HC Deb 13 April 1921 vol 140 cc1143-208

Order for Second Reading read.

The MINISTER of HEALTH (Sir A. Mond)

I beg to move, "That the Bill be now read a Second time."

This Bill is introduced in order to provide for commitments resulting from the passing of the National Health Insurance Act, 1920. Under Section 4 of that Act sanatorium benefit ceases to be included among the benefits conferred by the Insurance Act of 1911, and the effect is to take away from Insurance Committees the responsibility of providing institutional treatment for tuberculosis insured persons as from the 30th April, 1921, the date when sanatorium benefit ceases. It is essential that provision should be made for continuing the treatment without break, in accordance with an assurance given by the Minister on the Second Reading of the National Health Insurance Bill of last Session that There will be no hiatus in the change from one method of the treatment of tuberculosis patients to another. The consequence is that the passing of this Bill is extremely urgent if the machinery by which people have enjoyed sanatorium benefit is not to come to a standstill. The Insurance Committees ceasing to be responsible for sanatorium benefit, it is obvious that the work must be carried on by other public bodies. The county and county borough councils, as the House is aware, have already been responsible for a large amount of tuberculosis work, and have made arrangements for treating insured and noninsured persons in their areas. Therefore the logical course has been adopted in this Bill of providing that the county and county borough councils should take on the work of dealing with tuberculous persons, both insured and non-insured. These arrangements are made in accordance with schemes or agreements, approved by the Minister of Health or his predecessors, and Clause 1 of the Bill provides that councils which have made such arrangements, and which continue them, shall, for the purpose of the Bill, be deemed to have made adequate arrange- ments for the treatment of tuberculosis. In reality the bulk of the practical work has already been done, and what the Bill does is to sanction by law the system which has already been agreed upon in order to get a smooth transfer in operation.

Of the 145 county and county borough councils in England and Wales, 124 have already made such arrangements and the Bill imposes no fresh obligations upon those councils. Of the remaining 21 councils, all but one have made some provision for the treatment of tuberculosis, but in two or three cases the provision only extends to dispensaries, and in others the arrangements of the councils for treatment in sanatoria or hospitals do not make full provision for insured persons. In these cases the insurance committees at present provide directly for meeting the needs of insured persons, so far as those needs are not met by arrangements made by the councils. The great bulk of the county and county borough councils have agreed with the Ministry of Health to make full arrangements, and so far as they are concerned, the Bill is really an agreed Bill. There are a small number of councils who for one reason or another have not yet fallen into line. I understand they are all practically ready to do so if they understand that the obligations are statutory obligations and they have to carry them out; but in order to prevent the possibility, which I am sure the House like myself would very much regret, of having local authorities failing to carry out its duty in this matter, under Subsection (2) of Clause 1, there is a power given to the Minister by which, if a local authority fails to make adequate arrangements, he may make the necessary arrangements and charge them with it. This power is really a precaution. There is no intention, nor is it going to be necessary, to bring the provision into action, but we must be in a position to exercise this power in the interests of all concerned.

4. 0 P. M.

This is not a new story, but a rather old one. The Insurance Committee spent a considerable amount of money on this service, something like £300,000, and, when the Insurance Act was passed, the contribution under the new scheme was so arranged that this sum would be no longer available for this purpose. It would be obviously improper to try and go back on that Act. The whole of the Insurance Act was built up on the finance which the House passed. It would be equally unfair to charge this sum to the local authorities. Therefore, the proposal is that the amount should be contributed by the Treasury out of the taxes. The Exchequer will take the place of the Insurance Committee in taking up this burden. With regard to the rest of the finance, the old arrangements will continue, the burden being divided equally between the local authorities and the Treasury. This is the financial scheme of the Bill, and I do not think that any serious opposition will be raised.

There are one or two points upon which I might say a word, though they are more Committee points than appropriate to the Second Reading of the Bill. I know that some doubt has been felt as to whether the powers given under Clause 2, Sub-section (1) might not be used in such a way that if at any time the Exchequer contributions diminished the Minister might, by declaring that the arrangements were no longer adequate, impose great burdens upon the local authorities. I would like to say that there is no intention whatever on the part of the Ministry of exercising Clause 2 in that sense. If there be any doubt in the mind of any local authority on the subject and a form of words can be found to remove that doubt, I shall be very pleased indeed to consider an Amendment when we reach the Committee stage. Most of the other Clauses are practically merely re-enactment Clauses and machinery, but I might say a word on Clause 4, Sub-section (3), which deals with the position of County Councils and County Borough Councils. The point of Sub-section (3), as I understand it, is this. Insurance committees have been doing very good work for many years in looking after this question, and I can quite understand that they feel a certain amount of reluctance to see their work disappear and also that they should take no further part in the administration. On the other hand, hon. Members will agree with me that the local authorities, being responsible for the expenditure to the ratepayers, must be ultimately the judges as to who shall administer these services.

Therefore, we adopt a very reasonable compromise, which I venture to think in 99 cases out of a 100 will work without the slightest difficulty. It is to give power to local authorities to co-opt on their committees members from the Insurance Committees which have been doing this work. I think that is the fairest compromise. I cannot see my way, and I do not think anyone else standing in my position could see his way, to force a local authority which is elected by the ratepayers to conduct a certain service to co-opt members on a committee which is dealing with such service, whether they want them or not. It seems to me that to compel them by legislation to co-opt in that way would very much defeat the object which we have in view. I am sure that the elected members would feel that people whom they obviously did not want had been forced upon them. You would thus set up a kind of rivalry which would be very undesirable in these committees. I think local authorities would resent forcibly the introduction by Parliament of non-elected members on committees of this kind. On the other hand, it would be equally wrong to exclude the possibility of members of Insurance Committees sitting and acting upon these bodies. I am convinced, as I say, that in most cases there will be perfectly harmonious cooperation and working. It is worse to have a committee which is not harmonious, however excellent the members of it may be, than a committee which is not so good but which is harmonious. I therefore hope that the House will support me in the solution which we have found. I would like to read a letter, dated 31st March, 1921, which I have received from the Association of Municipal Corporations, addressed to the Secretary of my Ministry: Sir, PUBLIC HEALTH (TUBERCULOSIS) BILL. Adverting to your letter of the 18th inst., I am directed to inform you that the Bill has been considered by a sub-committee of the Association, who raise no objections to the provisions as they now stand. It has not yet been before the Council. I am, however, to state that the sub-committee accept the provision of Clause 4 with reference to co-option with some hesitation, and only because under the Clause as it stands co-option is entirely optional. The Association would strongly object to a modification of the Clause to render its provisions in any way compulsory. I thought it right to acquaint the House with this letter, representing, as it does, the municipal corporations of the country officially. That deals with the larger point in a very short, and, I might almost say, an agreed Bill. There is just one other point to which I should like to refer. I know that some doubt has been felt by some of my Welsh colleagues as to whether the position of the Welsh National Memorial Association which, as hon. Members know, was founded by private enterprise at the beginning of the treatment of tuberculosis, and which has become a leading factor in the treatment of tuberculosis in the Principality. There was some doubt whether the language of Clause 1 protected their interests. I looked into the question, and I was assured that the language of Clause 1 did cover the arrangements which they have with local authorities in Wales, but in order to make assurance doubly sure I would like to say that I have no objection, if it be thought desirable when we get into Committee, to insert any further Amendment to make it quite certain that the arrangement which has been made by the Welsh National Memorial Association with the various county councils and local authorities in Wales will be safeguarded under this Clause. I think I have now explained the Bill, which, of course, is familiar to the House, being merely a repetition of the Bill introduced last Session, as far as appears necessary at the moment, and I hope that the House will give it a Second Beading before dinner this evening, so that we can at the earliest possible opportunity get the Bill into Committee. It is urgent that the Bill should become law before the end of this month, because otherwise the sanatorium benefit ceases, and I am sure the House would look upon that as a catastrophe. The Bill has been delayed owing to certain circumstances over which neither I nor the House has had any control—the time has had to be taken up by a discussion of the grave industrial position—but I hope that we shall arrive at a conclusion of this discussion before dinner to-night.


Will the right hon. Gentleman himself introduce the Amendment that will give satisfaction to Wales, or will he expect the Welsh Members to draft an Amendment?


It is immaterial to me. I will either draft it and consult my Welsh colleagues, or, if they prefer it, I will accept an Amendment from them.


I am sure that the House is very glad that this Bill is being taken at a reasonable hour of the day. This is the first time since the Ministry of Health- was founded that a Bill dealing with public health has been introduced before 11 o'clock at night. Let us hope that the Report Stage will not be taken after 11 o'clock at night, but at a reasonable hour. I congratulate the right hon. Gentleman on this auspicious event in introducing the first of no doubt many Bills. This Bill is to fill the lacuna which was created by the Bill which amended the National Health Insurance Act which was introduced one night some time ago and which received extraordinarily little attention. Really, it is not much more than a skeleton. It prose ds on the right lines. Everything depends in a matter of this kind on the whole-hearted co-operation of the local authorities. Without that co-operation all efforts to improve public health in this country are doomed to failure. The Ministry can encourage it, can stimulate it, and can help local authorities, but I am quite sure that nowadays it cannot dictate to local authorities. I hope that it will be extremely rare where the Ministry have to fall back upon the powers which they retain in Clause 1, Sub-section (2). I am quite sure that if the fight against tubercular disease is to succeed it can only be done, not by the officials of the Ministry of Health, but by getting the county borough councils and the county councils thoroughly keen, not merely on the sanatorium side of this question, but on the whole treatment of the disease.

That, of course, is the difficulty of criticizing a Bill of this kind, which is only a skeleton. One has to bear in mind that it is a skeleton which has to be clothed with flesh and blood by the local authorities and the Ministry of Health. I am sure that most of the local authorities are keen to work this Bill, but frequently they have been kept back, and their backs have been put up by perpetual circulars and things of that kind. I believe that the county councils, and the county borough councils are willing co-operators but very bad servants if the Ministry attempts to drive them, and I hope that the right hon. Gentleman will take all possible steps, in co-operation with the county councils and the county borough councils, to improve the administration with regard to the prevention of the disease. The weakness that is usually pointed out is that the sanatorium treatment is too brief, and is, as it were, an isolated event in the sad career of the patient, that frequently the disease is not tackled soon enough, and becomes acute. The patient goes into a sanatorium and comes out again, and is, in some cases, almost lost sight of, particularly with regard to the conditions of his work and life after he has left the sanatorium.

The campaign against tuberculosis, as I understand, requires strategy as well as tactics, and a complete strategic policy is the most urgent necessity at present. For instance, I am told that one of the lacunae is this. Tuberculosis is notifiable since 1912, but it is notifiable to the district medical officer. The district medical officer passes on his information to the county medical officer, but it is confidential. Therefore the country medical officer, who is really more responsible than any other for administering this Bill, has to treat the information as confidential, and his action is frequently restricted. That seems to be a mistake. If we are going to follow through the life history and treatment of the disease, we have got to get over that administrative difficulty. I hate the word "co-ordination," but there does seem to be a lack of co-ordination there. Again, there does seem to be a lack of arrangement for after care. After care, following sanatorium treatment, which is, after all, expensive to the patient, wants far more attention than it is receiving at present. On every side one hears that there is insufficient hospital accommodation for the advanced cases. That, of course, is part of the general problem of the country. I only hope that when the right hon. Gentleman comes to deal with that, he will be more successful and expeditious than his predecessor. In regard to after care, a suggestion is made as to the difficulty of employing persons whose wound in the lung is healed, but may break out again except at certain very special occupations. It really means that the county authorities who administer this treatment have got to take up after-care work far more than they have taken it up hitherto, and I hope the right hon. Gentleman will stimulate that when he has got this Bill as a skeleton.

Fundamentally, you have to rely, not so much on these sometimes expensive cures, but in combating this disease so as to render this Bill unnecessary you have got to get down to the children, to the food and the hygienic conditions of the country. In that respect there is still an enormous leeway to make up. There are still people who will not open their windows, who bring up crowded families in an atmosphere that is never changed, and, unless there is a great deal more hygienic education, not only in the schools, but also by propaganda of that sort, I am sure that we shall never be able to get at the roots of tuberculosis. This disease, above all others, is one to the bottom of which we have not yet got, one in which there is still an enormous amount of research to be done. My hon. and gallant Friend the Member for the Waver tree Division of Liverpool (Lieut.- Colonel Raw) has now become famous for the work which he is doing. But there is still a great deal of work to be done, and it is essential not to try to run the thing too much on hard and fast lines. That is why I welcome the form of the Bill allowing for the utmost decentralization. It is important that all experience gathered by persons and authorities dealing with the disease, not only purely medical and scientific, but administrative, should be brought to a common pool and rendered fully available to all concerned in combating this dreadful disease.

The right hon. Gentleman I am sure would be well advised to encourage the county councils administering this Bill, and the medical officers of health to stimulate in every way research and reports on their experience, both scientific and administrative, and to make the results fully and widely known, because ultimately you can never get ahead with this work until you get beyond your local authorities, your medical officers of health, your medical profession, and get the whole lay population keen on stamping out a disease of this kind. When you have got your whole lay population working not against the bureaucracy but with it, you will get rid of a disease of this kind, but not until then. A great deal depends on the way it is done. A great many of the difficulties of the Ministry of Health have been due to the widespread suspicion that it is a growing bureaucracy of experts trying to force things down the layman's throat, instead of going out and getting ordinary chairmen of county councils and elected members of local bodies to come in and co-operate in a crusade against a disease of this kind. My right hon. Friend alluded to the co-operation of persons from the insurance committees who had experience of dealing with the subject. That is all very well so far as it goes, but in addition to the committees there are numbers of officers up and down the country who from the commencement of the original Insurance Act have been engaged in administering sanatorium benefit, and have had seven or eight years' personal experience of the working of it⁁medical and lay. It is most important to my mind that they should not be suddenly turned off into other occupations, but that they should be retained wherever possible by county councils who will administer this Act.

I may mention a case in my own constituency where the principal clerk who has been engaged on this really does know a great deal of the position of tuberculosis throughout the country. He has been told by the county council, "You are not likely to get a job from us in future, and you had better give up," and he has applied for a job in an orthopedic hospital in another county. It is a great pity to destroy the continuity of public service. This is due to hurried legislation, and the way in which the Amendment to the Insurance Act, Committee and Report stages, was rushed through this House. If it had not been for that the position of these officers would have been safeguarded in precisely the same way as it was safeguarded when the Ministry of Health was founded, when special safeguards were put in to secure the continuity of officials, or, if their offices were to be abolished, that they should receive compensation. Nothing of this kind was done in the case of the officers who have administered sanatorium benefit in the past. I think it unfair to the men themselves and bad policy not to have inserted in the Bill some indication that there would be continuity of employment so far as possible of the officers who did administer sanatorium benefit in the past. I hope that the right hon. Gentleman will con- sider this in the Committee stage of the Bill. I am sure that the whole House welcomes this Bill and will give it every facility for passing at the earliest possible moment. But I wish again to emphasize that it does not depend on legislation, or on the Clauses of a Bill passed in this House, but on the right hon. Gentleman and his officers securing the active good will and co-operation of the great county councils and county borough councils of this country.


Like the hon. Member for Stafford, I welcome this Bill both for myself and the Lab our party to which I have the honor to belong, but the Bill does not nearly approach what it ought to be, and if it is but the skeleton of a Bill, it should be clothed. It would appear from reading it that if county or borough councils have done anything at all that would be deemed sufficient to meet this foul disease. I trust that the right hon. Gentleman will take good care that Sub-section (2) of Clause 1 is enforced very strictly upon local authorities, so that the very best may be done. Remedial measures are all very well in their place for those who are now suffering. Probably nine out of ten of the Members now sitting in this House are in some way affected by this disease. The Army records more than justify all that has been said on the subject of the disease's ravages. During the War, when recruiting was very brisk, we found that largely because of tuberculosis we were a C3 nation. After 19 or 20 years of asylum experience I know that the mentally deficient are more susceptible to disease than many other classes of the population. I trust the Government will take measures for the isolation of all cases. People suffering from weak minds have not the physical or mental force needed to combat the activities of tuberculosis.

As to the scheme of the Bill generally, I hold that matters should not be left so much to the local authorities. After all, this is a national question and ought to be dealt with nationally and the expense ought not to be thrown on the local authorities. If we are to have an Al population we must take a greater interest in the question. Speaking generally, the poorer an area the more prevalent is this disease and the less able are the people to cope with it because of their financial position. I want to impress that fact on the Minister of Health. The cost of preventing the disease and even of arresting it ought to be thrown on the nation rather than on local authorities. We must take all possible preventive measures. The first thing that occurs to my mind is housing. Miserable, damp, ill-lighted and ill-ventilated houses are the breeding ground of this disease. If we allow such houses to continue in occupation we shall spend money in millions under this Bill and it will do little or no good. I admit that a great deal is being done to deal with the housing problem. I know the difficulties that the Minister of Health has to meet, and that there are people who are always crying out for economy, but to me the greatest economy is to save the lives of the people. The party with which I am associated is out for that rather than for saving in other directions. We want economy as much as any other group of Members in this House, but we want to save money in a direction that will help to conserve life rather than destroy it. I think the Minister of Health might send out instructions to all local authorities emphasizing the extreme danger of overcrowding and directing that it should be dealt with at once. I have seen as many as eleven people crowded into one room, and amongst them probably there were those who had this disease. From such conditions can we expect anything but a quick and serious spread of the disease? While such conditions are allowed money spent on remedial measures only will be money ill-spent.

Then there is the question of schools. As one who has taken a great deal of interest in the education of the children, it has appeared to me for many years that the idea too long has been that a school should be as ill-lighted as possible and that God's sunshine should be prevented from getting in amongst the children. Very often fresh air was excluded entirely from the schools. It did not matter whether a school was damp of dry as long as it was a school. We have done our best in various parts of the country to end that state of things. Unfortunately here again economists are against us. It is among the children that the greatest good can be done in preventing a spread of the disease. I want, therefore, to help our school medical service to take an active interest in the matter. Children should be ex- amined and notifications made as quickly as possible. What has been the experience of those who have taken a deep interest in our sick funds and our benefit societies? It is that when a man falls ill certificate after certificate comes along marked "Bronchitis" Finally there comes the certificate which has been expected throughout, marked "Tuberculosis" By that time the disease has spread so far that probably the man is doomed. I know the difficulty of diagnosing the disease in its early stages, but I hope that the medical profession will have made such an advance that that difficulty will be overcome. The conditions of lab our ought to be examined. In many of our mills and factories things are permitted in the shape of bad ventilation that are helping to spread and develop the disease. The Minister of Health should consider that also. I agree with the last speaker that the proper feeding of the children ought to be ensured. Ill-fed children and adults are more open to the attacks of the disease than people who are well-fed. The nation ought to do everything it can, at least for the children. It may be said that it is no part of the duty of the State to feed and clothe adults, because they can look after themselves. It is the duty of a well-regulated nation to see that at least the children of the nation are well-fed and clothed and kept from disease and harm.

Probably the greatest omission noticeable in the Bill has reference to after treatment. You may have you sanatoria, your dispensaries, and whatever else you like, and you may send these people back to their work improved in health or even thought to be remedied, but if nothing whatever is done to watch over them for years afterwards you will have the same trouble again, and probably lives will be lost in the end. Provision should be made for adequate nursing, and for pure food, pure milk and everything which is necessary to be sent to those who have the care of patients. It ought to be an instruction to every local authority that it must have an After-Care Committee. That Committee must be composed, as to at least half of its members, of representatives of the local authority, 'because of the expenditure coming out of the public purse. But there should also be on the Committee experts, including the medical officer of the local authority or some such person who knows exactly what to do. The advice of the experts ought to be available in all these matters. We ought to draw into the Committee also the friendly societies which are charged largely with the cost of maintaining the sufferers. All these services could be co-ordinated. By after care we would probably do more good than with costly sanatoria. Then again, every local authority ought to provide an open-air school for all children suffering from the disease. In large industrial areas many children are affected. They could be brought into one centre and educated in an open-air school at little more expense than that involved in teaching them in any other school. You could in that central school provide them with pure milk. In our industrial areas the milk bill of the poor is not very large. Where there are five or six or seven children dependent on one man's earnings and milk is retailed at a shilling a quart, each child's share is very small indeed. Possibly, it gets a tablespoonful in a cup of tea or coffee. That drawback we could remedy by having milk supplied at the open-air school. I shall be told that this will cost a lot of money. I am certain that if we can arrest the disease in the children we shall save ultimately millions of money. Not only are the people affected by the disease likely to be saved, but employers of labour would be huge gainers, because of the fact that people would be able to work for them regularly rather than at intervals only. Members of the Labour party will vote for the Second Reading of the Bill, but we reserve to ourselves the right in Committee to clothe the skeleton and to make it a Bill really worth passing into law.

Lieut.-Colonel RAW

I would first like to congratulate the right hon. Gentleman upon having introduced a Bill of such immense importance to the whole nation. I am quite sure every Member of the House will give it the most sympathetic and careful consideration and do everything they can to assist the Minister of Health in the task of stamping out this dreadful disease. I commend the Bill to the House for several reasons, but for two in particular. One is that tuberculosis is a preventable disease and should not exist in any civilised country, and the second is that if taken in its earlier stages it is a curable disease, Therefore every effort which the Minister of Health can devise should be backed up loyally by every Member of Parliament. We have to remember that there are at present in England over 600,000 people attacked by tuberculosis. We also have to bear in mind that England alone loses between 50,000 and 60,000 people per year as a result of their being afflicted by tuberculosis. To realise the importance of the disease, one has only to mention those two facts in addition to the enormous amount—running into millions every year—which is lost by the workng classes in wages alone. This Bill deals specifically with the treatment of tuberculosis. From my experience of the health authorities of this country I am perfectly certain each one of them is most anxious, not only to give the very best treatment to those suffering from tuberculosis, but to take every possible means, backed up by the Ministry of Health, to prevent the disease developing. Therefore, although this Bill, as has been stated by the hon. Member for Stafford (Mr. Ormsby-Gore), is really a skeleton Bill, I am quite certain that, after full consideration, it will be shown to contain very valuable provisions which will lead to great improvement.

There are one or two points to which I would like to direct the attention of the Minister of Health, and the first is in regard to Clause 3. While I agree with the hon. Member for Stafford that the Clause should be mandatory and not permissive, enabling members of Insurance Committees to be co-opted, perhaps the Minister of Health will be able to adopt an Amendment by which it will be made mandatory. In this way we should receive the benefit of the services of those who are specially trained and specially interested in the treatment of tuberculosis. It would be a great misfortune if the services of these excellent people were to be dispensed with. Another point is the enormous importance of the after-care of people who have been treated. An up-to-date and well-equipped sanatorium is today the very best method of treating the great mass of the people who are afflicted. But what is to happen to a patient after leaving the sanatorium? Is all the expense and trouble which has been taken to restore health to be wasted? Local authorities should have the power to appoint an after-care committee—which should be a statutory committee—to look after the patient and see that he is assisted and enabled to carry on in some degree the same treatment which he was receiving in the sanatorium. I may be out of order, but I suggest that the most important problem we have to consider is the wage-earning power of the man or woman afflicted. It is well known that a man attacked by this disease is in the best of circumstances only a 50 per cent. man so far as wage-earning capacity is concerned. We must devise some means by which suitable occupation can be found for those men and women who have to some extent recovered, by which they can earn a proper livelihood. Whether the wages will have to be subsidised—it is, perhaps, dangerous to speak of that at the moment—or whether some special work will have to be found in municipal workshops or Government workshops, or whether private enterprise will be assisted to provide work for them, the fact remains that something must be done to enable the worker who has been crippled by tuberculosis to earn a living. That is a problem which we are bound to consider in the future.

Another very important question is that of the isolation of advanced cases, which are the great means of spreading the disease. I am sure the hon. Member for Stafford will agree with me that one of the chief means by which a reduction of tuberculosis was brought about was the fact that the Poor Law infirmaries of this country isolated an enormous number of advanced cases. This work has been paid tribute to not only by English people but by people all over the world, and I hope the infirmaries will be encouraged to continue this very humane and necessary system of giving comfort and shelter to these afflicted people. There is also the question of sailors. Wherever sailors land) in this country, and at whatever time, if they are suffering from this disease the local authority should have power to give them whatever treatment they may require.

I should like to add how important it is that the whole civil population should be interested in taking a hand in the prevention of this disease. In England we have the National Association for the Prevention of Consumption, which for 20 years has carried on useful propaganda work, and done an enormous amount of good. I should like to refer to two other private enterprises which have also rendered valuable service. One is the splendid Welsh National Memorial, which has done incalculable good in Wales, not only in preventing but in treating tuberculosis. I sincerely hope they also will be encouraged and, if necessary, assisted, although they seem to have plenty of money to carry on their great work. The other is the industrial settlement which has been established at Preston Hall, near Maidstone, to treat soldiers and sailors suffering from tuberculosis. There the men are taught suitable trades and occupations during a period of 12 months while enjoying full pension. This work, I hope, will also receive support and encouragement, more especially as we have at the present moment still 25,000 soldiers and sailors suffering from the disease and requiring constant treatment. I commend this Bill cordially. I congratulate the late Minister of Health, who was largely responsible for drafting it; and I sincerely hope the House will give it a Second Beading.


The Minister of Health must be gratified by the reception given to the Bill so far. I wish to join in with those who would rather see more drastic and extensive powers given. Comparing the Bill to-day with the Bill introduced last year, instead of it being a more progressive measure it is in certain sections not so advanced. Reference has been made to after-care committees. In the Bill of last year direct provision was made for the working of those committees and local authorities were enabled to contribute to their upkeep. I hope it will be possible in the Committee stage for the present Bill to be strengthened in that respect on the lines of the Bill introduced last year. There is also some subtle difference in the way the Clauses are framed. Last, year's Bill made it a direct obligation on local authorities to set up the various committees. I believe the same power is given in this Bill, but it is rather by inference than by direct obligation. I hope there is nothing behind that. In many health measures of recent years not only has a direct obligation been placed on local authorities, but in case the local authority should fail the right has been given to a certain number of electors to make representations to the superior authority for the bringing into use of powers which may not have been exercised. It may be said that provision is made for this in the present Bill, because if the local authority fails then the Minister has power to act.


indicated assent.


I see the Minister assents to that but, with all respect to him, we do not know that he will always be there. The reform of the health services of this country owes very much to his predecessor, who found a moribund body and vitalized it into a living force. If he had remained in that office we should have no hesitation in believing that this Bill would be carried out to its utmost extent. We believe the same of the present Minister, but we do not know who his successor may be. Local districts require protection by giving them the same power which they had under previous Acts to make representation from the electors in case of any default by the local authority. I hope, although it may not appear necessary at the moment, that such powers will be added to the present Bill, so that the most laggard authority and the most negligent Minister may be brought to book by public opinion without waiting for elections.

5.0 P.M.

Reference has been made to Clause 1. That Clause seems to provide that where any arrangement has been made by the council of any county or county borough, that arrangement, whether it is adequate or not, may be deemed adequate if this Bill is passed. If you take that Clause literally as it is drafted, it means, no matter how inefficient or incomplete an existing scheme may be, that that scheme is to be deemed adequate after the passing of the Bill. I hope that in Committee we may have an opportunity of strengthening that Clause. After what the experts have said with regard to the necessity for dealing with this question we do not want to leave any loophole by means of which any precautions may be neglected. There has been undoubtedly a very great diminution in the death rate due to tuberculosis. In 1915 the rate was 151 per 100,000. In 1920 it fell to 112 per 100,000, and that decrease was very largely due to the excellent work initiated and carried out so successfully by the late Minister of Health. The diminution may not be so great as we would all wish to see, but still, there it is. What has hitherto crippled the local authorities in the administrative work of the Insurance Committees, who have done the work, has been the lack of funds for dealing with cases. Perhaps I may be allowed to make a reference to what was done on an Insurance Committee on which I served years ago. The advice of our local experts in Middlesbrough was this: "Your funds are so limited that it is no use attempting to deal with the whole problem, you must concentrate on one section of it." The advice as to what we should do was both ruthless and drastic. It was that we should leave entirely alone the advanced cases, as we could not hope to do much good for them and they would cost a large amount of money, but that we should concentrate on cases in which the disease was in its early stages. We did that at Middlesbrough. We concentrated entirely upon those cases which were in their early stages, and the work of three years has resulted in a very considerable reduction in the amount of tuberculosis. It was found that 60 per cent, of the patients who were dealt with were able to resume active work and to take their places as physically fit in the home or at their daily work. It was also found that the advanced cases, notwithstanding that they were ignored, had not increased in number. By concentrating entirely on those cases which were showing signs of tuberculosis we prevented an increase of the advanced cases. What further did that Committee find? They found that as far as the limited funds at their disposal operated, the value of the money spent worked out in these proportions. For every pound spent on after-care, £2 was spent in the dispensary and £8 upon sanatoria; in fact, eight times as much value was got for the money spent on after-care as upon other forms of treatment.

The question hinges largely on the personal equation. Unless you have a local authority which is virile and sympathetic carrying out the scheme, no orders from Whitehall can be of any service. I hope, therefore, when we get into Committee the Minister may be willing to give more power to these after-care committees. They should receive assistance from the local authority in carrying out a work which is yielding infinitely more in return for the money spent than any other form of treatment. (The Department should also relax some of its Regulations with regard to treatment in sanatoria. In my particluar district we have made arrangements with an unrecognised convalescent home whereby, for 30s. per week this year and 40s. per week next year, patients can be treated for three, six, or eight weeks where they will get taken care of, have good food, and fresh air, and have every chance of restoration to health. Because this particular home does not comply with Regulations which Whitehall likes to lay down, the authorities refuse to recognise it or to give it any grant towards its maintenance. They would be willing to give such assistance if we were prepared to spend £4 15s. per week in one of the sanatoria they do recognise, but because only 35s. or 40s. a week is expended in this home, they will not recognise it. I appeal to the Minister to extend recognition to those convalescent homes, which may not occupy such palatial buildings and have such a full staff of medical officers and nurses, but which do provide good food, fresh air, light employment, and exercise, and which are yielding such as excellent a return as the more expensive sanatoria. I hope the right hon. Gentleman will be prepared to consider the suggestions which I have put forward in order to secure an extension of the benefits of sanatoria treatment.

I would ask the right hon. Gentleman to consider who it is that has been carrying out the work up to the present. In every case it has been the Insurance Committee, and yet by this Bill you are wiping out the Sanatoria Committees of the Insurance Committees, which are being given no locus standi whatsoever. The right hon. Gentleman says that in these democratic days you must have popularly elected representatives for dealing with public money. But I would remind him that in the field of education, which is just as important a subject, and on which a large amount of public money is spent, you have statutory education committees, on which you must have so many people not popularly elected to represent technical, voluntary, and higher education, and women as well. On your Statutory Education Committee you have a proportion of members who have to be co-opted, and therefore I suggest you have a valuable precedent in that direc- tion, and, as it is one which has worked excellently in the administration of the educational services of the country, there is no reason why you should not have exactly the same result if your sanatoria committees are similarly constituted to carry out tuberculous work. You have only to make it mandatory that those who have done the work in the past shall find a place on the popularly elected body.

Then with regard to the question of finance, I hope more assistance may be given to the local authorities. It has been pointed out that where the need is greatest the burden is heaviest. You are making mandatory in this Act duties which up to the present have been permissive. Hitherto the treatment of non-insured tuberculous cases has been permissive, but now you are making it an obligation on the local authorities to deal with those cases. In view of the extra burden which you are thus imposing I think it is only right that the State should contribute more than 50 per cent., as is suggested in this Bill. 75 per cent would surely be a fairer share to fall upon the State. This is a national burden. You have your big industral areas with their big rates. In my own town the rate is 16s. in the pound, and the tuberculous cases are numerous, whereas in the town of Bournemouth, where the rates are only 9s. in the pound, it will be found that tuberculous cases coming before the Insurance Committees will be comparatively few in number. Therefore I say the need is greatest where the rates are heaviest, and you are putting upon the heavily rated industrial areas by this Bill a greater burden than you are imposing upon centres which are merely residential. This is a national question which ought surely to be looked at from a national point of view, and, while the administration must be left in local hands, yet I suggest the nation should bear its share of the burden and not put too big a strain on the locality.

Captain ELLIOT

In Scotland we have had a similar scheme to this in operation for a long time. We have these powers over local authorities which are asked for in this Bill, and, therefore, there is for this measure that which is so dear to the heart of every Member of Parliament—a satisfactory precedent. When we are faced, especially in these days of the utmost financial stringency, with measures for even the most bene- ficent purposes we really have to ask ourselves whether they are necessary, and, if they are, whether the methods to be adopted are likely to be effective. The Member for the Wavertree Division (Lieut.-Colonel Raw) gave us some very striking figures as to the necessity for the treatment of this disease. Last year 42,000 people in England and Wales alone died from tuberculosis, and the disease is killing about 800 people per week. The only figures I have been able to get as to the cost are some from the United States of America, where it is estimated that in the year 1903 tuberculosis cost that country £66,000,000. That is only tie direct cost. As to the indirect cost it is utterly impossible to get any sort of estimate at all. We are all agreed that the disease is one which we must treat. It is a national disease which should be treated by some systematic scheme of organisation. The question is, Does this Bill afford the best way to deal with it? Arguing from analogy it would appear the best plan is to divide the country into areas and to make one authority in each area responsible for dealing with the disease. That is the principle on which, under the Public Health Act, 1872, we dealt with fever in this country, and it enabled us to bring down the deaths from fever from 700,000 in the years 1870–1880 to 140,000 in the last 10 years. If the system has proved effective in dealing with other forms of disease we have every reason to hope it will be equally effective in dealing with tuberculosis.

We have the consolation of knowing that the work so far carried out has been effective. The number of deaths in 1914 was 50,000. In 1915, when War broke out, housing conditions were not noticeably worse, food was better and employment was good, while prices had not reached the terrifically high point to which they later on soared. But the deaths in that year increased by 4,000, bringing the total upon 54,000. In 1916 they remained at the same total; in 1917, they reached 55,000, and in 1918, the influenza year, they went up to 58,000. In 1919, they fell to 46,000, and in 1920, they fell still further, to 42,000. A certain amount of that decrease was undoubtedly due to the remedial measures introduced by the then Minister of Health, but a large amount of it was due to good trade in the country and I warn all sections of this House—I am sure every medical man will wish to join in that warning—against the almost inevitable disturbance in our vital statistics which the present industrial crises will bring in their track. Housing was not noticeably better in 1920 than in 1918. It had improved, no doubt, but not so much as to account for the drop in the number of deaths from 58,000 to 42,000. But with the present disturbances in trade, I warn all sections of the House that we are almost certain to have, a corresponding alteration for the worse in the vital statistics of the country. Our vital statistics are very much better than those of any other country in Europe just new, and better almost than those of any other country in the world. I have been able to get some figures for other countries. In 1919 our death-rate from tuberculosis was 125.8, and in 1920 it was 112.8. I will not quote the case of Vienna, because the conditions there are so exceptionally bad, but in Prague, where the conditions are fairly comparable with those in this country, the death-rate was 386, as compared with our 112'8. In the City of Warsaw it was 591: in Vienna, 490; in Cracow, 616.

Lieut.-Commander KENWORTHY

Has the hon. Gentleman got any figures for Scandinavia?

Captain ELLIOT

I am simply giving the figures in the disturbed areas. I want to bring it home to the House what we may fear if similar disturbed conditions begin to prevail in this country. There is no doubt whatever that a very terrible state of things might easily arise. I see some hon. Members opposite smile. I assure them we have no special immunity against disease in this country. If we have a starving population, diseases, of which tuberculosis is one, will follow as surely as the rising and setting of the sun. If, then, we want to deal with the thing, we have got to have a general national scheme, and we want to know whether this Bill is the best method of dealing with it. The system of local administration, with a grant-in-aid from a central authority has, I think, proved its value in public health in this country, and I think, therefore, the scheme which the Ministry of Health suggests is the best way of dealing with the matter. We have got very great results by this in other diseases. We have child mortality down from 110 in 1915 to 80 to-day.: People say that is simply to do with the care of mothers, and has nothing to do with clinics. I was discussing the matter with a medical officer of health for one of our boroughs not far from London, where the death-rats of children attending the clinic is 40, whereas the death-rate of children not attending the clinic is 77. You may say that is because the careful mother brings her child to the clinic, and the careless mother does not, and that therefore the death-rate makes no difference. I think it shows, at any rate, that the careful mother finds the clinic an advantage in looking after her child, and the same general principles applied to tuberculosis will be of the greatest benefit in bringing down the death-rate from this disease.

We have a splendid chance just now. Influenza swept the country, and swept out a large number of people who would probably have become acute cases of tuberculosis. There was no doubt that it was a bronchial disease, as it attacked people liable to be carried off by any form of bronchial attack. Consequently we have a very low number of people in the country to-day actually in an acute stage of tuberculosis, and now that we have—to use a metaphor often used at the Treasury Box—got it on the run, if we can drive our attack home, we have a very much better chance than we ever had before of reducing it to practically negligible proportions in this country.

The main question is whether these methods are the best methods to adopt. On this I would like to offer one or two criticisms on the Bill as a whole, but, before doing so, I would like to stress again the necessity of treatment for sailors coming in from the sea. Of all classes, they are one of the most liable to phthisis. They are peculiarly subject to consumption, owing to the small amount of air space which they have in ships, namely, about 45 cubic feet, whereas the air space for a tramp in a common lodging is about 400 cubic feet. That will need to be treated as an international problem, and I would suggest to the Ministry of Health that some special subordinate scheme will have to be brought in for dealing with sailors, so that they will not have to apply to the local authority in whose area they are usually resident, because many of them have no fixed place of residence at all, and it is just as important that we should not have tuber- culous sailors as that we should get rid of tuberculosis in every other class.

With regard to the general treatment of after-care, I think on this the experience of the Ministry of Labour will be of the utmost value to us in the long run. These people come to sanatoria, and, in addition to the extremely special kinds of employment, such as forestry and so on, which are taught to them there, we want, I think, a sort of disabled men's roll, some sort of national scheme for a certain proportion of places in industries being reserved for the casual ties of industry, just as we have done our best to reserve a certain proportion of places in industry for disabled soldiers coming back from the War. A certain number of light jobs in every industry are quite capable of being filled by men who are not capable of doing a full, ordinary day's work, and if these after care committees are set up, I put it to Members of the Labour party that on them we should have Labour representatives, and that they should acknowledge their share in this great work of after care by admitting that a certain proportion of light jobs in industry should be reserved for casualties in the industrial battles of the world. I throw that out for their suggestion, and I should be glad to know whether there is any comment to be made on it. In regard to the general conditions of treatment, the hearty co-operation of local authorities is essential, and the hearty co-operation of those who have set up voluntary schemes is essential. I beg the Labour party not to adopt, as they have sometimes done in the past, a stand-offish attitude towards the voluntary dispensary system, and particularly the voluntary dispensary systems in London. These are worthy of the most, hearty co-operation by all sections of the community, because they are carrying out that invaluable propaganda work which is so essential in getting into the minds, of the people that it is they themselves., who will have to look after themselves against this disease. I would urge them, therefore, to adopt a sympathetic instead of a stand-offish attitude, as they have done before.

The last point on which I wish to touch is the question of having some sort of clearing-house system before men are definitely marked off for sanatorium treatment. There are numerous methods of diagnosis which are not fully employed at the present day before a man is definitely diagnosed as tuberculous, and full advantage of modern methods should be taken before it is decided that a man requires sanatorium treatment and has to start on a long process, extending possibly over years, which will be necessary in the future when a man is sent to a sanatorium.

The clearing-house system would enable the whole battery of medical science to be concentrated on a particular case, and then it could be determined definitely after some residence in hospital—perhaps three or six weeks—whether a person needs to start the treatment. It seems incredible that there is in London a tubercular hospital, the Royal Hospital for Diseases of the Chest, which at this moment is in danger of being pulled down, and has come to an arrangement with another large City hospital by which this hospital, with 100 years of history behind it, will be pulled down and an equal number of beds erected in conjunction with the large general voluntary hospital. I would ask particularly the London Members if it is not possible for them to enter into some arrangement by which the organisation of this hospital could not be made available for clearing-house work, under the new London County Council schemes which will be necessary, or which they have already set up, with the approval of the Ministry of Health. Tuberculosis is an extraordinarily difficult disease to diagnose. To diagnose successfully you require not one factor, but perhaps half a dozen factors, and one physical examination is not sufficient to make adequate use of the large number of factors which we can use under modern conditions. I would, therefore, ask, more particularly the London Members, if it is not possible in this particular instance for some arrangement to be come to between the great London County Council and the authorities of this small hospital by which it shall continue to be used, as it has been used in the past, for chest diseases in general, and in particular for the differential diagnosis of tuberculosis.

I, also, as other Members have done, congratulate the Ministry of Health, and particularly the late Minister of Health, for having drafted and introduced this Tuberculosis Bill. These questions which are debated in a thin House with a few Members do not raise the great passions which other more controversial methods arouse, but they are far more important to the people of this country than half the questions that we spend out time threshing out on the Floor of this House. The great Sanitary Acts of this country have brought down our death rate to 13.5, far below the death rate of other countries. Work done on the fabric of the State, the people, is work done on the foundation stones of the building of the Empire, and is, in the long run, far more important to the Empire than any amount of flags which you may hoist on the flagstaffs, although they may appear a great deal more imposing at the time.


I would like to begin by congratulating the Ministry of Health on this Bill, and to differ from some of the speakers who have rather complained that it is only a skeleton. I think it is a great advantage that this Bill is rather short, and for that reason I think it will avoid a great deal of opposition in the present craze for economy. I believe that was the chief cause of the failure of the Ministry of Health in the Miscellaneous Bill of last Session, and I hope the Minister will not be induced to enlarge this Bill too much, otherwise it will meet with a considerable amount of opposition in quarters where there would be no opposition at the present time. I see two Amendments on the Order Paper against this Bill, and I believe they are on account of economy. I think that the importance of this Bill far outweighs any question of economy at the present time, but I would not like any of our very keen enthusiasts, like the hon. Member for Middlesbrough (Mr. T. Thomson), to persuade us to go in for too great expense and then arouse opposition. As a medical man, I would like to say that early treatment of tuberculosis is essentially the important thing. We have at the present time some very elaborate sanatoria in the country. There is King Edward VII's Sanatorium at Midhurst, which is of great advantage for research. I take it this Bill is to provide treatment for tuberculosis for the great mass of the people In that way I think we ought to avoid any great expense in the way of building. Plenty of accommodation is important, but there is no need for very elaborate buildings, where a few patients could be taken in, and where there would be a long waiting list.

I should like to mention to the Minister one instance that I have had in my own experience which, I hope, will be a proof to him that it is not at all necessary to have elaborate buildings in order to treat tuberculosis successfully. When 1 was a doctor in practice—and I am not a specialist like the hon. Member for the Wavertree Division of Liverpool—and I do not profess to be an expert—but as an ordinary medical man, I attended a man suffering from tuberculosis. I advised him to go to a chest hospital. The poor man tried to get into one. Letters were given to him. He tried for weeks, and then came back to me very much discouraged, and said he could not get in. I realised the importance of his being treated as soon as possible, and offered to treat him privately. I put him, not in an elaborate building, but I got a cottage or the hill, took out the window, and had the chimney, which had been blocked up, opened. There the man remained for two or three months, and gained two stories in weight. This was a case where there was no elaborate building required; there was no particular expert advice required. I went out to see him perhaps once a week. That man got the full advantages—I was going to say of expert treatment and an expensive building. I only give that small instance to urge the Minister of Health not to be pushed into great extravagance in the way of providing great buildings, for, as was said yesterday in relation to education, it is not always the greatest amount of money spent that brings the best results.

I would also like to urge that this Bill should be got through very quickly. I do not myself intend to take up much time here, but I think the House should not oppose this Bill. For my part I consider it is fulfilling a pledge to the country. When the National Health Insurance Act was passed we heard a great deal of the sanatoria which were to be provided for the population—of the magnificent—




Yes; first-class hotels were to be provided, and various things like that.


Rare and refreshing fruits!


I as a medical man, and we of the medical profession, feel rather bitter on this point; that the pledge has not been fulfilled. We ought now to fulfil our pledge, and carry out the efficient treatment of tuberculosis for the great mass of the people. It strikes me in this way. The husband, perhaps, has been to a doctor and has been told that he has got consumption. He goes back and tells his wife, and it is a regular blow to the whole of the family. He then, endeavouring to get treatment, is perhaps kept waiting for weeks and months. That is a most serious condition of affairs. I think we ought to be able to supply sufficient sanatorium treatment, so that a man who has been given, so to speak, his death-blow may be taken away and treated at once, so relieved of the natural anxiety of the case, and preventing him from spreading infection in his family. For these reasons I would urge that this Bill be passed promptly. I hope that the Minister for Health will consider the question of economy, not only in a sense the saving of money, but because for the same amount of money he can spread the benefit in this matter over so many more people. This question of treatment is a most important matter. I do not at all agree as to the necessity of bringing in a great many Regulations. In 1906 I had the privilege of seeing the work of a voluntary sanatorium at Brighton. It was not under any regulations. The work was done voluntarily and the results of the treatment there were particularly good. I would urge the Minister not to bring in many conditions or regulations. I would urge upon him, like some hon. Members who have already spoken, to work with the local authorities, and to get their freehearted and hearty cooperation. In that way, I am sure, he will be in the way of making tuberculosis treatment a very great success.


I wish to join with hon. Members who have preceded me in congratulating the Minister of Health on bringing in this Bill. Like others who have spoken, I believe that the Bill will be strengthened by Amendments in Committee. There is one thing the Minister of Health ought to feel very pleased about, and that is the unanimity with which his Bill has been received in all parts of the House—up to the present at any rate. I have listened to the Debate, and I feel diffident in intervening after listening to the experts. I am sure, however, that the valuable way they have contributed to this Debate has given us something to think about. I myself have not had much experience in being on any Committees, but I know this is a very dreadful disease. I think it must be apparent to everyone that that is so, and the more so by reason of the figures given by the hon. Member for the Wavertree Division (Lieut.-Colonel Raw) and the hon. and gallant Gentleman the Member for Lanark who has just spoken (Captain Elliot). This disease is making gigantic inroads on the health of the community and the life of the people. Whatever can be done should be done to prevent the disease, or remedy the consequences. Personally, I am with the hon. Member who says that preventive measures are the best measures. Hence the dispensary system should be inaugurated in every part of the country on a very large scale, so that the people suffering should be immediately put: under the best expert treatment available. To my mind that early treatment and aftercare are the two essential features of the treatment. I do not want to disparage or minimise in any degree the great work done by the sanatoria in this country, but I would like, so far as possible, to prevent the necessity of cases being sent to sanatoria by the dispensary people.

Clause 1 to me gives some cause of complaint; but possibly that is because of my inability exactly to understand what it means. It says: Where the council of any county or county borough has, before the passing of this Act, made arrangements for the treatment of persons suffering from tuberculosis … that council shall, for the purposes of this Act, be deemed to have made adequate arrangements for the treatment of tuberculosis … I hope the Minister of Health will get some Amendment in the Bill to give him the right not to allow some reactionary council to say there has been adequate arrangements made for the treatment of this disease when probably no arrangements worth mentioning have been made. As a layman I would also like to suggest that greater facilities should be given for the establishment of after-care committees in the municipalities. So far as I have read the Bill, I do not see that there is any real provision for setting up aftercare committees unless it is that the committees to be set up can take upon themselves responsibility of dealing with cases in all their stages. After care to me is a very vital and important matter in the treatment of people who have this disease. The hon. and gallant Member for Lanark generally has a tilt at the Labour party in any speech he makes. I may say for his gratification that we on these benches always listen very attentively to what he says, but I am not prepared to say that we always agree with it.

In regard, however, to after-care and the provision of work for these men, ex-patients, I do agree with him that it is the duty of every part of the community, and the persons on these committees, to take a lively interest in getting these people put into the most likely jobs to help in aiding their recovery He said he hoped the Labour members would do something in this respect. I cannot pledge the whole of the Labour people of this country, but I feel, if I were on one of these committees, I should be prepared to exercise my powers and influence in trying to get these people into the most likely jobs that employers would take them into. But a good deal of this responsibility should fall upon the employers, and the hon. and gallant Gentleman might make the same appeal to them that he has made to us. I should like to quote one or two paragraphs from a report issued, I think, by the Executive Council of the Tuberculosis Group of the Society of Medical Officers of Health. Doubtless the Minister of Health has a copy of this report, but possibly the House will be none the worse if I were allowed to read one or two extracts in regard to after-care: The tuberculosis campaign must of necessity be a prolonged one, for it deals with a disease that is typically chronic and not acute, and the intermediate stages of the conflict are at least as important as the initial ones. Any withholding of the necessary assistance in the latter stages may, and usually does, render useless the previous efforts, and unfortunately this has too often occurred in the past. It cannot be too strongly emphasised that unless adequate medical and financial relief can be provided at all stages of the treatment and for aftercare, the initial expenditure in many instances will have been simply wasted. Consequently it brings us up against one of the things which has been complained of, that is, the question of finance. In our after-care treatment, therefore, it will be necessary to finance these things. The hon. Gentleman who spoke before me was much concerned about economy, and the hon. and gallant Member for Lanark (Captain Elliot) suggested a voluntary system of contributions towards this aftercare work.

Captain ELLIOT

I did not mean to convey that impression. I merely discussed the dispensary system.


At any rate, some statement has been made in regard to the voluntary contributions. I believe the matter is of so serious a character that the nation ought to bear the financial responsibility for all after-care treatment. It is a national obligation, and the Government should govern for the welfare of the people. In trying to maintain or build up the health of the people, surely money spent in that direction must be well spent, and cannot be called extravagant. The report to which I have referred goes on to say: Some subsidy is necessary to help during the doubtful time of returning to work. A holiday once a week or a part-time job works wonders as a bridge to complete efficiency. Here, naturally, comes in the tuberculosis employment workshop where a full wage could be paid for part time, until complete working capacity is re-established. After care is the work of the army of occupation of conquered territory. If that fail, all other expenditure is in vain and merely wasted, and yet it is just at this stage that the tuberculosis campaign breaks down entirely. Sickness benefit is seriously diminished just about the time the breadwinner returns. There is no further good and sufficient food provided for the- patient free of cost. He returns to where he started from, with savings gone, home impoverished, anxiety for children and family reimposed just at the time when, if life's strain were somewhat relieved, he might again gradually and with care re-establish a working capacity. If tubercle is to be really mastered the home will require funds. The cripple must be supported until he is enabled to walk by himself. Therefore it is quite evident from this very efficient report of a large body of tuberculosis officers that the providing of food for the maintenance of these people is one of the really essential things in order to secure efficient results. During the process of treatment the patient may have been receiving his friendly society benefit and his insurance benefit during the process of time it has taken to deal with this man's Complaint through all its stages, and when he comes back to his home life he finds that the sickness benefit societies have somewhat reduced the amount, and the insurance benefit may also have been reduced in amount, and the man finds himself face to face with the dread spectre of poverty at a time when his own vitality has been considerably lowered by disease. Therefore it is, necessary in the establishment of aftercare treatment that financial assistance must be given so that the patient may have a chance of full recovery.

I would suggest that some amount ought to be inserted to secure more co-ordination. I think an annual conference of those engaged in tuberculosis work should be held to compare results. Personally, I think that would be a very good thing, and it is a vital necessity, that those dealing with this dreadful disease should meet from time to time at some good centre where they might exchange views with regard to research work and the treatment they have been meting out to the different people they have been dealing with. All this would considerably help to strengthen the doctors in their activity in battling against one of the most deadly diseases that this country is face to face with at the present time. In conclusion, I want to say that those on the Labour Benches will vote for the Second Reading of this measure, and in all probability will put down Amendments on the Committee stage.


I want to join with hon. Members who have given their approval to this Bill, and I should like to take the opportunity of congratulating my right hon. Friend the Minister of Health upon having introduced it. I think he will probably agree with me when I say that this measure is a provisional one, and I hope that he is satisfied with the approval which has been afforded by the House this afternoon, and I trust that with this approval he will go forward and produce; a real policy for dealing with this terrible disease. I do not know whether the Ministry has elaborated its policy, but I think my right hon. Friend will agree that this measure is only the first instalment of the policy which he intends to pursue. When the Ministry of Health was created, those of us who are deeply interested in the question of tuberculosis and its prevention and cure welcomed the creation of this Ministry as a promise that new strides, would be taken in the campaign for the prevention and cure of that disease. Up to now I do not think we have altogether had put for- ward the general policy of the Ministry of Health, and we have not had a complete system of campaign outlined of what the Ministry intends to do.

A great many hon. Members have made suggestions to the Minister this afternoon as to how he should proceed, and I feel sure that he will be anxious to put many of those suggestions into practice. I was very glad to note that he intends to amend Clause 1 in order that certain conditions which exist in Wales shall be recognised in the Bill. In Wales there is an association which consists very largely and almost entirely of members of insurance committees and the Welsh county councils. That association carries out the intention of Clause 4 of this Bill to set up joint committees whose duty it will be to administer the sanatorium benefits and all the funds set aside for this purpose for areas in which several counties can join. That principle has already been put into practice in Wales, and the results have been entirely satisfactory.

We desire that there shall be an Amendment in the Bill setting forth this matter quite clearly. We are told that it includes the agreements and schemes which have been entered into between the county councils and the association. I think we all desire that in Clause 1 mention should be made of the association and that the agreements between the county councils and the association should be definitely guaranteed. In Wales we regard this question of the treatment of tuberculosis as a national one. We think it is a matter which goes further than the mere county or county borough boundaries, and for that purpose we are of opinion that the resources of the whole country should be pooled in endeavouring to combat this disease. In the past Welsh county councils have combined together, and have carried out the intention of Clause 4. They have joined together with insurance committees in order to secure that the treatment shall be conducted on national lines, and in order to secure that not a single person throughout the length and breadth of the country shall fail to secure, if it is necessary, the treatment which he ought to receive. Again, may I thank my right hon. Friend for his promise to recognise the special conditions as they exist in Wales, and may I remind him that he would only be following the precedent set in other Acts of Parliament, more especially in the Insurance Act, which deals already with the special conditions of the Principality?

6.0 P.M.

I do not want to criticise this measure any more than I can help, but it appears to me that there is one blot on the Bill, and it is a sin of omission rather than commission. There is no financial Clause in the Bill, and I think it is intended that the financial arrangements which will come up in the Estimates for the Ministry of Health are to be based on the present arrangements.' The local authorities pay 50 per cent., or half of the deficit, and the remaining half is to come from the Treasury. I presume that means there is to be a block grant together with the contribution which is now obtained from the insurance committees, and that that contribution is to be stabilised in a definite amount- to be paid annually by the Treasury. I would like to recall the promise by my right hon. Friend's predecessor at the Ministry of Health that the local authorities should not lose through this transaction. I contend that the local authorities will suffer as a result of this financial condition. I believe that by fixing definitely for all time a block grant or contribution which at present conies from the insurance companies that that will involve the county authorities in a, larger expenditure than they are liable to at the present moment. My reasons for making that statement are two fold. In the first place, there is no doubt there will be an automatic increase in the number of insured persons. That means that there will be an increase in the number of people who contribute towards sanatorium benefit under the Insurance Act. Therefore this contribution which annually comes in from the insurance committees will probably increase from year to year, so that the 50 per cent, of the balance which is now payable by the local authorities will tend rather to diminish than to increase. The other reason is that the costs of treatment-have been steadily mounting up, and as the number of insured persons for treatment will probably have increased in the next few years, the cost of this treatment will be much more, and as there is no increase on the contribution which has hitherto been paid by the insurance committees, this extra cost will again fall on the county councils and the local authorities. I therefore think it would be much better if my right hon. Friend would press upon the Treasury, instead of giving this block grant, this fixed sum, which in the case of Wales will come to about £25,000 a year, to make a contribution of at least two-thirds of the balance. I believe that in the treatment of venereal disease the Treasury pay three-quarters of the cost, and the same principle, I maintain, ought to be applied in the case of the treatment of tuberculosis. If, however, 75 per cent, is thought to be too much, surely it is not unreasonable to ask for a contribution of two-thirds, and if the local authorities could be met in this matter, it would, I am sure, help a great deal in carrying out the provisions of this Bill.

May I point out also that the incidence of tuberculosis varies tremendously in the different counties throughout England and Wales, as another hon. Member has already pointed out, that there is a migration of people who are predisposed to become tubercular to counties where they think the climatic and other conditions of life are more favourable to their recovery, and that in the natural course of events their treatment would have to be borne by the particular county or county borough in which they happen to be resident because they have gone there for the actual purpose of being treated. It is therefore very difficult indeed to arrive at what ought to be the national proportion and the amount which ought to be paid by each of the local authorities. I appeal very strongly to my right hon. Friend not to shut the door and not to fix at the moment, for all time, the proportions which have to be paid for the cost of treatment by the local authorities and by the Government. In combating this disease, the Ministry should not be satisfied with a policy of cure and of endeavouring to prevent the disease, but they should aim at the definite goal of the entire elimination of the disease in the course of the next two or three generations. We are told by our medical friends that that is possible if the Government and the people themselves are willing to undertake the task. I therefore welcome this Bill as an instalment towards that end, but I hope it will not be the last word of the Ministry upon this great question of tuberculosis.


In the original National Insurance Act a sum was set aside out of the contributions paid by the insured person, by his employer, and by the State of 1s. 3d. per head for the cost-of sanatorium treatment. That was afterwards reduced to 9d. by the appropriation of 6d. for the cost of domiciliary treatment. In the memorandum issued by the Ministry it is stated that this amounts in all approximately to £300,000 per annum, and that payment from the Insurance Committees will cease from the 30th April. I understand that that will be made up by a grant from the Treasury to the local authorities, but will that sum of £300,000 be payable from the National Insurance Funds back into the Treasury, or will it be retained by the Insurance Committees for Insurance Committee purposes?


The £300,000 is a grant from the Treasury to the local authorities for tuberculosis purposes. It has nothing to do with the Insurance Committees. The money that used to go for this purpose is absorbed under the Insurance Act of 1920.


So that the 9d. per head is now absorbed for other benefits accruing to the persons coming under the Insurance Act?




I am bound to say, as a member of a local authority which has been treating tuberculosis and receiving payment from the Insurance Committees, that I think the better plan would be if that money available for the payment of the cost of tuberculosis treatment had been paid over to the local authorities, and that it should not be appropriated for other purposes. It was definitely set aside for this specific purpose of the treatment of tuberculosis. I quite agree with the general approval that has been given to this Bill. It is absolutely necessary that the Bill should be passed, in view of the passing of sanatorium treatment from the control of the Insurance Committees, but I view with great regret that it has been considered necessary that the sanatorium benefit should have been removed from the Insurance Committees. When the National Insurance Act was first introduced, I remember in what glowing terms it was held up to the poor consumptives and to the general community, and the great results that were to accrue from this great and glorious Act. They were to get 9d. for 4d., they were to get accommodation in first-class hotels;, they were to be restored to the full vigour of health by means of the rare and refreshing fruits of the National Insurance Act, and if there was one part of that Act, an Act that was most unpopular in many parts of the country, that reconciled a great many people otherwise opposed to it, it was this part that dealt with the treatment of tuberculosis. Many public-spirited men and women gave their services to national insurance work largely because of the appeal to the sympathy and imagination of this great attempt at last to deal with the great white scourge of tuberculosis.

I agree with those hon. Members who have spoken as to the value of sanatorium treatment. I think it is the one effective weapon that we have just now to deal with tuberculosis, but it is not without its defects. Far too much has been expected from it. It was thought at the passing of the Insurance Act that when people were scheduled as suffering from tuberculosis, all that was required to do was to send them into a sanatorium and that they would very soon be restored to health and vigour. At the very outset, sanatorium treatment was prejudiced by the fact that there had accumulated a great many acute cases of tuberculosis, and these cases sought to receive the benefit of the Act and were passed into sanatoria in many cases without any prospect of the treatment there being really effective. There were large numbers of hopeless cases for which there was no prospect of any chance of a recovery, and, in my opinion, cases should not be sent to sanatoria unless there is some hope of recovery. Those cases that are considered to be really hopeless had much better be treated in hospitals. The worst thing that can be done is to give a patient an impression that he is going to die. It has a most depressing effect on anybody, and if poor people suffering from tuberculosis have it impressed on their minds that they are only sent into a sanatorium for a short period and that at the end there is little prospect of recovery, that injures even the chances of many who otherwise might recover. The whole system of treatment in sanatoria is very defective. The great idea was at first that the patient should be fed up, that he should have perfect rest and quiet, and the great test was to put on weight. I think that is a mistaken course. The rest and feeding and open air treatment, good as they are, are not enough. In my experience many people have gone into sanatoria and have come out flabby, unfit for their ordinary work, having acquired the sanatorium habit, a lazy, loafing habit, and are not prepared to enter into their ordinary employment once again, even although reported fit for a certain amount of work.

The short period of treatment in sanatoria has told against sanatorium benefit. It is no use sending a man who is suffering from consumption into a sanatorium for three or four months; a longer period should be given. Another feature of sanatorium treatment that is most hurtful is what I call the "in and out habit." Some disciplinary power ought to be exercised over the patients in sanatoria. Men go in and come out of their own free will. They come out before they have fully recovered, they go back to their own vocations, give way to drink, live in unsuitable homes, become a menace to the public health of the community, and reach a condition which makes it necessary for them once more to go into the-sanatorium. In some cases they are refused admission on the second or third occasion and are handed over to the Poor Law authorities. It would be no undue infringement of the liberty of the subject if, when a man is being treated in a sanatorium, he should not be allowed to leave until the medical officer in charge has given a certificate that he is fit to be released from the sanatorium. That would be entirely in his own interest.

The one hopeful feature that I find to-day in the treatment of tuberculosis is the work colony. It is recognised now that the provision of suitable graduated labour in sanatoria is essential if the best results are to be obtained. The pioneers of the work colony in this country are Dr. Marcus Paterson, of the Brompton Hospital, Frimley, and Dr. Varrier Jones, of the Papworth Tuberculosis Colony, Cambridge. The principle adopted by Dr. Paterson was that only persons should be sent into the sanatorium in whose case there was some chance of cure, and the first thing he did was to give them light tasks, those tasks being increased until latterly the men in the sanatorium were able to do a full day's work. His object was to set up such a power of resistance within the human frame as would withstand the ravages of the disease. Along those lines he was able, by the treatment in his particular work colony, to make men fit, after they came out of the sanatorium, to do their ordinary work. Dr. Varrier Jones found that those who suffered from tuberculosis were not able, after treatment in sanatoria, to do more than 60 or 80 per cent, of the work which they were ordinarily accustomed to do, and so in his sanatorium he established workships. Workshops have been referred to by one hon. Member to-day, who desires that municipal workshops should be set up. Dr. Varrier Jones set up workshops in which men were trained to work at joinery, cabinet making and various other industries, and also in poultry keeping and horticulture—not, however, agricultural labour. He obtained marvellous results, but to extend that system of treatment throughout the country would prove a very expensive thing indeed. Possibly some method between the lines upon which Dr. Paterson and Dr. Varrier Jones have worked might be found, under which sanatorium treatment would not mean that a patient simply vegetated, put on weight, and acquired a lazy habit of life unfitting him for his future work. I think that along the lines of sound graduated labour schemes in sanatoria lies the hope for the future in the treatment of tuberculosis. I am satisfied that if we tackle the subject on proper lines, and if, as has been urged upon the Minister to-day, he gains the active co-operation of enlightened municipal and county authorities throughout the country, a great step in advance will be made, even under this humble Bill. Surely, in view of the deaths that occur from tuberculosis in this country and in view of the suffering and loss sustained, especially among the poor, no money that we can spend will be more usefully used than in seeking to stem the ravages of this fell disease and in doing something for those poor people who are calling for our sympathy and help.

Colonel NEWMAN

A number of speeches have been made in this Debate by hon. Members who have a knowledge of medical matters, but, although I have listened to all of them, I do not quite know whether they want this Bill or not. On the whole I think that they do. The Bill is only provisional. It is a humble Bill, and in a short time they, and probably other hon. Members of this House, will come and ask for further measures, which will cost more money. The Minister of Health, at the opening of his speech, made a true remark. He said that this Bill is largely an agreed Bill. If it were not, it could not be got through. This particular Bill was printed and in the hands of Members of this House on the 16th of March. We are now, practically a month after, about to give it a Second Reading, and it has to go through all its stages in this House, to go to another place, and to receive the Royal Assent, by the 30th April. If it does not, there will be a hiatus, during which tuberculosis benefit and the treatment of patients will cease. I will not say that this is a trick, but it is something which the Minister without Portfolio has been rather accustomed to do, namely, to put off his Bills until the very last moment, when we had to pass them through willy-nilly in two or three Parliamentary days, and, therefore, they had largely to be agreed Bills

An hon. Member has alluded to the fact that my hon. and learned Friend the Member for Baling (Sir H. Nield) and myself have put down Motions for the rejection of this Bill, and he imagined that we put down those Motions merely because we wanted to economise and belonged to the class of people who are being described as "stintomaniacs." That was not the object of those Motions. In October of last year a Select Committee of this House was set up to report upon the procedure in regard to Bills which involved charges on the ratepayers. That Committee reported with great celerity—in less than a month—and recommended that, in any Bill of this sort which came before Parliament or before the country, a definite statement should be made in the Bill of exactly what it was going to cost the ratepayer as well as the taxpayer. I went at once to the Vote Office and got my copy of the Public Health (Tuberculosis) Bill, but I did not find in it any statement of what the Bill was going to cost either the taxpayer or the ratepayer, and, therefore, I put down a Motion for its rejection. I may say at once that a White Paper has now been issued giving certain estimates of what the Bill will cost the rates and taxes, and therefore my objection is to a certain extent withdrawn; but I think that this White Paper ought to have been issued as part and parcel of the Bill. The Bill itself costs 1d, and the White Paper, which also costs id., was issued a fortnight or more after the Bill was printed. The White Paper and the Bill ought to have been issued together, so that the ratepayer, on getting the Bill, would have had a statement with the Bill itself, and would not have had to wait for a statement issued a fortnight later. With regard to the Bill itself, by a curious coincidence it is, almost to a day, ten years ago that the Prime Minister, who was then Chancellor of the Exchequer, introduced his famous National Health Insurance Bill; and today, as far as one large and important pat of that measure goes, we are singing its requiem. The Prime Minister devoted a large part of his opening remarks in moving the Second Reading of the National Health Insurance Bill to the question of tuberculosis. He told us that the Bill was largely based on German models, and he said that tuberculosis was to be combated with money provided under it. He laid great stress on that. This is what he said: In Germany they have done great things in this respect. They have established a chain of sanatoria all over the country, and the results are amazing. The first proposal of the Government is that we should first of all assist local charities and local authorities to build sanatoria throughout the country, and we propose to set aside £1,500,000 for this purpose. If I were a financial purist or of an inquisitive nature, I might ask the Minister of Health how much of that £1,500,000 has been spent or this purpose, and exactly how many sanatoria have been built during the past ten years out of that money. I think that that question has been asked, and perhaps it will be answered by whoever replies for the Government. Whether that £1,500,000 has been spent on sanatoria and whether those sanatoria have achieved their purpose or not—as to which many hon. Members seems to have grave doubt—the fact remains that the finance of the National Health Insurance Act with regard to tuberculosis has broken down, and that whatever scheme we are going to have is going to be run on subsidies paid by the taxpayer and the ratepayer. Personally, I do not believe that the Minister of Health or any other Member of this House has the faintest idea—I have not myself—how much this treatment of tuberculosis is costing the taxpayer or the ratepayer at the present moment. In the Ministry of Health Estimate for the present financial year, £1,210,000 is allotted for the treatment of tuberculosis. We are told in the White Paper that there is going to be a further sum of £300,000, which is to be a fixed sum; and, apparently, there is to be provided by the Treasury, or at any rate by the taxpayer, £100,000 for the after-care of soldiers who are suffering from tuberculosis. That, apparently, is a very rough estimate of about how much the treatment is going to cost the taxpayer; but then how much is it going to cost the ratepayer?

Just a week ago the Minister for Health was making a speech in reply to a private Member's Motion in regard to the question of local rating, and he made a statement in which I cannot help thinking he was wrong. He was talking about what a comparatively small charge was imposed by his Ministry on local authorities, and he alluded to what local authorities had to expend in regard to what is called personal, preventive and curative services, sanatoria, dispensaries, the treatment of tuberculosis, venereal and other diseases, maternity and child welfare. He said the cost of all these services was on the average only the equivalent of a 2½d. rate. In the White Book issued by his predecessor in 1919, I find that Ipswich alone was compelled to spend on these services not 2½d., but 11¼d. Again, in the White Paper we are told that the rate per annum charged to the ratepayers will never exceed the proceeds of a penny rate. Ipswich alone is spending 2¼d. on tuber culosis. In Sunderland it is again 2¼d. In Leeds it is 2¾d. Does the right hon. Baronet mean that this rate of 2¾d. in Leeds will be reduced to a penny by means of some Government subsidy? The measure is necessary, and I am not opposing it, but I should like to have some sort of estimate of what it is going to cost the taxpayer and the ratepayer. We all agree that tuberculosis is a terrible disease. The Prime Minister said, in introducing the National Health Insur- ance Act in 1911, that 72,000 people were dying yearly from tuberculosis. An hon. Member opposite has stated that at present the number is 42,000. That is a reduction but it is a terrible number, and we ought to do what we possibly can to find out the source of the disease and how to combat it. We are going to spend large sums of money on it. But tuberculosis is not the only disease. According to the laws of actuarial calculation one out of every eleven of them dies of cancer, and yet how little we are doing for cancer in comparison with tuberculosis. If the Minister of Health can possibly get money from the Treasury he might spend it much worse than in devoting it to cancer. Both are dread scourges, but to my mind cancer is the worst. On the assumption that the right hon. Baronet will answer the points I have raised, I do not propose to move my Motion.


I have listened to the Debate with great interest, and I have been specially struck by the extraordinary amount of sentiment specially directed towards the condition of the tubercular person without really considering the merit of the treatment which this Bill wishes to provide. I welcome the Bill, which is necessary in filling up the gap left by the Act of 1920. That Act took sanatorium treatment from the Insurance Committees and it is now proposed to hand it over to county and county borough councils. This Bill solely deals with the question of institutional treatment for tuberculosis, nothing more And nothing less. As I read the finance of the Bill, something like £400,000 will be available for this purpose. In my view sanatorium treatment at present is nothing more or less than en experiment. Almost everything about medicine is experimental. The spending of large sums of money on institutional treatment is not in my opinion either wise or justified by the results of the past. It is only one of the whole gamut of methods of treatment. It is only one little stage of treatment which often comes in unfortunately when treatment of any kind is more or less useless. It is one little aspect of the whole question of treatment, and I do not think it has justified itself up to now. I do not think it warrants the huge and unlimited expenditure of money. Honestly, I regard the sanatorium as little more or less than one element of an educational agency which the Ministry of Health has at its command now. The Ministry of Health as an educational agency, to my mind, has a duty more important than merely creating bureaucrats to dispense large sums of money in this direction or that. One fault I have to find with institutional treatment is that it reaches a certain degree of what I might call passivity on the part of the patient himself. The After-Care Association encourage that passivity when often all that is wanted is to rouse the patient to the knowledge that he is his own keeper, that his health is in his own care, that by simple attention to hygienic rules he can not only give himself a higher and better and stronger life, but he can cease to be a burden upon his fellow men. The sanatorium as an educational agency to my mind has its value. The sanatorium as a treatment agency has merely its little part in the whole scheme of treatment.

Incidental reference has been made to the financial statistics of the Bill as they work out in relation to county councils, county borough councils, and the State; but there is one point with regard to this question of finance which impresses me as perhaps unique. This is a simple little Statute which ostensibly deals with the limited question of the treatment of phthisis which introduces the idea of a simple transference of what I might call the onus of the incidence of payment for benefit given. In the National Health Insurance Act the benefits derived by institutional treatment were paid for by the employers, by the State, and by the insured person himself. The onus of the incidence of that is by a stroke of the pen removed and placed upon the local ratepayer and the-income taxpayer. I do not think that is a precedent which should be followed. If financial readjustments like that are necessary, they should not appear as a side issue, or in some way oblique or in distant relationship to the Bill before us. Apart from the dislocation of finance in regard to the Bill, there is a dislocation of the personnel of National Insurance committees dealing with tubercular matters. The hon. Member (Mr. Ormsby-Gore) referred to the sad case of an official losing his job because of this dislocation. That is, unfortunately,' possible, but it cannot be avoided. It is part of the wreckage of the whole National Insurance scheme in regard to tuberculosis. No Act can compel a county borough council, which is now becoming the authority under the Act," to take over the personnel of the County Insurance Committee, with which it has nothing but a very indirect relationship. That is another point on which obviously the Bill will create difficulty.

It has been suggested that it should be made mandatory on county councils to co-opt members of insurance committees. An Amendment in that direction suggests to my mind a most unfortunate and iniquitous principle. That it should be permissive on the part of the county council is right and proper. People with certain statistical information with regard to the treatment of tuberculosis in institutions will be very useful, and I have no doubt they are, but to compel county councils to co-opt and give an equal voice in the deliberations of these committees to members of insurance committees is introducing an entirely vicious principle. I wish to support the Ministry in most heartily resenting that. Where the ratepayers elect their representatives they should have a vote but those who are not elected by the ratepayers to these bodies should be deprived of a vote on those vital matters. They might be given a vote on matters which do not concern expenditure or treatment; but to introduce an entirely new element into the representative character of local bodies will be disastrous in the extreme. In conclusion I maintain that the institutional treatment is entirely experimental, and that this Bill has one or two defects which ought to be remedied in Committee, but with these exceptions I welcome it as filling up a gap left by the Act of 1920.


For many years I have sat on a local authority whose record in connection with this matter of tuberculosis will be admitted by all to have been of a very high character. I do not wish to say anything against the general principle of this Bill. We all recognise how absolutely necessary it is that increasingly effective treatment should be provided for dealing with this very great scourge. There is one point of which I do not think sufficient has been made, and that is with regard to the effect of the Bill on the finances of local authorities. There is a rather vicious principle in- volved in this Bill. I do not wish to be too severe upon this point, but I strongly object to the principle by which the Minister is to come down on to a local authority and inflict on it expensive action of which the State is not prepared to find the full cost. I believe in allowing local authorities as far as possible to have full and free action, apart from action being taken over their heads by the Minister. If action is really necessary and if it is necessary that the Minister should come down to coerce local authorities, they ought not to be put to any serious financial loss. I see from the White Paper that has been issued a statement that certain arrangements are to be made in order that the councils may be no worse off. On the fact of that it may seem that fairly good arrangements have been made, and I have seen remarks on it by the County Councils' Association; but it is certainly going to involve very considerable expense, and we ought not to be called upon to pass a Bill of this kind, involving a considerable increase in local rates by the mandatory, coercive action of the Minister, without something being said about it before the Bill passes.

We are to be granted in future a payment which represents the block grant of 1920 and one-half of all extra expenditure; but I want to point out that, whereas under the Insurance Act the payment which local authorities received was increased according to the number of patients, in future, now that the grant has been made a block grant, it will remain permanently the same. On the other hand, buildings will become more expensive and the number of patients will increase, and consequently the excess in expenditure of the councils will be more and the half which the local authorities will have to find will automatically become larger. The local rates ought not to be charged with what is largely a national matter. It is certain that the burdens will be heavier upon some counties than upon others in respect of the treatment of tuberculosis patients, and I maintain as an important principle that this increased expenditure upon the treatment of tuberculosis is one which should be treated as a national matter.

I want to say a few words on the subject of sanatorium treatment. I have heard a great deal of discussion on this matter, and it is certain that there is a great difference of opinion among medical men as to the actual value of sanatoria. There is only a certain amount of money that can be spent, and it is an open question whether in devoting so much money to this particular system we are really making the best use of the money we have to spend. There are many cases where a man goes into a sanatorium, and whilst there, subject to the treatment and the conditions, he! improves, but on his discharge he goes back to the bad old life, to the bad air of the surroundings from which he came, and becomes merely a carrier of the disease to other people. If there is any fault in the matter it is that the State is not prepared to spend more money to provide further treatment for the man when he leaves the sanatorium. It is questionable whether we are wise in devoting so much of the money which we have to spend to this particular treatment, which may in the end have a worse effect than if we spread the treatment over a wider area by dealing with the man in his home life or treating him otherwise without the necessity of his going to a sanatorium. With respect to the mandatory suggestion with regard to co-option I am certain that any local authority which is doing its duty would resent any mandatory system. I am glad to say that that is not in the Bill. Where there is a man who is worth co-opting, he will be co-opted. It would be a mistake to make this co-option mandatory upon local authorities, because it would do more to make them hostile than if it was left permissive.


I have not the knowledge or the ability to discuss the question of tuberculosis, but I want to ask the Minister to make clear one point on the financial side of the Bill. I am speaking on behalf of the Middlesex County Council in the absence of the hon. Member for Baling (Sir H. Nield) who is not able to be here. Under the present system, the Middlesex County Council began tuberculosis treatment 10 years ago, immediately the Insurance Act was passed, and they have had a definite agreement with the Insurance Commissioners for the handing over to them of those payments for tuberculosis patients which are now being taken away by this Bill. The treatment which the Middlesex County Council have provided has been provided voluntarily by them. There has been no statutory obligation upon the Middlesex County Council or upon any other county council to provide this treatment, but if they chose to provide it there was a statutory obligation upon the Insurance Commissioners that these amounts for the institutional treatment of the patients should be handed over to them regularly towards reimbursing them for the cost of the treatment.

As I understand this Bill, for the first time sanatorium treatment is being made compulsory upon county councils. There is a statutory obligation placed upon them that they are to carry out certain schemes of treatment, and if they do not do it, the Minister may take steps to do it himself. That alters entirely the position of the county councils. The county councils want to know where they are to look for the sums which hitherto they have received from the Insurance Commissioners, and which cease at the end of this month. Therefore the arrangement with the Insurance Commissioners is at an end. Where are the county councils to get the money? There is nothing in the Bill which authorises Parliament or the Minister to pay this money to the county councils. On the other hand, the White Paper, which is not signed by anybody, not even by the Minister, says that in order that the councils may be no worse off while continuing to provide treatment, it is proposed to ask Parliament to provide for a fixed amount of grant to the local authorities equal to the grants they have received from the Insurance Commissioners for the last year. That is all very well, but is the county council to rely upon a flimsy pennyworth of paper, which says that Parliament will be asked to make this grant? On behalf of the Middlesex County Council which is doing very important work in this direction I protest and ask that something of this nature should be embodied in the Bill. I do not think it is right for the Minister to issue this flimsy White Paper. This provision for the treatment of tuberculosis patients cannot be done in one year. It involves the erection of buildings, the appointment of doctors, nurses and staff. It is a continuous and progressive business.

Are the county councils, when it is made a statutory obligation upon them to do this work, to rely upon a White Paper, which has no statutory power whatever, and upon the mere statement of the Minister that he is going to ask Parliament to provide that grant? How is he going to ask Parliament to do it? The Middlesex County Council ask that this provision should be embodied in the Bill, and I ask the House of Commons to say that it is right that it should be so embodied. We have no right to rely upon the mere word of any Minister or any Government, however powerful they may be, that they propose to continue an annual grant. We must have it in the Bill. Then we come to a second point that the annual amount of half the extra sum of the cost to the county councils over and above the block grant is to be provided for by an annual grant coming up on the Estimates of the Ministry. It may be right to make H an annual amount on the Estimates, but I suggest to the House—and I hope the right hon. Gentleman will feel that it is in no hostile spirit that the Middlesex County Council is pressing this matter, seeing the very great work they have done and are doing—that something more should be done than the mere ipse dixit of the Minister, that it should be embodied in the Bill and that this particular block grant shall be paid for a regular time to the county councils.

7.0 P.M.


I should like to make some reference to the proposals referred to in the White Paper, and I wish to emphasise what has been said by the hon. Member for Barkston Ash (Mr. Lane-Fox). When sanatorium benefit ceases on the 31st April, the contributions of the Insurance Committees, which amount approximately to £300,000 per annum, are to cease, but in order that the councils should be no worse off, we are told that it is intended that this sum of £300,000 shall be voted by this House, and that that shall constitute the block grant that is to go to the county councils. How is that £300,000 made up? I suggest in the first instance it is made up of the 1s. 4d. which was available, and which the Government paid to the Insurance Committees to give institutional treatment to tuberculosis people. That was eventually cut down to something like 9d. per person, and it is pretty common knowledge that latterly during the War even that sum was not always available. Therefore I take it that that is the reason why it is stated in the White Paper that the councils are to-receive in respect of tuberculous infected persons, by agreement with the insurance committees, the amount which those committees had available for the treatment of such persons. That is to say, they did not get the 1s. 4d.; they did not get very often even the 9d.; but, in consequence of the depleted condition of the resources, of the insurance committees, they had to take whatever sum was available. I suggest that under these circumstances-it is not fair to county, councils to stereotype that sum at £300,000. The block grant ought to be based upon the full amount that the insurance committees should have paid over to the county councils. That, I am sure, did not reach the full amount in most cases, and I suggest for the consideration of the Minister whether it would not be well to look into these financial provisions and see if the county councils should not have something more than the £300,000 at which this institutional treatment is valued for 1920. Why 1920? I do not know why that year was chosen. It is last year, of course, but it may have been a specially bad year so far as county councils are concerned. In these days of constantly rising rates we are bound to look with scrupulous care at any proposals of this sort, because it is quite clear, as the hon. and gallant member for Barkston Ash and the right hon. Gentleman who spoke just now pointed out, that a very considerable additional cost is going to be imposed on councils in consequence of this way of dealing with the future treatment of tuberculous persons in institutions.

There is one other point I wish to mention. At the end of page 3, the Estimate is given for annual expenditure consequent on the Bill. It may be right that it is going to cost the Exchequer £20,000 and the rates £20,000—£40,000 altogether; but it does fill me with amazement that such a small sum as that is all that will be required for the very heavy services that will have to be met. Those are the points I wish to bring forward. I would, however, again ask that an examination may be made as to how this £300,000 per annum has been made up, and if it is found that the insurance committees have not been paid the full amount, that the Estimate of the block grant shall be based upon that and not upon the amount which they actually paid.

Lieut.-Commander KENWORTHY

The majority of the speeches this afternoon have contained nothing but praise for my right hon. Friend the Minister of Health and his Bill. It has been poured out like gallons of honey, except in the last speech or two, and I expect my right hon. Friend is as sick of it as you, Mr. Speaker, may be, and I am. I want to bring forward a little criticism of this Bill, and to criticise it very earnestly with one particular respect. This measure is going to do away with the -very valuable work which has been done in a great many districts by the insurance committees. The hon. and gallant Member for North Leeds (Major Farquharson) supports the Minister in the attitude he took, up that the local councils who will have to administer the Bill only may co-opt members on the insurance committees. The Clause is not made compulsory. I very much hope that although the Minister of Health nodded his approval when the Member for North Leeds was giving us the benefit of those sentiments that he will consider the matter again. There is no question of those co-opted members having any power over the purse or any control in the raising of rates or in borrowing money. They will not have anything like an equal voice because it is laid down distinctly, in Clause 3, that no less than two-thirds of the members of the committee or sub-committee shall consist of members of the council. Therefore they will always be in the minority. It is quite optional, under this Bill, for the council to co-opt these people at all. Hon. Members will agree with me that in a great many districts the insurance committees have done very fine work. They have mostly been officials of the great thrift societies and friendly societies. Their work mostly has been voluntary and a real labour of love.

I speak particularly, as every hon. Member must, of course, speak, for the constituency I have the honour to represent. In Hull, and in that part of Yorkshire, we have a very fine system of dealing with tuberculosis. There is a very beautiful sanatorium, a really first-class sanatorium, well away from the city. What is more important still, there is a very carefully organised system of after- care treatment. The man is watched after he goes back to his work, great care is taken that he shall not go to unsuitable work. If the man is working where there is a lot of coal gas or flour, or anything of that sort, he is not sent back there again, he is watched and taken care of, and put to work in the open air. All this close detailed treatment certainly does not require expert medical pundits to carry it out, but enthusiasts who have the welfare of their suffering people at heart. Those you have in my part of the world on the Insurance Committees, and they take an active part in this work. That may be swept away, and it would be a real disaster. What is going to be put in its place? I am informed that a Circular was issued by the Ministry of Health on 31st March last—Circular 109—which says that under this Bill the Ministry will see that residential treatment at least equivalent to that previously provided by Insurance Committees shall be supplied. Not better, only "equivalent," or, at least, approximate. In view of the objections that have been put forward even in this Debate from the point of view of expense and of dislocation in turning this work over to new bodies, I do not think that this Bill is justified at all. I do not think these Insurance Committees are being treated, fairly. I hope, when the right hon. Gentleman replies, that he will be able to hold out some hope that this will be made com pulsory and that the Insurance, Committees will really be given a voice in the matter. I assure him that they feel very keenly about it I do not want to hold out any sort of threat, but it will give him a good deal of trouble, one way or another. They are not uninfluential people, and they think they know what is best. I hope the right hon. Gentleman will meet them half way and give them full consideration in setting up these new bodies to deal with this all-important subject.

I know it is said in certain parts of the country that Insurance Committees have not done their work. I can only judge for those in my own part of Yorkshire. There they do their work very well and give great satisfaction. I regret very much that this Bill is threatening them to that extent. It is usual to say that we want to do all we can to cure this terrible blight of tuberculosis. I want to remind hon. Members who pay such lip-service to their suffering fellow-countrymen on these occasions—I do not mean lip-service, for they undoubtedly feel very sincerely on the matter and I am not speaking in any offensive way, but they always support the needs of their suffering fellow creatures in these Debates—do they realise what the question of the standard of living of the working classes will mean in statistical figures when we get our comparative returns in a few years? The hon. Member for Lanark (Captain Elliot) gave a warning which I hope was heard and will be taken to heart. There has been an improvement in the working-class standard of living during the War, and I think it will be found that the figures for tuberculosis have gone down in consequence. A depreciation in the standard of living will mean bad housing, under-feeding of children, and enfeebled health. Various hon. Members who are high up in the medical profession have told us about the need of stopping tuberculosis in its early stages. You can reduce the amount of it tremendously if you only improve the standard of life. That should be considered by hon. Members when they glibly talk about the absolute necessity of reducing wages and about cuts. It would be false economy, in the long run, for the only real capital of the country is the skilled worker who can produce wealth by his work. Your great wealth in future has to be a healthy people, as was stated during the War and since by the Prime Minister. I do not know if the Minister of Health is taking any part in the present negotiations, and I do not want to refer to them, but I hope that at any rate his voice will be raised in the Cabinet in defence of the standard of life of the working classes which has been so hardly won during the last few years. Whoever is going to pay for the War, I hope it will not be the workers of the country, because their children would pay for it in the future in injured health,


I am sorry that the hon. Member for Twickenham (Sir W. Joynson-Hicks) has left the House. He alluded to the White Paper, issued by the Ministry of Health, and asked why it is not signed? I had the honour of being a Member of the Committee appointed at the end of last Session to deal with the question of whether or not some step should be taken to inform this House as to the cost which would be thrown on the ratepayer by any Bill proposed in this House. We arranged that a paper should be circulated with the the Bill informing the House of the supposed cost of the Bill in question. That is what the right hon. Gentleman has done. He has carried out the recommendation made by the Committee set up for that purpose, and, therefore, I think no blame can be attached to him or to the Government. The advantage of our recommendation has been shown, because the hon. Member for Twickenham and other hon. Members now know what the cost of this measure, or the estimated cost, is going to be. They can take what steps they like to safeguard the interests of the ratepayers if they think those steps ought to be taken. The only reason for our making the recommendation was that the' House might know what they were going to pay. Of course, it is only an estimate. I should not venture to criticise the estimate, because I have not had the opportunities which the right hon. Gentleman has had for going into it. I am afraid, however, it is tarred with the error which generally tars all these estimates, namely, that it is very much under the mark, especially after the various speeches to which we have listened. I shall be very much surprised if this Bill emerges from Committee in such a form that the very moderate amount which appears in the White Paper will not be exceeded.

From the White Paper I gather that a certain sum not exceeding £300,000 will be provided by Parliament, and in addition an Exchequer grant estimated at £20,000 will also be contributed. I am glad to see the President of the Board of Education present, because I am going to say a few words on behalf of the people who provide the money, and as we have got to provide him with money perhaps he will help me in safeguarding the taxpayers until the finances of the country are a little better. Sub-section 2 of Clause 1 does inflict a charge upon the ratepayers which is not met by the White Paper. I gather that the actual effect of the Sub-section will be to put it in the power of the Minister to compel a county or county borough to provide dispensaries, sanatoria and other institutions approved by him, and if they do not do that themselves he may find the money for those purposes out of money provided by Parlia- ment, but he can recover that money from the county or county borough as a debt due to the Crown. That imposes on the county or county borough an expenditure which they may be unwilling to undertake. I understood from the right hon. Gentleman that he does not intend to put this particular Clause into force.


The words in the Clause are, "Be deemed to have made adequate arrangements for the treatment of tuberculosis." That refers to schemes now existing, and covers practically the majority of the local authorities. As long as those arrangements continue to be deemed adequate, the Clause will not apply. It will only apply when they fail to make adequate arrangements.


But where the county council or county borough fail to make any arrangements at all, then the Minister may step in and compel them to make those arrangements and to levy a rate to provide the necessary money. If a county council or county borough have not made an arrangement it is probably because they think it is not necessary. In those circumstances it is rather straining the power of Parliament to say you are obliged to make these arrangements. Therefore, I object to that part of the Bill altogether, and hope that in Committee that Clause may be left out. We have had an interesting Debate, and several hon. Members agreed with the hon. Member for the Wavertree Division (Lieut.-Colonel Raw), who was very eloquent as to the necessity of sanatoria. But the hon. Member for North Leeds (Major Farquharson) as a medical man said that there was grave doubt among the medical profession as to whether the sanatoria did any good. He was inclined to think that the money spent on them to a very great extent was wasted, and that another system should take its place. He said that they were very good for educational purposes for the members of the medical profession, but he did not seem to attach very much importance to them for what is after all their primary purpose—that is the healing of disease.

The hon. Member for the Wavertree Division, although very eulogistic of sanatoria, said that unless the sanatorium treatment is followed up by something else a great deal of the money spent on sanatoria is wasted, and he suggested an extraordinary doctrine. I was so much astonished that I said to one or two hon. Members who were sitting by me, that I could not understand an hon. Member on this side of the House making such a suggestion. I was informed that he was a very strong Tory, almost as good a Tory as I am myself. That makes it more curious that he should make such a suggestion. I suppose it is due to the fact that if you understand a particular subject and become an expert upon it you push it to extremes. The hon. Member said that it is all very well sending these people to sanatoria, but you had to follow it up and suitable occupation ought to be found for them, and that there ought to be municipal workshops. If hon. Members opposite talked about municipal workshops I should not be surprised. I believe that even they have rather changed their faith in municipal workshops. Probably they have read what happened in Paris in 1848 when municipal workshops were set up and they have now come round to the view that they are dangerous institutions.

The hon. Gentleman went further and suggested not only municipal workshops but Government workshops and he also suggested a subsidy and he said that suitable occupation should be found and that full rates of pay must be given, even though only half a day's work was done. In all seriousness I request the right hon. Gentleman to be a little stiff when we get into Committee, because he is going to have a very difficult time in Committee. He is going to be met by friends of the hon. Gentleman with the suggestions which I have just quoted. He is going to be met by hon. Gentlemen opposite with not more dangerous suggestions but very dangerous suggestions. They say that you ought to combat disease in children by providing them with milk, food and clothing. Also, when we are discussing the Bill, let us consider what has Seen the effect of the sanatoria which ten years ago we were told were going to be set up like first class hotels, and going to do all sorts of things which apparently they have not done, and there seemed to be some likelihood of a new world, of which about a year and a half ago we heard a great deal, which does not seem to have materialised. At any rate I have seen nothing of it.

Then on the subject of elaborate buildings, I hope that the right hon. Gentleman will not mind me if I say that probably the education which he went through in the Office of Works has rather led him into the habit of being fond of elaborate buildings, and he may regret that some of these buildings, which very likely the Office of Works will ask you to allow them to put up for these new sanatoria, may not be very beautiful to the eye, but neither will they be pleasant to the pocket of the ratepayer and taxpayer who will have to find the money. I hope that there will be no attempt to press local authorities to take action against their will. What is the use of establishing local authorities unless you think them competent to do the work entrusted to them? If you are going to allow a Government Department to run the country, get rid of local authorities and have a Government Department, but if the idea of local self-government is to continue, let the local people manage their own affairs and let the Government Departments manage theirs. They have quite enough to do. We are always told that it is necessary to have these enormous staffs to cope with the work. Let them do with less work, and they will require less staff. I conclude by hoping that the right hon. Gentleman will maintain a stiff attitude in Committee.


In common with many other Members I welcome this Bill, but at the same time I must offer one or two criticisms of it. It makes no provision for preventive operations, and at the other end it makes no adequate provision for after-care treatment. The Bill is described as one "To make adequate arrangements for the treatment of tuberculosis at or in dispensaries, sanatoria, and other institutions." Such a definition of "adequate arrangements" is too narrow. It assumes that the only method of treatment to be entered upon is at or in the institutions specified. The hon. and gallant Member for Wavertree (Lieut.-Colonel Raw) told us that no civilised community ought to have tuberculosis in it and that it could be prevented. If that is so the first line of attack ought to be in a direction of prevention. There is nothing in this Bill which proposes to do anything in that direction. We are confronted with two aspects of the same problem, and those two aspects send us in different directions. Tuberculosis in the child and tuberculosis in the adult call for different methods of treatment. Tuberculosis in the child is due to food, and in the case of the adult it generally arises from physical contact and infection. Obviously, if we are to treat the disease in the child we must tackle the food supply, and particularly the milk supply. During the whole of last Session we had upon the Order Paper a Milk and Dairies Bill. We are now told that the Bill cannot be reintroduced during the present Session. It is a well-known fact that there is being sold to-day in large quantities milk from which all the feeding properties have been abstracted before it is sold. If tuberculosis is a question of resisting power in the child and milk is one of the chief articles of the child's diet, it is obvious that if the milk is deficient the resisting power of the child is weakened. Milk is also being sold to-day infected with tubercle.

The hon. and gallant Mamber for Wavertree is credited with a declaration that of all the milk-giving cattle in the country 3 per cent, throw off tuberculous milk, and that if the milk of one animal is mixed with the milk of 25 others it will contaminate the whole supply. Therefore, not only have we a low quality of milk sold, but there is a distribution of milk which contains the germs of disease. We may set up all the institutions we choose, but, so far as child life is concerned, the problem will not be changed until we tackle the milk supply. In the "adequate arrangements" mentioned in the Bill there should be a periodical and systematic inspection of all milk cows, within given areas. In the case of adults, we treat the disease as it is passed from one person to another. The little experience I have had in public health administration justifies me in believing that one of the important things at the moment is earlier diagnosis of the disease. The next aspect of the problem is that dealing with amelioration. Complaints have been made this afternoon about the ineffectiveness of insurance committees. Insurance committees have done good work within their possibilities, but they were hampered from the start. From the day when the medical profession took 6d. out of the 1s. 3d. that was available for domiciliary treatment and left 9d per patient for all other forms of treatment, effective administration was doomed, because the funds were inadequate. Moreover, while the medical men of the country appropriated that 6d., very little of the work has been done. Domiciliary treatment has been an absolute failure. We shall not deal effectively with the ameliorative aspect of the question until the housing problem is tackled. Some hon. Members will say that we are attacking that problem now. We are not tackling it, at all, so far as tuberculosis is concerned; we are simply increasing the number of houses, without any regard to the tremendous number of unfit houses now occupied in our industrial cities and towns there are thousands upon thousands of back-to-back houses and dwellings of a similar character which should be demolished.

An hon. Member this afternoon told us that sailors who come into the country are more prone to tuberculosis than any other section, despite the fact that they are constantly living in the open air, and he attributed that to the very small cubic air space provided in their quarters. If that applies to sailors who live on the open sea it must apply with greater effect to the industrial population living in our towns. In Ireland, the population is, comparatively, very sparsely distributed, but with all the advantages of open-air life there tuberculosis is much more prevalent in proportion to the population than in any other part of the United Kingdom. Let us deal with matters which come within the curative aspect. Dispensaries are among the most important units, and from whatever point of view they are judged they are doing excellent work. The sanatorium method of treatment has not met with the same measure of approval from those who are entitled to express an opinion. I believe that it has not had an adequate opportunity. The sanatoria have had to take a very great many advanced cases, or cases which have been long on the waiting list. The period during which patients are under treatment is altogether too short. I believe that an improved system of sanatorium treatment and proper after-care treatment, together with some efficient method of looking after the housing and the working conditions, and the social habits of the sufferers, would produce much better results. As to other methods of treatment there are differences of opinion among medical men. This Bill makes little or no allowance for those differences of opinion. This afternoon we have had sanatorium treatment approved, and we have had it almost condemned. That is typical of the differences of opinion. A furious controversy is raging in the ranks of the medical profession to-day as to the virtues of tuberculin. It is a fact that while some experts hold that tuberculin should be applied only by a person who has specialised in its use, and has a full knowledge of its constituent elements, and then only in limited quantities, the ordinary medical practitioner, who claims to know little or nothing about tuberculin, as a short cut in the treatment of tuberculous cases that come under his care, applies tuberculin. Yet we are told that it is more likely to do harm than good to the patient if applied in this way.

The administrative side of the question has been discussed in so far as the financial responsibilities of local authorities are concerned. I believe the local authorities will do much more work in this connection than they have done hitherto, now that the whole of the responsibility is upon them. If they do more work they will spend more money, and as the cost of administration has greatly increased a heavy burden will be placed on them. To call upon local authorities to deal with this question and to carry the financial responsibility is hardly equitable. The hon. and gallant Member for Lanark (Captain Elliot), in his remarks about after-care treatment, said that when a patient was supposed to have recovered his active physical capacity as a workman was only 50 per cent, of what it had been before. The hon. and gallant Member said it would be necessary in such cases to find some means of providing light employment. I agree! In one of those good-natured tilts that he frequently has at the Labour party the hon. and gallant Member said he wondered whether the industrial population would set aside a number of soft jobs in order that these people could be employed. He invited our opinion on the subject. I am not here to answer for the industrial workers of the country nor eyen for the Labour party. The hon. and gallant Member for Lanark can have my opinion without reservation. The responsibility for the treatment of tuberculosis should not come upon any one section of the community. I agree with him that the casualties of industry should be provided for just as much as the casualties of military activity. It is one of our grievances against the present social and industrial system that the casualties of industry, are not adequately provided for, but if my hon. Friend goes so far as to say that the victims of tuberculosis are casualties of industry, I will join issue with him. Tuberculosis is the result of underfeeding, low nutrition, bad housing and defective public services. To make the suggestion that when all these evil effects have operated upon the community the industrial workers of the country should shoulder the responsibility of attending to the convalescent victims, is a suggestion which, after mature consideration, even the hon. and gallant Member will see is rather—

Captain ELLIOT

I do not want to interrupt my hon. Friend, but as he has challenged me on the point may I say I did not make the suggestion that they should shoulder the responsibility; I merely suggested we should have their co-operation in dealing with the problem, as I am sure we will have after my hon. Friend's remarks.


I do not think there need be any doubt as to the co-operation of every phase of our working-class movement in endeavouring to make up the deficiencies of the State in this direction; but, after all, it is the responsibility of the State. I suggest that the chief defect of the Bill is that the "adequate arrangements" specified are altogether too narrow. They ought to include some definite form of preventive policy and they ought not to particularize upon one class of institution. There should be definite provision for after-care treatment. The burden upon our local authorities may possibly have a tendency to slacken their activities, and in order to avoid that, a greater measure of State financial responsibility should be recognized in the treatment of the problem. It is a national problem. It does not operate to the same extent in one locality as in another, and no locality should be called upon to carry the burden. The responsibility should lie in the wider administration of our national finances.


The House will recognize that it is quite impossible for me in the time which remains for us to get this Bill read a Second time—as I am sure the House is anxious to do—to cover the whole ground of the very interesting and important discussion we have had. I am gratified at the kind manner in which the Bill has been received and the unanimous opinion expressed as to the necessity for giving it a Second Reading while reserving certain points for discussion in the Committee stage. Our discussion, however, has ranged over a very much larger field than seems to be justified by the very modest scope of the Bill. We have heard discussed the whole question of tuberculosis, also dispensary treatment, aftercare committees, the feeding of children, housing, and a number of other subjects which are all undoubtedly cognate to the general treatment of the disease, but are rather outside the scope of a Bill, which merely transfers certain obligations from insurance committees to local authorities and provides for- the finance of this arrangement. This Bill deals only with institutional treatment of a certain character, and hon. Members who seem to have overlooked that fact have blamed me because it does not contain all kinds of provisions to deal with other matters affecting the treatment of tuberculosis which are already in existence, which are already being carried on, and which, so far as I am aware, require no legislation. I have been asked a question as to the total expense involved in the treatment of tuberculosis. The total expense is estimated at £2,300,000 a year, of which the Exchequer is bearing £1,300,000 and the local authorities are bearing £1,000,000. Another £100,000 has to be added to the Exchequer expenditure because that is the sum which will come on the Exchequer which is now borne by the Insurance Vote. What we are discussing here is £300,000 out of a total expenditure of £2,300,000, which, of course, is not being disturbed, and therefore need not be dealt with. The House will therefore not expect me to go into all of the many questions raised, but I have been glad indeed to listen to the remarks and criticisms of hon. Members who have taken a very active and energetic part in this branch of the administration of my Department. I can assure them that their observations will be carefully noted and that I shall take full advantage of the many valuable-suggestions which have been made.

I do not profess to be an expert on tuberculosis A number of hon. Members evidently are great experts at laying down on what lines of treatment we ought to proceed, but I am not such a sanguine person. Where doctors disagree it is difficult for laymen to be dogmatic. Undoubtedly, one of the difficulties for anyone holding my position is that he has to deal with questions regarding which the greatest experts have differences of opinion. For instance, we have been told to-day that sanatorium treatment is a failure and also that it is most valuable. To an unprejudiced mind both statements are true. It has not achieved everything that was expected, yet I do not think anyone will say that it has not achieved beneficent results. In all these questions there is a medium, and I hope to see the day coming—the hon. Member for Wavertree (Lieut.-Colonel Raw) is evidently advancing on the road—when, without all this sanatorium, aftercare treatment and other expensive methods, it will be possible by the injection of a serum to cure anybody of this disease. When that point arrives, I shall say that the medical profession has nearly solved this problem—which it has not done up to the present time.

A number of questions have been asked on the financial aspect of the Bill which deserve and require reply. I would point out that the £300,000 which is mentioned in the White Paper is not a fixed amount, but an approximate amount. It is the contribution which would have been received from the insurance committee by the local authorities. The local authorities are actually receiving from the Exchequer the full equivalent of the amount available in 1920 out of the insurance committees. They are in exactly the same position as before. If this £300,000 is exceeded, the Exchequer will find the equivalent amount, and that sum is to be taken as an estimate, in that sense. The point has been raised that it is possible that at some future time local authorities may have to find more money out of the rates than they are finding to-day. That is perfectly true. That may be the case anywhere. It does not necessarily follow, however, that if the old arrangement had been continued this would not have occurred, because the old arrangement was also a limited arrangement—limited to certain services—and services might become less important as others became more important. Further, I might say that criticism of that kind would have been more applicable to the National Health Insurance Act than they are applicable in this case. We have to fare the facts as they are and make the best arrangements we can. The hon. Member for Twickenham (Sir W. Joynson-Hicks) raised a question as to the Middlesex Council, who seem to be alarmed lest they should be damnified by this Bill. I do not see why they should be alarmed, and the County Councils Association takes the same view. I have had some discussion with the hon. Member for Baling (Sir H. Nield), who had an Amendment down, and he came to the conclusion that the fears entertained were not founded.


He would have moved the Amendment in order to get an explanation on the point as to whether this grant would not be embodied in the Bill. At present it is only in the White Paper.


I would point out that the 50 per cent, grant, which is a much bigger grant than the £300,000, is an annual Vote. I cannot see why you should differentiate between two Exchequer payments for the same purpose. The Exchequer will provide the £300,000 and the 50 per cent. Such amounts have always appeared on the annual Votes to give the House of Commons an opportunity of discussing them.


These never appeared.

8.0 P.M.


No, but it is a much similar sum. The Exchequer is contributing £1,300,000. The £1,000,000 is an annual sum, and we are asking to make the £300,000 a statutory obligation, and personally I cannot see what the local authorities have to fear. It seems to me more logical to treat the whole thing as one sum. Of course I will consider an Amendment in Committee on these lines, that if the £300,000 is diminished the Department should not for that reason damnify a local authority on the ground that it has not made adequate arrangements. An Amendment in that sense would only be fair. It would not be fair to say to the local authority, "We accept the arrangement which you make on the basis of this grant," and then to adopt the other course. I am prepared to consider an Amendment of that kind in Committee, such as would meet the apprehensions which have been raised Comment has been made on the amount of £40,000 mentioned in the White Paper. I would point out that that is only the expenditure estimated on a very small number of local authorities who have not come up to the standard of other local authorities. The number is small, and therefore the amount is small. There are very few Cases where the local authorities have not made suitable arrangements. It does not say there is no possibility of an increase in the future. I hope when we get into Committee no attempt will be made to turn the Bill from one for a specific purpose to a kind of general omnibus Bill dealing with all kinds of matters associated with the Ministry of Health. We already have had a health measure introduced into this House of great length and complexity, but nothing has been done with it. There is a great deal of work to be done on the whole question of health, and no one could be more anxious than I am to see that work develop along sound and proper lines. But we cannot expect everybody to be as enthusiastic as many Members are who have fully gone into this subject. I earnestly beg hon. Members not to overload this Bill.

Lieut.- Commander KENWORTHY

What about the Insurance Committees?


I dealt with that subject in my opening remarks.

Lieut.-Commander KENWORTHY

But when the original Bill went through was not an undertaking given by the right hon. Gentleman's predecessor to turn "may" into "shall"?


I have not looked into that, but I understand it is not actually the case. I know that both the municipal corporations and the county councils' associations are strongly opposed to turning "may" into "shall," and I myself do not agree in doing so. When you have a body elected by the ratepayers to administer their money it is not fair to force upon them other gentlemen, however enthusiastic they may be, who have not the slightest responsibility financially for what may be done. These gentlemen no doubt are well known in their localities and their worth must be known. They would have no trouble therefore in getting elected. An hon. Member suggested that they were wanted on these bodies as experts, but you do not necessarily want experts on these bodies. Experts rather should appear before them. It is not always good to make an expert an executive member of a committee, and therefore I feel I must resist any such Amendment. After all, the functions and responsibilities of the Insurance Committees have ceased; they have no longer a clientele, and when their services are needed no doubt the local authorities will consult them in a friendly way, but we cannot agree to force them on popularly elected bodies. I am convinced such a course might lead to a great deal of bad feeling which would not be in the interests of the people who are most concerned—those who require treatment.


Will there be any opportunity of discussing the financial aspects of the Bill? As there are no financial Clauses at present, I assume there will be no Financial Resolution.


The proper time for discussion will be when the amount is voted on the Estimates. Provision will have to be made in the Estimates for the 50 per cent, to be paid by the State.


Will the right hon. Gentleman's predecessor have an opportunity of replying to the attack made on his policy?


I do not understand the hon. Gentleman means.


The House does.


Does the hon. Member suggest that I made an attack on my right hon. Friend's policy? I absolutely repudiate that. I have not said a word in the Debate that could be so interpreted.


Will the proposals for setting up unit areas be made known before the Bill is taken in Committee?


I cannot say offhand. I will inquire into that.

Lieut.-Colonel FREMANTLE

May I ask if the proposals of the Bill of last year dealing with sanatoria for soldiers and village settlements will be included in this Bill?


They certainly will not be included in this Bill.

Question, "That the Bill be now read a Second time," put, and agreed to.

Bill read a Second time, and committed to a Standing Committee.

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