HC Deb 08 December 1920 vol 135 cc2333-63

(1) The council of a county shall on such terms and conditions as may be approved by the Minister have power—

  1. (a) to acquire by agreement with any Poor Law authority any existing Poor Law hospital or infirmary belonging to that authority within their area and maintain the same as a hospital for the treatment of illnesses and diseases generally or for the treatment of any particular illness or disease or any particular class of illnesses or diseases; and
  2. (b) to establish and maintain or to con tribute towards the cost of or other wise to aid in establishing or maintaining an ambulance service for dealing with cases of illness either within or without their area.

(2) Where on the application of the council of a county the Minister is satisfied that there is a deficiency of hospital accommodation in the area of the council and that any Poor Law hospital or infirmary could be made available for meeting such deficiency,

Question put "That those words be there inserted in the Bill."

The House divided: Ayes 23; Noes.31.

he may in default of agreement under this section between the council and the Poor Law authority concerned after giving the authority an opportunity of being heard by order require the authority to transfer the hospital or infirmary to the council on such terms and conditions as may be prescribed in the order.

Any such order may contain such provisions with regard to the vesting of the hospital or infirmary in the council and such consequential and supplemental provisions as the Minister may think necessary and any order so made shall be binding on the authority:

Provided that any such order shall be provisional only and shall be of no effect until confirmed by Parliament.

(3) The councils of two or more counties may with the consent of the Minister and subject to such conditions as he may prescribe combine for the purposes of maintaining hospitals under this section and where any councils so combine they may appoint a joint committee under section eighty-one of the Local Government Act. 1888 and that section shall have effect accordingly.

(4) The council of a county may with the approval of the Minister delegate to any joint hospital board or in the case of the London County Council to the managers of the' Metropolitan Asylums District the management on their behalf of any Poor Law hospital or infirmary acquired by them under this section.

(5) Section one hundred and thirty-two of the Public Health Act 1875 (which gives powers to recover the cost of the maintenance in hospital of a person who is not a pauper) as amended by section sixty of the Public Health Acts Amendment Act 1907. shall apply to any patient who has received treatment in a hospital maintained by the council of a county under this section and the council shall have the same power of recovering expenses as is given to a local authority under that section.

(6) The expenses of a council under this section shall be defrayed in the case of the council of a county as expenses for general county purposes or if the Minister by order so directs as expenses for special county purposes charged on such part of the county as may be provided by the order and in the case of the council of a county borough as expenses incurred in the administration of the Public Health Acts 1875 to 1908.

(7) A council shall have power with the approval of the Minister to borrow any sums required for the purposes of this section in the case of the council of a county in the same manner as for the purposes specified in section sixty-nine of the Local Government Act 1888 and in the case of the council of a county borough in the same manner as for the purposes of the Public Health Acts 1875 to 1908.

(8) If any person is deprived of any office or employment or suffers pecuniary loss by reason of the acquisition under this section by any county council of any Poor Law hospital or infirmary the Minister may order that compensation of such amount as appears to him to be just shall be paid to that person out of the fund out of which the expenses of the hospital or infirmary were defrayed before it was acquired by the council and any compensation so ordered to be paid shall be paid in such manner whether in the form of a lump sum payment or of an annual payment as the Minister may think proper to direct.

If any persons who were members of the staff or were employed in connection with any hospital or infirmary acquired by the council of a county under this section are transferred to and become officers of the council they shall not while they continue in office be in any worse position as respects their tenure of office salary and superannuation allowances than they would have been if they had continued to be such members or so employed.

(9) In this section the expression "council of a county" includes the council of a county borough.

Mr. ORMSBYGORE

I beg to move to leave out the Clause.

I opposed the Clause on the Second Reading and in Committee both in general and in detail and in my point of view the Clause as it now stands is worse than it was when originally introduced. The action of the Minister in accepting an Amendment moved by the hon. Member for Mid-Herts which now forms Sub-section (2) of the Clause really makes it compulsory on the Poor Law authorities of the country to hand over their institutions to the county councils to be maintained and run as State general hospitals for the treatment of all and sundry for all kinds of diseases. That is in direct contravention of a pledge given by the Minister to the hon. Member for Newcastle. When the hon. Member for Newcastle wrote to the Minister to explain the Clause the Minister replied on October 12 saying there was no intention to compel boards of guardians to give up their infirmaries to the county councils but that the Clause contemplated a purely voluntary arrangement between the parties. An extract from a letter written from the Ministry of Health to the hon. Member for Newcastle said: Dr. Addison desires me to say that he would be prepared to move Amendments making this quite clear. Then the Minister in Committee upstairs accepted a far-reaching Amendment compelling the boards of guardians to hand over their institutions to the county councils willy nilly. I regard that as a direct breach of the promise which the Minister gave less than two months ago to the hon. Member for Newcastle. The point is that the right hon. Gentleman wishes to break up the Poor Law and instead of doing it openly and honestly he has done it in a piecemeal fashion. This Clause was introduced without the boards of guardians or their association being consulted or ever having one word heard on their behalf by the Minister. In this matter he has been the consistent opponent of boards of guardians. He has treated them most unfairly and still more unfairly by the arguments he used in support of the Clause on the Second Reading. He gave a lot of figures about empty beds in Poor Law infirmaries and these figures I have been endeavouring to get checked through the Poor Law Guardians' Association and I find in every single particular he gave that the figures are not borne out by the guardians themselves. Further the right hon. Gentleman gave figures for the summer months whereas everyone knows that there is less sickness then than there is in the winter and I believe he has been completely misinformed as to what he is likely to get out of this Clause. He wants to render available for the general public the beds in Poor Law infirmaries which are not now occupied by the pauper patients. Let us remember that the boards of guardians after this Clause is passed will still have laid upon them the statutory obligation of treating necessitous not destitute persons who come to them in Poor Law infirmaries and institutions or of making arrangements with county councils who have taken over their institutions under this Clause for the taking in of the pauper patients in those council institutions. There remain in certain Poor Law institions a certain varying number of surplus beds not now occupied. Instead of coming down to the House and asking for a Clause drafted in some such manner as my Amendment which would have enabled local authorities to take in these people and so utilise their surplus beds he proposes to force boards of guardians to hand over their institutions to the county councils. The first limitation is that the county councils would obviously not wish to take over workhouses or a hospital or infirmary inside a workhouse. They will only want to turn over a few-big Poor Law infirmaries that are separate institutions.

We heard from the Minister that there are about 54 of which 27 are in London and the other 27 in the provinces in county boroughs. These are to be handed over to the county councils to be maintained by them possibly in competition with the local voluntary hospitals and maintained entirely out of the rates for the treatment of all and sundry pauper and non-pauper for all kinds of diseases. That is a far-reaching revolution in our hospital system and Poor Law system. It is new work to throw on the overburdened county councils. For many years past the Poor Law guardians have given devoted service. They visited and took an interest in the institutions and their inmates. In Stafford which I represent a large county you are not going to get the farmers and small landowners who represent different parts of the county on the county council to come into the county town and keep a careful eye on the expenditure and management and welfare of the inmates in the Poor Law hospital which is to be taken over. They are not equipped for the work. What will happen is that these admirably run hospitals will be handed over to a new set of officials a new bureaucracy under the county councils. It is not a good thing. It is tinkering with the subject. It is all because the right hon. Gentleman will not face the hospital question of the country and deal with it as a whole instead of piecemeal. He must also deal with the great voluntary hospitals and nursing homes at the same time. He is going to set up a Committee to deal with the finance of the voluntary hospitals. Why does he not wait till the Committee reports before taking these institutions over. He brings it forward as a matter of urgency yet the procedure under this Clause is going to take months to bring into operation whereas if he accepts my alternative he can put it into operation at once. His procedure means long and protracted negotiations between the poor law authorities and the county councils and in view of the way he has consistently put up the back of the boards of guardians I am afraid it would be difficult to secure a very smooth working of this Bill. Since its introduction the Poor Law guardians' representatives have held their annual meeting in London. They strongly denounced this Clause and suggested the alternative which I move on their behalf. They passed a resolution nem. con. against the Minister's action and the proposals contained in this Clause. The Minister will put in operation the proposals of Sub-section (2) and make an Order for the board of guardians to hand over their hospital to a county council. That Order is to be confirmed by both Houses. It is going to be mentioned before you get the surplus beds in the Poor Law infirmaries available for the sick whereas if he had approached the guardians in the beginning and assented to some such scheme as that in the City of Birmingham instead of exciting the hostility of the boards of guardians instead of effecting this revolution in our hospital system instead of embarking upon this great system of county council maintained hospitals he could have got the surplus beds available in a fortnight from the passing of this Act. I have no other course than to move the rejection of the Clause. It is a thoroughly bad Clause and is going to cause endless friction. It is the wrong way to deal with the problem. So far from getting 30000 beds he is going to place the boards of guardians who are responsible for providing the institutions for the reception and treatment of necessitous persons in a most embarrassing position because goodness knows how they are going to fulfil their statutory obligation. He is not going to advance public health in this country.

I would in that connection like to point out this sort of situation. Take Southampton where there is a very fine Poor Law hospital. It has got 446 beds. For the moment there are 80 vacant beds but last September there were only 11 vacant beds. From the report of the local board of guardians I see they estimate that by next September they will not have a bed to spare. It is the same at West Ham. They are filling up the West Ham hospitals and more and more patients are being admitted. The effect of this Clause is going to be most serious upon the provision for the poorest of the community. Do not let us forget that in our zeal to scrap the Poor Law we have to see that provision is made for people who cannot afford to pay at all. Then we come to deal with the people who can afford to pay something. Because that is what is contemplated under the Clause when one of the Poor Law hospitals is transferred from the Poor Law authorities to the county councils you will see that the county councils under this Clause have power to obtain payment from the persons treated in that county council hospital.

Dr. ADDISON

And so have the Poor Law guardians.

Mr. ORMSBY-GORE

But why do you not legalise what some of them are doing to-day taking in paying patients? Because the Minister in charge of the Bill is obsessed all the time with having a hit at the guardians; he is obsessed all the time with breaking up the Poor Law and he is obsessed all the time with the desire of tinkering with the hospital system in this country. I oppose this Clause just as vigorously as I have since the introduction of the Bill and I shall continue to do so.

Mr. LORDEN

I beg to second the Amendment. I will not go over the ground which the hon. and gallant Member has so well dealt with but on the Order Paper I have down a notice to postpone the Clause. I put it down because I wanted the Clause postponed until such time as the Report is made upon the voluntary hospitals. I feel that we are only tinkering with the subject. If you are going to break up the Poor Law and there has been a great number of reports upon the Poor Law why not do it in a Parliamentary way. Do not tinker and play with it like this. There are only 54 institutions and there are 134 authorities amongst which you are to divide them. If the Minister had only legalised payments to be made to boards of guardians you would have carried out this work just as well. Whether you call it county council or Poor Law I cannot see that there is any difference. The most extraordinary thing in this Clause is Subsection (4) in which the Minister takes powers to turn over these institutions in the London area to the Asylums Board. One would think that the Asylums Board dealt entirely with imbeciles. It is nothing of the sort. They are really overflow institutions from the Poor Law. There is not the slightest difference between the Asylums Board and the Poor Law guardians I know they have the infectious hospitals to do with but generally speaking they are simply the overflow from the infirmaries into the institutions covered by the Asylums Board. What does strike me as an absolute waste of money is that in taking over there must be surveyors and people who have to be paid and what for? Only a temporary thing. This is the start of something much larger. Why not utilise the institutions which you have without going to all the expense of taking them over from another authority? As an example there is one medical man in charge of several of these places and he has assistants under him. Are you going to divide up all these places? The one man will not be able to give his services and you will have a number of men over each of these institutions. That is where you are going to waste a lot of money. I feel extremely strongly. I have had considerable experience of boards of guardians. Nobody will say they are ideal and for many of the things they have done in the past one feels rather resentful but for this very small experiment I say at this time the country cannot afford all this expense.

Dr. ADDISON

I am sure we all admire the energy and freshness of my hon. and gallant Friend who has brought this Amendment before us at this time in the morning. It is reminiscent of the same gallantry with which he fought it in Committee upstairs. I think the reasons are fairly familiar. My hon. and gallant Friend did not quite represent except in very picturesque fashion what was in the Clause. The sanction of a Provisional Order by both Houses of Parliament seems an effective safeguard. Also it has to be on the application of a county council. It is not that the Ministry of its own notion can go down somewhere and poke about. It has to be on the application of a responsible county council. They are satisfied that there is a deficiency of hospital accommodation in the area of the council. That is where the thing begins. There is nothing haphazard or ill-considered about that. But the main point is what is the best way in the interest of sick persons to make use of the hospital accommodatioin which is really available? The hon. and gallant Member did not in Committee dispute the real and urgent necessity of making use of this accommodation—

Mr. ORMSBY-GORE

As quickly as possible.

Dr. ADDISON

As quickly as possible although he suggests the alternative which he puts before us. That alternative is that the Poor Law guardians should be entitled to become the general hospital authorities for the treatment of sick persons of all classes. That would be putting back the clock for a generation and I will give my reason why. I say now as I said in Committee upstairs that from the period from the first of the Poor Law Commissions there have been Commissions ad nauseam on the subject. Every body of men which has investigated the matter has come to the conclusion without exception that the only effective way to procure the proper health development of the country is to associate the hospital system with the proper health authority. Why? Because there are 635 Poor Law unions and you do not want to have 635 separate hospital authorities in the country. That would be an absurdity. You do not want to have 635 separate hospital authorities because the supplies of skilled personnel and highly-trained staff available in the country for general hospital service is extremely small and it would not go round 635 hospital authorities.

The next thing is that to have a hospital devoted to general purposes you must make it available for the needs of the people covering a wide area and in counties you must make arrangements to transfer those people by ambulances to the places in which the hospitals are situated. That is the only practical way of developing the hospital system. The area of the Poor Law union is limited and the pressing need is for hospital accommodation. You would have all the miserable consequences among the various small unions as to their aspirations and their arrangements. You must get a proper staff and you must have an efficient staff. The unit of area for these purposes must be a county. You will not get an efficient staff while you have these hospitals under the Poor Law authorities and as a matter of fact it is absolutely true that people will decline to use these Poor Law hospitals. It is not an accident that time after time when this thing has been considered in this country during the last 25 years it has been recognised by all concerned that the people whether it is right or wrong whether it is foolish or absurd have an inherent obstinate objection to going into Poor Law institutions. In saying that I am making no reflections on the guardians. They have done their work splendidly and with very great effect. But the fact remains that in a very large number of cases where the authority is the Poor Law guardians the average person will not be associated with Poor Law administration. That is the fact and no amount of expressions of opinions in this House will alter it. It is rooted deep in the minds of our people and you arc not going to alter it by any Clauses of Acts of Parliament. What is the good of trying to pretend it is not there? The fact remains that these people will not go into these hospitals. In a large number of cases the Poor Law guardians are in my opinion quite rightly willing to receive payments for patients and in fact they have already taken in the people who are willing to pay on account of their position.

Mr. ORMSBY-GORE

They do not have to be destitute but necessitous. Were these people necessitous?

Dr. ADDISON

The Poor Law authorities have taken in people who have paid. They have done it because there were these waiting lists. Notwithstanding that you have large numbers of empty beds in these places. I gave the figure of 30000 and I have had that figure re-investigated and I see no reason to alter it. But supposing it is wrong and that the figure is only 20000 you have all these waiting lists and surely it would be permitting a pitiable spectacle of waste that you should have these people waiting to get into these places with these empty beds available. Many of these people have been waiting for weeks and months and these beds are eminently suitable for the purpose. Could there be anything more foolish than not to use the accommodation so provided for the relief of the sick? That is what I am proposing in this Bill. If you want to get rid of human and material waste if you want to practise economy then for heaven's sake make use of. this accommodation already provided in these public institutions.

Further if there was one pledge more than another exploited in this matter by all those associated with this Government at the last election it was the pledge given to the people that this Government when elected—and for my part I am not going to make it a "scrap of paper"— would deal with this matter. These were substantially the words used: That the Government accepts in principle the recommendations of the Maclean Committee in regard to the functions of the Poor Law Guardians and other authorities and regards as a matter of urgency that the treatment of the sick poor should be merged in the general health services of the community. I drafted that myself before the manifesto was issued. No system will be allowed to become part of the health services of the country unless it is based on an area not less than that covered by county councils. County councillors are not inexperienced people. These proposals are along the line of the proper development of the health services of the country. They are in accordance with our pledge that the grievous waste of men and material and the suffering that goes on is a matter of urgency and I ask the House to give its support to this Clause.

4.0 A.M.

Mr. HOPKINS

I shall be very glad when the infirmaries in London are placed under the management of a single body. That is clearly a necessity but I do not think that the change ought to be made by a single Clause in a miscellaneous Bill. I understand the urgency of the Ministry to get this change made but I think it would have been just as suitable to bring in a separate Bill bringing in this pledge and dealing with this necessity. I am sure that the change as proposed by this Clause is going to involve a good deal of expense. I do not know of any provision that has been made for dealing with the staffs of these Poor Law institutions. If these staffs decline to be transferred to the county councils—and the staffs for the most part I believe are pensioned it is going to involve a good deal of difficulty and expense. I would also like to know whether the right hon. Gentleman intends to take over the whole of the Poor Law infirmaries in London. If he is only going to take part of the Poor Law infirmaries in London he is going to cause a great deal of difficulty. For instance in my borough we have two Poor Law infirmaries one of which undoubtedly the Minister would be glad to take. The other one is a wing almost of the workhouse and I doubt whether he would want to take it. It would be difficult if you were to leave the. guardians with half their infirmaries to run and give the other half to someone else. It is going pretty well to double the staff expenses. The beds must be arranged to avoid these difficulties. All this scheme is carried out in the limits of a Clause in a miscellaneous Bill. I very much wish the right hon. Gentleman could see his way to postpone for a short time say till next Session taking action in this matter. In the meantime he might get over the immediate difficulty by the suggestion of the hon. Member for Stafford. At the same time I disapprove of the method of doing this. I am inclined to think he is set on getting the infirmaries of London under the control of the county council but I hope he will take all the infirmaries.

Mr. MYERS

I cannot share the enthusiasm or the hostility of the hon. Member for Stafford in his tirade against the Ministry. I subscribe to the findings of the Poor Law Commission or at least, that part of the Report that we should break up the Poor Law and distribute its functions among those avenues where the work is being done by in many Poor Law institutions in the country T am willing to concede that in many poor law institutions in the country there are. really excellently equipped hospitals and infirmaries where very excellent work has been done in the treatment of sickness and incapacity. I further subscribe to the view that the Minister just now expressed, that the hospital system should be associated with the local authorities of the country. I share that view, and I am somewhat loath to strike a hostile note when anything is suggested in the direction of relieving physical incapacity or supplying ameliorative measures. But it is because the Minister is not prepared to act up to the declaration he has made that I express the hostile note I must present. The first attack on the Bill was on the floor of the House when the Minister voluntarily surrendered one-half of it. Upstairs the Bill was further mutilated. My opinion now is that, if we are to get the whole of the Bill as it stands, it is not worth a great deal in an administrative or ameliorative sense. The Bill as we had it upstairs provided for contributions being made to the voluntary hospitals, and it enabled local authorities to make such contributions towards their maintenance. Under the pressure of hon. Members who desired to retain the voluntary hospital system every word of that was eliminated from the Bill, and in the Bill as it is now before the House there is no reference to the voluntary hospital system of the country. Consequently, we must discuss this matter on the assumption that the voluntary hospital system of the country is to remain intact.

Then we come to the part of the Bill which provides for the taking over of Poor Law institutions and putting these institutions under the respective local authorities. I ask any Member of the House who is acquainted with anything in the nature of public administration how they expect that double-barrelled policy to work satisfactorily? It simply cannot be done. Voluntary hospitals are largely maintained out of contributions received from large numbers of people. The Noble Lord the Member for Horsham in the Committee upstairs admitted that in some parts of the country 85 per cent. of the working people make systematic contributions to the voluntary hospitals. Now one section of the hospitals is to be put on the rates and brought within the control of the local authority. Voluntary contributions in the circumstances must inevitably stop. That applies also to people who make large contributions to voluntary hospitals. They will not come with their donations when they know that they are paying through the rates for hospitals of a different category. All the evidence goes to show that the financial stringency which prevails so far as the voluntary hospitals are concerned is going to be intensified by the operation of this Bill.

The matter does not end there. I recognise the tremendous difficulty, so far as county councils or boroughs are concerned, in getting hold of Poor Law institutions. The initiative has to come from outside the authority. The operation of the principle is to result in just one authority here an another there making application for a Poor Law infirmary. We shall land in the position that we shall have voluntary hospitals and hospitals on the rates, while hospitals not taken over will continue under the Poor Law, an intermingling of administrative interests which is serious to contemplate. Even these complications are insignificant in comparison with the complications that must follow the complications of a financial character. Voluntary hospitals to-day open their doors to everybody, although most people going in give a contribution for the treatment they receive. The hospitals under the control of local authorities for the treatment of infectious diseases simply come up to the doors and take people away, asking no questions and making no charge. While I was at home on Saturday my five-year-old child was taken to hospital for scarlet fever. I was not asked how much I wished to pay. In the interests of the family and the community the child was taken to hospital.

Inside this Bill there is a Clause resurrected from the Public Health Act, 1875, which says that every person who receives treatment in any hospital under this Bill will have a charge made upon him, or on his estate if he dies in the hospital. It means that the ordinary working person has to contribute to voluntary hospitals, pay through the rates for the hospitals taken over, and if he is taken ill he will have a bill sent to him. The hospitals taken over are going to come on the local rates. That cannot operate equitably because the allocation of hospitals is altogether out of proportion to the localities. The only equitable method is a charge upon the whole community and then there is no hardship in any area. Another factor is that the financial stringency coming to the voluntary hospitals will operate in this way. You are going to have two classes of institutions for those that can afford to pay and for those that cannot. The voluntary hospitals will be for persons who can pay a reasonable fee. The Poor Law hospitals are going to be the hospitals of the poor people while the voluntary hospitals will be for the middle class who can afford to pay three, four or five guineas. It is a vicious system perpetuating the class distinctions that we are anxious to eliminate. The question needs to be tackled boldly. The Minister declares that the hospitals ought to come under the local authorities of the country. Let us bring the Poor Law institutions under the local administrative authorities, and at the same time let us also take over the voluntary hospitals of the country. No two systems, but all institutions on the same basis, all sections of the community treated alike! That is the only sound and solid method of treating this matter. The charges on the rates will stop voluntary contributions. The financial aspect of the matter will be on a national, not a local, basis. The Treasury at present contribute 75 per cent. towards the treatment of venereal disease, and for tuberculosis 75 per cent. of the capital, and 50 per cent. of the administrative expenditure. Why should not the hospitals be treated on the same basis? There would be a great tendency for the local people to continue contributions to make up the rest and the local rates would escape.

Lieut.-Colonel RAW

The hon. Member for Spen Valley (Mr. Myers) has outlined an ideal scheme of hospital administration for this country. The present hospital system in England is in a state of confusion and almost chaos. That has arisen because for many years the voluntary hospitals treated diseases, and the poor law hospitals treated diseases they were never intended to treat. We must admit that our hospital system is absolutely inadequate for the needs of the community. We are all glad to know that is entirely due to the fact that the social conditions in this country have improved and made the Poor Law institutions vacant. The Minister of Health has a serious duty in trying to provide accommodation for the community at large. People only go to the Poor Law institutions because of destitution or necessity. The Minister has truly told us that there are between twenty and thirty thousand beds vacant in the Poor Law infirmaries. Having regard to the serious shortage and accommodation in the voluntary hospitals, the Minister had no other alternative than to take this opportunity of dealing with the Poor Law hospitals. There are very few institutions which are available for transfer from the Poor Law to the local authority, and it should only be those institutions which are quite separate from the workhouse and have no association with the workhouse which could be dealt with under this Clause. There are, I think, about 50 or 54 separate Poor Law infirmaries in this country which are quite dissociated with the workhouse and workhouse administration. These institutions could quite well by agreement be taken over by the local authority, and made very excellent institutions under the control of the health authority of the district. I am sure my hon. Friend the Member for Spen Valley (Mr. Myers) need have no feelings that there will be any distinction or difference made in these hospitals when they are taken over from the Poor Law authorities. I sincerely hope the House will give the Minister the powers he seeks to meet the great emergency of to-day. The expense incurred in transferring the institutions will be infinitesimal.

Captain ELLIOT

There are just one or two points to which I should just like to refer. The hon. Member for Spen Valley (Mr. Myers) used an admirable piece of theory in his speech but the point is that the facts will not agree with him. He said that the municipal hospital taken over by the town would dry up the contributions to the voluntary hospital There are signs of that already. Bradford has a voluntary hospital with a big deficit. Sheffield with one municipal hospital has an overdraft of £100000. It does not work out his way in practice. Then he said and he made a very powerful case that the problem was an extremely complicated one. Everybody agrees that the problem is complicated. But he did not bring forward any constructive suggestion except that of nationalisation. I submit that that is not a practical remedy at the present moment. He suggested that this was a piece of class legislation in that the wealthy people would move into the voluntary hospitals and that the poor people would be thrown on to the Poor Law institutions. But is that happening at present? There are voluntary hospitals through financial contingencies which have to take in paying patients. Take the London Hospital which is at present working on the system of admitting paying patients. In a statement given by Lord Knutsford he expects the expenditure for 1921 to be £300000 although he only expects to derive in revenue from paying patients £20000. It is clear in this respect that the hon. Member's fears are illusory. The voluntary hospitals will continue to preserve their great tradition of catering-alike for the rich and for the poor for the necessitous and needy cases and will not rely to any great extent on the payments which it is getting from the people who are able to contribute. Then the hon. Member touched on an extraordinary theory which is often found on the Labour Benches when anybody introduces the Income Tax. I assure him that is foolish. It is an argument against taking this Bill at half-past four in the morning and the only reason it is not a conclusive argument against it is because the same argument was used upstairs in the middle of the day.

Mr. MYERS

The hon. Member misunderstood what I said. I said that the contribution from the State towards the upkeep of the hospitals was too far away for the people to see.

Captain ELLIOT

He says if the money is paid from the Exchequer instead of from the municipality people would not notice the expenditure. I think he underestimates the closeness with which expenditure is watched and likely to be watched in the near future.

Mr. W. R. SMITH

Good old "Dailv Mail."

Captain ELLIOT

It matters very little whether the money is taken from the man's right breeches pocket or the left. Then the hon. Member stated that his remedy was to nationalise the whole thing to put it under State administration and as far as one can see to do away entirely with voluntary contributions which have for so long maintained such a great and efficient service in the country. That is an academic point to be debated. It is not one we can debate at this time and on this Bill. It is not practical politics. We are dealing with an immediate practical problem—the abolition of the waiting lists. That is what the problem comes down to. If this great problem is to be postponed until we have fought on the Floor of this House the whole question of nationalisation of the medical services of this country we shall not get those waiting lists clear this year next year or the year after. I admit that this is not an ideal way of dealing with it. I admit that the boards of guardians have probably a very real and genuine grievance but I would appeal to them to make sacrifices on account of the desperate pressure which there is on hospital accommodation in the country. The hon. Member for Stafford stated that in the one particular institution which he gave there were 80 vacant beds when the census was taken and only 11 beds now. I have the waiting list of a London hospital within a stone's throw from these doors. It has got 388 beds and a waiting list of 701. It is not a question of having II beds vacant. These institutions are crowded to the doors just now. In one case of a hospital with 600 beds it has 100 extra beds planted up and down in the wards. It is on account of that I appeal to the boards of guardians to make their great institutions valuable for the hospital cases of all classes of the community.

The problem is only just beginning when you have actually taken over the hospitals by the county councils A new set of problems will then arise. I assure the House that the problem of hospital administration will be very large and very complicated and that there will be a very complicated system of problems as to what share the medical profession is to take in the administration of these hospitals when taken over because they will largely need to be controlled by the county councils and that control will need to be exercised by some committee of which the medical men staffing the hospitals and doing work at the hospitals will need to have pretty large representation. There is only one point I should like to make. [HON. MEMBERS: "Hear hear!"] It is all very well for hon. Members to cheer. If they want trouble they can get it. It would not be very difficult to make a speech on this subject which would last for one and three quarter hours, and I am quite ready to do it. Half-past four o'clock in the morning is a late hour, but half-past five is a later hour, and a quarter to six is later still, and if we have to discuss all the problems connected with this question I am quite willing to go on definitely. I do not wish to detain the House, but these health problems are always brought forward at night. Take the Insurance Act; that was debated at two o'clock in the morning, and we never get a decent Debate on health because of the habit of the Ministers on the Treasury Bench of discussing all sorts of problems which they consider to be of great importance but which are really nothing compared with the great matters touching the life of the people, such as the health administration of the country. I am not disposed to apologise for encroaching, at what might be considered excessive length on this subject. I do not consider it possible to Debate the health problem of the country at half-past four in the morning. The only point I want to make is that it shows the difficulty into which we have fallen by this splitting-up of this health administration into Scotland and England. I understand that I should not be in order in discussing hospital administration in Scotland on this Bill, and yet the whole thing will really depend on the decision arrived at on this Bill I should like Scottish Home Rulers to consider the problems raised by this policy of nationalism which is becoming such a part of our latest legislation. This separate health administration for Scotland has been broken down, the first time it has been put into practice. I do not wish to detain the House any longer.

Mr. D. HERBERT

The Minister of Health waxed very eloquent, not to say warm and loud, over his professions as to the need for making use of these empty beds because of the pledges given at the last election. I feel sure that even the right hon. Gentleman himself will agree that we are in favour of doing our best. I consider this Clause to be incapable of amendment in any way sufficient to carry out the object which is required. The Minister of Health spoke of putting the clock back if we left these hospitals to be managed by the present authorities, the Poor Law guardians, in certain Pool Law unions. The point is, however, that the right hon. Gentleman, when he decided that the great voluntary hospitals were to be dealt with by a Committee, proceeded to deal with these Poor Law infirmaries alone and to deal with, them before the other questions were dealt with by transferring them to the county councils. He is not, perhaps, putting the clock back but he is smashing up the works of the clock and is making arrangements the results of which will not be final, but which will involve a great change, considerable expense, trouble and time, and even more legislation in this House before they are finally completed. May I point out to the right hon. Gentleman that we have a very serious objection to Sub-section 2 of this Clause,1 which is not removed by the right hon. Gentleman's answers that the compulsory taking over of those infirmaries cannot be done without the consent of Parliament. It is all very well to say that. If the Minister has power to do that by coming to Parliament in this way he can effect what he wants by the mere threat of coming. The whole question of the hospitals should be dealt with as a whole, and the great voluntary hospitals are not included in this Bill. Surely the right hon. Gentleman had better do the best he can by making available for persons who need them those empty beds of which he has spoken, rather than to create this great machinery to be worked by the county councils. By doing so he would not get rid of the different character of voluntary hospitals and of the hospitals on the rates. Undoubtedly there is still that great objection to the Poor Law infirmary and I believe that that objection will be only a little less when supported by the rates and run by the county councils.

Question put "That the words pro posed to be left out to the word 'and' ['within their area and'] stand part of the Bill."

The House divided: Ayes 70; Noes 28.

Captain Sir ROWLAND BLADES

I beg to move in Sub-section (1, a) after the word "area" ["within their area"] to insert the words provided that the treatment of the sick poor within that area shall not be prejudiced either through their having to be removed from their own area or from any other cause. In addressing the House for the first time at this early hour of the morning I hope Mr. Deputy-Speaker I shall receive your assistance. There is no doubt very grave unrest among the guardians of this country especially in the rural areas and it is for that reason that I move this Amendment. The hon. Member for Stafford has so fully stated the case that I do not propose to add anything except to acknowledge the work which the guardians are doing. In my own Division we have the Epsom Board of Guardians who are doing excellent and devoted service and this practically applies throughout the country. I hope the Minister will look upon my Amendment with sympathy.

Mr. ORMSBY-GORE

I beg to second the Amendment.

Dr. ADDISON

I am sorry I have not had an opportunity of reading the words which my hon. Friend has moved until this minute and I could not without further consideration say that I could accept the Amendment. I would have liked to have done so after my hon. Friend's maiden speech and I do not see that there is any particular objection to the Amendment on the face of it. I do not however like to accept an Amendment like this which I have only now read. As far as I am concerned I do not quarrel with the principle and if I can devise words to meet it without doing damage to the machinery of the Clause I will try to get them inserted in another place. It seems to me there is no reason why I should object to the Amendment on principle but I would like to consider it a little further.

Sir R. BLADES

I beg leave to withdraw the Amendment.

Amendment by leave withdrawn.

Mr. T. THOMSON

I beg to move in Sub-section (1, a) after the word "diseases" ["illnesses or diseases"] to insert the words "including the care and treatment of persons suffering from mental disorder which is incipient in character and of recent origin."

This is to make it quite clear what the Minister meant for we may not always have him. He said that one of the purposes of Clause 8 was to enable these cases of mental disorder being treated in some of these Poor Law hospitals taken over under this Clause. I want to put it on record that the words of the Clause include this particular form of incipient mental disorder.

Amendment not seconded.

Mr. ORMSBY-GORE

I beg to move in Sub-section (1, a) to leave out the word "and" ["illnesses or diseases; and"] and to insert instead thereof the words or to make such other arrangements with Poor Law authority as may having regard to any existing deficiency of hospital accommodation in the area of the council appear desirable for the duo reception maintenance and treatment of sick persons in any hospital or infirmary belonging to that authority within or without the area of the council. I made the point pretty clear in my original speech on the Clause. I originally submitted these words as an alternative to the Government proposals. Now I want them as an addition in order to make available the surplus beds that are available in the institutions that are not taken over. I want the House to bear in mind the speech of the hon. Member for Wavertree (Lieut.-Colonel Raw) who said there were only about fifty suitable for the county councils to take over containing only a small proportion of the beds. Under my Amendment many more could be made available. Several hundred institutions are not separate and cannot be taken over but a certain number of beds can be made immediately available for non-pauper cases. The right hon. Gentleman will say it is putting the cart before the horse because he will not deal with the Poor Law first instead of tinkering with the whole system. I gave an exactly opposite pledge from his at the election. I told my people I would do all I could to prevent doing away with the guardians. He will have to legislate on the whole question of hospitals next year certainly the year afterwards. If he is going to fulfil his election pledges he will have to legislate for the Poor Law. This is merely tinkering. What is the objection to my proposal? It is merely an interim proposal pending legislation rather than to render available for sick persons a certain number of beds that would otherwise be surplus.

Mr. D. HERBERT

I beg to second the Amendment. We can appeal with some confidence to the right hon. Gentleman on this especially after the way in which he urged upon us the scandal it was at the present time to leave these beds empty and that is what he is likely to do if he merely confines his operations to taking over some of these infirmaries as a whole and not using the machinery to take the beds of the smaller ones.

Colonel WILSON

The acceptance of this Amendment would be a complete reversal of the policy of the Government on this Clause. It is therefore quite impossible to accept it. It would in substance make the Poor Law authority the hospital authority. As my right hon. Friend the Minister of Health argued the question a short time ago and convinced the House how unfeasible it was I do not propose to argue it again.

Amendment negatived.

Mr. ORMSBY-GORE

I beg to move to leave out Sub-section (2).

5.0 A.M.

I do not intend to trouble the House with a Division unless I get considerable support. I think it is a most 5.0 A.M. iniquitous proposal and if the right hon. Gentleman likes to keep it in the Bill he knows he has the ill-will of all the members of the boards of guardians.

Dr. ADDISON

This particular Amendment is clearly unnecessary. We must have some power.

Amendment negatived.

Mr. LORDEN

I beg to move at the end of Sub-section (2) to insert the words Provided that when there is in any hospital or infirmary belonging to a Poor Law authority accommodation in excess of that for the time being required for the sick poor in the area of such authority and not required by the county council for the purposes of this Section it shall be lawful for such authority to utilise such excess accommodation for the reception and treatment of persons other than the sick poor. This seems such a reasonable proposal that I cannot think that the right hon. Gentleman can possibly have any objection to it. It is simply to provide that when there is any; hospital or infirmary belonging to a Poor Law authority with accommodation in excess of that for the time being required for the sick poor in the area of such authority it shall be lawful for such authority to utilise such excess accommodation. It gives a widening aspect for dealing with these institutions. It is a very small matter but it is a very important matter if the right hon. Gentleman is serious when he says that every bed should be utilised. This will give that opportunity.

Major HAMILTON

I beg to second the Amendment.

Colonel WILSON

I must confess that I felt the difference between this Amendment and the Amendment moved by my hon. and gallant Friend the Member for Stafford.

Mr. D. HERBERT

That comes from going on so late.

Colonel WILSON

It would create a hospital authority in the same area and we have discussed this question on the main question with regard to leaving out this Clause. I cannot add anything more to what has already been said by my right hon. Friend and myself. This would go at the very root of the Clause and for that reason it is impossible to accept it.

Mr. ORMSBY-GORE

This is not going to avoid having two hospital areas under this Bill. Take Manchester. Under this Clause the infirmary and two other small institutions will remain under the Poor Law authority. The right hon. Gentleman is only going to take about 50 or 54. The whole of the rest of the 500 hospitals are going to remain under the Poor Law. It the hon. Gentleman really thinks that he is going to affect finality and unity by the Clause as it stands he has utterly misunderstood the situation that is going to arise if the Clause ever becomes operative. There is a substantial point of difference between the Amendment moved by the hon. Member for St. Pancras (Mr. Lorden) and that moved by myself and if he goes to a Division I shall certainly support him. It is really scandalous that you should be asked to consider great changes in our Poor Law system at 5 o'clock in the morning. This is the only chance we have had of discussing on the floor of this House details of far-reaching effect. This is the way we are legislating about the Poor Law. This is the way we are dealing with the hospital question. The Government thinks that matters of public health are something that can be considered in an Autumn Session in the middle of the night. That is the only interest this Government has in the matter of public health.

Amendment negatived.

Amendment made: In Sub-section (4) leave out the words "with the approval of" ["with the approval of the Minister"] and insert instead thereof the words "subject to such terms and conditions as may be approved by."—[Dr. Addison.]

Mr. MYERS

I beg to move to leave out Sub-section (5).

This is the most pernicious provision in the Clause. Section 132 of the Public Health Act 1875 says: Any expenses incurred by a local authority in maintaining in a hospital or in a temporary place for the reception of the sick ('whether or not belonging to such authority') a patient who is not a pauper shall be deemed to be a debt due from such patient to the local authority and may be recovered from him within six months after his discharge from such hospital or place of reception or from his estate in the event of his dying in such hospital or place. Having regard to the fact that we treat venereal disease tuberculosis infectious diseases of every kind and sort without question simply because these diseases are a danger to the community if a person gets into one of these hospitals physically incapacitated you are going to send him a bill for expenses. If he happens to die in the institution you are going to make a charge upon his estate. If the hon. Gentleman really thinks that ness in the case of a large section of our population at present is very largely the result of the locality in which they are compelled to live or the particular industrial system under which they are compelled to work. They are features of circumstances both social and industrial and to add to that a penalty a charge for incapacity which these conditions impose upon them is retrograde and not progressive.

Mr. W. R. SMITH

I beg to second the Amendment. I quite agree with my hon. Friend that the step proposed here is a very retrograde one in establishing the conditions attaching to the Act of 1875. I do not think that there is anybody who has been a member of a board of guardians but will agree that one of the worst features of that administration has been in the investigations to which people have been subjected. Where people are able to pay for any treatment they may receive why should they not contribute? After all how is the local authority going to say whether or not it is able to recover any other cost incurred? You cannot take proceedings against anybody unless there is some investigation beforehand as to their means and that would mean a close investigation into the means of different people in order to determine whether their financial position is such as to permit that being done. What principle is to be the guide in the differentiation between particular kinds of disease for which a person may require treatment? A workman in one particular industry may develop tuberculosis. For that disease he can have free treatment. Another person working in another industry may develop a disease requiring hospital treatment for which he is not prepared to pay. Where is the equality? I cannot see in view of the length we have gone in this Clause dealing with public health by which we are now seeking to establish facilities for medical treatment why we should adopt this old system which must re-establish one of the worst features of Poor Law administration the system of investigating the financial position of the persons concerned and of penalising them merely because they contract one particular form of disease as against another. If we are going to protect the public health and if we are going to ensure proper treatment let us make it easy for the people to have the treatment necessary for the purpose.

Dr. ADDISON

The Mover and Seconder of this Amendment have made a great deal out of it which is not in it at all. Unless a provision of this kind be inserted in the Bill it would mean in the event of the county councils taking over Poor Law infirmaries and using them as medical hospitals that no charge at all could be made for anybody who came in. That would be very wrong especially as my hon. Friends are anxious to avoid setting up what is called a "double-barrelled system." It would be very foolish to prohibit a county council from making charges. The investigation to which allusion has been made will not take place to any material extent but we must give the power otherwise they will not be able to make any charge.

Mr. HAYDAY

I desire to support the Amendment and I do not think that the Minister has cleared the matter up satisfactorily because in the Act referred to it is stated that in the case of any patient other than a pauper is considered a debt.

Dr. ADDISON

There is no obligation on anybody.

Mr. HAYDAY

Section 132 of the Public Health Act 1875 is as follows: Any expenses incurred by a local authority in maintaining in a hospital or in a temporary place for the reception of the sick (whether or not belonging to such an authority) a patient who is not a pauper shall be deemed to be a debt due from such patient to the local authority and may be recovered from him at any time within six months after his discharge from such hospital or place of reception or from his estate in the event of his dying in such hospital or place. The Section leaves it open for the authority to consider whether anyone not a pauper if there is a debt at any time within a period of six months shall be charged with that debt. I imagine the proceedings might be taken. One might ask the right hon. Gentleman if he would give us a further definition of the term "sick" because my mind is a little bit troubled. Sometimes a man is stated to be sick from a disease which may come under the Workmen's Compensation Act. That man cannot be deemed to be a pauper. Is it to be expected that a charge is to be made so that it should be counted as a debt against that patient I Certainly he has by means of his compensation got a certain income but that income is far short of his ordinary weekly wage and may be insufficient to maintain any family for which he is responsible. In the event of a patient being in such a bad state when taken there that he eventually dies there is it intended that that part of his estate as represented by the Workmen's Compensation Act should be in any way used to pay the debt so incurred by the fact of his having been a patient?

Question put "That the words proposed to be left out stand part of the Bill."

The House divided: Ayes 76; Noes 18.

Division No. 396.] AYES. [5.20 a.m.
Addison Rt. Hon. Dr. C. Ganzoni Captain Francis John C. Newman Sir R H. S. D. L. (Exeter)
Allen Lieut.-Colonel William James Gibbs Colonel George Abraham Ormsby-Gore Captain Hon. W.
Amery Lieut.-Col. Leopold C. M. S. Goff Sir R. Park Parker James
Archer-Shee Lieut.-Colonel Martin Green Joseph F. (Leicester W.) Pease Rt. Hon. Herbert Pike
Baird Sir John Lawrence Greenwood William (Stockport) Pollock Sir Ernest M.
Baldwin Rt. Hon. Stanley Hailwood Augustine Raw Lieutenant-Colonel N.
Balfour George (Hampstead) Hamilton Major C. G. C. Remer J. R.
Blades Capt. Sir George Rowland Harmsworth C. B. (Bedford Luton) Robinson Sir T. (Lanes. Stretford)
Boscawen Rt. Hon. Sir A. Griffith- Herbert Dennis (Hertford Watford) Roundell Colonel R. F.
Broad Thomas Tucker Hilder Lieut.-Colonel Frank Sanders Colonel Sir Robert A.
Bruton Sir James Hope James F. (Sheffield Central) Scott A. M. (Glasgow Bridgeton)
Carr W. Theodore Hopkins John W. W. Seddon J. A.
Casey T. W. Hotchkin Captain Stafford Vere Shaw Hon. Alex. (Kilmarnock)
Chilcot Lieut.-Com. Harry W. Jones Sir Edgar R. (Merthyr Tydvil) Shaw William T. (Forfar)
Coats Sir Stuart Kellaway Rt. Hon. Fredk. George Stanley Major Hon. G. (Preston)
Coote Colin Reith (Isle of Ely) Kidd James Sugden W. H.
Courthope Major George L. Law Rt. Hon. A. B. (Glasgow C.) Sutherland Sir William
Craig Colonel Sir J. (Down Mid) Lindsay William Arthur Ward-Jackson Major C. L.
Davidson, J.C.C.(Hemel Hempstead) Lorden John William Whitla Sir William
Davies Thomas (Cirencester) Lort-Williams J. Wilson Daniel M. (Down West)
Edge Captain William Lynn R. J. Wilson Colonel Leslie O. (Reading)
Elliot Capt. Walter E. (Lanark) M'Lean Lieut.-Col. Charles W. W. ' Wise Frederick
Eyres-Monsell Commander B. M. Mitchell William Lane Wood Sir H. K. (Woolwich West)
Fildes Henry Moore-Brabazon Lieut.-Col. J. T. C.
Forrest Walter Morrison-Bell Major A. C. TELLERS FOR THE AYES.—
Fraser Major Sir Keith Murray C. D. (Edinburgh) Lord E. Talbot and Mr. Dudley ward.
Fremantle Lieut. -Colonel Francis E. Neal Arthur
NOES.
Adamson Rt. Hon. William Maclean Neil (Glasgow Govan) Smith W. R. (Wellingborough)
Bell James (Lancaster Ormskirk) Mills John Edmund Thomson T. (Middlesbrough West)
Davies A. (Lancaster Clitheroe) Morgan Major D. Watts Waterson A. E.
Edwards C. (Monmouth Bedwellty) Myers Thomas
Grundy T. W. Royce William Stapleton TELLERS FOR THE NOES.—
Hayday Arthur Sexton James Mr. Tyson Wilson and Mr. Frederick Hall.
Hirst G. H. Shaw Thomas (Preston)
Holmes J. Stanley Sitch Charles H.
Mr. MYERS

I beg to move in Subsection (8) to leave out the word "may" ["the Minister may order"] and to insert instead thereof the word "shall."

This deals with compensation to Poor Law hospital officials. The Clause is permissive and I think it should be made obligatory.

Mr. MILLS

I beg to second the Amendment.

Dr. ADDISON

My hon. Friend does not achieve anything by this Amendment. The specific wording of this Clause has been agreed by the Poor Law Officers' Association and there is no reason to suppose that I or any future Minister will not carry out the intention of Parliament in this Clause. It is very difficult to say "shall" because in some cases people would not be entitled to compensation and I should have to do something which I was not called upon to do by the intention of the Clause.

Mr. W. R. SMITH

I would like to put a point of some importance. If a Poor Law hospital is taken over by a county council or a borough council it may be that certain members of the staff may not be required. A number of these officers have paid into the superannuation fund and if they were taken over it might be that the county council had no superannuation scheme and the interest that these officers have established so far as their former services are concerned would be placed in jeopardy unless they have a guarantee that they would be compensated. Does the Minister say that this Clause would cover cases of that description?

Dr. ADDISON

Certainly that covers that very class of case.

Mr. MYERS

This Amendment is put forward in response to the representation of a large Poor Law authority in Yorkshire. I beg leave to withdraw the Amendment.

Amendment by leave withdrawn.

Mr. CHARLES EDWARDS

I beg to move at the end of Sub-section (9) to insert the words and the expression 'illness' includes any case of accident or other cases requiring surgical treatment and any case of confinement in respect of childbirth. The object of this Amendment is to give the widest possible interpretation to the word "illness." There is no provision made for childbirth under the Insurance Act and if a woman is in hospital for this purpose they can recover the expenses incurred from that woman at least the expenditure of the doctor's fee and we believe that when these institutions are kept by public funds the treatment should be free to everyone whatever the disease they suffer from may be.

Mr. W. R. SMITH

I beg to second the Amendment.

Colonel WILSON

It is the intention of the Government to give the widest possible interpretation to the word "illness." It is not desirable to catalogue all the various diseases and illnesses but it is best to try and confine it to as few words as possible. There is a point of some substance in this. If I may take the case of childbirth I am advised that the case of confinement is covered by the Clause as it stands but it is a doubtful point. I could not possibly put the Amendment in where the hon. Member has proposed it but if he is satisfied with this undertaking I hope he will withdraw it. The undertaking is that if I am not quite satisfied that it is unnecessary to insert this and that the Bill does not cover all the illnesses specified I will cause to be inserted after the word "generally" the words "including cases of confinement in respect of childbirth." With regard to the question of accident I think my hon. Friend may rest assured that the word illness covers accidents.

Mr. C. EDWARDS

I beg leave to withdraw the Amendment.

Amendment by leave withdrawn.