 5,000 beds in institutions in England ample accommodation for every insured person suffering from tuberculosis? It is nothing of the kind, and I was astonished to hear the right hon. Gentleman commit himself to so mistaken a statement.
We have had a statement from a roan who has had experience as a tuberculosis 631 officer. By the way, I notice that I was made in the OFFICIAL REPORT to describe him as a "tuberculous" officer, which I should be very sorry to do. The tuberculosis officer of Marylebone Dispensary points out the truth of the old saying, that you may call a rose by any other name and it will smell as sweet. It remains a rose. You may call a fever hospital, or an an isolation hospital, or a ringworm hospital a sanatorium, but you do not make it so. He points out that in many cases the institutions which are approved by the Local Government Board are overcrowded, that the treatment which is given is too short really to attain its fullest possible results, and that the results of the whole system are unsatisfactory because they are incomplete. Why is the detention of the patients in sanatoria too short to be of the fullest value? Because there is not enough money. I am not saying this in order to make an attack on the Government. I say it because I believe it to be true, and unless something is done the Government is not fulfilling the obligation which it undertook in regard to the insured people.
What I say with regard to the provision of sanatorium benefit, applies to domiciliary treatment just as much as it does to institutional treatment. The Act provided 1s. 4d. for the provision of sanatorium benefit. One penny was to be retained for the purpose of research, and 1s. 3d. was to be available for the provision of sanatorium benefit. That was the provision that was made when this House parted with the Bill, when it first became an Act, and it was only after this House had parted with the Bill that the negotiation between the Chancellor of the Exchequer and the medical profession resulted in the diversion of 6d. out of the 1s. 3d. from the fund for the provision of sanatorium benefit towards the payment of doctors who gave domiciliary treatment. It is not that the doctors do not deserve the extra money; it is not that they do not give services which entitle them to extra remuneration. The point is that the money ought not to have been taken away from the fund which provide sanatorium benefit. It ought, in fairness to the patients, to have been provided from some other source, because what has been the result? Instead of having 1s. 3d. per head in order to provide institutional treatment and domiciliary treatment, you have only nine-pence for other than domiciliary treat- 632 ment. The Chancellor of the Exchequer, when he introduced the Bill, told us that this 1s. 4d. was the minimum sum which could provide the benefit which the House was determined to give. He said he was assured by those who had taken the matter carefully into consideration, including the President of the Local Government Board and his very able staff, that it will enable us at any rate to do something for the purpose of stamping out this terrible scourge. The whole of the actuarial calculation for the provision of sanatorium benefit demanded the provision of 1s. 3d., and it is not right; it is not fair to the insured people that the sanatorium fund should have been denuded to that extent. I want to know what steps the Government are going to take in order to make that sum good.
We are told, of course, that treatment in an institution is not the only form of sanatorium benefit. Of course it is not. Treatment in the home may be perhaps in some cases the best kind of treatment under proper conditions. But not a single man in this House can pretend for a moment that where you have a father and mother and perhaps two or three children living in one room, that is a case in which domiciliary treatment is appropriate at all. I have quotations here from the Chancellor of the Exchequer in which he describes the evil of tuberculous people living with their families. One of the things we all started out to do when we began to consider this Act, was to try and provide some means by which a man who was living under conditions of that kind might be able to go into an institution to avoid infecting his family, and to cease to become what the Chancellor of the Exchequer called a recruit in the destructive army. We wish to prevent him from injuring mortally those to whom he is most attached, and scattering infection and death in his own household. The fact that the fund for the provision of sanatorium benefit has been depleted in the way I have mentioned prevents local insurance committees from giving institutional treatment to a large number of persons who otherwise ought to have it. I can give you cases, and give the names and addresses, where this very thing is happening now—single-roomed families, the father infecting his own children—and that is a thing of which we all ought to be ashamed. Whether we sit on this side of the House or whether we sit on that, we ought to bring pressure to bear upon the Government in order that 633 the sanatorium fund should be restored to the figure at which it was intended to stand.
One word in regard to medical benefit. I repeat the point I made the other night because I want the hon. Gentleman to give me some answer The House decided that the medical treatment was to be adequate, but serious illness ought to be treated as well as slight. The hon. Member (Dr. Addison) said that one of the best features of the Insurance Act was that it attacks illness and disease at its beginning, treats it while it is slight, and prevents it from becoming severe. That is what we want. We also want serious illness to be treated where serious illness exists. Hon. Gentlemen opposite, of course, want it as much as we do, but under the Regulations that are made that treatment is impossible.
§ Dr. ADDISON
I am sure the hon. Gentleman does not wish to say anything unfair. Adequate treatment is not impossible under the Regulations for any disease which can be treated at home. Pneumonia and other diseases can be adequately treated at home. The hon. Gentleman is referring to those cases which require special forms of treatment.
§ Mr. FORSTER
I will put it no higher than that. I take the case as the hon. Gentleman says. This House never laid down that the adequate medical treatment to be given was to be limited to treatment to be given in the home, and I venture to think that the hon. Gentleman has carried the matter a good deal further than the Regulations allow. I think he will find that there is a good deal of treatment that could be given in the home that is not allowed by the Regulations. The point is, that owing to the necessities of the case—there is not enough money—the intention of this House has been limited by the Regulations made by the Commissioners far more drastically than the House expected or intended when the Bill was passed. The Chancellor of the Exchequer told us that it was intended that every patient was to have the best treatment of a doctor and the best drugs. There was to be no limit to the amount of money Spent upon drugs. I do not wish to labour the point. I only wish to remind the House of the intention of the Chancellor of the Exchequer, as well as the intention of the House. The Chancellor of the Exchequer said:—We have separated the drugs from the doctor and if the doctor thinks that a certain drug is the only thing 634 to save a man's life or health, we tell him to write it down and the State will see that he gets it. For the first time in the history of the country, fifteen million workers can secure as pure and potent medicine treatment as the richest duke in his palace.That is what we all intended. That is what the Act provides, but people do not get it. This is what the Leeds Insurance Committee says—I am quoting the "Yorkshire Post":—In moving the minutes of the medical benefit subcommittee. Mr. Kelly read a letter he had written to the Chancellor of the Exchequer on 3rd March, in which he said. 'I am desired by the Leeds Insurance Committee to communicate with you in reference to the deficit on the committee's drug fund for the year. The committee have been compelled to restrict the supply of expensive medicines, and have declined to allow certain drugs and other similar remedies to be provided for insured persons owing to their considerable expense, although the same have been strongly urged by the medical profession on the committee. The large deficit on the drug fund will not allow these remedies to be prescribed. Moreover, the committee have had expert evidence showing that many of these remedies ate very effective, and would really effect a cure where others have failed. The committee feel that it would be a crime for any class of human beings to be debarred from these remedies.'That is what the House said, but the people are not getting these remedies. I say that these things demand, and ought to receive, the attention of the Government, and I hope that the Government are not going to put us off by beating the party drum and by attacks upon their political opponents. I have endeavoured, so far as I could, and my hon. Friends behind me have done their best, to treat this matter from the business point of view, and we are entitled to expect that the Government are going to treat it from the business point of view as well. In the hope that we will hear something which will encourage us to believe that they are going to deal with this matter in the interest of insured persons, and deal with it very thoroughly, I shall wait to hear what the right hon. Gentleman has to tell us.
§ Mr. HERBERT SAMUEL
I am afraid that the pressure of Departmental work has prevented me from hearing the whole of the Debate, but I heard the speeches of the hon. Member for Plymouth (Mr. Astor) and the hon. Member for the Sevenoaks Division (Mr. Forster), who dealt mainly with sanatorium benefit, which is the part of the subject with which the Local Government Board are primarily concerned. The hon. Gentleman put his question in the form of a dilemma. He said, "If it is the case that there is now adequate accommodation for insured persons in sanatoria, why are you proposing to spend £1,500,000 on the provision of sanatoria? Either the 635 accommodation now is inadequate, or else your further expenditure is wasteful?" There are two answers to that. In the first place, the £1,500,000 is not intended for the provision of sanatoria only for the insured population, but for the whole population. That Grant is to enable health authorities to provide buildings for the population as a whole, and therefore, whatever accommodation there may be now for insured persons must be multiplied at least threefold before we are able to provide accommodation for the whole of the population. Secondly, much of the accommodation hitherto provided for insured persons is avowedly of a temporary character. It is not inadequate for its purpose, but it might be better. Hospital buildings, which may have been built for the treatment of infectious diseases, and which are not used for that purpose, have been placed at the disposal of the insurance committees, in order to house tuberculous cases. It is obvious you cannot in a moment erect all over the country the sanatoria which are needed for the accommodation of the persons who suffer from this most grave disease. Neither the Local Government Board, nor the insurance committees, nor the health authorities, are satisfied that the accommodation which has been provided from the outset is the best which can be provided, and they are of opinion that far better sanatoria may be provided if they are planned specially for the treatment of this disease than can be provided in buildings which were not erected for that purpose. Therefore, for these two reasons, in the first place, that the whole population has to be provided for in future, and not only the insured population; and, secondly, that the temporary accommodation has to be replaced by permanent accommodation, it is proposed to spend this money. The hon. Member put another dilemma. He said that many persons are receiving domiciliary treatment. I myself stated the other day, on the authority of the Insurance Commissioners, that about 10,000 insured persons were receiving domiciliary treatment in addition to those who were receiving treatment in institutions.
§ Mr. HERBERT SAMUEL
I cannot give the time. The Insurance Commissioners are now preparing a return which will shortly be laid before Parliament, but I have not seen any statistics. The hon. 636 Member says that if these 10,000 people are receiving domiciliary treatment, it is obviously because there is no accommodation in sanatoria, or no money to send them there. He himself gave a much better answer, for later in his speech he said that if the conditions are proper, treatment in the home may be the best kind of treatment. There is the answer to his own question.
§ Mr. FORSTER
I pointed out that domiciliary treatment is proper where the conditions are proper, but not where the conditions are improper.
§ Mr. HERBERT SAMUEL
The hon. Member says that domiciliary treatment under improper conditions is a bad thing, but he does not say that the conditions are improper in every case, and that, therefore, no one should receive domiciliary treatment. The hon. Member has stated that if the home is not overcrowded, not poverty stricken, and so forth, and if the conditions are proper, domiciliary treatment may be the best form of treatment. He did not say that every person receiving domiciliary treatment is receiving it because he cannot be provided for in a hospital. That I could understand, but he did not say so. He said the opposite. If he admits that it is right in some cases to treat patients in their own homes, then he cannot say that because some persons are receiving treatment there, it is because there is no room in sanatoria, or no money to send them there. The hon. Member speaks on this matter with great authority. He has devoted most laborious attention to the whole subject since the Bill was first introduced. I think he was the first Member to speak on it when the Chancellor of the Exchequer made his proposals, and ever since then he has watched it with a great deal of care. But I am sure that he himself would not suggest that his authority on these matters of diagnosis and treatment is comparable to that of the Committee known as the Astor Committee, of which the hon. Member for Plymouth was chairman, which included my hon. Friend (Dr. Addison), who is not only a Member of Parliament, but also a medical man who has specially studied this matter, and which included also the principal medical officers of the Local Government Board and the Board of Education, the Medical Officer of Health of Manchester, and some twelve or thirteen of the most distinguished medical men in the country, each one of whom was 637 put on the Committee on account of his expert knowledge. That Committee said that it is not necessary to send every case to a sanatorium or to an institution. The Committee further said:—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 insure efficient treatment. Under suitable conditions, especially if the treatment is being carried out on the advice of a medical man with special knowledge of modern methods, home treatment may be in all essentials sanatorium treatment.
§ Mr. HERBERT SAMUEL
It says:—Without prejudging the question as to whether sanatorium treatment should be carried out at the patient's home, in a hospital, or in a sanatorium, it may be said that under existing conditions most patients suffering from pulmonary tuberculosis would be given their best chance by a period of treatment in a sanatorium. It should, however, be borne in mind that a short stay in an institution in which the patient may be educated, followed by a course of home treatment in shelters, etc., under close medical supervision, is a form of sanatorium treatment which has certain advantages, and which may be successfully adopted in a large number of cases.That passage says that in most cases, but it does not say in all cases.
§ Mr. HERBERT SAMUEL
I very much question if he did. This Committee says that in most cases sanatorium treatment is the right treatment; that in some cases it may be brief and followed by treatment in the home under suitable conditions. No one will dispute that. The figures which I gave the other day showed that the number of cases of domiciliary treatment are only half the number of the cases of sanatorium treatment under the Act. The hon. Member would almost suggest that in no case ought there to be domiciliary treatment and that in every case there ought to be sanatorium treatment. And the hon. Member, in order to support his view, asks me to quote another passage, and I have read that passage, from the Report of the Committee, and it does not bear out his contentions.
§ Mr. WORTHINGTON EVANS
I thought that you would like to put the complete statement before the House.
§ Mr. HERBERT SAMUEL
I read the whole of this particular passage, which was an answer to the hon. Member who was suggesting that if there was any domiciliary treatment it must be be- 638 cause the sanatoria were inadequate. I hope I have dealt with that sufficiently. The hon. Member who has just spoken laid emphasis on the report of the tuberculosis officer of Marylebone, which was also quoted in debate the other night. I have here an extract from a newspaper which happened to be published on the same evening as that on which the debate took place, giving the reply of the Sanatorium Benefit Sub-Committee of the, London Insurance Committee to the criticisms of the medical officer of Marylebone. They protest emphatically against his statement that there was an unfortunate tendency to limit the stay of all patients in sanatoria and that patients are sent out to make room for others, and they say that both statements are absolutely inaccurate, so far as persons recommended by the committee are concerned. As many as 936 patients have remained in sanatoria for more than three months. How many patients would have remained in sanatoria for a single day if there had been no Insurance Act?
§ Mr. HERBERT SAMUEL
What proportion of the cost of their treatment is really represented by their contribution? But if there had been no Insurance Act these patients would be infinitely worse off than they are now, because while they would keep in their pockets the few shillings or the pound or two which they have paid in contributions, they would have lost, on the other hand, three months' sanatorium treatment which they have been able to enjoy in consequence of the Insurance Act. Of the 936 patients who have been in sanatoria for more than three months, 109 have received institutional treatment for varying periods, in all cases exceeding six months, and in three cases exceeding a year. The average duration of the institutional treatment given to all patients is necessarily low owing to the fairly large proportion who are admitted for the purpose of observation or for instructional purposes. That is in accordance with the recommendations of the Astor Committee in the passage which the hon. Member asked me to read. Then the hon. Member has said that obviously the number of beds is inadequate, because in the vast figures which he represented as based on a statistical basis of his own he said there must be so many hundreds of thousands of insured persons who are tuberculous for whom accommodation 639 has not been provided. Again, we go back to the Astor Committee. The Astor Committee made their interim Report, giving the number of beds that the Government and the insurance committees should see were provided. When they issued their final Report some months later they saw no reason to modify their previous conclusions. As I stated the other day, on the basis of that Report, 2,100 beds would be required. At present 5,145 are available in sanatoria approved by the Local Government Board for this purpose, so that the estimate of the Astor Committee has been exceeded. The insurance committees have also gone considerably beyond that estimate. Last month there were, in fact, in these sanatoria 3,215 persons, or nearly 50 per cent. more than the Astor Committee thought it necessary to provide accommodation for. For hospital treatment the Committee suggested there ought to be 2,100 beds. There are, in fact, 2,580 available, and 1,658 insured persons are being treated there.
§ Mr. HERBERT SAMUEL
I cannot say that. Of course every consumptive person thinks that he ought to have sanatorium treatment, and for such length of time as he may think desirable; but everyone who has studied this subject knows that there are many cases which are not detected until they have been for some time under observation, and there are many for whom it is clear that sanatorium treatment would be of no use. There is not the least use in sending advanced cases to sanatoria. Therefore, when a person in an advanced stage of consumption comes, or the friends of that person come, to the insurance committee, and they say that he wants to go to a sanatorium, it is not necessary. Of course it would be a kindly act if funds were unlimited to send him to a sanatorium. but from the medical point of view it is not a proper case to be sent to a sanatorium. On the other hand, there are cases which are in the very first stage of phthisis, or which may be still under observation, and they may have to be under observation for a very considerable time before the tuberculosis officers can tell whether it is really a case of tuberculosis which ought to be sent to a sanatorium or not. The diagnosis of this disease in its earliest stages, as everyone knows may be a difficult one. There are, no doubt, 640 many applications which are refused on that ground.
§ Mr. ASTOR
The right hon. Gentleman does not wish to suggest that the estimate which he quoted was a final estimate; it was only the minimum number. If he will look at the Report, page 26, he will see that the figures given in this Report must be taken to be extremely tentative and provisional. Nor did the Committee feel in a position to make a reliable forecast. All the Committee said was that they felt that a minimum of 9,000 beds would be required. The right hon. Gentleman has rather suggested that the 9,000 was the full number which they anticipated would be required.
§ Mr. HERBERT SAMUEL
That is for the whole United Kingdom. The smaller figure which I gave was for England.
§ Mr. HERBERT SAMUEL
That is for the whole population, insured and uninsured. I do not want to repeat the speech which I made the other night, but I then made it quite clear to the House that the Committee did their best to present as reliable an estimate as they could, knowing that the data on which they had to go were very scant, and I emphasised that, and therefore did not repeat it to-day. I am well aware, as the hon. Member has stated quite correctly, that the Committee stated that the estimate must be a minimum one.
§ Mr. HERBERT SAMUEL
That minimum estimate was 2,100 beds for insured persons in England, or 9,000 for the whole population of the United Kingdom. Instead of 2,100 beds in sanatoria, there are 5,145, and there were, in fact, 3,215 insured persons in these sanatoria, or 50 per cent. more than the minimum estimate that was made.
§ Sir C. KINLOCH-COOKE
I understood the right hon. Gentleman to say there was sufficient accommodation for advanced cases of tuberculosis. I would ask him to refer to one of his own statements, in which he says that in some districts there is insufficient accommodation at present for advanced cases of tuberculosis, and that the councils are taking steps to provide fuller accommodation. If that is the case, how can the right hon. Gentleman say that there is at present sufficient accommodation for advanced cases?
§ Mr. HERBERT SAMUEL
So far to-day I have said nothing about advanced cases. I was talking about sanatoria on the last occasion. I said then, and I now repeat, that there are districts in which the insurance committees have not yet made adequate arrangements for all their local cases in their own neighbourhood. If I gave the impression on the last occasion that I thought that everything was perfect and that no progress needs to be made in the future, and that the country is now adequately dealing with the whole problem of tuberculosis for insured persons and others, that is an impression which I did not intend to convey, and I do not think that I did convey it. There are districts in which further efforts should be made and are being made; but taking the country as a whole, the number of beds available is statistically adequate for the number of tuberculous persons among the insured population. There are districts where, at present, the insurance committees have got some persons on their waiting list, or had some time ago. They are making the greatest efforts to make good that deficiency where they exist, and they are being urged to do so by the Commissioners and by the Local Government Board. I can assure the House that we are watching this matter with the utmost care and that we shall not be contented until every district has within reasonable reach of its own locality full and adequate accommodation of a permanent and not merely temporary kind for its own population who can properly be recommended for that treatment.
§ Viscount WOLMER
I should like to draw the attention of the House to another aspect of this subject, namely, the way in which the Insurance Act has broken down and has affected the position of small friendly societies. I am glad to see Members of the Labour party in their places, for I am sure this question is one which affects, not only friendly societies, but trade unions as well. I should like to quote to the hon. Member for St. George's-in-the-East (Mr. Wedgwood Benn) a letter which I have received from the president of the Gilbert Greenall Friendly Lodge of the Loyal Order of Oddfellows, in my Constituency. This small friendly society is in a healthy agricultural district, and up to the time of the Insurance Act it had always been very flourishing. The short account which I received of its condition I think summarises the most disastrous effect which the Insurance Act has upon 642 these small friendly societies. I am informed that this case, about which I have received information, is identical with others in different parts of the country. The president of the society said:—We have eighty-four members, and had a capital of £700 or £800 invested. After so short a time (since the Act came into operation) this has been reduced by £200. No young men joining; they say we cannot afford to pay to two. The State Section is in a very bad way indeed. We cannot get money from the Commissioners to pay the sick. Up to Saturday last we were owing to sick members £10. One man was actually six weeks behind. He thought some of the other members were worse off than himself, so he would wait. Another member, the secretary, found the money out of his own pocket, as the poor sick man was badly in need. Last Friday we sent in a requisition for £17. Yesterday I received £10. This amount you will see is all owing up to last Saturday. As our Member, is it possible you can give us any advice. I may say our little society has been going more than a hundred years. The contributions are 4½d. per week, and the benefits are 10s. per week for fifty-two weeks, 5s. for fifty-two weeks, £10 at death, and £8 at the death of wife Now we have reduced the sick pay to 8s. and 3s., respectively. We are now considering whether to break the thing up or raise the contributions.I wrote to this gentleman, who informed me that the Gilbert Greenall Lodge is an independent lodge, and that there had been delay in the payment of money that was due to the fault of the Insurance Commissioners, and not of the provincial office of the order. Since then I have heard from him that the remainder of the money due from the Insurance Commissioners has been paid up, so I do not propose to dwell upon that further. But what I do desire is that the lion. Member for St. George's-in-the-East will consider the matter. I want him to picture for himself the position in which the society must feel itself to be. Here is a society which has been the centre of the village for over 100 years, and which in that time accumulated nearly £800. Every year there was a fresh increase to the funds and resources at their disposal. The Act has now come into operation, and, in two years, over £200 of their reserve has been dissipated. What is the position in which the men of this society find themselves? They find that the society is going to absolute ruin. If this sort of thing continues for a few years longer, the society certainly will have to face the alternative of either raising the contributions or winding up the society. In order to show hon. Members how the Act has affected the finances of this lodge, I will quote from the balance sheet before the Act came into operation, and since it has been in operation. The index to the prosperity of any society is to be found in the sick fund, whether there has been a profit on that fund or a loss. [HON. MEMBER: "No, no!"] It is a very good index.
§ Viscount WOLMER
I agree with the hon. Member that it is necessary to take other factors into consideration, and I think I have already pointed out to the House, in the letter which I read, that no young men are joining this society, because they cannot afford to contribute to it and to the State section as well. It is one of the most serious points with regard to the society that no young men are joining. Therefore, the financial position of the lodge may very well be worse than would appear from the figures.
§ Viscount WOLMER
I think that can he extracted from the balance sheet. According to it, the sick fund, in the year 1910, showed a total gain of £29. In 1911 there was a total gain of £13; then, in the year 1912, the first year of the working of the Act, there was a total loss to the fund of £44, and again last year of £36.
§ Viscount WOLMER
The total loss in the last year was £36 16s. 3d. These figures show that since the Act has been in force there has been a loss on the sick fund. Previous to the Act being in force there was a gain, and that gain must have been regular to accumulate to the amount of £800 during the last hundred years.
§ Viscount WOLMER
This society found that the young men of the district could not afford to pay under what they called the State scheme and also under the voluntary scheme. We know that in this House it was expected and anticipated that the two would be amalgamated. You have got to consider the ways in which these small friendly societies work. They have their own traditions, they have their own esprit de corps, and they did not want to be amalgamated under the National Insurance Act. They have made every effort to keep their own individuality, but the result of the Act is that they are being crushed out. I say this—not as an enemy of the Insurance Act: I have always tried to deal with that Act in a fair way—but I do say that unless drastic Amendments are made in this Act these small societies 644 will be gradually driven to the wall. I should like the Government, if they can, to give their attention to this case. I will send the hon. Member for St. George's-in-the-East, if I may, the full facts and a balance sheet, and I will ask him his advice, because I am sure his advice would be respected by the committee of this particular society, and that they would welcome any assistance that the Government could give them to divert the ruin which their president sees staring them in the face. If these small societies are crushed and if their work of generations is to be-broken up and put on the scrap heap then, indeed, the Insurance Act will have done a great deal of evil as against undoubted good which it is doing in other directions. It is because I realise that the Insurance Act has done great good in some directions that I do urge the Government to consider the individual right and individual character of those small societies, which I am sure have played a very great part in building up a spirit of thrift arid sense of responsibility and experience of government among the workers in different parts of the country, and I do make an earnest appeal to the Government to give their attention to the state of this particular society, and many others that are in the same position, and which have a splendid record behind them, though a dismal future seems to threaten them at the present moment.
§ Mr. WEDGWOOD BENN
I will first deal with the question put by the Noble Lord. I am glad, in the first place, to hear that the complaint made by this small society appears to have been settled, and that the money having been paid by the Insurance Commissioners, they have received satisfaction on that point. It is quite impossible to say what may be the position of one of these small societies until the necessary material has been obtained as to the age of members, the conditions of membership, and other factors of that kind. The Act provides that there shall be credited to these societies certain sums, varying according to the age of the members, and other particulars. Until the facts have been ascertained, it is quite impossible to say whether this or other societies is in an insolvent or a solvent position. I would point out that the society to which the Noble Lord referred had a reserve, but that no young members joined, because they said they could not afford to join the approved system as well. The Noble Lord said that the result of 645 this was that the little society is in danger of ruin. If that be the fact, the society is living on the subscriptions of young members, instead of accumulating a reserve as it ought to do.
§ Mr. BENN
I am not arguing that point—I am dealing with the facts. The society should have in reserve in respect of its members sufficient to meet the claims of those members, and if this is a society which could not do so because young men would not join, then I say the society is doomed to failure. The hon. Member for Wilton (Mr. Bathurst) raised points which were also raised by the hon. Gentleman the Member for Sevenoaks (Mr. Forster) as to the adequacy of the medical service, local dispensaries, nursing, and so on. I make bold to say that nobody, when this Bill was passed through Parliament two years ago, was under the impression that for a contribution of 4d. per week that insured persons suffering from every sort of illness, however complicated and difficult, would receive medical or surgical attention. Does the hon. Gentleman mean to say that 4d. per week was intended to cover complicated and difficult cases in which surgical treatment and surgical appliances were necessary?
§ Mr. BENN
The words, "adequate treatment" are not a description of medical benefit. What the Act contemplated, and what everybody contemplated, was that the same treatment as is given by the family doctor or general practitioner to the family of a man with £160 per year, should be given to everybody insured under the Act. Just as we know that we would never think of asking the family doctor to do things at critical moments without a second opinion, or the assistance of a specialist. It was impossible to contemplate that an Act levying contributions of this kind should have contemplated assistance of that nature to every insured person. I do not recollect 646 that that was contemplated at the time, and I do not think anybody in the House believed that it was.
§ Mr. FORSTER
May I remind the hon. Member that the Chancellor of the Exchequer expressly insisted on modern methods of exact diagnosis.
§ Mr. BENN
I think that everyone that hears me will agree that what the Act contemplated was to provide a general practitioner for everybody insured under the Act. [An HON. MEMBER: "What did the Chancellor say?"] The hon. Gentleman who moved the Amendment put the point that a certain number of persons had not selected their doctor, and consequently their names were not on anyone's lists, and he complained, because the money in respect of those persons, 7s. per head, was being paid to doctors who had not earned it.
§ Mr. BENN
The money is there for the doctors who are on the panel. The hon. Gentleman seems to think that a doctor is paid 7s. for attending a sick person, and he does not seem to understand that the doctor is paid 7s. per head for persons sick or well, all alike. The hon. Gentleman also said that the Chancellor of the Exchequer had tried to make people believe, when the Act was being passed, that whatever happened the minimum benefit was guaranteed to them. He says that the Chancellor of the Exchequer made that point at the time. The hon. Gentleman referred to a book. In that book the Chancellor of the Exchequer specifically spoke about a society becoming insolvent, or unable to pay minimum benefit, and pointed out that a man transferring from one society to another carries with him his transfer value arising from deficiencies and so on. He made it perfectly clear in the book that deficiencies might occur owing to bad management. Does the hon. Member for Colchester (Mr. Worthington Evans) say that however badly a society or branch was managed, the benefits were to be guaranteed for ever to its members. I am sure nobody thinks that, and the Chancellor of the Exchequer never stated it.
§ Mr. WORTHINGTON EVANS made some observations which were inaudible.647
§ Sir C. KINLOCH-COOKE
That is not my point. My point was that the Chancellor of the Exchequer said that there was to be a State guarantee.
§ Mr. BENN
No, the Chancellor of the Exchequer never did, and never could have made the statement that however badly a society or branch of a society was managed, its members were to receive minimum benefits, because if he had done so, he would have undermined the whole principle on which the Act is based, which is, that the approved societies shall manage the moneys for themselves. As to the question of nursing, to which the hon. Member for Wilton referred, I am not quite sure that it is within the competence of an insurance committee under its powers under the Act to set up nursing associations. I would draw the hon. Member's attention to the fact that it is within the power of a society to contribute to associations for that purpose, and perhaps if societies turn their eyes in that direction something of the kind which he desired might be done. The right hon. Gentleman opposite spoke about deficiencies in the drug fund. He read a letter from the Leeds Committee complaining that there was not enough money to meet the charges. I did not gather whether it was an official or private communication.
§ Mr. BENN
The fact of the matter is that in this case of the drug fund the regulations and the agreement with the chemists provide and always contemplated that the tariff which had been drawn up should be regarded as a tariff and not as the schedule of fixed prices. It was on that basis that the tariff was agreed to by those who made the negotiations when the Act first came into force. It was on that basis that the regulation provided for scrutinies of the prescriptions with the bills by the members of the medical profession and the chemists respectively. In the case which the hon. Member for Salisbury (Mr. G. Locker-Lampson) is pressing constantly in this House, there is such a scrutiny going on at the present time. The 648 hon. Member complained on Tuesday night that I did not answer his point. Unfortunately time did not permit for everything to be said which we desired to say, but the fact of the matter is, as regards Manchester and Salford, where a deficiency between the bills and the amount available is apparent, the scrutiny is proceeding by a joint committee of the chemists and doctors, and the chemists themselves have entered into an agreement for a fresh year with the committee on the understanding that the prescriptions would be scrutinised by this joint committee. The reason I did not answer in the sense the hon. Gentleman desired—the questions he put to me about the alleged deficiency—was that that scrutiny is proceeding, and it is therefore absolutely premature at the present moment to make any statement as to what may be done. Moreover, as I pointed out to the hon. Gentleman himself, he is not authorised by any official body of chemists in Manchester or Salford to make such representations. Then, again, in some districts whereas there appears to be a deficiency until scrutinies have taken place, in many districts there is, in fact, a surplus, and some part of the floating sixpence will not be required to meet the chemists' bill. For instance, although in Manchester and Salford the prescriptions appear to be in excess over the money available, on the other hand, in Liverpool, St. Helens, Southport, Warrington, and other places, there is, in fact, a surplus, and the provision to meet the charges of the chemists is, in fact, adequate.
There is only one other point with which I wish to deal. Some hon. Members have represented that Section 11 of the Act is doing some harm to working men. They represent that when a man receives compensation for an accident, if that compensation exceeds the amount of sickness benefit to which he is entitled, that then that compensation is taken into account in determining the amount of sickness benefit. The fact of the matter is that this provision has had a most valuable effect in increasing the funds available for the working men and insured persons generally for meeting their needs in case of accidents or in cases of sickness. It has also resulted in actions being set in motion by approved societies, and I will give the House one or two examples from those which have been given to me. Here is a case of a woman run over by a pair- 649 horse van, with her ankles broken. The owners denied liability, and judgment was obtained for £500 against them. Here is another case of a bricklayer's labourer who fell from a scaffolding, and who was said to be suffering from the effects of the accident, and eventually succeeded in obtaining £40. Then there are cases of £25 and of £20, and of £50, and so on. Those are sums which have been recovered at the instigation of the approved society, and the result is that instead of sickness benefit being drawn by those members of the society they have recovered money under the Workmen's Compensation Act, and the other money for sickness benefit which would have been paid to them has gone into the funds of the society, as the actuaries contemplated it should. I hope I have met most of the points which have been raised, and I do not wish to occupy the time of the House further in order that other hon. Members may have the opportunity of speaking.
§ 8.0 P.M.
§ Mr. HODGE
I think I was here when the hon. Gentleman who interrupts was not here. At any rate, I repeat that the Noble Lord seldom, if ever, addresses the House without a sneer at the Members of the Labour party. I assume that that is a part of his nobility. As a member and as an official of an approved society, I desire to say that individually I am conscious of many defects in the Insurance Act. At the same time, not only from my experience prior to the passing of the Act, but my experience since it came into operation, with all its defects, it has been of incalculable benefit to the lower paid workers in this country, male as well as female. One of the points I desire to place before the hon. Member for St. George's-in-the-East (Mr. W. Benn) is with reference to the women. I remember when the Government calculations were made there was no actuarial experience with respect to sickness so far as the women are concerned, and a great many of the societies all over the country which have great numbers of women members find that the allowance under the Act is altogether insufficient to meet the responsibility and 650 liability that they have undertaken. I had hoped that the two Members of the Government who addressed us would have given the House some assurance on that point, that they would not see the various societies bankrupted as a consequence of that deficiency. The amount of sickness benefit which women get at the present moment is so small that were the amount to be reduced it would hardly be worth having. I desire to press upon the Government the necessity of taking the House into their confidence, and telling us what they intend doing so far as that particular feature on the Insurance Act is concerned. I know that as the result of my own experience there is not a deficiency so far as the women are concerned. In the society of which I have the privilege of being secretary we have some 800 women workers who are employed in the tinplate trade in South Wales, and the sickness experienced there is perfectly normal, and the allowance under the Act meets the liability and responsibility of the approved society. I can therefore, as the result of my knowledge and experience of other societies, press the more strongly upon the Government the necessity of doing something in this matter for those other societies, because of the fact that I am not begging on behalf of my own. Something has been said with respect to the doctors. My experience is that the heavy sickness experienced, particularly with respect to males is absolutely due to the fact that the doctors do not do the duty that they are paid for doing. If you talk with a doctor, and ask him why he gives certificates so indiscriminately, the invariable reply is: "If I do not give a certificate, they will leave me and go to another doctor who is not so particular." That experience is not confined to any one society. Every approved society complains of exactly the same thing. The only remedy is a State medical service. That would place doctors in such a position that they would not have to dread individuals changing from one panel to another. The doctors themselves have said that they want a system of medical referees established: that is, they want to cast on to a second party a responsibility which rests upon them—and that after all that we have heard about the dignity and honour of the medical profession. As secretary of an approved society, I have also had experience with respect to sanatorium treatment. 651 On the whole, I have really nothing to complain about in that respect. The greatest difficulty in some districts arises from the local authorities not being in harmony with the provisions of the Act, and doing everything they can to harass and hamper its operations.
Hon. Gentlemen opposite have from time to time criticised the defects of the Act in a reckless spirit. They wax very eloquent with respect to the misdeeds of the Government in not accepting their advice in the framing of the Act. The old maxim with regard to people in glass houses not throwing stones holds good. I remember an Unemployed Workmen Act being passed by the party opposite, and, after our experience of that Act, it appears to me that their criticisms of this great measure are in consequence impotent. With respect to the Amending Act passed last year, I venture to say that we on these benches were largely responsible for it. Many of its provisions were provisions which we had suggested to the Chancellor of the Exchequer when the original measure was going through the House. The right hon. Gentleman did not see eye-to-eye with us, but as a result of experience it was demonstrated that our suggestions were of a practical character, and they have now been embodied in the law. The hon. Member on the Front Bench opposite (Mr. Forster) depicted the horrors of a man suffering from consumption, and living with a family of three in one room. He pointed out the dangers arising to the family in such a case and the necessity of the man's being sent for sanatorium treatment. But after the man has undergone the treatment, what is the use of putting him back under the same conditions? If there is any sin so far as that is concerned, the hon. Gentleman and his party are not guiltless, for when they were in power they did nothing to remedy the conditions which he so eloquently depicted. We have a remedy for these things, but that remedy does not appeal to hon. Gentlemen opposite. The hon. Member for Devonport had some rude things to say about the Members of the Labour party. He can take it from me that we are not going to be made tools of by Gentlemen such as he.
§ Sir C. KINLOCH-COOKE
Will the hon. Gentleman elucidate a little what he means by the phrase, "Gentlemen such as he?"
§ Mr. HODGE
I am very sorry if I re ferred to the hon. Gentleman. It was not 652 he whom I had in mind; I meant the hon. Member for Plymouth (Mr. Astor). As a consequence of our experience of the untold benefit that has accrued to thousands of men, who otherwise would not have been provided for so far as sickness is concerned, we are not going to be duped by Members such as the one to whom I have already referred.
§ Mr. WORTHINGTON EVANS
As there are only two or three minutes remaining, the hon. Member (Mr. Hodge) will perhaps excuse me if I do not follow him in reference to the points he has made. I want to deal rather with two observations of the hon. Member for St. George's-in-the-East (Mr. W. Benn). The hon. Gentleman, when dealing with the question of minimum benefits, said that we on this side did not think that the minimum benefits were guaranteed, and he called attention to a leaflet on which the question "Are the minimum benefits guaranteed" was set out, and the reply, "Certainly not" given. I never thought that the minimum benefits were guaranteed. What I objected to was that the Chancellor of the Exchequer should say that they were. In the book published by him he said as plainly as anything could be said, that the State would guarantee the benefits. It was because of that statement, and statements made by other Members of the Government, by Mr. Masterman himself, that that leaflet was issued. Mr. Masterman, speaking on 31st October, 1911, at the Croydon Public Hall, said that the Bill gave a State guarantee where the insurance societies might be insecure. That is reported in the "Daily News" of 23rd October, 1911. I remember, too, that the hon. Member for Wisbech (Mr. Primrose) made a very strong statement to the effect that one of the things he liked most about the Bill was that in future the benefits of insured persons were to be guaranteed. It was because of that sort of statement that the leaflet was issued. It will not do for the hon. Member now, two years after the publication of the book, to say that somewhere else in the book there is a contradictory statement. It is quite true, but the Chancellor of the Exchequer is always contradicting himself. He has never withdrawn the statement. He might withdraw it now if he chose.
Another question raised to-night was in reference to the medical benefit. We have asked that a Return should be made showing how many of the insured people, all 653 of whom are paying for medical benefit, are in fact getting it. There is no difficulty in making that Return, but it is always refused from the Treasury Bench. The chairman of the London Insurance Committee, the hon. Member for Walworth (Mr. Dawes), joined with me in asking for that Return, but owing to the formalities at the Table the Return could not be put down in two names. It is not a party question at all. There is a real desire to know how the medical service can be improved, but we have not the figures. In London nearly 25 per cent. of those who are being charged 9s. every year for medical benefit are not getting medical benefit at all; they have neither chosen a doctor nor had a doctor assigned to them. In Essex the percentage is about thirteen. Out of 325,000 insured people 42,000 have neither selected a doctor nor had a doctor assigned to them, although £15,000 a year is being taken from them with that object. Can the hon. gentleman say that that is an adequate medical service for the people who are being charged for it? It is no use saying, "It is their own fault; why do they not get a medical ticket and choose a doctor?" I know that that is the answer that is given. But with whom are you dealing? With people who are not yet accustomed to the Act, with people who are, if you like, careless. But you are not giving them the medical benefit for which they are insured—
§ The PRESIDENT of the BOARD of EDUCATION (Mr. J. A. Pease)
rose in his place, and claimed to move, "That the Question be now put."
§ Question, "That the Question be now put," put, and agreed to.
§ Question, "That the words proposed to be left out stand part of the Question," put accordingly, and agreed to.
§ Main Question put, and agreed to.
§ (In the Committee.)