SUPPLY. (Hansard, 15 July 1920)

§ Mr. MYERS

Most hon. Members who had the opportunity and privilege of listening to the statement of the Minister of Health this afternoon recognise the 2734 tremendous responsibility of his office and the great volume of work that has been attempted. Not only was the statement important from the point of view of the work that had been done, but of the new features of public health administration which are proposed to be initiated. Every hon. Member who has made himself familiar with the Report of the Medical Officer of the Board of Education with regard to the physical defects of our school children will be satisfied that a further and very extensive development of public health administration is necessary. On the other hand we have the Reports of the Medical Boards who investigated the physical condition of the men who offered themselves for service for the Army, and the results of those investigations were lamentable. We should like to see more substantial progress made in housing schemes. We on this side are of opinion that many things have been neglected that might have been attempted. We do not accept all that has been said as to the lack of workers. We have said many times that the Government should have taken hold of the building materials available and rationed them in the interests of the community in those areas where they were required.

The general body of opinion on this side is not quite in sympathy with the financial processes that have been carried out. I would not like to say a single word to prevent anyone subscribing to Housing Bonds, but if the War had continued for another six months or a year the Prime Minister suggested the other day that the money would have been found. It is just as necessary, indeed, more necessary, that money should be found by the State for the erection of houses for the 2735 people as to find money if the War had been continued for 12 months longer. Criticism has been hard this afternoon in respect of the use of skilled labour in various directions. We say that it can be proved beyond question that buildings other than houses have been permitted to be erected to a far greater extent than ought to have been allowed in this crisis. I presented to the Minister of Health recently a set of figures prepared by a surveyor of a provincial town. In one month the town council passed plans for buildings other than houses equal to one housing scheme of 114 houses, and the same council in the following month passed plans for buildings other than houses to an equal extent. That ought not to be permitted. Travelling about the country, we can see evidences of substantial building—anything but houses—and labour and material. Drastic steps ought to be taken in those directions. Something has been said with regard to pensions. As a member of an Old Age Pensions Committee, I urge that one thing that ought to be necessary, and that only, ought to be the production of the birth certificate of any person who is entitled to pension. It would do away with a lot of irritation and make for economy. Even if a few people over 70 with an income which did not justify them in doing so did claim the pension, I am satisfied that the economies effected would more than counterbalance the amount of such claims.

I want to deal with some of the greater questions of public health administration, and, first, to make reference to the maternity and infant welfare service. I know from my own personal knowledge and experience the tremendous work that has been done in this direction, but there is room for a great deal more. I find, according to the Report of the Ministry of Health, that it is estimated that something like 2,000 professional health visitors are required in the country, and that on 1st July, 1918, there were only 762 full-time officers in the employ of the local authorities. There are quite a number of others who combine the position with that of visitor to tuberculosis cases and that of sanitary inspector, a totally undesirable proceeding, but if we include every person who does any health visiting at all, either whole or part-time, there is still some 700 short of the 2,000 2736 required in the country. I would ask the Ministry of Health to call upon the local authorities to make up the deficiency. Let every health visitor be a fully qualified midwife and trained nurse, able to speak with some authority on questions of public health and from their association with prospective mothers, and I am satisfied that the great work that has been done in the past will be improved and extended in the future. I am asked by one of my colleagues to make reference to one particular point. Under the Regulations for maternity and infant welfare, if a health visitor or a midwife visits a case and, in her judgment, it becomes a difficult case, she is entitled to call in a doctor. The general practice is that, when a doctor is called in by the official of the local authority, he sends in his bill to the local authority, and in those cases which have come under my experience the local authority has readily paid, but I am told that in some parts of the country, not only do the local authorities refuse to pay, but they call upon the person who has had the service to pay, and they have actually gone to the length of appointing an official to go round and collect weekly payments from these people until the responsibility has been discharged. If that be so, I hope that the regulations will be insisted upon, and that this system will be discouraged. If we are going to preserve infant life we want an efficient midwifery service in the country. According to the report of the Ministry of Health, in 1909 50 per cent. of confinements were attended by midwives and in 1916 70 per cent. While the number of confinements attended by midwives has been increasing, the number of midwives available has been decreasing. Since it has been insisted that midwives should have the certificate of the Central Midwives Board and that those who do not hold that certificate should not practise, the number of midwives available has decreased considerably.

If there is one need in the public health side to-day, it is to develop practice in this direction, even if local authorities have to be subsidised. I am quite familiar with what has been done, and I wish the work well and hope that it will be extended to the fullest possible point until we are satisfied that the supply of midwives in the country is up to the demand. In infantile mortality 2737 by far the greater proportion of infants die in the first week of life, and in many instances that is due to inefficient midwifery service. Another calamity is the loss of a mother of child-bearing age. It is a great domestic tragedy and a serious loss to the State, and often results from inefficient midwifery service. The housing problem creeps into all these questions. There is the fact that a third of the population of Great Britain live in houses of three rooms or under, which means one living and one sleeping room, and confinements under such conditions are a very serious matter. It is very desirable to have maternity homes extended. The necessity of our time is not so much to look after the children in later years as to give the child a decent start and let it have an opportunity of being well born. There are two sides to the question of tuberculosis. The child contracts it through food and the adult from another person, and we have, therefore, to tackle the question of food and infection. The first essential is pure milk, and we are told a Bill for that purpose is shortly to be introduced, and it never was more necessary. For two years on a local authority I advocated veterinary inspection of milch cows. It was strongly contested on the grounds of economy, and ultimately it was decided upon, and the corporation will not go back on that decision. Every animal in the borough is examined twice and sometimes oftener in the year, and the result is that the standard of cattle in our neighbourhood is of the highest possible type. Quite a number of places in the country have adopted the same principle, and I would suggest that it should be made compulsory on local authorities to do so. A distinguished medical Member of this House, who is an authority on this question, informs me that three per cent. of the milk-yielding animals of this country throw off tuberculous milk, and if the milk of one tuberculous animal is mixed with the milk of 25 other animals it will contaminate the whole supply. Here we have children suffering from tuberculosis and milkmen going round selling tuberculosis at from 8d. to 10d. a quart. Every tenth sample taken by local authorities for testing purposes has tuberculosis in its composition. A few years ago when we wanted cream the milk had to be left standing overnight and the cream was drawn off and the 2738 milk that was left was sold as old milk and given to animals. To-day, with the introduction of mechanical separators, within a quarter of an hour of the milk coming from the animal the cream is all taken away and the milk is sold as new milk, with not an ounce of fat in it and very slightly removed from water in its nutritive properties. These facts are all evidence that a very drastic milk Bill is required to be introduced in this House. The question of infection with tuberculosis is bound up with that of housing. The other day I suggested that one of our great defects in the treatment of tuberculosis was the lack of early diagnosis, and that medical men failed completely to diagnose it sufficiently early. The London County Council has received a report on tuberculosis and a resumé of that report appeared in the "Times" of yesterday. In one of the metropolitan boroughs there were 205 deaths from tuberculosis in a given period. Sixty-four of those cases were notified when death took place and 39 were notified within a month—which shows the want of early diagnosis. Institutional treatment has not had a chance. We were getting along nicely with it up to the outbreak of the War, and in addition to the civilian population, it had put upon it from 30,000 to 50,000 soldiers suffering from the same disease. The result has been that neither civilians nor discharged soldiers have had an opportunity of remaining in these institutions the length of time they should have done to give them any possible chance of improvement. On these grounds we ought not to condemn institutional treatment.

I want to see dental clinics increased. Medical testimony is unanimous to the effect that tremendous advantages can be secured by the extension of these institutions. There is room for the extension of these institutions. We also require greater facilities for minor operations. Such operations on school children, for adenoids and the like, are arranged with difficulty. Parents cannot afford to pay, and the voluntary hospitals, which are overcrowded, do not care always to take them in. This problem of the hospitals calls for attention. We are told that one-half of the hospital beds in the country are in Poor Law institutions. Obviously there are only two alternatives for those who 2739 desire treatment. They have either to go into the Poor Law institution and accept Poor Law relief or go to a voluntary hospital and accept charity. Meanwhile, the hospitals are appealing for funds in order to keep going. I want to see the hospitals now under the Poor Law authorities brought under the range of the public authorities, and after that the voluntary hospitals will "come to" and the co-ordination of all these agencies for the benefit of the community will result. The problem of finance is very serious. Local rates have gone up from £70,000,000 to £100,000,000. There are economists in local authorities as well as here. They will economise on anything except their dinners. They will not support a public health service unless the State backs them up in the demands they make. What we have to attend to is the claim that our greatest national asset, the health and physical efficiency of our people, is restored and sustained at the highest possible level.

§ Lieut.-Colonel FREMANTLE

In the few minutes left, I would be glad to back up the congratulations to the Minister of Health for the extraordinarily satisfactory statement he has given us as to the way in which his Department, in the first year after its creation, has tackled the innumerable problems it has had to face. We have heard with very great sympathy the remarks of the hon. Member for Spen Valley (Mr. Myers), who shows a great acquaintance with these subjects, and we are glad to feel that in political life there is no distinction between parties in the sincere desire to do what is best for the community in the prevention, as well as the cure of disease. I would like to focus my attention on one point—the organisation of the public health service in London. As long ago as September, 1917, a very notable report was produced by a Committee, under the chairmanship of the right hon. Member for Peebles, which inquired into the future of the poor law service of the country. The Committee reported on 19th December, 1917. Acting on that, the London County Council appointed in 1918 a committee to inquire into the way in which it should be applied to London. The difficulty with the co-ordination of these services is more acute in London than in any 2740 other part of the world. Therefore, I think it should be recognised that the London County Council have done a great service to the State in taking up this matter and bringing the thing to a head in a concrete report, which was presented to the right hon. Gentleman by a deputation which he received in April of this year. In this report it was shown that by the Ministry of Health Act of 1919 one of the duties laid upon the Ministry was to provide means for effecting a rearrangement of health functions of the Government Departments: It shall be the duty of the Minister to take all such steps as may be desirable to secure the preparation, effective carrying out, and co-ordination of measures conducive to the health of the people. This Poor Law service is of the utmost value, because people do not recognise that it is the earliest attempt for the provision of a preventive as well as a curative service for the whole country. It is about 80 years old, and the time has gone by now when it can any longer be taken as the basis, because successive Governments, having no policy whatever on this subject, have introduced one Act after another improvising administrations, and authorities, and officials of one kind or another, regardless of the original basis for which the Poor Law was laid down. It was shown that, as regards different health services, they are divided up as follows: First of all, in general terms, there are the environmental and other Public Health services of a local character. Environmental services deal with what is commonly known as sanitation, and these are matters more particularly affecting the locality, and which should be charged to the locality and carried out by a locality. The second service is in respect of infectious diseases. These are, to a large extent, local, more public than individual, but individual as well. The Poor Law medical services combine both prevention and cure, and as far as they are individual they are more essentially individual only on those who can afford to pay. The school medical services are again introduced as part of our educational system, which cares now for the body as well as for the mind, and therefore they are rightly a definite charge on the public authority. Then there are the Health Insurance Acts, which are definitely intended to be a self-supporting service 2741 of cure and incidentally of prevention. Finally, you have maternity and child welfare Acts, which introduce other services more especially in the interests of the community; and last of all you come to the voluntary health agencies, of a very large number, which do most important work—not only the voluntary hospitals, which are the most important, but also the Red Cross Societies, the Order of St. John, the nursing associations, of growing importance, and the different councils for special diseases. The overlapping is shown to be enormous, overlapping of finance and of responsibility for the health services, duplication of inspection, divergence of policy between the different bodies carrying these things out, competition for accommodation in the different institutions under the different authorities; and it is shown that these must be tackled.

The financial policy brought forward by the county council is as follows:—In the first place, that the functions of the London Poor Law authorities should be divided between the county council on the one hand, and the City Corporation and the Metropolitan boroughs on the other; that the administration in London of such additional health services as may be required in future shall be divided between these councils by a definite scheme; that the county council shall be definitely the central organising authority for organising schemes and for surveying health services from time to time; that they shall produce a definite scheme after consultation with these other bodies who are working the health services, the county council to have power to appoint a health committee with power to co-opt those to help it; that the cost of the public health services, in so far as they are environmental or local, shall be borne by local funds; that the cost of the prevention and spread of infectious diseases should be borne up to one-half by national funds, and the rest by local funds, but private fees may be charged to those who can afford to pay. As regards the medical treatment of school children, the charge should be continued to be met by the authorities responsible for the provision of such treatment. As regards medical treatment provided by public authorities, individuals should be obliged to pay to the extent of their ability to pay. Lastly, a central council—