§ Order for Second Reading read.
§ The MINISTER of HEALTH (Dr. Addison)
I beg to move "That the Bill be now read a Second time."
It is rather a late hour to move the Second Reading of this Bill, but in the
§ circumstances which I will explain I am sure this departure from our usual practice will be overlooked. It is proposed by the Bill to bring into operation certain increased benefits on the 5th July next, but certain parts of the Bill relating to the remuneration of medical men and increased allowances to approved societies to cover their administrative expenses date back necessarily to the 1st January of this year. In order to comply with the conditions precedent to the alteration, and to provide new cards, new stamps and other processes required in the administration of the Department so that the amended Act may come into 193 operation at the date suggested, three months of active work is necessary. Furthermore, unless we can secure that the amending Bill will some into operation on the required date the finances necessary for providing the funds, particularly for increasing the societies administrative expenses from the 1st January will not be forthcoming. It is for that reason necessary to secure, if we can, the Second Reading and the necessary Financial Resolution for this Bill before the House rises for the recess. Members will be familiar with the programme of Parliamentary business from now to the Adjournment; and in consequence of the circumstances, we are asking the House to take the unusual course of taking this Bill at a late hour.
§ The main provisions of the Bill arise out of the altered financial situation. It is proposed, as set out in the White Paper which has been circulated, to increase the benefits in the case of men from 10s. to 15s. a week for sickness benefit and from 5s. to 7s, 6d. for disablement, and for women it is proposed to increase sickness benefit from 7s. 6d. to 12s. and disablement benefit on the same lines as for men. These increased benefits necessitate increased contributions, apart from the increased Treasury contribution, of 3d. per insured person. It is proposed to secure 2d. from the employer and Id. from the insured person. The result of the adjustment of the contributions is that, in the case of the male contributor, the employer will contribute 5d. and the insured person 5d. In the case of women, the employer will contribute 5d. and the woman 4d. This applies to all cases save those exceptional instances where the age of the insured person is below a specified figure. The figures are set out in the Schedule to the Bill.
§ Another important change relates to maternity benefit, which it is proposed to increase from 30s. to 40s. Another important change is the proposal to take sanatorium benefit out of the Insurance Act altogether. That, as the House will possibly rightly gather, is only the first change of a comprehensive policy which I hope, at some date, to be able to set out, under which we propose to deal with the problem of tuberculosis as a whole with respect to all sections of the population. The fund which will thereby be set free is devoted towards the increase of the 194 other benefits. Then we propose that the administrative allowances to societies shall be increased by one shilling per member. At present the contribution towards the administrative expenses of societies is 3s. 5d. per member. We are proposing that it shall be 4s. 5d. I think that every society and all members associated with the administration of this Act will recognise that that is a very necessary proposal. I wish that we could have gone even a little further. Societies have laboured under a serious disadvantage; they have had the perplexing alternative either of under-paying their staff or of losing on their administration account.
§ There is another proposal which is not apparent in the Clauses of the Bill because it is an administrative arrangement. There is a fund, as set out in the White Paper, an extra amount roughly equivalent to 2d. per insured person, which we propose to use for the employment of medical referees and consultants, which societies have hitherto had to employ for themselves. The proposal is roughly this, that cases which have been a long time on the sick benefit list, and other specified cases, at the behest of a society or of the insured person or of the medical man, can have the benefit of the consultant or referee who is provided under this scheme. Many societies have spent at least 2d. per insured person in employing referees on their own account hitherto, in order to deal with these cases. There is another change in the financial scheme of the principal Act, which is necessitated by the altered figures of contribution. In the principal Act the contribution from the Treasury towards the benefits in the case of men was two-ninths, and in the case of women it was one-quarter. It is proposed now to make the contribution towards the benefit uniform throughout the Act. That immensely simplifies the transactions under the altered scale of contributions; in the case of women we propose to adopt the same basis of Treasury contribution as in the case of the males, that is two-ninths, and to add twenty-five per cent. to the special fund which has hitherto been set aside for women societies in consequence of certain risks which the experience of those societies has shown to exist. That provision is contained in Clause 5 (3), and 195 is also dealt with in Clause 1 (3). There are also a considerable number of minor alterations which relate more to Committee points than to Second Reading. There are various benefits, for instance, to soldiers and sailors in respect of which hitherto 1½d. per week has been deducted from their pay by the Army and Navy authorities. We propose to do away with that deduction, which in future will be borne on the Service Votes as the employers' contribution. There are some minor technical Amendments which I shall be glad to explain in reply to hon. Members, and which are principally Committee points. In accordance with the altered scale of wages and diminished value of money we have, as will be seen from the Schedule, raised the figures of wages per diem which would entitle the worker to receive assistance from the State from 2s. to 2s. 6d. There are also some alterations as to medical benefit, and at the request of the societies in order to make the finance clear we have put into the Bill in Clause 7 the actual contribution from the insurance funds towards the cost of medical benefit a sum of 9s. 6d There was an item known as "the floating sixpence" which, as a matter of fact, never floated, but still, there it is, and we propose definitely to simplify the accounts: and in the same way we have arranged for a sum which in the aggregate amounts to £300,000, which will be devoted, under appropriate supervision, to assisting the locomotion of practitioners in scattered rural districts. In this connection I must refer to the medical benefit Regulations which are coming into operation now and which, I hope, will help to make good a number of deficiencies in the medical service. The medical men, with whom I have had many meetings, have recognised that in many respects, in certain places anyhow, the practice for insured persons has not been as satisfactory as it ought to be, and I hope that under the improved medical benefit Regulations, coupled with the assistance which the medical consultants must necessarily give, we shall steadily improve the quality of the service. The standard which I laid down, and which was accepted by the Central Medical Committee, was that the practitioner should give to the insured person as good, as complete and as frequent attendance as he gives 196 to an ordinary private patient. In connection with this, there were considerable negotiations. I made an offer of 11s. to cover these various costs, and ultimately, in consequence of the difference between us, this was referred to an independent board of arbitrators. I am happy to say that the arbitrators confirmed my figure, and their decision was the 11s. I had pro posed. I hope that with this short explanation hon. Members will be satisfied that the Bill is on the right lines, that it helps to remove some well-marked anomalies, and that it will secure for the insured person a rate of benefit more commensurate with the money values at present existing than is the case under the Act as it stands at present.
§ Mr. MYERS
As one who has had considerable experience in the administration of the Act for a number of years, I would like to make a few observations on this Bill. I shall not refer to the financial provisions of the Bill, because I take it they will have stood the test of actuarial investigation and will simply be based upon the extended rates necessary owing to the changing value of money. I was glad to hear the right hon. Gentleman refer to the provision that is to be made for medical referees. It has always been a very delicate matter for a private practitioner, attending persons as panel patients, to exercise his authority at the time when he might have done for fear of suffering injury in other directions, and an independent medical man over and above the particular doctor who is attending the panel patients is a very desirable thing and has been long overdue.
The right hon. Gentleman referred to the attempt to make up the deficiencies in the administration of the medical benefit. These deficiencies have been very pronounced and far-reaching, and for some time have been calling aloud for redress. I am glad that he has the assurance—and I hope that it will be carried out—that the practice will be extended to panel patients, and that it will be just as good and as satisfactory as the service given to private patients by the same medical men. The practice of the Insurance Act has a long, long way to go before in many respects it reaches that standard. Unfortunately, there has developed in the public mind, and among those who are insured persons, an idea that there are two standards of treatment, and it is a 197 matter of common knowledge that some medical men have taken one part of the day for ordinary patients and another part of the day for panel patients, and sometimes have cut off panel patients for given days in the week. It was not expected that the provisions of the Act would be carried out in that fashion, and it is hoped that this practice of giving one method of treatment to panel patients and another method to private patients will be discontinued. There are some medical men who, I believe, carry out the provisions of the Act as merely incidental to the ordinary practice in which they engage. There is still one very serious omission from the National Insurance Act in respect to the responsibilities of panel doctors. Owing to a large number of doctors leaving their practice and going to serve in the War, a tremendous number of panel patients were thrown into the surgeries of particular medical men. It is recognised that many medical men had upon their panel considerably more patients than they could do justice to. In peace time that ought to be prevented. There ought to be a limit to the number of patients any medical practitioner can take into his panel. The present distribution of patients among the doctors is altogether irregular even in industrial towns. Sometimes, it is purely a question of geographical location or the fancy of patients for a particular doctor. It is not outside the range of efficient administration to remedy in some degree that inequality in the distribution of patients, and I am hoping that the Regulations to which the Minister for Health has referred will stiffen up this matter in two directions. I hope that the Government will see to it that doctors, in the granting of certificates, keep to the Regulations and that the sharp line of distinction between panel patients and private patients is obliterated. I am also glad to note that an agreement has been effected in regard to the Sanatorium Benefit, because there is one section of the Act which still leaves the ordinary panel practitioner in charge of consumptive patients. The treatment of tuberculosis under the Act has been exceedingly unsatisfactory, and the medical men of the country are very largely responsible. They threatened to take direct action or something of that sort. When the Insurance Act was on its way, 1s. 3d. per 198 member was agreed to as being that part which should be set aside for sanatorium benefit, and the doctors came along and said "We want 6d. out of that for domiciliary treatment." Now domiciliary treatment has been an absolute failure. The doctors have got the 6d., and I know they have visited the patients at their homes, but when a patient has been so bad that he was not fit to be admitted into an institution, the Insurance Committee have allowed domiciliary treatment, which was expected to be for the initial stages of the disease rather than the back, end of the disease, and the doctor has made his weekly call and taken his 6d. until that man has died. That has been the operation very largely of domiciliary treatment. Forms and charts and all the rest of it have been provided. There is not an Insurance Committee who can tell the Minister of Health how many people they have in their area under domiciliary treatment. Owing to the fact that ever since the Insurance Act has been in operation Insurance Committees have only had 9d. per member to provide institutional treatment in the nature of dispensary and sanatorium treatment, the whole thing has been unsatisfactory from many points of view. Insurance Committees at the start could not get the institutional treatment they desired, and if available, they were not able to pay for it. As soon as a consumptive patient is notified by the private medical practitioner attending that patient, I could wish that the case could be taken absolutely out of the hands of the Insurance Committee, and put under the control of the local authority, with a little bit of that ginger which the hon. Member for the Wrekin Division (Mr. Palmer) mentioned the other night.
One of the most popular benefits of the Insurance Act is the maternity benefit, and I am disappointed at the figure put upon the maternity benefit by the right hon. Gentleman. It ought at least to have been doubled. To-day £2 is altogether inadequate, having regard to the value of money as against pre-war times, but even if that were not so, the expenses of a confinement are tremendously heavy, and £5 is quite little enough for an ordinary man's household on an occasion of that sort. With some experience of the administration of the Act, I would say that, if the actuarial arrangements will not permit of any further benefits being paid, I would curtail some of the benefits for 199 married women on the weekly pay, and counter-balance it by additional payment in cases of maternity. I believe that would not create any measure of hostility, but would be generally accepted by insured persons. In any case, I think the maternity benefit ought to be increased, if it can be done. Further, I think we ought to have provision in this Act of Parliament for insurance contributions ceasing before a person reaches 70 years of age. As a matter of fact, there are very few continued legitimately up to that point. I know of numbers of instances where people have ceased work before 70, and have gone outside the Act to maintain their contributions until 70, in order that they should secure the free medical advantages that the Act provides. Very few people, under the pressure of modern conditions, are able to follow an industrial employment until they are 70, and even if they are, they have done their share long before that, and ought to be relieved of the responsibility of paying National Health Insurance contributions. I should like to see that age limit, and also the Old Age Pension age limit, brought down. If a man or woman has worked until the age of 60, they have been a real asset to the State during that period, and in the latter days of their life the State ought to be ready to take care of them as a State liability full and complete. Even if we cannot approximate that standard, we might relieve the burden by giving them, at least, free medical attendance after the age of 60, without any further contribution.
When everything has been said that can be said in regard to this Bill, and to the Act which it seeks to improve, it is only an ameliorative measure; but I do not want to depreciate its value on that account. It is a tremendous step forward as compared with the conditions that prevailed before the inception of the Act. The title of the Act itself, however, is a misnomer. It does not insure health; it makes a payment for sickness, and it waits till sickness comes, and deals out advantages or benefits to the medical man, the chemist, and the member who is affected. There is too much of that waiting until illness comes rather than tackling the problems from the preventive aspect. I think there ought to be something in this measure which will impose upon Insurance 200 Committees and local authorities a definite line of policy in the direction of preventive work. So far as I know, it does not contain a line as to that. In the earlier Act a responsibility was put upon local authorities to do certain propaganda work against the evils of bad housing and so forth; but I know of two places where that has been done. It ought to be imposed, as one of the conditions of the Act, upon Insurance Committees and local authorities. The measure lacks vision from that point of view. It ought to have inside it a measure of sentiment which will create in the public mind a national interest in health matters, instead of merely waiting for the calamity to come, and then endeavouring to take off the sharp corners and soften the ill effects. It ought to be a direct stop in the direction of a national medical service, where every person in the community should be under custodianship of the community, in order to secure and maintain the best standard of health we can get.
I will not indulge in any criticism of the Act or of this Bill. Perhaps it is as far as public opinion at the present moment is prepared to go, but it is for us, as far as we are able, to show the way. I hope that one or two of the points I have mentioned may be noted by the Government, and that the Bill may be stiffened up, in order that we may look upon it in the future as a direct contribution towards securing that Al population of which we hear so much and towards which we do too little.
§ Lieut.-Colonel Sir A. WARREN
The purpose of this Bill is to try to remedy what has arisen as a result of present economic conditions and the depreciated value of money. Last Session, in respect of National Health Insurance, a very reasonable proposal was passed through this House, raising the income limit to £250, as against £160, because the circumstances of the employed persons of the country had so materially changed. Tonight we have to deal with National Health Insurance in a more comprehensive manner in relation to the benefits under the Act and to payments made in respect of the various services rendered. The right hon. Gentleman the Minister of Health, in his Second Reading speech, referred to certain matters that had been under negotiation, and to the results which followed. The medical profession 201 had made representations that, owing to the altered circumstances, they felt that they had a just claim to an increased payment in respect of every panel patient. This Bill provides for a payment of 9s. 6d., plus 1s. 6d.—I take it that that is to come out of public funds—giving the doctors, in the aggregate, the sum of 11s. That is a very excellent advance upon their previous payment—an advance equal to at least 57 per cent., and I am very hopeful, like the hon. Member who has just spoken, that there will be a materially improved medical service, and that those of us who have to deal with the administration of the Act up and down the country will not be constantly confronted with the reasonable complaints that are made by large bodies of persons as to the treatment which is meted out lo them. They are as much entitled to full and free benefit, and the very best medical service, as any private patient of any doctor.
Other matters were mentioned by the right hon. Gentleman, but I have been waiting expectantly to hear from him some reference to the approved societies of the country. Having had to do with this matter of National Health Insurance before it became an Act, and knowing something of the difficulties in relation to the matter, and to the passing of the Act through this House, I have got rather tired of hearing so constantly about the doctors. The doctors never have been satisfied. There have been constant complaints ever since the Act commenced working in 1912. Those of us who sit upon the Medical Service Sub-Committees for the various counties are conscious of the legitimate complaints that come in as to the treatment which many panel patients receive, and I hope that now, having got such an admirable advance, we are going to get an improved service But, as I have said, I have been waiting to hear something regarding the approved societies, and I am going to suggest to the right hon. Gentleman that, if he has anything to thank the doctors for, he has also a great deal for which to thank the approved societies. They have never indulged in direct action, and, although they have had a great deal of negotiation, both with him and with his predecessor, yet it has always been with the most loyal intention and desire to work the Act. In all the improved benefits that are mentioned in this Bill, and that have 202 been metioned in the Debate in this House to-night, there has been no reference to the economic conditions that apply in relation to the approved societies. Let me remind the House that in 1912 the proposal in respect to approved societies, for administration in relation to employed persons was 4s. per head per annum. Passing reference was made to a floating sixpence, and the right hon. Gentleman said the sixpence never floated. I beg to suggest that it floated out of the administration of the approved societies, and that another penny also floated out, giving them, in the aggregate, 3s. 5d. per person, to administer the Act in all its many phases and ramifications. In the beginning the friendly societies of the country were deprived of 15 per cent. of the original sum intended for the working of this Act. They started off with that dead weight. The result was that they had to cut, carve, and curtail. Although the approved societies have earnestly endeavoured to work the Act, yet none of their officials have ever been in any sense adequately paid. I wish the right hon. Gentleman had found it in his heart to have offered some terms to the members of these societies, and to have told the House as to their future. There is no mention in the Bill of any increased payment. If I am correctly informed, the Consultative Council have had this matter under consideration, and proposals have been made to increase the administrative allowance by 31s. per head per annum, making the 3s. 5d. into 4s. 5d., an advance of 29 per cent. The figures of one of the largest and most reliable of centralised approved societies, one operating all over the country, show the administation allowance for 1919 to be 91,523. This was an increase upon 1913 of no less than 43 per cent. Fees and salaries have increased by 58 per cent., printing and stationery by 149 per cent., rent 132 per cent., rates 142 per cent., lighting 75 per cent., other matters—carriage, etc.—25 per cent., and travelling 21 per cent., making in all 43 per cent. I would have had other figures prepared by the Manchester Unity of Oddfellows, but that I was under the impression that this Bill would not come on till after Easter. The approved societies have had a very great struggle. I know the right hon. Gentleman can reply that 203 during the years 1912–13 there were in a certain number of cases surpluses. How did these arise? Because of the anxiety of the societies not to have a deficiency they went to the other extreme, and cut and carved to such an extent that, again I say, those who have been primarily administering this Act in more than 10,000 branches of more than 2,000 approved societies have been paying their members the merest pittance, and a sum in no sense adequate to the services rendered. I am therefore very hopeful that before this matter is finally dealt with the right hon. Gentleman will look very carefully into it. We are not talking about striking or direct action or downing tools. We are asking only for that which will enable us to pay in some sense reasonably adequately those thousands of men whose economic conditions are just as much touched as those of the doctors who are affected. The same as every other class of the community in the falling value of money, and we ask that on their behalf there shall be some due recognition, that we shall have the satisfaction of knowing that in administering this great measure of national health neither the approved societies nor the Government can be charged with sweating.
§ 12 M.
§ Mr. ORMSBY-GORE
I think we ought not to proceed with the Second Reading of the Bill without a little further guidance from the Minister of Health in regard to Clause 4. I was on the Committee of the original Insurance Bill, and on the first amending Bill, and I remember what tremendous hopes were held out to the country with regard to sanatorium benefit, and now, with the exception of Ireland, sanatorium benefit is to be swept away and we are to have an entirely new and as yet nebulous scheme for dealing with tuberculosis. Any attempt to deal with this disease merely in the case of insured persons is doomed to complete failure, and above all other things it is absolutely essential that we should begin with children and persons under insurable age, and I hope before this Bill leaves the House we shall get from the Minister of Health a clear lead as to what the intentions of the Government are to put in the place of the sanatorium benefit which he is abolishing, 204 because it really is vital to many people to know what is being put in its place. If you confess that sanatorium benefit is a failure to deal with the white scourge in England, why do you continue it in Ireland? Why are you going to continue to saddle Ireland with this thoroughly unsatisfactory way of dealing with this disease I There is a great migration from Ireland to England, and you will never deal with this question if you deal with it in one way in Ireland and another in Great Britain. The sole explanation is that you do not give medical benefit in Ireland, and you must give them some benefit for their contribution. But if sanatorium benefit is not good enough for dealing with tuberculosis in England the only honest thing to do is to reduce the Irish contribution and abolish sanatorium benefit there, or else increase the Irish contribution so that you give them whatever you are going to give to the English tuberculosis patient.
Paragraph 3 of the Memorandum fixes the total charge upon the fund at 9s, 6d. per insured person per annum for medical benefit "including drugs as well as attendance." I gathered from the speech of the Minister of Health, in introducing the Bill, that drugs were to be treated separately and that it is not to be an inclusive fee of 9s. 6d. for atendance and drugs as well, but the Memorandum seems to set that out. In my constituency there is the utmost feeling on the part of the medical profession with regard to any system which makes an inclusive fee for drugs. They say, as long as that happens, they cannot give to the insured person the drugs he ought to have given in certain cases. There are a large number of panel doctors up and down the country who are having a pretty hard time to make both ends meet, when they have to keep cars going and all the rest of it, especially in country districts, and they cannot afford expensive drugs, and it is essential to the smooth working of the panel system that the payment to the doctor should be exclusive of drugs; and I should wish to see in any amending Bill drugs treated, not as part of an inclusive fee, but as a separate thing altogether. It is only in individual cases, that special drugs are required, and it stands to reason that a separate central fund ought to be created for the purpose.
205 Then there is the question of the enormous number of patients which some doctors have on their panel list, and the small number that others have. The War has accentuated that. The public demand is for the maximum possible free choice of doctors. There is no getting away from that. That is the democratic demand. The question is how to reconcile that demand with the situation that undoubtedly has arisen since the War where some doctors, have far more patients than they can reasonably deal with. There again you are up against facts, and I should like to hear from the Minister of Health whether he has any concrete proposals for dealing with that situation, because in my Constituency there is still a certain rather strong feeling on this question of free choice of doctors; and I have no doubt there is in other Constituencies, and I hope the question can be settled under this Bill once and for all, and that we can come to some arrangement which will prevent doctors and insured persons endeavouring to contract out of the national scheme because they are not satisfied with the provision that is made under it, either on the one side or the other. I regret that the Second Reading of a Bill so important as this was taken after eleven o'clock, and I hope the Government will not make any attempt to rush the Bill through the Committee and Report stages. All who care for the progress of public health should give the measure the closest consideration in all its details. We have now an opportunity of doing leally good work, but Parliament never docs really good work if you try to rush Bills through and take the stages in the early hours of the morning. Having taken the Second Reading now, I trust the Government will give all the more time for the fullest possible consideration in Committee and on Report.
§ Mr. G. LOCKER-LAMPSON
I, too, regret that the Bill is being taken at this hour. I had what I thought was reliable information that the Bill would not be taken until after Easter. The Second Reading to-night has taken everybody by surprise. This is a very important Bill. It adds £1,750,000 every year to the burden of the Exchequer. It adds over £6,000,000 a year to the employers' contributions, and it adds £3,000,000 to the contributions of the insured persons. I rise in no hostile 206 spirit because I feel that it is a very valuable and very necessary Bill. I am sorry that in this Bill the right hon. Gentleman has not done what he could to simplify the scheme of national health insurance. Not only has the scheme not been simplified, but to a very large extent this Bill extends the complications that already exist under the Act of 1912. A Bill was passed in 1918 doing what was thought possible to simplify health insurance, but this Bill seems to extend the complications of the scheme. I am sorry to see that nothing is being done to put the Post Office contributor under the national Health Insurance. The case of the deposit contributor has always been a bit of a scandal. They pay exactly the same contributions as everybody else, but they do not get the same benefits. The only benefits they get amount to the sum which is actually to their credit. They do not get the benefit of the pool; they only get the benefit of their individual contributions. Supposing a post office deposit contributor has 10s. to his credit, and he falls seriously ill and becomes a permanent invalid, he only gets 10s. He cannot get any more, because he has only 10s. to his credit; whereas the man who is a member of an approved society, if he is in the same circumstances, would, under the ordinary scheme, get 15s. a week for 26 weeks and 7s. 6d. for life. In the same way in regard to maternity benefit, if the miserable man has only 10s. to his credit he only gets 10s. towards the maternity benefit for his wife, whereas the man who is a member of an approved society gets 40s. maternity benefit for his wife under this Bill. I do not think it is in the interests of humanity that this large class of persons should be outside proper life insurance, certainly not as regards maternity benefit. It is very much against some of the children and child life in this country. It is not insurance at all. It is absurd to call it health insurance to bring these people into the National Health Insurance Act at all. When the Bill was brought in in 1912 it was stated definitely that those deposit contributors should come to an end by 1st January, 1915. I have heard the Prime Minister in those old days say that they must come to an end, that the problem was a diminishing one, that these deposit contributors would gradually diminish until they became extinct. That is not so. I have looked up the figures 207 and find that just after the Prime Minister—he was then Chancellor of the Exchequer had spoken in 1912, there were then 395,000 deposit contributors. According to the actuaries' report in July this year there are going to be 450,000. AH these ought to be transferred to the National Health Insurance Act. I do not think that very many of the approved societies would object. In the old days the Prime Minister used to argue that all these persons were bad lives, but it has been shown that they are not bad lives, but that on the whole they are very good lives. They are not people whom the approved societies would refuse to admit on account of ill health. They are people who object to compulsory insurance, or who would not take the trouble of joining a society, but on the whole they are good lives, and I believe that they would be welcomed by the approved societies if they were brought in. Now is the time to do it. The insurance committees have got three duties. They have to look after sanatorium benefit, medical benefit and deposit contributors. You are taking away sanatorium benefit. Under the scheme foreshadowed now by the Minister medical benefit would be taken away from them when he brings in his poor law scheme. It will probably be handed over to some kind of health council, and if you transfer the deposit contributors to the National Health Insurance you do away with the necessity of insurance committees altogether.
Another point is the case of low wage earners. Under the Bill, if a worker earns 2s. 6d. or less a day the employer pays 9d., the State Id., and the worker nothing. But if the employer pays less than 2s. 6d. a day to a person over 18 years of age he ought to pay that 1d. contribution himself. The payment by the State not only adds to the cost on the Exchequer, but adds greatly to the complexity of the machinery of the Bill. The employer under the Bill has to pay 10d. He has then to make a claim to the State to get back the Id. It only amounts to 4s. 4d. a year, and the payment of this by him would save very costly investigation of claims and incidentally save the Exchequer a consider able sum. I am very sorry to see in the Bill the differentiation kept up between men and women. That means another 208 complication of machinery, and increases the cost. The employer pays 5d. for a man and 5d. for a woman, but the man pays 5d. and the woman 4d. They get exactly the same disablement benefit, the same medical benefit as the men, but the woman gets 12s. sickness benefit, instead of the 15s. given to the man. Why cannot you make the benefits and the contributions identical? That would be infinitely simpler, it would do away with the complication of having different bases of contributions and benefits, and it would be juster as between the sexes. Although I am not a Member of the Committee upstairs, I understand that in the Committee on the unemployment Insurance Bill, the Government has promised to consider abolition of the differentiation between the sexes in regard to benefits and contributions. If you are going to do away with it in the case of unemployment insurance, I do not see why you should not do away with it in the case of health insurance. Men and women are treated practically equally politically. I hope that the Bill will be carefully scrutinised in Committee, and that it will be greatly simplified on the lines I have suggested.
§ Mr. JOHNSTONE
The deposit contributor out of a spirit of pure cussed-ness, has refrained from getting the full benefits of the Act, because he could quite easily have become a member of an approved society. I believe that one of the great approved societies offered to take over the whole of the deposit contributors. Something ought to be done, I agree, to solve the problem. When the Act was initiated I took a very prominent part in Scotland in opposition to it, because I think the whole structure of it is bad, and that it is an ill-digested scheme, most extravagant in all its operations. The one feature of the Act that appealed to me was the sanatorium benefit. It was the great feature dangled before the public at that time; it was the rare and refreshing fruit that was held out to the poor consumptives. The promise was made to the ear and then broken; it was ninepence for fourpence—an appeal to the basest element in human nature. The Act provided for sanatorium benefit the paltry sum of 1s. 3d.; any amount of money for officials and for administration and for the doctors and for drugs, but for the poor consumptive, the most pathetic figure in our social 209 life, there was only 1s. 3d. And he was robbed of 40 per cent. of the 1s. 3d., for sixpence was docked to be given to the doctors. In credit to the doctors it must be said that they did not desire to rob the poor consumptive of that sixpence. There was left to the poor consumptives under this much lauded Act a miserable sum of ninepence. And to that extent the Act was bankrupt from the beginning. When promises were made to insured persons, and they were called upon with the employers, to contribute for certain benefits, they had the right to get the full benefits promised, but what happened was that the poor consumptives were thrown on the rates of the local authorities and the local committee had to come forward and give the benefits outlined. It is little wonder that the sanatoruim benefit disappears out of this Bill. The Government had no choice but to do since the treatment of consumptives had got into such a muddled condition, and now the local authorities have to find the money for the whole of the consumptives in this country, whether insured or non-insured, and they have been doing so in the past.
§ Dr. ADDISON
There have been generous contributions to the local authorities who have never found all the money.
§ Mr. JOHNSTONE
They have found their share of the deficiency. The State contributes one half and the local authority the other half. In my own county, in Scotland, we have treated every case of consumption presented to us in a sanatorium, whether coming from an Insurance Committee or outside, and the local authority there has readily borne its part. It has cost that local authority about £2,000 per year as their part of the deficiency. But what was the promise in the Health Insurance Act, under which contributions for benefits were exacted from employers and insured persons. The benefits outlined under the Act were not afforded and the Act was, to that extent, fraudulent and bankrupt from the beginning. Now the sanatorium benefit disappears without much lament and without any reference.
§ Mr. JOHNSTONE
I regret I did not hear the opening part; of the right hon. Gentleman's speech. There was 210 no choice, after the colossal failure of this part of the Act, but to allow the benefit to disappear from it, but it is no great credit to the Government and to those responsible for the institution of this Act that it should have come to such a sorry pass. May I say as a word of consolation to the right hon. Gentleman that I think in no part of the country has this Act been worked so well as in Scotland. With regard to the administration of the drug fund, we have set up there under the Regulations laid down by the Scottish Insurance Commissioners a Drug Bureau, which has been most successful, and under which we have managed to keep the cost within the two shillings provided. As a result of the operations of the Drug Bureau, many abuses have been checked and an improved quality of drugs given to the patients, and there is no reason why that should not be done elsewhere. I do feel that it was necessary, before agreeing to the Second Reading, that some emphatic protest should be made against the deletion of sanatorium benefit from the Act, and that no fuller explanation should have been offered in regard to it.
Mr. TREVELYAN THOMSON
Notwithstanding the apologies for taking this important subject at this hour, the Debate which has already taken place on various subjects shows that this question really deserved consideration at a time when the House could properly understand it. The one point alone of sanatorium benefit is surely worthy of more consideration than can possibly be given to it at this late hour. With regard to the Bill the reason given for it is the fall in the value of money. We are told by the Board of Trade figures that the increased cost of living amounts to 130 per cent. I do not notice that the benefits under this Act are increased at the rate of 130 per cent. Bather they vary from an increase of 50 per cent. in the case of men and of 60 per cent. in the case of women, figures which I think are totally inadequate. Surely, if the reason for the alteration is the extra cost of living, then the increase, no matter how it is made up, should be something approximate to that cost of living, and I hope it may be possible, even although the Second Heading may be carried in its present form, that when the Bill gets to Committee these rates may be reconsidered. When this 211 point was discussed on the Second Reading of the Unemployment Insurance Bill it was thought by some who were ignorant of the procedure that in Committee the rates of contribution and of benefit could be dealt with, but in Committee they were ruled out of order, because the House had already settled, on the Financial Resolution, that the Committee could not in any way vary those matters. Therefore, I would like to ask the right hon. Gentleman in charge of this Bill whether it is possible, in framing his Financial Resolution, to put it in such a form that the Committee will be able to discuss and, if necessary, vary the rates of contribution and of benefit. Otherwise, it seems to me that the Second Reading here is the only occasion when any material alteration can be made, and that only with the consent of the Government on these particular points. In the Unemployment Insurance Bill we were met with the objection by the Government that they could not raise the subsistence allowance for women for unemployment benefit because the Government had a corresponding Bill, this Health Insurance Bill, where the rates for women were less than those for men, and I suppose that in Committee on this Bill we shall be told that the Government cannot make the rates the same, because you have already, in the other Bill, got this differentiation. I would appeal to the Government whether they consider this paltry sum of 12s. a week an adequate subsistence allowance for a woman. It is not a question of making the rates for men and women the same, because nobody can suggest that even 15s. is an adequate allowance during sickness. I am sure the right hon. Gentleman, with all his technical knowledge, will not say that it requires less to sustain a sick woman than it does to maintain a healthy woman. I hope that the Financial Resolution will be so framed that we can go into this question, and that it will be raised in the Committee upstairs. At this juncture the health conditions of the country are of infinitely more importance than ever before. After the ravages of the War we have to build up the health of the country in a way that it did not require before. Therefore it is very desirable that a full allowance should be given as the weekly benefit under this Bill.
212 As regards the treatment of tuberculosis, I understand the reason this has been taken out of the Bill is because it is of great importance, and it was thought it was not being adequately dealt with so far as the nation as a whole is concerned. I differ entirely from some hon. Members who have disparaged what the Health Insurance Committees have done with regard to the administration of the tuberculosis benefit. It has differed in different parts of the country, but I think it would be unfortunate if the impression went out that throughout the whole of the country there had been a totally inadequate handling of this problem so far as insured persons are concerned. The defect of the Act was that tuberculosis treatment could only be given to insured persons and that their children and others who did not come within the scope of the Act were excluded. The question is so important that it is to be dealt with on national lines, and for that reason has been taken out of the Bill. I would like the Minister to give us an assurance that, until the national scheme is established, those benefits which are in existence under the Insurance Act shall be continued, so that there shall be no interregnum during which those who are now getting benefits will be without them. As to drugs, we shall all welcome the change which the right hon. Gentleman suggests, and although it may not be clear where it is outlined in the Bill, we have his assurance that they are going to make a definite grant for drugs. I hope the right hon. Gentleman when he comes to reply will be able to give some assurance as to this question of sanatorium benefit, which we all realise is of the utmost importance. It is not that we desire to see an increase in the number of institutions, because if you have good expert advice you may get as good preventive treatment at home as by establishing expensive sanatoria throughout the country. Again, I differ from the hon. Member who spoke last as to extravagant administration. I do not think anyone can charge the Government or the Health Commissioners with extravagance. Few Acts have been passed under which greater benefits have accrued to those concerned. The Bill would be greatly improved if it were possible to increase the allowances to be granted, and I hope when the Bill goes into Committee 213 that it may be possible to deal with that.
§ Captain ELLIOT
I must say how deeply we regret that it has been necessary to take a measure of this importance at this late hour, a measure dealing with vast sums of money and affecting a large percentage of our population—15,750,000 according to the White Paper which has been issued. To hurry this, the Second Reading of a measure like this, is altogether inadequate treatment. If the Minister for Health could have made it possible to give us some outline of his idea of what the health policy of the country should be, this is a fit moment to declare it. He has very large health measures in view—the break up of the Poor Law and so on—and it is only right that these policies should be before the country for a certain time before they are brought in in the form of a Bill. The congestion of business will come next autumn, and then these other measures will be brought on in a hurry and hurried through Parliament again, and we shall have no opportunity of a general discussion of the health policy of the country, which badly needs overhauling. Surely the Second Heading of the National Health Insurance Bill is a fitting time for the Minister of Health to give us an outline of what he hopes to do. The problem divides itself into a preventive section and an administrative section: What are you going to do to prevent disease and what are you going to do to look after it? The preventive section, as the hon. Member for Spen Valley (Mr. Myers) said, has been very little developed in the country as a whole. There has been no linking-up of the hospitals. The hospital system of the country is crying out for new treatment. The position is really serious with regard to the hospitals, and while we have no indication from the Minister of Health as to the course he proposes to take, the hospital service is one without which the Insurance Act would have been bankrupt from the beginning. Many of the benefits of the Insurance Act would have been illusory but for the hearty co-operation of the great voluntary institutions of the country. These are faced with ruin just now, and if they go down or their usefulness is impaired in any way, it would do far more injury to the health of the country than all the benefits this Act can 214 give will compensate. The hospitals of the country ought to be increased in number and size instead of finding themselves faced with the prospect of actually closing down their wards because they have not enough money. The waiting-list at our hospitals is a scandal. If every patient in the beds of our hospitals could by a stroke of magic be cured to-night you could to-morrow morning fill again every bed in every ward from the waiting-lists alone. It is a sickening thing to stand at the gates of one of our large hospitals and realise that you are taking down the names of men who by no possibility will get treatment for weeks or months, or, perhaps, never receive any treatment at all. Perhaps it is a case of a minor operation concerned with the, cartilege of the knee. The man, who is not able to get out to his work, will go on unable to work, unable to play his part as a citizen, unable to keep himself in good health, simply because he cannot get treatment, yet a few weeks in a hospital would be sufficient to put him right. Sanatorium benefits have been mentioned to-night, and I understand the Minister has a large scheme in prospect. Surely an occasion like this is the opportunity to give a few details of what it is hoped to do. We hear of big schemes for the treatment of ex-service men, big schemes for the treatment of all manner of people suffering from tuberculosis, but if we are not told more about these things we cannot criticise them authoritatively, and if the Minister does not get criticism from the country he does not know what the country is thinking. Tuberculosis is a preventable disease. Why should it not be prevented? There are millions of people in this country suffering from tuberculosis, and if they are worth £1,000 apiece—and any of us is worth more than that—it shows that the country is losing £1,000,000,000 just now through this one disease alone. There ought to be printed across the front page of every one of the Sunday newspapers "1,200 people died last week of preventable diseases." If that were done week in and week out the country would be roused to the facts of the situation. If every hon. Member would realise that out of every five glasses of milk he drinks there is one glass full of live tubercule bacilli he would understand why we have this large number of patients throughout the country.
215 As to the administrative section, this Bill will do nothing to help the treatment of disease. The treatment of the disease when it has arisen must be based upon the general practitioner, and he is the man whom we must seek to help and encourage in every possible way. The general practitioners should be got together in clinics, so that they may, each in his own way, specialise to a certain extent. There ought to be a big surgery with modern improvements, and a waiting-room. The ordinary doctors' waiting-room is a really scandalous thing in many ways. We ought to have clean and decent places with proper accommodation where people can meet who are waiting to see the doctors and not be crowded together, some of them in suffering, for hours together in rooms which no man—certainly not a doctor—would sit for ten minutes if he had his own free choice. Then there is the question of improved administrative arrangements in respect to orderlies, nurses, and other helpers. We found out during the War, in the Army, what an unnecessary amount of work was being done by the doctors. We are using razors to chop fire-wood, when the minor details of nursing and surgery are done by the doctors. It is a waste of his time and skill to have a man who is paid £1,500 or £2,000 a year doing that. It could be got rid of by making a small administrative change. These are points which we could have discussed on the Second Reading of a Bill like this, and only on the Second Reading.
There is much that could be done, but we cannot begin to discuss it at the end of a long day's Debate on another subject. A great deal has been accomplished, but much remains still to be done. The people of this country are healthier than the people of any other civilised country in the world. They have, on the average, longer lives than the people of France, Germany, or even the United States, that rich country crowded with so many institutions. Since the Franco-German War, science in this country has added five years to the life of every one of our 40,000,000 inhabitants. We have done that since 1870. If the Health Ministry could give us a lead, I believe we could still add from 10 to 15 years of life and full mental and physical activity for everybody 216 in this country. These are things worth discussing and worth any amount of trouble, but they cannot be gone into now in this discussion at a quarter to one o'clock in the morning. By adding five years to the average life of the 40,000,000 of our people, what have we done? Each person produces, say, £40 a year at least, so that we have saved 40,000,000 times £200 on the five years, which comes to £8,000,000,000. We have therefore saved since 1870 the cost of the War to this country. We have been calculating on indemnities from our late enemies, but we should try to win greater indemnities from victories over the kingdom of death. These are worth securing, and would be better than adding to our debt and having to rescue the starving people of Austria and Germany. We should get for the money spent a great return in the added strength of our young men and women. That is the gold and riches we should possess if we had not only the knowledge but also the power and energy to prevent the spread of tuberculosis and other diseases. This disease knocks down men and women between 35 and 40 years of age, the most yielding and fruitful years of life. If we could spend on the science of health what we spent on the science of war we should get a great reward, if not in cash then in public securities in the health of the nation. Last year the Manchester Health Committee saved £700,000 for the Assured Societies. That was money saved for the benefit of the nation. The members of these societies are stronger and better people than they were before.
These are the things we can do. We can deal with tuberculosis; we know enough about that. It is not more research that is needed, we want its application; but in many cases we want more funds for research work. That is an investment that would pay thousands per cent. Hundreds of thousands of pounds are saved in a single year as the result of research in this country. If we got the money for research, and it were spent to promote the well-being of the people, we would get a dividend that would out-do the promises of some of those bankrupt bucket-shops in connection with the Stock Exchange. We tell you what we know; we testify the things that we have known, but you believe not. We can give you these results, but you will not accept them. It is wisdom crying in the market 217 place where nobody pays attention to it, though I should say that the marketplace is the last place one would expect to find the voice of wisdom. I want these things discussed, and one becomes rather heated because one feels very deeply about them. We want to diminish disease and give to the people the root rights that the old philosopher claimed for them—life, liberty, and the right to pursue happiness. That is a democratic ideal, that everybody should have the inheritance of a sound mind in a sound body, with equal opportunity for all. To secure that is the greatest task that can be laid upon the Government and the nation. If we take these things seriously in hand we shall be able to claim that we are really a great nation.
§ Dr. ADDISON
In making a brief reply to what has been said, I may say, in the first place, that I agree with the hon. Member for Edmonton (Lieut.-Colonel Sir A. Warren) that I ought to thank the Consultative Council on Approved Societies work for the help they have given in the preparation of this Bill. Their good work has justified the departure we made in setting up these councils. In reply to another hon. Friend I may say we have not at present any regulation limiting the number of persons who shall be on one medical man's list of patients, but that is to be provided for in a new regulation. I can give an assurance that there will be no hiatus in the change from one method of the treatment of tuberculosis patients to another. As to what has been said by the hon. Member for Stafford (Mr. Ormsby-Gore) and other Members, I agree that we ought to deal as a whole with all sections of the people, but this is not the proper time to go into the details of that. We are not proposing to deal now with all these points and could not now debate the questions of the Poor Law and other departments of the work. Nobody would rejoice more than I would if the opportunity arose. The deposit contributors are not such unfortunate persons as the hon. Member seems to think. They are in some respects the aristocracy of the insurance contributors. They are, in the main, deposit 218 contributors by their own choice. Many societies would be glad to have them. Some of them have accumulated considerable balances. With regard to the low wage earner, the hon. Member did not make a proposal that the employer should pay the whole amount, but I should be willing to consider favourably an Amendment on these lines if it is the wish of this House. The differentiation between men and women is not fully understood by my hon. Friend opposite. It would mean, for example, that we should have to increase the contribution of the women by twopence per week while we only increase that of the men by one penny, while there are difficulties arising from the fact that there are 1,500,000 women workers outside the scope of the unemployment insurance scheme. We shall, however, have an opportunity of discussing this in Committee. I think I have covered the main points raised and I thank the House for the generosity it has shown in dealing with this measure.
§ Bill accordingly read a Second time and committed to a Standing Committee.