§ Again considered in Committee.
§ [Mr. ROBERT YOUNG in the Chair.]
§
Question again proposed,
That a sum, not exceeding £12,724,290, be granted to His Majesty to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1931, for the Salaries and Expenses of the Ministry of Health, including Grants and other expenses in connection with Housing, certain Grants to Local Authorities, etc., Grants-in-Aid in respect of Benefits and Expenses of Administration under the National Health Insurance Acts, certain Expenses in connection with the Widows', Orphans', and Old Age Contributory Pensions Acts, and other Services.
§ Mr. GREENWOODI now propose to say a few words on a matter of absorbing interest to me, namely, that of the Poor Law. When the present Government took office there were in existence three boards of guardians which had been appointed by the late Minister under powers conferred by the Boards of Guardians (Default) Act, 1926. The present Government decided that the responsibility for Poor Law work in those three unions should no longer be borne by the nominees of the Minister but should be handed to representatives locally selected. As from the 1st August last year the boards of guardians in West Ham, Chester-le-Street and 66 Bedwellty were boards who had been nominated by the local authorities in those particular areas. Twelve persons were so nominated to act as the board of guardians in the West Ham Union area and three persons were nominated to serve in that capacity in Chester-le-Street and Bedwellty. These posts, unlike the posts of the first appointed guardians, did not carry a salary but, having regard to the circumstances of the persons selected and the arduous nature of the work, it was thought right to approve of allowances for subsistence and loss of time incurred by the guardians whilst attending their Poor Law duties. The guardians in the West Ham Union, other than the chairman, were paid one guinea per day of attendance at a duly convened meeting of the board or any recognised committee, together with actual out-of-pocket expenses incurred in travelling on the board's business outside the area of the union. The allowance for the chairman was fixed at one guinea per day of attendance at any of the establishments or institutions of the board, it being clear that as far as he was concerned it was a whole-time job. The allowance for members of the boards of guardians of Chester-le-Street and Bedwellty were fixed at £7 per week, inclusive of travelling expenses.
As to the effect of the administration, in the case of West Ham there has been a slight increase in the number of persons relieved by the board. The increase was not so substantial as many persons feared, although the amount of relief given to the persons assisted has increased. The amount of out-relief per head given in July, 1929, by the old appointed board of guardians was 5s. 4½d. and in December, 1929, under the second appointed board it was 6s. 5d. The guardians, who took office on the 1st August last, continued the principle of investigation, and although they dropped the test work arrangements that had been put into force by the previous board, they inaugurated in January last a scheme of instructional and educational classes for the training of the younger able-bodied men who received outdoor relief. The policy of the West Ham Board, the elected board, left a substantial outstanding debt amounting to nearly £2,000,000. Their successors, the first appointed guardians, reduced that amount, and the board of 67 guardians which I appointed last August fulfilled its obligations and also made the requisite provision for reduction of the outstanding debt. During the period that they were in office the poor rate was reduced.
In the case of Chester-le-Street, there has been a fairly substantial increase in the number of persons relieved and in the amount expended on out-door relief. That increase is partly due to the grant of relief to able-bodied men. Under the first appointed board of guardians relief had been given only to wives and children and not to able-bodied men. Part of the increase is also due to an increase in the scales of relief. In the case of Bedwellty there, again, since the new board of guardians took office there has been an increase in the number of cases relieved and in the amount spent on out-door relief.
§ Sir KINGSLEY WOODCan the right hon. Gentleman give us the figures?
§ Mr. GREENWOODYes. In Bedwellty for the week ending the 3rd August, 1929, the last week under the old appointed board of guardians, the number of persons in receipt of out-door relief was 4,386, and in the week ending the 22nd March, 1930, which was about the end of the time of the second appointed board of guardians, the number of persons relieved was 6,071. That figure is substantially less than the number of persons in receipt of out-door relief in the days of the elected board of guardians.
§ Mr. GREENWOODYes. For the week ending the 3rd August, 1929, the total amount of out-relief given cost £983 and for the week ending the 22nd March, 1930, the cost was £1,585. As in the case of Chester-le-Street the increase in numbers relieved and the increase in the cost since the 1st July is attributable to the fact that the guardians have not refused out-relief to particular classes or groups who had previously been refused relief by the first appointed board of guardians, and also to the increase in the scale of out-relief where the guardians thought that was desirable. It was suggested, in fact I hinted at the possibility of it, that the newly appointed board of guardians would give relief to a larger number of 68 people than had been relieved by their predecessors and that probably there would be some increase of expenditure, but that increase, broadly speaking, has, I think, been justified by the fact that the relief has been given to destitute people, which relief had been denied to these people during the days of the earlier appointed board of guardians.
§ Mr. GREENWOODThe figures for West Ham for the week ending 3rd August, 1929, show 14,941 persons receiving out-relief at a total cost of £4,011 and in the week ending 29th March, 1930, 15,308 persons receiving out-relief at an expenditure of £4,629. For Chester-le-Street during the week ending the 3rd August, 1929, 3,948 persons received out-relief at a cost of E928, and during the week ending 22nd March, 1930, there were 5,607 persons in receipt of out-relief and the expenditure was £1,881.
As to the wider question of Poor Law administration, the Committee will remember that the Poor Law statutes, covering a period of more than 300 years, were consolidated in the Poor Law Act of 1927, which has been consolidated with the relevant portions of the Local Government Act in the Poor Law Act of 1930. Similarly, it has been found necessary to consolidate the mass of Poor Law Orders which previously existed in the Public Assistance Order of 1930, which has been published. It is a consolidation of a large number of previous Orders with only such adaptations as are necessary to bring the provisions into harmony with the changes made in the Local Government Act. The Order was the subject of discussion with a number of bodies, including the County Councils Association, the Pharmaceutical Society, the Society of Medical Officers of Health, and the British Medical Association, and various amendments were made. There have been some suggestions of substance on which amendments could not be made, under which there would be a substantial difference in the powers exercised by the Minister.
The right hon. Gentleman the Member for Edgbaston (Mr. Chamberlain) gave an undertaking that, when once these new authorities were in the saddle and had settled down to their work, the oppor- 69 tunity would be taken to discuss the consolidated Poor Law Order with a view to its revision and such changes as might be made to bring it more into conformity with modern needs. The County Councils Association is pressing even now for very substantial changes with a view to ridding the new public assistance authorities of the control which was exercised by the Minister over the now defunct boards of guardians. It will be remembered that the Pharmaceutical Society criticised the Order on the ground that the Minister had not interfered sufficiently with the power of local authorities, but the whole trend is towards giving local authorities more rather than less freedom.
There is one exception to this general principle of consolidation which is to be found in the Relief Regulation Order of 1930. During my tenure of office, I have given a good deal of thought to this problem of out-relief, and I came to the conclusion that the Relief Regulation Order of 1911 required drastic amendments if it was to be brought into conformity with existing conditions, and the Relief Regulation Order of 1930 does represent a substantial departure from the previous Order. The principal changes are: First, that institutional relief is no longer to be regarded as the proper form for the able-bodied. As hon. Members are aware, under the Relief Order of 1911 the theory was that out-relief was a very exceptional thing and that people offered relief would go to the workhouse. That has not been the practice for years, and, I imagine, will never be so again, and the change which has been made in the Order is to meet the change in the practice of Poor Law authorities. The second change has been to suggest that conditions which might be attached to the grant of relief should not have as their object merely the deterrence of a destitute worker, but should be designed to maintain or improve his moral and his physique; to regard the problem not merely as one of original sin, but to regard it rather as a manifestation of something that might perhaps be put right by a more humane and constructive system. At the beginning of this year I sent a circular to boards of guardians in which these points about out-relief were stressed, and they were stressed in the covering letter sent to local authorities with a copy of the new Public Assistance Order. It is interest- 70 ing to note that practically no representations were received from local authorities with regard to the Relief Order, and I presume therefore that the new Order meets with the approval of the new public assistance authorities.
§ Mr. WOMERSLEYIs it not a fact that it varies so little that there was no need to complain?
§ Mr. GREENWOODIf a departure of principle of so far-reaching a character means nothing to the hon. Gentleman, I cannot help that. I do not want to minimise the difference between the 1911 Order and the 1930 Order, and I should mislead the Committee if I suggested that they had the same principle.
§ Mr. GREENWOODI am not so sure of that fact. I am hoping that, as a result, the administration will be different. I gather from what has been said in the Press that there is a good deal of anxiety in the minds of hon. Members in regard to the increase of sickness claims under the Health Insurance Act, and I propose to say a few words about that, because I understand some Members wish to raise it. The problem is, of course, a very serious one, and it has been occupying the mind of the Ministry for some time. Two years ago the National Health Insurance Joint Committee authorised the Government Actuary to make an investigation into the substantial increase that had taken place in recent years in claims for sickness and disability benefits. The Report of the Government Actuary is now in the hands of members of the committee. In the meantime, the Department has been doing what it could in consultation with the approved societies to improve the supervision of claims and the selection of cases for reference to the regional medical officers. In 1928, there was a fall in the number of sickness claims from those in 1927, but in 1929, even after discounting the serious cases of influenza, there was a considerable rise over 1928. This year, I am glad to say, for the first three months, there is an appreciable reduction in the amount of sickness benefit, due primarily to the milder weather as compared with that of last year and the absence of an influenza epidemic.
§ Dr. MORRIS-JONESDoes the right hon. Gentleman attach importance to the fact that there has been little influenza this year?
§ Mr. GREENWOODI say the reduction is primarily due to that fact. It was quite clear that further examination had to take place into the problem laid before us. Suggestions had been made that there should be a Departmental Committee. In my view, a committee of that kind is not the proper body to deal with what is essentially a problem of administration, and, on receipt of the report of the actuary, the National Insurance Joint Committee decided to extend the scope of the investigations, and the whole question is now under the close attention of the officers, administrative and medical, of the insurance departments in all parts of the United Kingdom, England and Wales and Northern Ireland. When their investigations have proceeded sufficiently far, the approved societies will be brought into consultation as will be the Insurance Act Committee of the British Medical Association, and, out of their investigations and deliberations, I hope that we may get some clearer opinion on what lies behind this very large increase in the claims for benefit.
I am convinced that there is no simple explanation of this increase. Precisely the same problem is arising in other countries which have fairly well developed schemes of sickness insurance. In these countries the claims for sickness benefits have in recent years shown a most extraordinary increase. In Germany, for example, the increase between 1924 and 1929 was no less than 70 per cent., so that we are dealing with a problem in no way confined to this country.
§ Mr. MELLERIn the case of the increase in Germany, has there been a corresponding increase in the benefit paid or has there been a flat rate for these years?
§ 5.0 p.m.
§ Mr. GREENWOODI understand that both actual numbers and costs have increased. As to the cause, I do not wish to speak too definitely, but the prolonged depression through which this country has gone is, I believe, one very important contributory fact. Many insured persons who would have a perfectly good claim for benefit prefer, when work is available, 72 to go on working, but, if they fall on days of unemployment and work is not available, quite naturally, and quite properly, they come on to the National Health Insurance Fund, and the ranks of these people during a long period are naturally swollen by many whose physique is debilitated as a result of prolonged unemployment. I think, if a person is ill and is not working, he will go to the doctor, whereas if he had work he would work longer before going to the doctor. Another factor, which seems to me to be important though it is difficult to assess its value, is this: People are to-day seeking medical advice earlier than they used to do. In fact, the public have been urged repeatedly not to delay treatment, but to obtain it at the earliest possible moment. In so far as the increase of sickness claims is due to this, it is an increase which is to be welcomed for it means, in the long run, an economy in the funds of the insurance societies. There will be cases existing where, owing to faulty certification or administration, persons are in receipt of benefits who are not properly entitled to them, but in so far as there are defects in the administration, which means that benefits are going improperly to persons, this should be remedied. But it cannot be due entirely to this. It is clear that it is necessary for some societies to have a more effective sickness visitation and more discrimination of the cases going to medical officers. A new regulation is to be issued shortly which will enable effective disciplinary action to be taken where it is proved beyond doubt that practitioners have failed to exercise reasonable care in the issue of certificates.
§ Mr. WALLHEADDoes that mean that the nation is becoming definitely more C3 from unemployment?
§ Mr. GREENWOODI do not wish to assess the relative value of these things, but if it is due to the fact that people are going for benefit after three days, instead of after three weeks, that means not that we are going downhill, but that we are showing more sense. With a view to getting a more precise knowledge of the situation two separate tests are being conducted now. In the first place, an analysis is being made of about 80,000 73 cases referred to the regional medical officers by a large number of societies throughout the country during 1929, and it is hoped when the analysis is completed that we shall obtain a good deal of information which is not now available as to the periods at which societies refer cases to the regional medical officers, and the adequacy a the arrangements which are made for sick visitation by the various societies. Secondly, with the object of Obtaining more precise knowledge as to the standard applied in interpreting the phrase "incapacity for work" an investigation is to be made shortly covering a large number of persons who are in receipt of benefit on a particular day, and by this means it is hoped that information will be forthcoming which will enable the Department to bring about a more uniform standard of certification throughout the whole country.
§ Mr. E. BROWNDepartmental?
§ Mr. GREENWOODThe inquiry is being made by officers of the Insurance Department. I think everyone will agree that the public, and particularly approved societies and insured persons, are indebted to the Government actuary for the figures he has produced. I am impressed myself with the value of these figures, and I hope to make permanent provision for the collection of statistics of this kind so that similar information will be available annually.
In the last few minutes I would say a few words about the health services. Unfortunately, the problem of maternal mortality remains, and during the last five years there has been a slight increase in the maternal mortality rate. That is serious. A special committee was appointed by my predecessor to consider the complex problems of maternal mortality, and that committee has, amongst other things, been examining in detail individual maternal deaths, and out of that detailed investigation I believe that new light will come to us bearing on this subject. I am hoping that within the next month or two the committee will issue an Interim Report. It will be remembered that the Departmental Committee appointed to consider the working of the Midwives Act, with special reference to the training of mid- 74 wives, reported not long ago, and their main recommendation was that a national maternal service should be instituted based on insurance principles under which necessary medical services should be provided as part of the medical benefit under the National Insurance Acts, and the aim of the service would be to provide for more women proper attention during confinement with a view to reducing the volume of mortality. The recommendation of that committee and other recommendations on this problem which have been made are now under consideration of the Government with a view to devising a scheme of maternity service which will have due regard on the one hand to maternity benefit under the National Health Insurance Acts, and on the other hand to the services provided by local authorities under the Maternity and Child Welfare Act, for I am convinced that this complex problem will only he solved by utilising every means at our disposal.
With regard to the problem of tuberculosis, it is good to know that there is still a declining death rate, but more remains to be done. I think it is clear that a great deal has been done by sanatorium treatment, and that more or less permanent cures have been effected and that people after full treatment have been able to resume normal life and employment. But, unfortunately, in many cases a patient who has had sanatorium treatment cannot well go back to the rough-and-tumble of ordinary life, and ought to lead a sheltered life for a period. No doubt he has in most cases no financial resources, and unless cared for in such cases there may be a relapse and a man may become a source of infection. In the past the tuberculosis campaign has had two objects in view: in the first place the prevention of infection by the earliest possible discovery, and, secondly, the provision of adequate treatment with a view to a cure of the disease when discovered. In the Public Health (Tuberculosis) Act, 1921, power was given to counties and county boroughs to make arrangements for the after-care of persons suffering from tuberculosis. Something has been done, but the fact that treatment seemed to be more urgent and that hitherto expenditure on after-care did not rank for grant as provision made 75 for treatment did, has no doubt deterred local authorities from making after-care provision.
The time has now arrived to press this question of after-care a little further. As Members are aware, the financial provisions of the Local Government Act have obliterated any distinction between grant-earning and non-grant-earning services of local authorities. I think, also, the fact that public health authorities, county councils and county boroughs are now public assistance authorities will lead them to see that, it is cheaper in the long run to do all you can to restore people who are suffering from tuberculosis to wage-earning employment rather than allow them to fall on the funds of the public assistance committee. Something has been done by means of village settlements, a few of which exist in this country, the two most important being the settlement of Papworth in Cambridgeshire and Presten Hall in Kent. The primary object of these establishments is to provide tuberculosis patients who have had treatment at a sanatorium with remunerative employment suitable to their physical condition and regarded as part of the cure, and as a means of bringing them back to a position of relative economic independence.
These settlements have been more or less successful. There is a hospital section where cases are studied, where they are passed into the sanatorium when ripe for treatment, and where a certain amount of training can be undertaken under strict medical supervision. Then there is the training section where patients are sufficiently recovered for them to undertake definite instruction as part of their treatment, as well as with a view to fitting them for the industrial section of the settlement, and there is the industrial side of the settlement where a man has sufficiently recovered to work, say, six hours a day, and where he cannot be driven but where he can employ himself for wages on work suited to his physical condition, where he can be watched and can be removed if his condition should become worse. Those experiments are hopeful, and the experience of the existing settlements and the principles on which their successful working depends have been brought within the last few months to the notice of certain local 76 authorities where, it seemed to me, conditions were favourable to the successful establishment and maintenance of similar establishments. I hope that before very long the number of village settlements for tuberculous persons will be increased. Even if we were able to provide settlements for all those for whom settlements would be appropriate, we should still be left with a number of people who would require after-care, following on sanatorium or other treatment. I hope that the local authorities, as the next move in the campaign against tuberculosis, will consider and experiment in methods of after-care for tuberculous persons.
Less than three weeks ago, I had the pleasure of announcing in the House that the Government had agreed to make a contribution of up to £250,000 for buildings in connection with the proposed postgraduate hospital and medical school, and although no money is being asked for, under that head, in the present Estimate, it seems necessary to say something about it. The Government contribution, as I say, is for the buildings, but increased grants will in future be given through the University of London when the school becomes a recognised school of that university. The publication of the scheme, I am glad to think, has been received with unanimous approval in both the lay and the medical Press. I have since communicated with the London County Council and the University of London in order to get their co-operation in the scheme. That co-operation is necessary, and I hope, now, that in a very short time, we shall have completed the next step in this process by the appointment of a fully representative committee representing all the various interests concerned, to consider the very complex problems of planning and administration and so on which must be solved before the scheme can be brought into operation.
I believe, myself, that this is, perhaps, the most important single step which this country has taken in the interests of public health since the passage of the original Health Insurance Act, because, not only will this be a centre for postgraduate teaching for people from other parts of the Empire, but it will enable the general practitioners of this country, including the 16,000 panel doctors who serve the State under the National Health Insurance Act, to have the chance, which 77 they do not enjoy to-day, of keeping in touch with the rapid developments and the changes which are taking place day by day in the art and science of medicine. One looks forward to seeing, after it has been at work, a great improvement in the service which the medical profession will be able to provide for the people of this country.
Dr. VERNON DAVIESWill the total expense of the post-graduate course be borne by the medical men themselves?
§ Mr. GREENWOODNo; I hope that we shall have a certain amount of provision made to assist them. The final matter to which I wish to refer is one which interests a number of hon. Members, judging by the questions appearing on the Order Paper. I refer to the question of psittacosis. I must confess that until six months ago I had never heard the name of this disease, but since then it has been prominent in the newspapers, and since last autumn psittacosis cases have occurred in many countries—most of these cases, though not all of them, being attributable to parrots imported from South America. In this country, up to the present time, we have known of 115 cases of psittacosis, of which 22 have been fatal. All of them, I may say, were not associated with the importation of South American parrots. Apparently, all birds of the parrot tribe are liable to the disease, and some of the cases have been associated with African parrots, and others, I grieve to say, even with love-birds. On account of the seriousness of this problem the Ministry, in February, issued a memorandum giving advice and making suggestions to the public and arranging for co-operation between the medical officers of health and the medical officers of the Ministry in investigation work. That work has been going on, and a comprehensive report on the whole question is now being prepared in the Department. Meanwhile, events have made it imperative that action should be taken under the Public Health Acts to prohibit the importation of parrots for the time being. As hon. Members have probably seen in the Press to-day, a new Order has been issued which will come into operation on 20th May prohibiting the importation of parrots and similar birds. [HON. MEMBERS: "Why 20th May?"] That is sufficient time in which to warn people who may be on the point of importing parrots.
§ Mr. GREENWOODI had considered the question of fixing a quarantine period but apparently there is not yet sufficient information about the duration of infection. We could not therefore prescribe a safety line, and the solution of the problem seems to be to prohibit importation for the time being. It is becoming urgent to do so now because the trade is a summer trade, and it is all the more urgent because several other countries, including France, Germany, Holland and the United States, have prohibited the importation of these birds. However much one may adhere to the principles of Free Trade, I do not see myself permitting this country to become the dumping ground for all the parrots from South America. I hope that the public will realise that this is the reasonable course to take, and when circumstances permit the order will, of course, be withdrawn. I am sorry to have detained the Committee for so long but it was necessary to do so even to give the very imperfect survey which I have given of the work of a very great and complex Department which touches the daily life of the people at a hundred points, and, if I may say so, touches the life of the people more closely than the work of any other Department. In conclusion, I assure the Committee that the Department, in co-operation with the local authorities of this country, will do all in its power to develop the big social services for the betterment of the people.
§ Sir K. WOODI think I can say to the right hon. Gentleman the Minister of Health that he has to-day made the best speech on these Estimates that I have heard him make for six years. It is a speech of a very different kind from his five previous efforts made during the tenure of office of my right hon. Friend his predecessor. Only the other day I read an appreciation of the right hon. Gentleman by the present President of the Board of Trade which ended up with the reflection that the more one examined the character and qualities of the right hon. Gentleman, the more one was impressed by the way in which his character and qualities grew after experience. One feels that to be so in connection with the Estimates which he has presented to-day; and it is noteworthy that the 79 Socialist Minister of Health, almost in his first words, should tell us about the housing situation; about how 1,500,000 houses have been erected in this country; about how two-thirds of them have been provided by private enterprise, and about how this country has expended some £85,000,000 in endeavouring to find better housing accommodation for its people. That is a wonderful tribute to the efforts of the Governments which have preceded the right hon. Gentleman's Government. I had anticipated that the right hon. Gentleman would give us figures as to the number of houses erected in the last 10 months, compared with the number erected in the preceding 10 months, but, no doubt, the Parliamentary Secretary to the Ministry, at a later stage, will supply what the right hon. Gentleman obviously forgot.
The Minister told us that the low cost of housing had been maintained. That is a rather curious observation. The record of my right hon. Friend the previous Minister of Health in connection with housing needs no commendation from me and one of his most successful efforts was the reduction in cost which he brought about almost from month to month. What the right hon. Gentleman the Minister has done, I am afraid, has been to maintain the cost of housing, which, he tells us, is an average of £338 per house. We debated housing the other day and I do not propose to open a housing Debate now, because there are other matters which we desire to raise on this occasion, but anyone with a knowledge of the present housing situation—and I think the right hon. Gentleman, the Member for Penryn and Falmouth (Sir Tudor Walters) would support me in this statement—will agree that it is no matter of satisfaction to the people of this country that the price of £338 per house should be maintained. The right hon. Gentleman ought to be reducing the cost of houses, or considering methods of bringing about such a reduction, because we are in an unfortunate situation at present in relation to housing. We have a Slum Clearance Bill designed to make provision for slum-dwellers but I want to know what is going to be done to provide houses at lower rents for other poorer paid workers. It is no satisfaction to me 80 to be told that the cost of housing is being maintained at £338. If that is to be the right hon. Gentleman's view of the situation, it simply means that many of the poorer paid workers will be compelled, during the whole of his tenure of office, to pay rents which are far too high. It also means that a very large number of them will never be able to get decent housing accommodation at all. I do not look with any satisfaction upon that situation, and I had hoped to hear from the right hon. Gentleman that he was going to do something to bring about an improvement in that state of affairs.
To me, the most interesting parts of the right hon. Gentleman's speech were his references to the Local Government Act, and I invite hon. Members, and especially hon. Members opposite, to study those passages of the speech in the OFFICIAL REPORT to-morrow. I hope that some of them, when addressing meetings at the week-end, will read out the passages from the right hon. Gentleman's speech relating to that important Act. I was glad to hear that the right hon. Gentleman fully recognised the work which my right hon. Friend, his predecessor, did under that Act in breaking up the Poor Law. I remember the criticisms which were directed against my right hon. Friend on that account.
§ Mr. GREENWOODNot from this side.
§ Sir K. WOODThe right hon. Gentleman is tempting me. I was going to put a check upon myself and I was not going to refer to the observations of the right hon. Gentleman himself on that Act. But I must remind the right hon. Gentleman, since he has protested, that we were told from the Labour benches when that Bill was in Committee that the idea of breaking up the Poor Law was a pretence and a fraud. I remember Lord Passfield devoting a great portion of one of his speeches to the miserable effort which my right hon. Friend was supposed to be making in that direction, and how it filled the breasts of hon. Members opposite with dismay that nothing was being done. It was very interesting to hear that 16 county councils and 49 county borough councils have taken the vital step in that connection, and it was also interesting to hear the reason which the right hon. Gentleman 81 gave, and the explanations which he has accepted, why the other counties and county boroughs have not yet taken similar steps. I think my right hon. Friend, who had so many words of abuse showered upon him during the progress of that Measure, will at any rate go home to-night and sleep quietly in his bed with the reflection that the good work which he has done has now been recognised in very curious quarters.
I was also interested to hear the right hon. Gentleman's account of the only new and constructive work which he has done in the last 12 months, namely, the abolishing of the appointed guardians of West Ham, Bedwellty, and Chester-le-Street. He has, perhaps with some hesitation and doubt, followed in the footsteps of my right hon. Friend. I do not think anyone can find in his speech any novel suggestion or any fresh vision that he has brought to bear upon the Ministry of Health during the last 10 months, but all credit is due to him for that one action, namely, the abolition of the appointed guardians in those three areas. From such information as reaches me, the result of the change in West Ham has not given that satisfaction to the people of West Ham which they were led to believe from the speeches of the right hon. Gentleman, would follow. He has told us that in West Ham there has been a slight increase only in the number of people relieved. I remember that, on many occasions during the last five years when I have had to get up in the House, I have been assailed with abuse and vulgar epithets, such as that I was a murderer, a scoundrel, and a hypocrite because of what the appointed guardians in West Ham were doing.
Now, after all that, we are told that these new gentlemen in their new posts, for which there was considerable competition, have only after all made a slight increase in the number of people relieved. [Interruption.] I remember, towards the end of the last Parliament, the present Parliamentary Secretary to the Ministry of Health, in one of her bursts of enthusiasm, saying that within three weeks of a Socialist Government being on the Treasury Bench the whole face of England would be altered. I wonder where it is. It is certainly not 82 in West Ham, where the guardians, the remunerated guardians, from what I can judge—
§ Mr. J. JONESWhat do you—
§ The TEMPORARY CHAIRMAN (Captain Bourne)Order! Two hon. Members must not be on their feet at the same time.
§ Mr. J. JONESOn a point of Order. The three guardians that he appointed got £2,000 a year between them, but our guardians get only out of pocket expenses, and they are doing the work better.
§ The TEMPORARY CHAIRMANThat is not a point of Order.
§ Sir K. WOODIt would not be fitting that I should make any reference to the West Ham Guardians without some assistance from the hon. Member for Silvertown (Mr. J. Jones).
§ Sir K. WOODSomething would have been wrong if I had not had some interruption from that quarter; but I want to call the attention of the Committee, because I do not think the right hon. Gentleman did so sufficiently—I do not think he showed a sufficient grip of the situation—to the present position under the National Health Insurance scheme and to the information which has been supplied to this House by the Government Actuary. It is a matter of considerable anxiety to the approved societies of the country and the many thousands of administrators who are engaged in that work, and the position is sufficiently serious for the Government administrators themselves to say that the present position, if continued, is undoubtedly threatening the surpluses of the approved societies, and the additional benefits, and particularly the hopes of expansion of benefits under the National Health Insurance scheme in the future.
I do not say that the finances of the scheme are not in a thoroughly strong position and that they have not large reserves—I think the surpluses at the last valuation amounted to some £65,000,000—but it is a very surprising thing that we should have this revelation, given us 83 in very impartial terms by the Government Actuary, of the very surprising rise in these claims, when we remember the many millions that have already been expended in connection with health benefits in this country. I do not think it is an exaggeration to say that during the term of the National Health Insurance Act no less than £100,000,000 has been spent on medical treatment and attendance during these 17 years; and when we remember that nearly £500,000 is being disbursed each week in cash benefits, that nearly £2,250,000 per annum is being expended on drugs, and that some 15,000 members of the medical profession give 60,000,000 attendances every year to insured persons, it is a most surprising thing that we should have this statement of the Government Actuary presented to us.
There is another very curious side to it. It is particularly surprising when one recalls the great improvement in national health generally. We have had in this country a very remarkable decrease in infant mortality; I think in the year 1928 it was the lowest on record. So far as the tuberculosis death rate is concerned, one can say the same thing, and I think it was the Chief Medical Officer of the Ministry of Health, Sir George Newman, who said that the year 1928 was perhaps the healthiest year in the history of this country. Notwithstanding all that, we have a record in relation to sickness and disablement claims which, in the words of the Insurance Comptroller,
constitute a challenge to all who are responsible for the welfare of the scheme.It is doubly a matter of anxiety, because these increases have been continuing for so long. I remember that there was an actuarial investigation into this matter when the National Health Insurance Commission was holding its sittings, and in recent years there have been repeated warnings from the insurance department of the Ministry of Health as to the position of affairs; and we now have certainly one of the most disconcerting documents that has been issued in connection with the National Health Insurance scheme since its inception. I see that in connection with the percentage of claims to expectation, in the year 1921 the sickness benefit claims for men were 76 and in the 84 year 1927, the latest available date, they had risen to 107. The figures in connection with married women are more surprising still, because in 1921 they were 63, and by 1927 they had actually risen to 130. If you look at disablement benefit, the figures are more remarkable still. In 1921, for married women, the figure was 66, and in 1927 it had risen to 171.
§ Mr. E. BROWNThat is, of the samples taken?
§ Sir K. WOODYes, but I have no reason to believe that the samples in the investigations made by the Government Actuary were not perfectly impartial and well representative of the insured people generally. From the summary of the Report, we find that, comparing the years 1921 and 1927, the claims of men in respect of sickness benefit have risen by 41 per cent., the claims of unmarried women by 60 per cent., and the claims of married women by 106 per cent. The claims in respect of disablement benefit are even more disturbing. The claims of men have risen by 85 per cent., of unmarried women by 100 per cent., and of married women by 159 per cent. Then the numbers of claims have vastly increased, and the investigation indicates that in 1927, among every thousand unmarried women in insurance, 210 drew sickness benefit and 39 drew disablement benefit, while among every thousand married women 380 drew sickness benefit and 92 drew disablement benefit. One could quote a great deal more from this Report, but those extracts give a very good idea of the results presented to us by the Government Actuary.
It is only right that it should be stated, as the right hon. Gentleman said, that there is doubtless a changed standard of medical treatment, and it is perfectly true and right to say that there have been influenza epidemics and that a comprehensive scheme of national health insurance such as this covers very many cases of poor physique and of persistent ill-health, and undoubtedly the prolonged spell of industrial depression has played its part in these figures, but no one can say that that is the end of the story or that it by any means accounts for the position in which the national health insurance societies find themselves at the present time. I have been able, through the courtesy of a good many societies who have communi- 85 cated with me, to read with interest the reports of some of these bodies. I will refer to two of these, because they are societies of a totally different character; their reports were, of course, written without any regard to this Debate or of what might be said in any assembly such as this. The first society to which I should like to refer is a very excellent body, as one would expect, because the hon. Gentleman the Member for Westhoughton (Mr. Rhys Davies) is the secretary. It is the National Union of Distributive and Allied Workers' Approved Society. In their report for 1929 they say:
It is clear that the Health Insurance is the only State scheme left based upon sound actuarial principles. We agree with the Royal Commission (1926), on National Health Insurance which laid particular emphasis upon the danger, even to this scheme, of political influences; and we support the views of the present Minister of Health and other responsible persons, that this business should transcend party prejudices. It should be developed on sound insurance lines, and not on the vicious and perilous policy of benefit being distributed by party-political competition. If any State scheme is to continue upon a contributory basis, it should rest upon a properly ascertained and fairly apportioned system of contributions by employé, employer and State. If not"—and I commend this to hon. Gentlemen below the Gangway—we should scrap them all and proceed to a non-contributory system as soon as possible.This is the interesting part of the report. They then refer to the continued increase of sickness due to the influenza epidemic and to the bad social and economic conditions that exist, and there follows this interesting paragraph, which I hope the hon. Gentleman will develop a little more when he speaks:There is food for thought in the fact that, in our society at any rate, the increased claims are mainly from those who have grown up in an atmosphere of 'State Insurance,' i.e., those between the ages of 16 and 35.That is a very important observation, and throws some light on this question. The hon. Gentleman will no doubt explain it a little more. The other report, which again throws a curious light upon the situation, is the report issued by the National Conference of Industrial Insurance Approved Societies, which has a very large membership. They draw special attention to the extraordinary difference in claims which 86 arise in the North of England as compared with those that arise in the South of England. They give the excess percentage of the northern area over the southern area, which throws a considerable light upon the situation. I have heard what the right hon. Gentleman has suggested with reference to this disturbing situation, and I have no doubt that the approved societies and those who are specially interested in them will study the proposal which the right hon. Gentleman will make, and will consider whether they think that it meets the present situation.The right hon. Gentleman, however, will have to direct himself a little more closely to the position. After all, he is mainly responsible for the medical service under this Act, for the approved societies are not concerned in it. Several hon. Gentlemen below the Gangway will remember the many Debates and disputes which took place over that matter. The approved societies were given no right of interference with the medical profession. The right hon. Gentleman is mainly responsible, and if any improvements are to be brought about, they will have to be very largely done at his instance. One is driven to the conclusion, after reading these reports and the statement of the Government Actuary, that there is a good deal of lax certification. The doctor on the panel is in a serious difficulty; he has to decide, when a man presents himself, whether he is ill or not, and it is a considerable responsibility to refuse a certificate. It is a remarkable thing, however, that according to the Insurance Controller, directly cases are referred from the panel doctor to the regional medical officer, some 55 per cent. to 65 per cent. immediately declare off the fund. That undoubtedly calls for some further explanation from the medical men who are engaged in this work.
I hope that the Parliamentary Secretary will tell us exactly what is the new regulation which is proposed and which, I understand, is to impose some penalty upon medical men. What are the exact proposals of the Ministry? One cannot say what proportion of these sickness claims are improper claims, but whatever the amount—and undoubtedly there is an amount—a considerable part is due to the alteration that has been made in the period in which an insured person is enabled to change his panel doctor. 87 At the present time an insured person can change his doctor on giving only a few days' notice and go to another, and there is no doubt that there is a considerable danger in that relaxation. [HON. MEMBERS: "Why?"] If Hon. Members want me to pursue it, I will. What medical men have said—I am not repeating what I say, but what medical men themselves say—is, "How can you expect many doctors to refuse certification—everyone being human—when they are faced with the position, if a certificate is refused, that the insured person can immediately go to another doctor?"
§ Mr. PERRYSurely the right hon. Gentleman recalls that we often had numerous complaints from insured persons about the difficulty of changing doctors under the old system.
§ Sir K. WOODWe have gone to the other limit now. The hon. Gentleman has had as much experience of this Act as anybody, and anyone who has had experience of it will say that the easy method of changing the doctor is a contributory factor to the number of claims. I will invite my hon. Friend the Member for North-West Camberwell (Dr. Morgan), since he has challenged me, to say whether he does not realise, as everyone who is connected with the administration of this Act does, the great difficulty of a doctor in circumstances such as these. Undoubtedly there could be a considerable improvement without interfering with the proper rights of insured persons, and I hope that the right hon. Gentleman will give a good deal more consideration to this matter than he has given up to the present. It is a difficult position, but it would be a great deal worse but for the approved society system. I tremble to think what would be the position if we had one big State scheme. The only hope of maintaining this scheme in a sound actuarial position, and of doing justice to the insured people, who in the end have to pay, is undoubtedly to maintain the approved society system. It is not often that I am able to congratulate the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) upon his 88 accuracy, but I was very glad to observe what he said in 1910. It is a remarkable statement:
How are these surpluses to be made? They will be made far more out of good management than out of good lives. Societies that happen to have skilled, able, and experienced men at their head, and not merely at their head but in all branches of local administration, that have the courage to stand against malingering, even at the risk of losing membership, will have a good surplus. Money will be lost far more from cowardice than ill-health. It is a very difficult thing for societies to apply their rules ruthlessly.He ended the speech in these terms:It is the way in which the management of a society examines the claims for sick benefits that is important. If it just looks at a claim the moment a man sends it in with a medical certificate and decides to honour it and pay its 10s. or 12s. a week, that society will soon have a deficiency.The right hon. Gentleman had the courage to talk about medical certificates in those days:On the other hand, a society that examines claims carefully and has checks upon them will have its surplus. I do not want to see a surplus, built up in that fashion, taxed to the extent of 10 or even 20 per cent., for the benefit of the other society.These are very true words when one realises the considerable increase which has now been made in this scheme. They can be repeated with great usefulness at the present time, because the safeguards mentioned by the right hon. Gentleman are the great bulwarks of the system. I hope that the Minister will give consideration to this matter, and see what he himself can do, apart from the deliberations with the representatives of the approved societies, the medical profession and the Insurance Committee.6.0 p.m.
I would like to have dealt with the claim of the right hon. Gentleman in connection with the Poor Law Regulation Order, but I shall take an opportunity to deal with it on some other occasion when we have the Estimates up again for examination. He takes credit to himself that it has made a vast difference in the Poor Law regulation in this country. He made an astonishing claim, and I wonder what the Poor Law administrators of the country will think of it, if they ever read his statement. Of course, the right hon. Gentleman, after some experience of the Department and the affairs which he has to administer, has 89 been very cautious in dealing with that question, as one knew he would be. There has been practically no alteration at all, although my right hon. Friend was called a "murderer" in respect of it.
§ Mr. J. JONESHe is now.
§ Sir K. WOODThe hon. Member for Silvertown (Mr. J. Jones) still thinks my right hon. Friend is doing this work. Perhaps he cannot see the right hon. Gentleman. Who is the baby-killer to-day? The Poor Law regulation is practically the same in all respects as it was in 1911, although the right hon. Gentleman said he had brought it up to modern conditions. I hope that someone from the Liberal benches will take part in this Debate, because there has been one great omission from the right hon. Gentleman's observations about the Poor Law. He has said not a word about stone-breaking. We were said to be criminals in regard to stone-breaking. It was an outrage upon the people of this country that stone-breaking should be going on. As for the hon. Lady the Parliamentary Secretary to the Ministry, I would not like to describe what her feelings were. I used to tremble at times over what would happen to her.
§ Miss WILKINSONAnd now we tremble over what will happen to you.
§ Sir K. WOODNotwithstanding the support which the hon. Member is getting from her active assistant, who is so silent nowadays in the House, it is a very remarkable thing that stone-breaking is still permitted by the right hon. Gentleman. The right hon. Gentleman used to compare the conditions of the prisons in this country with those under the Poor Law when it was administered by my right hon. Friend the Member for Edgbaston (Mr. Chamberlain). He said that criminals were treated better; that if a man went to prison he did not have to do stone-breaking but attended concerts. According to him, stone-breaking was an outrage against the human law of this country. It is a very remarkable thing that after 10 months of Socialist administration stone-breaking is still permitted. What a dreadful thing! What a reflection upon the sincerity of the Socialist party! From every platform at this week-end hon. Members 90 opposite must say a word about stone-breaking. They must tell their friends, especially on May Day, that under a Socialist administration these poor men skill have to break stones. It is a very dreadful thing, but it is some commentary upon the administration of the right hon. Gentleman at the Ministry of Health.
§ Sir D. MACLEANIn the last two speeches we have had the accustomed mixture of congratulation and recrimination which is inseparable from those who have held office and those who now hold office.
§ Sir K. WOODYou are spared that.
§ Sir D. MACLEANAs we are dealing with a medical subject, it is perhaps as well that the Committee should be treated to "the mixture as before." I congratulate the Minister on the statement he made this afternoon. It was a wonderful reflex of the amazing progress which the nation has made in services which, with all their faults, have a very great credit balance to the good. I would like to say a word or two on the subject which has been most prominent in the minds of the Committee and most frequently mentioned in the Press, namely, the large increase among those who come within the scope of the benefits of the Insurance Act. Reference has been made to my right hon. Friend the Member for Carnarvon Boroughs (Mr. Lloyd George), and he has been congratulated on his accuracy. It is a good thing that one's accuracy should be a subject for congratulation, but I think some tribute might have been paid to him as the principal author of the vast scheme of national insurance which is now permanently embedded in our national life. I remember very well the bitter opposition of the Conservative party, and of the right hon. Member for West Wool with (Sir K. Wood) himself, to what they spoke of as a new tax. I can remember no more determined opposition from any political party than that which was experienced by the widely beneficent schemes instituted by the right hon. Gentleman the Member for Carnarvon Boroughs.
It is extraordinarily easy to take prejudiced views in this matter and miss the real issue which is raised by the remarkable increase of notified invalidity. On one thing, at least, we can congra- 91 tulate ourselves, and that is that there seems to be no likelihood of the insolvency of the Health Insurance Fund. When the last valuation was taken, about five years ago, there was a surplus of no less than £65,000,000, and I have yet to learn that that huge sum has been substantially reduced; the new valuation, I understand, is now taking place. Therefore, we can regard the future in a very different light from that of the Fund in connection with unemployment insurance. I quite agree with the reasons put forward by the Minister for some of the increased number of claims. I do not deny that advantage is taken in many quarters of the facilities for getting sickness benefit; but following the year 1926, which started a period of great social difficulty for this country, with an immense amount of unemployment, and as an inevitable reflex of it, we had a decline of the vitality of millions of our fellow-citizens.
Anybody will realise that who knows what it is to be out of a job, as I do. I remember very well indeed when I had nothing to do, and was waiting for work to come, that I was from time to time attacked by every conceivable kind of disease; but as soon as I got work I forgot about myself. Anybody who knows anything about nervous troubles will realise that there is nothing more devitalising than for a man who wants to work to be out of a job, and millions of our fellow men and women have been reduced to a state of lowered vitality which has quite properly come within the scope of the sickness benefit. I, myself, think that the attitude taken by the Minister the correct one. It would be a futile thing to appoint an ad hoc committee, either in the Department or outside. What is required at present is an intensive internal examination into the whole problem by all the sub-departments concerned. Anyone who knows anything about the Civil Service knows that such an examination will be thoroughly impartial as well as efficient, and the House will be supplied with data upon which it can form an opinion as to whether any change of policy is necessary. There cannot be a better method of ascertaining the facts, and it is the facts we want, in order to form a judgment on this 92 matter, upon which varying opinions are held and on which there is not sufficient information available.
While dealing with the subject of medicine, I would like to say a word or two about the very satisfactory announcement which the House heard the other day and which was amplified to some extent by the Minister, regarding postgraduate schools. I entirely agree with him that it is one of the most important projects which has been undertaken for many years past. Our most brilliant medical men have been making a practice, have been forced to make a practice, of attending what are really post-graduate schools in Vienna, Berlin, Paris and one or two other centres on the Continent. Some of them have gone so far as to attend one or other of the wonderful schools there are in the United States of America; but at the same time we have in this country the most capable, efficient and progressive body of medical men in the world. The research work which is accomplished so quietly in this country needs to be much more widely and fully utilised, not only for the benefit of our own practitioners but for those who wish to come to this country from abroad.
If I may give a personal reference, I remember, when crossing the Atlantic two years ago, making the acquaintance of an American surgeon of the highest standing. He told me that he was coming over for six weeks, and was crossing to France to attend a post-graduate school. He said he would very much like to have the opportunity of seeing what was being done in this country, but that there was no centre to which he could go. Knowing a great many medical men I said that I would do what I could for him, and it chanced that I was able to put him on the right track. He went to the Continent, but stayed there as few days as he could. He hastened back to London, and told me afterwards that the time he had spent away from London he regarded as wasted time, because here he could obtain the most valuable information and had seen very remarkable operations and some of the best research work in the world. I hope that with the hospital arrangements being made at Hammersmith, to which a grant of £250,000 has been given, we shall be able to establish a school the benefits of which will be felt not only 93 here but throughout our Dominions. On that point I would say that quite recently a committee appointed by the British Medical Association made a tour of Australia and New Zealand. May I give two or three sentences from a letter which I received from the immediate past-President of the British Medical Association:
On my visit to Canada and my recent tour to the branches of the British Medical Association in New Zealand and Australia—notably the Congress at Sydney as well as at Brisbane, Melbourne, Tasmania, Adelaide and Perth, and again in Ceylon, Bombay and Cairo—I was profoundly impressed by the constantly reiterated inquiries as to the prospects of the establishment in London of well organised facilities for post-graduate study and research. I believe the scheme submitted will go far to meet this urgent demand from our medical colleagues throughout the Empire—at home as well as overseas—and that in its fuller developments it will constitute London, what she should long ago have become, a world medical centre for post-graduate work of the highest standard.I congratulate the Minister of Health upon the announcement which he has been able to make this afternoon. I would also like to say that the right hon. Gentleman who was the former Minister of Health performed a very great service in this connection by setting up a committee and initiating schemes. I think that both parties are entitled to share in the credit for the very great and most fruitful achievement which has been announced to the Committee this afternoon.I would like to say a word or two about the question of housing. One of the prime causes of the great amount of sickness is still defective housing. I would very strongly press the point that the effects of rural housing are lamentable and disastrous in the extreme. To go through some of our country districts and compare these little nests of slums, far away from urban centres, is to see a state of things which is not a credit to our civilisation. There is need for immense pressure to remove defective housing in our industrial areas, but the problem is just as urgent in the rural area. The representatives of country districts are not so well organised as the representatives of industrial areas. You can get a crowded meeting anywhere to discuss housing in industrial areas, but quite a different state of affairs arises in the case of the rural areas. I hope that the Minister will see whether it is not 94 possible for him to take much stronger and more active measures in regard to rural houses than have hitherto been taken.
I must thank the Minister of Health for personally undertaking, at very considerable inconvenience to himself, a matter which I brought before his notice. I brought before him one of the most shocking cases of tubercular infection that it is possible for anyone to imagine. The mixture of the various authorities has resulted in this scandal being continued. The case I put forward was that there was a tuberculous father who came back from treatment twice to a home which was a centre and source of further infection. This man's wife was in an advanced state of tuberculosis; two of their childhren were infected, and nothing could be done for them. One department after another dealt with them, and a solution was arrived at only after a personal appeal to the Minister himself who, amid all his multifarious duties, found time to give this case his personal attention, with the result that this family has been placed in a decent house where they have some chance not only of ridding themselves of this pest, but of ceasing to be a centre of infection to other people.
With regard to the transfer of the duties of the boards of guardians to the public assistance committees, that is a matter in which I have some slight interest. Undoubtedly great changes of that kind always bring about local hardships which, I think, to some extent could be met. I do not join in the predictions which one hears as to the failure of adequate relief and efficient administration. We heard that kind of complaint when the small school boards were abolished, and the work of education was handed over to education committees and to the county councils. There are many grievances which are calling for a remedy. We must be very careful in the administration of public assistance authorities to see that local touch is maintained as far as possible. It is most important in connection with the administration of relief which is in no sense a charity, but an act of justice, that we should see that those who are best acquainted with the problem should have a full and effective voice in the relief and assistance which are given under the administration which has recently been set up by the House itself.
95 Let me say a word or two about the question of the administration of this great Department itself, which is enormous in its scope and meticulous in its details. It is very difficult, indeed, to administer such a Department effectively from a financial point of view. Here I would like to refer to a subject which is too often forgotten by the Committee of Supply, namely, that it is our duty to supervise the expenditure of this great Department with its ever increasing scope. It is our duty to see that the national activities of this great Department are economically administered. I note that on page 3 of the Estimates of the Ministry of Health there has been a large increase in the cost, and I hope that the Parliamentary Secretary, when she replies, will be good enough to take note of what I am about to say. There is an increase for 1930 of £202,073 in the Estimate for Salaries, Wages and Allowances. I know there are small increases in some other items, but the one I have pointed out shows a very large increase indeed.
I dare say that the answer I shall receive will be that the increase has been brought about by increased duties which have fallen upon the Ministry of Health by reason of the new Local Government Act, and we shall probably be told that the increases have not been met by economies which have been effected in other Departments. At the same time, I hope that the Parliamentary Secretary will tell the Committee what justification there is for this large increase. As far as I am concerned, I see no reason why we should do otherwise than criticise these Estimates in this way. I hope that the Committee will take this opportunity of criticising the executive of the day in the control of the expenditure of the nation. This great Department, with its very able and zealous officers and its ever-increasing scope of activities, possesses the finest health service in the world, and I hope that those officers will be given the fullest share of credit for the success which has been achieved.
§ Mr. RHYS DAVIESI join with other speakers in paying a tribute to the Minister of Health for the excellent statement which he has made to the Committee this afternoon. I will, however, confine myself to the remarks which the 96 right hon. Gentleman made with regard to National Health Insurance. I think that the right hon. Gentleman was quite right when he remarked that there is no simple explanation of the increase in the number of claims that are made upon societies. I will deal more fully with that point before I sit down. The speech of the right hon. Gentleman the Member for West Woolwich (Sir K. Wood) interested me very much indeed, and I am sure he will not mind my criticising one point he made. I think he find that there is little connection now between either infantile mortality or general mortality and the frequency and length of sickness.
In his general remarks the right hon. Gentleman (Sir K. Wood), in my view, was very much more effective in boosting his own side than in criticising our people, as he always is, and always has been since I remember him. I would, however, pay him one tribute; he is conversant with the National Health Insurance Scheme. He knows a great deal about it, and, if I am not mistaken, once upon a time he wrote a book on the scheme, though I am not sure that at the present he would stand by all that he said then. The right hon. Gentleman the Member for North Cornwall (Sir D. Maclean) and the right hon. Gentleman the Member for West Woolwich (Sir K. Wood) made similar remarks about the millions upon millions of money in the funds of the approved societies. The situation is, that the total value of the funds of the approved societies at the moment is £125,000,000. The amount disclosed as surplus at the last valuation was £65,000,000. I would ask the Committee, however, to have a sense of proportion. If that £65,000,000 on the last valuation were all available for disposal, it would represent only £13,000,000 per annum, because the £65,000,000 has to cover five years' additional benefits. There are nearly 17,000,000 insured persons, so that it is less than £1 per annum per person. But then all the £65,000,000 is not available for additional benefits.
§ Mr. E. BROWNNor for all persons.
§ Mr. DAVIESThat is a very small point. The Committee must, of course, face up to the facts that have been placed before them by the Actuary and 97 the Comptroller-General. In spite of all that may be said to the contrary, those who administer the approved societies are faced with these facts every day, and they have to deal with them; and, in spite of the right hon. Gentleman's statement this afternoon that there is nothing very alarming about the situation, it is clear that if the experience continues as it is now, or the tendency develops, the administrators of approved societies will want one of two things done—they will want more money from the State or they will want more money by way of contribution income—
§ Dr. V. DAVIESOr less benefits.
§ Mr. DAVIESOr, may be, less benefits, and probably also less pay for the doctors. I notice that two medical Members nodded assent at everything except the last part of those remarks.
In passing, I would say that the officers of the Ministry have done a great deal of good in publishing these facts, and I feel sure that the Debate this afternoon will have a salutary effect upon the whole administration of National Health Insurance. In fact, the issue of these documents has already had some effect in the right quarters. But I do not want Members of this Committee or the public to believe for a moment that the 17,000,000 insured persons in this country are claiming benefits wrongly. They are not. 99 per cent. of our insured population are honest, straightforward, decent people. There is only about 1 per cent. in all sections of society and in every class of the community whom we have to watch, no matter to what organisation they may belong.
§ Mr. DAVIESI am afraid that the percentage among capitalists may be higher.
I should like to say a word or two now as to the consideration that is now being given by the Government themselves to the question of co-ordinating or amalgamating all these social insurance schemes. If a word of mine is worth anything at all, I would say that I trust that no Government will ever completely amalgamate this scheme and the pensions and unemployment insurance schemes all into one. I will tell the Committee why. If 98 they were amalgamated, all that an unscrupulous Chancellor of the Exchequer—and we have had some—would need to do would be this. He would say, "There is a balance of £125,000,000 to the credit of the Health Insurance Fund, and a debt of £40,000,000 on the Unemployment Insurance Fund; let us square the accounts." That is exactly what might happen if these schemes were amalgamated. Co-ordination I do not mind, provided that the accounts of each scheme are kept separate. There is a possibility of co-ordination, but personally I would object to amalgamation of any kind.
A great deal has been said to-day about the stability of the finances of this scheme, but the right hon. Gentleman the Member for West Woolwich concealed one fact, probably deliberately. He never said a single word about the first blow aimed at the finances of this organisation, when a reduction of the State grant by £2,500,000 per annum was made in 1926.
§ Sir K. WOODWhy has it not been put back?
§ Mr. DAVIESThat one Act alone, the Economy Act of 1926, reduced the income of the societies to date by £11,000,000.
§ Sir K. WOODAnd it is still going on.
§ Mr. DAVIESThen the right hon. Gentleman complains that the funds of the societies are becoming unsteady. Another thing has happened. The societies have lost under the same Act, since the 1st January, 1926, £2,000,000 per annum by rearrangements in connection with medical benefits. That represents another £8,000,000 that they have lost to date. All told, £19,000,000 has disappeared by the action of an unscrupulous Chancellor of the Exchequer.
Nothing has been said so far about the cost of administering this scheme. I have administered a small society ever since its commencement, 18 years ago. It is interesting to know that the cost of administering this scheme is only 13 per cent. of the premium income. [HON. MEMBERS: "Hear, hear!"] Some hon. Members may not cheer my next statement. The cost of administering industrial assurance is 29 per cent., and the cost of administering workmen's compensation is 32 per cent. of the premium income, so that 13 per cent. is not a very large amount for administering this scheme.
99 The Minister was perfectly right in saying that this increase in claims is not confined to this country. I have made inquiries in regard to the Irish Free State and Northern Ireland. In the case of the Irish Free State, where, I may say, the benefits were at the same rate, and consequently the increase will be more understandable, there was an increase from 17s. 1d. per member in 1923 to 28s. 9d. in 1929, in sickness and disablement benefit alone; and I think it is common ground that all societies paying provident benefits—both trade unions and friendly societies, and I think industrial assurance companies also—have had to alter their actuarial calculations and their tables of contributions and benefit as a result of the change in what the Americans call "behaviourism" among the people. [Interruption.] That is an American term; I learned it when I was in that great country, and it is a very good word too. It describes very well what one would describe in English as a change in the psychology of the people.
The increases about which complaints have been made have occurred, strangely enough, concurrently with the granting of treatment benefits for the prevention of the very sickness about which we are now complaining. Approved societies have granted additional benefits—dental treatment, optical treatment, surgical appliances, convalescent home treatment and so on—and there has been a gradual increase in those benefits for each valuation period; but, strangely enough, just as those benefits have increased, so has the duration and number of sickness claims also increased. I think the Minister was perfectly right when he said that it is very difficult to understand how this has come about, but I will venture to give the Committee the reasons which I think account for this increase. I suppose it is not the business of the Actuary or the Comptroller-General to tell us, but the first cause, without any doubt whatever, is the destruction of a million and the maiming and bruising of millions of the fittest men of this country, in the Great War. Those men who were wounded in the Great War, unless they receive 100 per cent. pensions from the Ministry of Pensions, come on the funds of the approved societies; and I venture the opinion, 100 therefore, that the fundamental reason for this increase lies in the consequences of the last War.
§ Dr. V. DAVIESThat does not account for the women.
§ Mr. DAVIESSome women were in the War too, and, as a matter of fact, the women who had to remain at home, with rationed food, were as much in the front line for this purpose as some of the men.
The right hon. Gentleman the Member for West Woolwich and the Minister of Health were perfectly right about one reason that I have come across. I do not know that I can find words to put my statement clearly, but it is something like this. There are thousands of men and women who, although they are not quite fit for heavy work, can and do find employment when jobs are plentiful, to suit their low physical standard, and they go to work. When, however, there is a struggle at the factory gates, those who are physically the weakest go to the wall, and there is the natural tendency for them to come on the funds of the approved societies. While I agree entirely in regard to the point that has been made about excessive certification by panel doctors, there is one thing to be said in favour of medical men, and that is, that if anybody goes to a doctor and complains that he is not well, I know of no medical man, however eminent, who can challenge that statement. That is the trouble. But that is not all that the approved societies complain of. It is alleged that, when a young man comes out of the university properly trained as a doctor and sets up in practice, in order to build up his practice successfully and soon, he descends to issuing certificates in competition with other doctors. That is the allegation; whether it can be proved or not I cannot tell.
§ Dr. V. DAVIESOf course not!
§ Mr. DAVIESAnyway, I could give to the medical gentlemen who are here this afternoon proof from my office that we have had a medical certificate showing that a man was incapacitated from work when he was actually dead. [Interruption.] Of course, he was probably incapacitated then, but we were not sure—
§ Mr. DAVIESSurely, a Christian Scientist cannot believe that a man is incapacitated from following his employment when he has passed to the great beyond—[Interruption]—you could not send the benefit after him anyway. There is undoubtedly a great change in the attitude of people claiming benefit from the funds of the societies now, as compared with some years ago. How to get over that difficulty I do not know. No committee in the world can do it. The Ministry is right in making an investigation by way of a special medical examination. I understand that they propose to take a group of societies and conduct that examination very shortly.
I am not speaking now of the present Government. I am speaking of the Ministry of Health, and the right hon. Gentleman the Member for West Woolwich is as much to blame for this trouble as any Member of the House. The scheme has been loaded from time to time by the addition of sections of the community which actuarially were never properly catered for. I will give one or two cases. Take the man who leaves his employment, goes into business on his own account and becomes a voluntary contributor. He meets with an accident in the course of his own employment. He is not entitled to damages at common law or to workmen's compensation. He naturally comes on the funds of the approved society. There were no actuarial calculations to meet a case of that kind and, consequently, the funds of the society have to bear the cost.
§ Mr. WOMERSLEYIs it not a fact that many societies took him as a contributor before national insurance was brought on to the Statute Book?
§ Mr. DAVIESThe friendly society as a rule has a specific period of benefit payment, and finishes often after 26 weeks. Benefit goes on interminably here. The tables of the friendly societies are not comparable with what we are doing under this scheme. In fact, for the contributions paid, the best benefits in the world are paid under this scheme. That is because it is a State scheme, because it is worked cheaply and because the administrators of the approved societies are not too well paid.
102 I am very loth to question any point that the actuary has given us in this pamphlet, but I should like to point out one thing. It was assumed by everyone, when we cleared away all insured persons from the approved societies' books at 65 years of age, that we should reduce the number of claims. What actually happens is, that people are living longer than they did, not only from 65 upwards, but from 50 up to 65, and the claims have increased in part because of that fact. But there is a cause that is deeper than all this. I once worked as a coal miner for about 10 hours a day, and I worked later in a shop for about 11 hours a day. I have seen the hours of labour reduced as time has gone on. There has been concurrently with that a complete change in the attitude of the employer towards the worker when he is ill in the course of his employment. There is no time now for a man to have sick headache in the shop or a factory. He must either be well enough to work all the time or sufficiently ill to go off and declare on the funds of his society. Rationalisation and speeding-up, in my view, is one of the greatest causes of the increase in the claims on approved societies' funds.
There is another reason which is not generally known. I trust that the Parliamentary Secretary will take note of this point if she forgets everything else I say. The approved society is sometimes in a difficulty with the Ministry in this way. A member declares on the fund and claims benefit. The society is not satisfied that the claim is genuine, and sends the case to the regional medical officer, who turns it down. The claim goes to an arbitrator, who also turns it down. The claim is then sent to the Ministry of Health, which sanctions it. Not always, maybe; but when a society does its duty in connection with cases of that kind, and the administrator is turned down once by the Ministry, he throws in the towel, as it were, and says, "What is the use of it all?" That is a point that must be borne in mind by the Ministry itself.
In running this scheme, the administrators must have the support of the community and, in spite of all that has been said to-day about the huge sums available and all the rest of it, when you divide 17,000,000 into these Funds, they look very small indeed. There is £125,000,000 in the State Insurance Fund, 103 but the industrial insurance companies have invested funds amounting to £800,000,000. We must have a sense of proportion when we talk of these large sums. I have been in the offices of 10 approved societies in the last week or so, and, in the main, the figures they give tally almost completely with the samples that the Actuary has given us to-day. There is an element of unfairness against the societies here. The right hon. Gentleman the Member for West Woolwich is guilty again of imposing liabilities on the funds of these societies that they were never intended to bear. I will give an illustration. Regulations were issued under the last Government to allow an insured person to go to an Employment Exchange to get his card franked in order to keep him in benefit. I am not speaking of what ought to be done; I am speaking all the time of the liabilities and commitments within the scheme itself. No benefit society can possibly carry on if it is compelled to pay benefits without any premiums being paid. No private concern can do it; but the State is called upon to do it. I object to an idea that prevails in some quarters. It is this, that if a man cannot get unemployment benefit, if he cannot get Poor Law relief, send him to the approved society. That is the attitude in some quarters. The approved societies should not be called upon to bear burdens that ought to fall on the whole community; and it is unfair to try to push a man on to the funds of an approved society, merely because he is unemployed, in order to relieve the Unemployment Insurance Fund. That case ought to be a burden borne by the whole community.
As to what is to be done, it is difficult to suggest very much, except, may be, one or two points with which I will deal. I am not so sure that societies have a proper system of sick visitation. The same thing prevails in Northern Ireland, and I understand it was suggested there that sick visitors should be appointed by the Ministry of Labour and that an approved society should engage a sick visitor from an Employment Exchange to call upon sick persons if needed. I want to reject that suggestion outright. I think the approved societies can manage this business themselves except for one 104 thing, that if Parliament wants the insured population to get so much benefit out of this scheme, Parliament must not reduce the premium income, or the State grant. I have familiarised myself with the schemes, so far as they are known, all over, and I say unhesitatingly this is the best State insurance scheme of any kind in existence in the world. [An HON. MEMBER: "Passed by this party!"] Amended by ours.
There is growing in this country a very serious anomaly. I am an official of a society which pays most of the additional benefits allowable. Thousands of men and women in it are the sons and daughters of miners, and you have this anomaly, that a member of my society, the son of a miner, gets £1 a week sickness benefit, 10s. disablement, 50 per cent. of the cost of optical treatment, surgical appliances, convalescent homes, dental treatment and all the rest of it. The father, on the other hand, because he is in a miners' approved society—a segregated society—gets nothing but statutory benefits. You hare the anomaly carried further. You may have six people in one house, each belonging to a separate approved society, and, though they are all members of a national State insurance scheme, the benefits of each differ from the other. I think that anomaly ought to be removed.
A strange thing about this scheme is that, the more drugs our people take, the longer and oftener they are ill. I live in Manchester. People say it rains more there than anywhere else, but it is not true; it takes longer to come down, that is all. The number of chemists' prescriptions in Manchester increased from 1,500,000 in 1924 to 2,250,000 in 1929 for approximately the same insured population, and still they were more sick than ever. As stated, it is very difficult to know what remedy there might be to deal with this problem, but the Committee will be glad to hear one thing. I have asked several approved societies what is their experience for the first quarter of this year. I will give the experience of my own society. I understand it tallies with the experience of practically every other. The first quarter of 1930 is the best quarter for the last six years. Some people say the weather has been better and, if you sat in the office of an approved society, you would 105 soon find how far climatic conditions affect the health of the people.
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Some of the reasons which have been given to-day are not as real as people imagine. There is no malingering except in respect of about one per cent. of the insured population claiming benefit. When you remember the epidemics that have taken place almost every year, the lowering of the vitality of our people consequent, upon unemployment, especially in the mining districts, the effects of the War and all those forces that are at work, it is not surprising that claims are heavy. There are some subtle forces at work, which I hope the Minister will inquire into some time, which not only affect the insured population but the whole of the community, where people are sometimes playing with the fundamentals of life. I will leave it at that. This scheme will, in spite of it all, survive in my view and will go on. I trust that this Debate will have the desired effect of finding out ultimately what can be done, not merely to decrease the number of claims but to put this scheme once again in the position it found itself in at the beginning, of being actuarially sound. I would like to bring back to its funds the amount of the State grant promised in 1911, and I trust that we shall never again see the funds of the societies plundered by an unscrupulous Chancellor of the Exchequer.
§ Mr. MELLERI should like, first of all, before entering upon this discussion, to which we have all listened this afternoon with very great interest, to say a word of congratulation, which I am sure will be echoed by the Members of this House, to the hon. Member for Westhoughton (Mr. R. Davies) who has just spoken. Some of us know that he has passed through a serious illness, and the evidence he has given this afternoon of his recovery is a matter for congratulation. In the past, as a Member of this House, he has taken a very deep and anxious interest in the question of national health insurance. We looked forward this afternoon to the observations he had to make, relying upon the fact that those observations were based upon a long experience. The discussion this afternoon may range over many subjects, for the question of the Ministry of Health Vote touches, as the Minister 106 himself says, the people of the country at a hundred points and more. Before dealing with the subject which seems uppermost in the minds of Members this afternoon, that of National Health Insurance, I should like to say a word of thanks to the Minister for bringing up a point, which has been misunderstood throughout the country, with regard to the Act of 1929. A good many people imagine that certain increases in the rates have been directly due to the de-rating Section of the Act of 1929. Last night I had the privilege and pleasure of explaining to a certain group of my constituents why it was that, the rates of their particular part of the constituency had increased, alleged as it was by certain members of the district council that it was due to the extra spending of the county council and to an increase due to de-rating owing to the loss of the rateable value. I was able to show that the White Paper published setting forth what might be the relief to particular areas had, in fact, come out to the very farthing in this district. The guardians of this country, too, have apparently taken to themselves the message, "Let us be merry to-day, for to-morrow we die," since they passed over to the county councils an empty till. I am not certain that some of the district councils have not also anticipated some of the relief for 1929 and have dipped into the balance and now find, when they come to make up their estimates this year, that they have to increase their rates to make up for what they have spent previously in anticipation of the good things to come in 1930.
So much for the general question. Now may I turn to National Health Insurance? The publicity which has been given by the Press to this particular question is going to be of real help to this particular scheme. I am not sure that the people of this country have realised what has been going on. They have not realised from the actual sickness they have seen around them that sickness was so deep-rooted as, apparently, it is shown to be by the statistics of National Health Insurance. I am glad it has been brought out, because it is well that we should call a halt to the extravagance of National Health Insurance—if extravagance there be—before we have arrived at that stage of insolvency when we must say that either the benefits must be reduced or 107 there must be a claim on the State to put the scheme once more in a satisfactory and solvent state. It is true that insolvency is not imminent, but it is equally true to say that if the sickness experienced is year by year constantly to increase, as has been shown by the White Paper of the Government Actuary, the people of the country insured under the scheme will have to pay more contributions or the State will have to pay more money or the benefits—certainly the additional benefits—will be reduced.
There are two features of this report that strike us more than anything else. The first is the remarkable and consistent rise in sickness benefit, and, secondly, the abnormal increase in the sickness of married women. The hon. Member for Westhoughton tried to give some explanations for the increase. As regards the men, he said we must not forget that the War had placed in our midst a number of men maimed in body who would yield to any attack of sickness. I would like my hon. Friend to refer to the Government Actuary's report on page 10, and there he will find in Table C the number of claims for sickness benefits respectively for each 100 members within the age group. We should expect to find, if there is an increase in sickness due to ailments as a result of the War, that it would be shown somewhere in the ages between 34 and 50. Look at the Table and it will be seen where the increase is. Between 16 and 19 the percentage was 14 in 1921 and 24 in 1927. Now let us turn to the ages that might be affected as a result of the War, and we find that between 35 and 39 the percentage in 1921 was 13 and in 1927, 21. So that, instead of finding the increase among the ages who would have been serving, we find the actual increase in the sickness experience shown most in the ages from 16 to 19. We can, therefore, dismiss that as the probable cause. I see my hon. Friend opposite who is a medical man shaking his head. I am not going to be dogmatic upon this—no one can be dogmatic. If my friend suggests that, medical opinion might come along and say something else. The fact is that where you would expect sickness to rise from War service, it does not do so according to the Actuary's report. Is there then any definite cause expressed 108 according to this sickness experience? Have there been any remarkable epidemics which from year to year have shown great developments? We have had the epidemics of influenza, and one would have expected in the period 1921 to 1927 some years in which sickness experience would have dropped very rapidly indeed. Instead of that, we find the peak of one year becoming the low point of the following year. There has been a gradual increase with, apparently, no particular reason for it.
There has been one striking thing referred to this afternoon which deserves the consideration of Members of this House, and that is the expectation of life of people of this country. I take these figures from the report of the Registrar-General for 1928 giving the mortality rate for the years 1919 to 1928. I take 1919 especially, as I want to avoid any suggestion that the increase in the mortality rate was due to the War. Taking the later years, therefore, I find that in 1919 the rate was lower than in 1913 when the rate per 1,030 was 13.2. In 1927 it had consistently dropped, except for a slight decimal point rise for a year or two, to 10.6 and in 1928 to 9.9. It is a most remarkable thing. The Government Actuary shows not that there has been a marked lengthening in the periods of incapacity, but that there has been a broadening of the area of the people who come upon the sickness funds. There immediately arises a question to one's mind. How is it all this medical treatment gives you that remarkable decrease in the mortality rate and the remarkable increase in the sickness rate? There are some people who say that, when you increase the expectation of life, you do it by increasing your sickness experience and by coddling and carrying on a number of lives which, in the ordinary course, would have gone out altogether. I do not know. That is one of the views put forward. There is another aspect of it. Are we raising a very puny race, who in the old days were prepared to throw off comparatively slight ailments and carry on, and who are to-day falling at the very suggestion that there is something wrong? Do the medical men of to-day actually encourage by this so-called very humane treatment a prolongation upon sickness funds?
109 Then think for a moment of the aspect which the examination of medical referees shows of this matter. It is said that during the past year some 400,000 cases were submitted to the referees. Of that number, some 45 per cent. either declared off or failed to attend for examination; some 35 per cent. were found incapable of work; and the balance were, found capable of work. It has been said by some medical men that the standard of examination of the medical referee is different from the standard of examination of the medical practitioner, that the object of the attending practitioner is to get his patient so well that there is not likely to be an immediate recurrence of his trouble, whereas the referee's attitude is to say to himself, "Can I satisfy myself that the man is so well now that he can work, and, if so, get him off?" There may be that difference of view between the practitioner and the referee.
Let us accept as to 45 per cent. that the people were either afraid to come along or were declared off there still remains 55 per cent. It is a sad reflection that over a period of years this percentage of persons found capable of work by the referee has been certified—it may be for days or even weeks—by the doctor to be incapable of work. The inquiry which the Minister contemplates may throw some light on the subject. It may throw some light as to whether there is a discrepancy between methods adopted by the referee or difference in methods adopted by the doctors throughout the country. It is clear that every person who is entitled to benefit under this scheme should get benefit, and that there ought not to be a differentiation in treatment by any of the medical practitioners. If a man is incapable of work, he should be declared by every doctor incapable of work. If he is capable of work, there ought not to be that varying standard or period of time in which the persons should be declared off.
There is another striking thing. The recovery from long illness seems to take place more rapidly when the value of the benefit is reduced. I hope that the inquiry will throw some light upon that matter. Some figures were given to me by a society recently which were very illuminating. This society had come to the conclusion that the persons who 110 declared off seemed to be greater upon a Saturday than upon any other day in the week. The Committee will probably be surprised to know that in an examination which they made approximately 45 per cent. of their members on the fund declared off on a Saturday. [HON. MEMBERS "Quite naturally!"] I do not know whether the answer which is going to be given is that they contemplated that with the Sunday intervening they might be well enough to go to work on the Monday.
§ Mr. J. JONESWhat rot!
§ Mr. MELLERI do not think that my hon. Friend opposite quite understands the position. It may be true, or it may not be true. But, why had Nature chosen a Saturday to pour out her healing balm and neglected other days in the week to a great extent? There is another question which will have to be considered. No claim for benefit can be initiated without a certificate, and benefit cannot be continued without a certificate. We have to consider whether or not the methods of certification in this country are right and proper. For my part I have always said—and I claim to have very large experience in the matter—that malingerers are made and not born. You may leave people upon the funds on the assumption that they are sick when they are not sick, when what they require is help from the practitioner to pull themselves together and to get back at work. I know the difference between unemployment and employment, but in these cases probably far more good will be done in this way than by any number of bottles of medicine. The moral effect of some encouragement and the confidence which medical men may give to their patients, I am sure, will be good for the patients and worth more than tons of medicine which they may pour down their throats.
What of the remedy? I was glad to hear that the Minister contemplated calling into his conference representatives of societies, of the medical profession and of the other bodies connected with National Health Insurance. They may be able to arrive at some satisfactory conclusions. At least, they will be able to show to the medical profession that this subject is being very closely watched and that doctors have to do something more than merely to certify; that they have 111 to certify with proper care and precaution. If this Debate does nothing more than bring to doctors a realisation of their duties, it will have done something.
There is another question which raised some objection on the other side this afternoon. It is the proposal that the insured person may return to the old order of things of changing from one doctor to another. The proposal to reduce the period from six months to one month, unless there had been an arrangement by the acting practitioner and the proposed practitioner, was very largely taken on the initiative of the doctors themselves. [An HON. MEMBER: "No!"] An hon. Member says "No." Let me state the facts, if the hon. Member disputes the point. As a matter of fact, it was very largely upon the initiative of the doctors themselves.
To-day, another state of things has arisen altogether. It is the doctors who find the real difficulty in this case of transfer, and it was because they were said to have some objection to having a disgruntled patient and an unwilling practitioner that you altered the six months' period to the one month period. But to-day the practitioner says: "If I am to do my duty, and I want to do my duty; if I am to be in the position to say to my patient, 'Look here, I am not going to give you a certificate. I do not believe that you are incapable of work,' what is the answer? My patient turns round to me and says, 'Thank you. If you are not going to believe my subjective symptoms I can go to another one who will believe me.'" It is because of the pressure which occurred very largely during the strike of 1926. Let hon. Members not forget now the sickness figures ran up during the great Coal Strike, and that as pit after pit got to work once again so the sickness experienced in those areas fell immediaely. What did you find in South Wales? Medical men were crying out and complaining bitterly. They said: "Because we cannot honestly give certificates here, they are going down the street to some other men with not the same conscience in the matter of giving certificates." In my view, whatever else the Committee may find out as the result of the inquiry, they are going to find out 112 that they have to get back to the old order of transfer.
Steps must be taken to see that no insured persons is compelled to remain with a doctor in whom he has no faith. In all medical progress a great deal of success depends upon the faith of the patient in the medical practitioner. We may talk as we like. We may talk about certificates being properly or improperly given. If there is collusion between patient and doctor, there can be no cure. If we encourage honesty on the part of the doctor, and if we can persuade the people that by making improper claims on the funds they are doing not only an injustice to their society but an injustice to their fellow men, and if this Debate can awaken the medical men of this country to their right duty in this matter, the Debate will not have been in vain.
§ Dr. MORRIS-JONESI am sure the Committee have listened with very great interest to the comprehensive survey given by the Minister of Health. It struck me, when I was listening to him, that the Department has now become one of the most important Departments of State. As a Member of this House, I believe I have listened more to the Minister of Health than to any other Minister, which, I suppose, testifies to the very comprehensive and wide scope of the functions of the great office which he holds. One can easily understand that he was not able to touch upon many important aspects of the administration of the Ministry of Health, and I am sorry that the Minister did not mention one important matter, the question of vaccination. That is a matter which affects medical and lay circles in this country, and will have to be faced. We know that there are international obligations associated with it. We saw this a very short time ago when we had an epidemic in this country, and when our neighbour across the Channel raised difficulties with regard to people arriving there from this country. I hope that the right hon. Gentleman will face this matter. At the present moment, the administration of the law with regard to vaccination is almost farcical. If it is the opinion of His Majesty's Government that vaccination should be compulsory, it ought to be made compulsory. At any rate, if they do not agree in that sense, steps ought to be taken to abolish compulsory vaccination.
113 I should like to say a few words with regard to the effect of the Local Government Act of 1929 on a large number of men and women in this country who have been giving voluntary services on some of these public bodies. I am rather sorry that the right hon. Gentleman the late Minister of Health, who initiated and carried out that very great Act, has prevented a large number of public-spirited citizens in this country from giving their services to local bodies on account of the fact that they would have to resign appointments which they have held for many years and which, financially, bring them very little benefit indeed, but which under the Act they have to give up or give up their voluntary services on a public body. I know that in my own municipality—I speak about medical men because I happen to know them better—it affects men and women who give their services to local bodies.
There is the case of a parish doctor who has been on the county council since the very beginning of that, authority. Under this Act, he has to take the choice of resigning an appointment which he has held for 30 or 40 years or resign his membership of the local authority. It is a pity that the right hon. Gentleman did not preserve this great tradition of public service. Not only have these people to make the choice now as to whether they will give up their appointments or resign their membership of a public authority, but they know that if they give up their appointments and continue to serve in a voluntary capacity on the public authorities they will lose all superannuation payments, towards which they have contributed over a series of years, as well as the State contribution. It is an injustice that these men and women who have given services for a great proportion of their lifetime should now, because they may choose to continue their voluntary services to the State, be deprived of the superannuation towards which they have contributed for a large number of years. I hope that the present Government will be able to find a way of redressing that anomaly under the Act.
I should like to refer to a matter which has received public notice, and that is the large number of claims under the National Health Insurance Act. I see from the White Paper—which most of us 114 only received this afternoon and which we have not had an opportunity of examining in detail—that the increase in claims is certainly a very serious factor. The sickness benefits and claims by married women have gone up between 1921 and 1927 by 106 per cent., and in the case of disablement benefit, and the claims of married women the claims have increased by 159 per cent. One can see, therefore, that it is a very serious matter for the societies. The Minister of Health referred to some of the causes of this increase and the hon. Member for Westhoughton (Mr. R. Davies), who has had very considerable experience in this matter with regard to the approved societies, also analysed some of the causes. I agree with him that the main cause is the serious industrial depression since the War.
There are amendments of the National Health Insurance Act whereby persons who are unemployed are still able to retain their rights to medical benefit. By going to the Employment Exchange and having their cards checked, they are able to continue to receive medical benefit. It is perfectly right that they should continue to receive medical benefit. Although the payment of this benefit may result in the depletion of the funds of the approved societies, it would not be fair at a time when the insured persons are the subjects of enforced idleness, due to no fault of their own, that they should be deprived of medical benefit. From my experience as a medical man I find that enforced idleness, enforced unemployment is bound to cause more sickness. The man who is working is much healthier than the man who is not working, and the same remark applies to a woman. A person who has nothing to do except to analyse his own slightest symptom is in such a frame of mind that a small symptom which would not receive any notice at a time when he is working is magnified when he has nothing to do but to think about it. I feel sure that this is a very potent cause of the increased number of claims for sickness benefit.
There are, of course, other causes. There is the War and the increased illness as a result of the War, even amongst those who did not participate as combatants in the War. In the course of some years experience under this Act, people have come to consult me or I 115 have had to attend people who did not take any part in the War but who, nevertheless, were suffering very seriously from having gone through that very great catastrophe. Many insured persons have suffered from the bombing that took place in London. It is no exaggeration to say that there are hundreds of people in the county of London who, since the War, are directly or indirectly suffering as a result of the experiences which they went through during that time. There is another reason for the increased claims. I agree with the hon. Member for Westhoughton when he said that 99 out of every 100 per cent. of national health insured persons are honest, hard-working people, but that 1 per cent. are malingerers. I have had experience of persons who have come to me, as a medical man under this Act, and have said: "We have been paying long enough." One person said to me: "We have been paying to Lloyd George for years and it is time that we got something out of it." [An How. MEMBER: "Ninepence for fourpence!"] Well, it is a great Act and every party in the House is very proud of it to-day, although some Members of the House were not very proud of it when it was Passed.
§ Dr. MORRIS-JONESNothing succeeds like success, and that has been the case in regard to this Act. It now has the happy co-operation of the whole population of this country. I should like to say a few words in regard to the alleged laxity in giving medical certificates. The giving of medical certificates is a very difficult matter. Medical men are neither worse nor better than any other class of human creature, certainly no worse and I do not suppose they are any better. They are confronted day by day with very great difficulties under this Act. One hon. Member mentioned that a young medical man, newly qualified and anxious to build up a practice, would be rather keen to please his patient and therefore he would possibly give a certificate when it was not really required. Quite possibly that may be the ease, but I think such cases are very rare. It is an extraordinarily difficult thing to tell when a man is or is not 116 capable of work. One of the most difficult things in the world is to prove that a man is not ill.
There is a story told of a medical man who dealt rather cleverly with a man who he knew was very definitely malingering. The man was making a very substantial claim upon a railway company as a result of a railway accident. He stated that the pain in his back was so great that he could not stand upright. He walked into the doctor's consulting room, bent on two sticks, but the doctor had no doubt on the question of the man's capacity. As the man was bent in front of him the doctor said: "I can see that you are unable to stand upright on account of the pain in your back. Would you mind showing me how you used to stand before you met with your accident?" At once, the man stood upright.
There are occasions when one is able to find out whether or not a man is really ill, but generally it is very difficult. There have been cases known of responsible medical men, men of great experience, pronouncing a man fit and that man has died the same day. Medical science is not an exact science. There are very grave doubts in regard to many ailments. Certain possibilities of a very grave character do not show on the surface as obviously as they do in other cases. On the whole, we see from the report of the Ministry of Health for last year and the statements made by the chief medical officer to the Ministry that the general standard of treatment under the Act has improved and that great blessings have been conferred upon the community. The claims upon the service are constantly increasing. I am certain that the steps taken by the Minister of Health to inquire searchingly into the causes of the alleged, not only the alleged but the definitely large, claims under the Act, will result in some more certain causes being found than we have elicited so far. It is only fair to the insured population to point out that the same thing is happening in other countries that have adopted the health insurance system. In Germany and I understand in Ireland the same thing applies as applies in England and Wales.
I hope that the Minister of Health will be able to see his way, amid numerous difficulties and a large number of other commitments, thoroughly to 117 overhaul and to reorganise if possible the whole scope of the National Health Insurance service in this country. I hope the Parliamentary Secretary will be able to say that the Government contemplate before long being able to bring before the House a scheme to enlarge the whole of the service of national health insurance, co-ordinating the numerous branches of it and bringing within its scope women and children and dependents, thereby crowning an Act which has been a very beneficent Act for the people of this country.
Dr. MORGANI happen to be one of those who every day is engaged administering this Act. That is my excuse for intervening in the Debate. Let me take, first, the question of lax certification. We have been told by the representative of one of the industrial approved societies, who is not now in his place, that the malingerer is made and not born. That is to say, he is made apparently either in his own house or in the doctor's surgery. We were also told by the right hon. Member for West Woolwich (Sir K. Wood) that lax certification is due to the fact that new doctors come along and want to make their practices very quickly out of the National Health Insurance Act. As one who administers this Act every day, I say from the medical point of view that there is no general laxity of certification on the part of the medical profession. There is no general malingering going on. Every day I have patients coming to me to whom I have given a certificate of incapacity, and they ask me to certify them as fit. I may say, "No, in my opinion you are not fit to be taken out yet, and I will give you a certificate of incapacity still." They always agree, and leave it to the doctor to decide whether they shall come off or not.
People are gradually getting to have a knowledge of their rights, not only under the National Insurance Act, but under every piece of social legislation. They are demanding more and more the rights to which they know they are entitled. Some approved societies for years have been trying to educate the insured person as to his rights against the doctor, and trying to get him to make charges against the doctor. The doctor's job is difficult enough at any time, but certain societies and their agents have tried to excite a feeling against the medical pro- 118 fession for what they think is laxity. They forget that, at the same time, the insured person is being educated in his rights against approved societies, and he knows now what he is entitled to, that when he is ill he can receive the benefits for which he pays. What is more, his employer is much more keen now that his employé should come under the Act and gets its benefits.
The Actuary makes it perfectly clear that it is a wider number of persons claiming benefit for a shorter time, and not persons claiming benefit for a long period, that is responsible for the increase. A larger number of the population are taking advantage of the Act. They are ill, and the plea that the increase is due to malingering or to laxity on the part of the doctor is not true. I have found as a doctor that it is to my benefit as well as that of the insured person that he should come on the panel early. Many say, "Shall I come on the panel or not?" I use my judgment and say, "You should," and I keep them there as long as I think they should be. The Insurance Act was not brought into existence for the sake of the approved societies, the doctors, the chemists, or the State, but for the benefit of the insured person, and the individual insured person, goodness knows, has enough to suffer! There is equality of contribution but not of benefit. A man may have registered in Manchester, become unemployed, go to London, choose another doctor and get ill. Then there is a whole series of performances to go through, sending certificates to Manchester, and so on, beforehe can get the benefit. The whole system is riddled with anomalies to the disadvantage of the person for whose benefit the Act was introduced, and part of the criticism of the doctors is intended to hide the criticism of the approved societies.
I can give an instance in connection with ophthalmic benefit. A person came to me for a certificate for ophthalmic benefit. If we give such a certificate and send it to the Prudential Society, whose representative has just spoken, it pleads that the person should be sent not to an ophthalmic surgeon—which is the right thing to do, because the eye is the most valuable organ, and should not be played with—but to an optician. In this case the patient preferred to accept the recomrnendation of the doctor and not that of 119 the approved society. She went to a hospital, and we managed to save her from a desperate attack of retinitis. If she had gone to an optician, her eyes would probably have been lost. In another case an expectant mother, four weeks before the birth of the child, was sent to be examined by the assistant referee. That society, the National Union for Insurance, examined the patient and decided that she was fit for work—four weeks before the event—and struck her off the benefit I was giving her for incapacity because of her condition.
These things are happening every day, and because approved societies want to hide the charges against them for their administration of the Act, they level charges against other people It is not the change from one doctor to another, which the patient has a perfect right to do. It is due to more than that. If one examines the Insurance Act one will find that the doctors are organised, the State is organised, the chemists are organised and the approved societies are organised. The one person who is not organised is the insured person. The sooner—I wish I had the time to do it—somebody in the country calls a league of insured persons, making them pay, say, a penny a month to see that they get their benefits and their rights under the Act, the better it will be. They require to be protected not only from the doctors but from the chemists, the societies and the State. The sooner that is done, the quicker there will be a change in the administration of the Act, and the full benefits recommended by the majority of the Commissioners brought in. The sooner, too, there will be brought about the changes recommended by the minority—hospitals and convalescent treatment, dental treatment, eye treatment, not only for those who happen to be in favoured, rich societies or favoured, rich occupations, but all insured persons. Seeing that they pay equal contributions, they should have also equal benefits.
The Minister of Health, in my opinion, made a perfectly excellent speech in defence of the position. He gave a very impartial view of the situation. He said, "Here are certain allegations and charges being made, and it is our duty to investigate departmentally or otherwise those allegations." What he said was perfectly correct, that there was a 120 gradual lowering of physique due to unemployment. You do not find it in the year the unemployment started. It takes some time owing, perhaps, to a lack of nutriment and the proper vitamin content if you like, in the lowered dietary, but after a series of years of unemployment you find people gradually deteriorating in physique, and when they are ill they have a tendency to ask for the benefits of health insurance. I have what I call the "in-and-outers" on my list. There are, for example, the ladies with varicose veins. At any time these people, if they so wish, as every doctor knows, could ask for certificates of incapacity, and I defy any doctor, specialist, medical referee or regional referee to refuse a certificate of incapacity. They never ought to be at work. The same thing happens with cases of bronchitis and asthma, and I have cases of men hanging on to work when really they should not be out. They prefer to be at work, they get more, some of their employers are fairly decent and only when an extra attack comes on do they come under the Insurance Act.
These "in-and-outers" under a decent system of society would not be at work at all, but would be treated as sick and invalid. I find as a doctor—I think I have made this point before, but I like to make it again—that early certification is a benefit to me as well as to the patient. It may be a wrong thing for a doctor to do, but if I see a patient of mine walking the street not looking very fit, I stop him and say, "Come and see me in my surgery." If he is at work, I tell him to come on Sunday morning, and by a preliminary examination of that sort I can save myself much work. So much did I lower the cost in one year that the regional medical officer called me to book to explain why my rate for prescriptions for that district was so much below the average, and when I gave him the explanation he did not believe it. Those whose prescription rates are above the average are called upon for explanation, and if you are below you are also called on for an explanation; so that whatever you do you will be called upon by the regional medical officer. The heavy clerical work entailed hinders the treatment of patients.
I want only to say this in conclusion: You will find Members of this House who 121 are not administering the Act and have only a secondary knowledge of it, who may sit in comfortable armchairs in the offices of societies. They have not got to go into dark, dismal dwellings, barking their shins and hurting their hands on doors, and so on, and seeing the conditions under which people are living every day. We have to go to these people, to treat pneumonia in damp dwellings, and maternity cases in disgraceful conditions. These people of whom I am speaking sit in comfortable offices and say, "Lax certification." Frequently they telephone to know whether your certification is correct or not, as if a doctor will sign a certificate without knowing what he is doing. I am not saying doctors do not make mistakes. Doctors make grave mistakes. A greater man than any of us here said that a person who did not make a mistake did not make anything. Doctors are no more susceptible to mistakes than a Cabinet Minister or a minister in the pulpit or anywhere else, or even the hon. Member for the Sutton Division of Plymouth (Viscountess Astor). We are all liable to mistakes. A young doctor may, in an excess of zeal, say, "Yes, I think you ought to go on or off the panel." But I am sure in my own mind, from discussion with medical men all over the country, that there is no malingering on the part of the insured person, and no lax certification on the part of doctors.
8.0 p.m.
There are many changes necessary in the Insurance Act, and I am as sure that approved societies will have to be changed as that the sun will rise to-morrow. We shall have to have amalgamation, national amalgamation, and apooling of surpluses. The insured person will insist upon an equality of benefits for an equality of contributions, and when that time comes approved societies with a large number of members in sheltered occupations will be up against it. I am thankful to the Committee for having allowed me to make these remarks. It is a matter in which I am concerned and I hope that the Committee will allow the Minister to go on and do his business without hindrance, that the committees will be allowed to do theirs, and that the medical profession will carry on the provisions of this onerous Act with the least possible difficulty.
Viscountess ASTORI am not going to follow the hon. Gentleman who has just spoken in discussing the merits of doctors. It is obvious that something is wrong about insurance, and I do not think it is a good thing for the House of Commons to say that there is nothing wrong and that the doctors are all right. I would be the last person to condemn a doctor. They, like other people, comprise some who are bad and some who are good, some who are stupid and others who are clever. The hon. Member has just made a speech which no doubt would be popular in his constituency, but here we are anxious to get at the bottom of the insurance trouble. I have listened to the speech of the Minister of Health and from his unexciting remarks it might have been made by any ordinary Minister of Health. Of course, the late Minister of Health would have made a more interesting and a more vivid speech than even the present Socialist Minister, but we on this side, after our experience during four years of the lashing criticism of the present Minister of Health, and the heartbreaking criticism of the hon. Lady the Member for East Ham, North (Miss Lawrence), have always expected when they came into power that we would have something new accomplished. However, so far as I can make out, the Minister of Health has not done anything which the late Government did not start. He said something about hoping to deal with maternal mortality, but I would ask the hon. Lady if she is certain that the money which has been voted for this has not already gone and that when she goes to the Chancellor of the Exchequer he may not say there is no more money. The Minister did not give much promise that anything was to be done, but he said that, when the report came forward, they would see what could be done.
The Government are now saying what wonderful schemes they are and that they will try to improve upon them. That is interesting, but it, is not what we were led to expect from a Socialist Minister of Health. How easy they are being let off! These benches ought to be filled—[An HON. MEMBER: "Where are they?"] I will tell you. It is because they are honest men and women, and they know that probably no Minister of Health can do more than the present one is doing. I am not blaming the Minister for not doing more, but I am blaming him for 123 not apologising to the House of Commons for the attitude which he took up during the four years that he was in opposition. [An HON. MEMBER: "Two hundred majority!"] I am not talking about majorities. I hope the hon. Gentleman will just listen patiently to what I have to say, even if it is not pleasant.
I would like to quote some of the things promised by the hon. Lady only a year ago when dealing with a question of health in the House of Commons. Only last night, I had to go into the Union at Maidenhead, and there I saw and talked to the 60 Communists from Wales who are marching to England. I saw them because I am interested in the "down-and-outs." Last year the hon. Lady, when she spoke, drew a terrible picture of distressed areas, and she said that there were certain things that the Labour Government could do in three weeks. She went on to draw a picture of Merthyr. A number of these distressed areas are represented in the House by Socialists, but we hear nothing about them in these days, so someone has to speak about them. The distressed areas are to-day more distressed than they were last year, and it looks as though this distress will go on increasing. The hon. Lady, in talking about Merthyr, told of how many people there were living under appalling conditions due entirely to the policy of the late Minister of Health. She said:
Why is it that last winter and last summer the cry of distress was so great that charitable people were asked to help? The distress and the suffering and the misery are entirely due to the policy of the Minister of Health.I would ask her: Is the distress in Merthyr now and in these areas due to the present Minister of Health? It may not be the policy of the present Government to get people off relief, but it is a result of their being in office that many of them got on to it, and now that they are on, are the Government doing anything more than the late Government did for them? The hon. Lady said:What sort of relief do the recipients get? I have here a document which has had considerable publicity.… I will give one or two cases taken from it. In the case of a husband and wife and four children the relief granted was 23s. 6d., and after rent was paid there was 14s. 6d. left, or an average of 2s. 5d. per person. Another case is that of a husband, wife and eight 124 children under 14, the husband being an ex-service man. The relief granted was 35s. and the rent 9s. and the balance had to maintain 10 persons.I would ask her: Is the relief given now any greater than it was during the time of the late Government? Certainly, some guardians are giving more, but not because of the policy of this Government. She goes on:Human misery, which it is almost impossible to contemplate, has resulted from that policy and that is what will continue to happen to the unemployed if, by any misfortune, the present Minister of Health of the present Government are allowed to remain in control. But if we come back we will end the misery, the hunger, and the starvation. I know that to bring in a proper Unemployment Insurance Measure would take months, and to start everybody who is unemployed on schemes of work would also take months. We will do these things, but we will not only look to the curing of unemployment; we will deal with the people who are suffering from hunger and cold, from want of boots, from want of milk and want of clothes. These are things which a Labour Government can cure within three weeks of coming into office. They are things which we can cure without Acts of Parliament. They are things which can be cured by administration just as was done in 1920. We shall cure them by administration, just as the evils themselves have been caused by administration.Then the hon. Member for Doncaster (Mr. Paling) intervened, and remarked that the right hon. Gentleman the Member for West Woolwich (Sir K. Wood) was laughing, and the hon. Lady said:The right hon. Gentleman the Member for West Woolwich laughs and jeers, but if I am right in my view, his place will know him no more.If you act up to your promises, your place will know you no more. The hon. Lady proceeded:To pass a new Unemployment Insurance Act—that can be done. But these are things which any Parliamentarian knows must take some little time. I repeat, however, that to stop hunger is a thing which can be done in three weeks.… There is no mystery about it, and when we come into power we will end the hunger, the want of milk, the condition of 'no boots for bairns.' We will take it as our first and most sacred duty to see that the harmless and the innocent shall not suffer actual physical privation. I we were going to do more than that, it would be well worth winning the Election, and it would be well worth while for everybody with an ounce of humanity in their hearts to put every scrap of their courage, their strength and their intelligence into bringing about that victory and sweeping the present Ministers away 125 from the Departments of State."—[OFFICIAL REPORT, 1st May, 1929; cols. 1597–1602, Vol. 227.]The right hon. Gentleman knows that in the distressed areas things are far worse than they were a year ago. There are many hungry, many children wanting milk. I am not blaming the present Government for everything. I do not believe that any section of the community can see the unemployed and remain unmoved and without a desire to do something. But I say that now that the Socialists are in office there is something that they ought to do. It is the duty of the Socialists who have been talking for years to get up and say to the country, "We have told you things that we know are not true. We no longer believe them. It is rationalisation now." I feel just as strongly about these things as the hon. Lady, but I will not take advantage of her. I want to see something done for people like the boy whom I saw last night, who had walked all the way from Wales, and another boy who walked all the way from Birmingham. I want to see what can be done for the two fellows I picked up on the road from Maidenhead—one an ex-soldier and one a youth of 18. I want to try to give a chance to all the unemployed and the unemployable, but I know that it is going to take time, and the hon. Lady opposite knows that it is going to take time, and the worst thing the Government ever did was to promise people things which they knew they could not give.
§ The DEPUTY-CHAIRMAN (Mr. Dunnico)The Noble Lady is not entitled to discuss anything which involves legislation. She is only entitled to discuss administration.
Viscountess ASTORThis could be done by administration. It will only take three weeks. There are many people on this side who would help the hon. Lady to deal with this question. We would all help her to do away with the conditions in these distressed areas, which really are much worse than they were before. One has only to go down to Wales and see the conditions there to realise that this is so. The people there are absolutely in despair, but not one word do we hear from hon. Members opposite about the conditions of those people. I ask the hon. Lady, who taunted me with 126 having the mind of a child, to have courage and to get up here and ask us for our help. The party opposite would get that help, but they will not get it until they repent for the foolish things which they have said.
§ Mr. T. LEWISI am very pleased that the subject of National Health Insurance has occupied so much time this afternoon, although I believe that many grossly exaggerated statements have been made regarding certain phases of the Ministry's work, and I refer more particularly to the question of alleged or implied malingering. The hon. Member for Mitcham (Mr. Meller) represents a very large organisation. I do not know what the members of that body will feel when they are told, in effect, that a very serious state of malingering exists at the present time. The hon. Member said that people did not realise what was going on and that we would have to call a halt in extravagance with regard to National Health Insurance. I hope that the Minister of Health will not take too much notice of the criticisms which have come from the other side. [HON. MEMBERS: "Why not?"] Because it is in the ordinary order of things that an Opposition should taunt the Government of the day and criticise its administration, and the approved societies know that the corn-plaints which are now being made against the Government have been made for many years.
The charge which is made here as to lax certification was made in the time of the late Government and I hope that the present Government is going to be swifter with regard to these matters than their predecessors. There is probably some measure of exaggeration with regard to this question of lax certification and I do not think there is any justification for suggesting that everything is all right with the medical profession and that everything is all wrong with the approved societies.
I do not know what types of approved society the hon. Member was referring to who said that they were on the watch and got their members to try to make trouble with the doctors. He could not be speaking of the respectable approved societies. He could not mean societies such as that with which my hon. Friend the Member for Nuneaton (Mr. F. Smith) 127 is connected with or those with which other hon. Members are connected. If the hon. Member can name any societies which have been guilty of conduct of that kind I hope he will do so in order to free the respectable societies from reproach. My objection against the Ministry is that they should have allowed gross exaggeration to go on with regard to the rate of sickness. We have had speeches made by the Controller of the National Health Insurance and the Deputy-Controller at various meetings. These have been followed up by a big Press campaign and an interview with some prominent representative of a Government Department—which I presume to be the Ministry of Health. That is a practice which I regard as improper and reprehensible.
§ The PARLIAMENTARY SECRETARY to the MINISTRY of HEALTH (Miss Lawrence)I did not quite follow what the hon. Member was saying.
§ Mr. LEWISI was saying that we have had a campaign on this subject. There have been speeches by the Controller and the Deputy-Controller dealing with the subject of suggested malingering—I do not say that they used the term "malingering," but with regard to the excessive sickness rate, which implies malingering—and that has been followed up by a big Press campaign. In the "Daily Chronicle" of 23rd April we find the headings: "Health Insurance Crisis." "Too Many Claims." "Sickness Payment may be Reduced." "Ministry Alarmed at Large Increase." Then we find:
Interviewed by the 'Daily Chronicle' a Government official put forward reasons for the increases which he said were more marked than ever.The interview stated that if doctors were very strict in dealing with doubtful claims the claimants would go to a doctor with a reputation for greater leniency, and that in times of industrial depression it was often found advantageous to take a rest under doctor's orders and to receive sickness benefit. That interview was said to be with an official of the Government, and I presume that means an official of the Ministry of Health. It is also stated that the same official explained that behind the present position there was the threat of retaliation by the approved 128 societies—that if the claims continued to increase the societies would seek to make good their position by making a reduction in the additional payments. I ask the Parliamentary Secretary to deal with that matter in her reply. If these statements have been made by officials of her Ministry, I hope she will take steps to see that in future those officials do not take part in public discussions upon matters which have to be dealt with by other organisations. The Minister of Health hinted that the Departmental Committee's Report would be submitted to the meeting of the Consultative Council. My objection is to having opinion formed before the report reaches the bodies which are chiefly concerned with this matter. It seems to me that opinion has been skilfully focussed upon this question of suggested malingering.I am rather disquieted because of the future of additional benefits, and I think I see same connection between this campaign and the third valuation, which is now going on. The Ministry do not like increases in monetary benefits. I attach considerable importance myself to the other forms of additional benefits which will seek to prevent disease, and I think on the whole they are more effective, but most well-regulated societies have given an additional benefit of about 5s. a week, and have increased the statutory benefit from 15s. to £1 a week, but however beneficial these treatment benefits are, people must have the wherewithal to live, and I believe the approved societies, if they have surpluses available, are not going to reduce their cash benefits from their present level.
I am not suggesting that the Minister of Health or die Parliamentary Secretary are against monetary benefits, but I believe it is the view of the permanent officials, the experts, that this increase of monetary benefits is not so advantageous as giving treatment benefits. The Ministry of Health is a vast concern, and the insurance department, big as it is, is only a section of that concern, and thee Minister and the Parliamentary Secretary have to be guided by their experts, but I hope they will not be stampeded in this matter by the opinions of their experts. I feel that ordinary malingering is to a large extent due to lax certification, and that the increase in sickness experience is due to the fact that illnesses are not properly diagnosed. It is the 129 place of my hon. Friend the Member for North-West Camberwell (Dr. Morgan) to defend his profession, and he did it like a man, but the whole medical business is in a very unsatisfactory position.
§ Lieut.-Colonel FREMANTLEWhy not join us and show what you can do?
§ Mr. LEWISIs it suggested that at my time of life I should do a thing like that? That is no answer to what I am saying. You can never deal with this doctor question without causing great excitement, but they must sometimes have the truth, and I feel that a good deal of this extra sickness is due to inefficiency on the part of the medical profession. We want more specialist treatment, and we cannot have it because the doctors cannot give it, in the main. You can only get for your ordinary terms the service that a doctor of ordinary competence and skill can give. When we pressed for specialist services the medical profession had to stand by the great bulk of their membership. They knew that the average doctor could not give it, and it has been opposed right through, but I hope we shall get it in the very near future, and that the Minister will be able to devise ways and means whereby a thorough-going medical service, which will include every form, will be given. But they will have to take a much firmer stand than they have taken up to now if they are to get that.
How much further have they progressed with regard to certification, which, I believe, has been under review quite recently? The societies pressed the late ministry in regard to certification. They want not only an effective system, but also one under proper control, and I hope the Ministry will insist, if the certification scheme comes into operation, that all parties are represented on the body. It is no use having certification which is left to the doctors entirely. That is all that the doctors want. If that is done, you will not have a much better system than you have to-day. When one speaks of the doctors, one knows that there have been dozens, even thousands of cases— [Interruption.]
§ The CHAIRMANIf the hon. Member will address the Chair, he is less likely to have interruptions.
§ Mr. LEWISI beg pardon, Sir, but I do not object to interruptions. One does not care to say too much at the present juncture, if there is a possibility of agreement being arrived at with the doctors, but it is well known that there have been very grave cases. In my own society there was a case where a doctor gave a man a certificate for two or three months, and the man was not sick at all, but was in prison for several months, and on not a single occasion had that man been seen by the doctor, but the certificate was given to the wife—a South Wales case. There is a number of other cases which one could quote in this connection, and irregularities of every kind; and the fines inflicted have been too small to have any real effect on the individuals concerned.
I should like now to look at the White Paper, and in this connection I hope the Minister will not pay too much attention to the Actuaries. Actuaries are not infallible. Some of us know many actuaries who have had to eat their words, or rather their figures over and over again, and while I dare say the figures given in the present Report can be maintained by the Government Actuary, they need very careful consideration by the Ministry. In the first place, I think it can be said that no real real basis for sickness experience of the type required existed when national health insurance commenced. A different type of persons were brought in to insurance than those which had been in the friendly societies, and they are brought in at all ages, while many of them are of a much lower physique. The first and second valuations disclosed enormous surpluses, which, I think, shows conclusively that very general and generous estimates must have been used. The Report of the Government Actuary on the second valuation of the assets and liabilities of approved societies, on page 30, Clause 51, shows that there was no real basis for the original scheme. The Actuary states:
It is appropriate to mention here that in accordance with the recommendations of the Actuarial Committee, the financial system is now to be altered in regard to the provision made for sickness and disablement benefits, both for men and women. In the case of men, the Manchester Unity experience of 1893–97 will be employed without loading, thus reducing the provision made by approximately one-ninth. In the case 131 of women, the basis is supplied by the experience of a large and representative sample of women membership of approved societies, thus removing the ground for a criticism that the sickness risks of women were measured by tables deduced from the experience of men.This shows, I think, that the original basis for women was wrong, and it may be that the second basis was wrong, although the Actuary states thatthis element of doubt in the financial structure of the system will now disappear. It may be added that under the new conditions the whole expenditure on sickness rind disablement benefits provided for in the case of women is about 60 per cent. greater than it would be if the basis used for men were employed also for women.Let us turn to the present Report of the Government Actuary, table A, on page 5, dealing with sickness experience as compared with expectations between the years 1921 and 1927. In this connection, it is worth while noting that in the case of sickness among men it was not until 1925 that the experience reached the expectation; therefore, for 13 years the experience was apparently hopelessly below expectation. In the case of disablement among men, it was only in 1927 that the experience reached expectation. The same point applies in connection with women, but the expectation was reached approximately between 1923 and 1924. It seems extraordinary that such an amount of publicity is given to the fact that the experience is 107 per cent. of the expectation, as this is compared with 1921, when it was only 76 per cent. of the expectation. Surely it would be fairer to compare the experience of 1927, when it was over expectation, with the year when it reached expectation, and not with the year when it was 24 per cent. below expectations. Hon. Members will notice that the particular years quoted were 1921 and 1927, and there are several points worth noting with regard to those two years. The year 1921 was an exceptionally light year for sickness, and many actuaries regarded it as an abnormally light year. It was known as the "trade boom year." The figures in the statement in Table A show that, following the trade boom in 1921, economic conditions were following on to establish a normal year. The General Strike was in 1926, and 1927 was a year in the first three months of which there was an influenza epidemic, and it was 132 also affected by the General Strike. It does not, therefore, seem reasonable to compare an abnormally light year, which also happened to be a trade boom year, with 1927, which had an influenza epidemic and was affected by acute unemployment owing to the General Strike.In spite of all these disadvantages, however, 1927 shows an increase of only 7 per cent. over the expected sickness, and no increase in respect of disablement. Several hon. Members have hinted at the real cause of this increase of 7 per cent. Surely, if you have an expected rate, you expect that at some time it will reach that rate, and I am sure that the Minister of Health, as a student of social affairs, can put his finger on the spot and tell us really why there is an increase of 7 per cent. It is due to the reduced standard of the people. We cannot have unemployment, with lower incomes, without the standard of the people being affected to a very marked degree. Then there are the conditions, to which hon. Members have referred, due to employers sacking men at an early age. Circumstances in the past six or seven years have been of an abnormal character, and the Ministry of Health must be aware of it.
The only point where experience seems to be unreasonable is in connection with married women. There was a 30 per cent. increase for sickness, and 70 per cent. increase for disablement over the expectation in 1927. It should be remembered again that the expectation was only reached in 1923, which was 11 years after the Act had commenced. Although this increase is great, compared with the entire population the number of insured married women is not a very substantial proportion. In some large societies the proportion is less than 4 per cent. When it is remembered that at the last valuation 66 per Cent. of the insured population were men, whose sickness experience is only 7 per cent. above expectation, and whose disablement benefit is normal, it will be agreed that this seems to detract from the seriousness of the position. Not long ago the Royal Commission on National Health Insurance presented a report, in an appendix to which five eminent actuaries, which included one of the Government actuaries, commented upon this position in regard to expectation. They said: 133
The higher level is probably explainable by the claims incidental to epidemic sickness, and the character of the fluctuation is such as to create doubt as to whether under existing conditions—including the liability to frequent and sometimes severe visitations of influenza—an experience of even six years' claims is sufficient to give a reliable average. In any case, it enforces the need for retaining a reasonable margin if such average be adopted for the purpose of a new basis.They said further:It appears to indicate that in the earlier years of the period covered by the statement some cause was operating to produce an abnormally low volume of claims for disablement benefit and that the trend throughout the period has been towards the development of what may be regarded as normal conditions. We are inclined to think that this is the case.Therefore, arguing on another matter, they say that six years is not a reasonable time in which to form a conclusion of the character which, I suggest, is being formed to-day. On the question of reserves, although the experience may exceed expectation, the fact should not be overlooked that ample reserve has been made by the Actuary. In the first place, a society is given a contingencies fund; secondly, there is a central fund and reserve values; lastly, there is the amount withheld from the disposable surplus for extraordinary contingencies. Presumably, the Government actuary either anticipates that these reserves are being used up too quickly, or that they are required for other purposes. The fact still remains that, in respect of 66 per cent. of the membership, the experience is only 7 per cent. above the expectation in the case of sickness, and that disablement has only just reached expectation. In view of the fact that in only two years out of 16 has experience exceeded expectation, in regard to men, I submit that it is too early to suggest that reserves are being unduly eaten up through increasing sickness.It is suggested that the increase is due to malingering, and particularly to members not declaring off as quickly as they ought to do. If that he so, the increase in duration or experience of the claims ought to be greater than the increase in the actual number of claims, but, looking at Table A, it will be seen that the sickness experience or duration in 1927 was 41 per cent. over the actual experience in 1921. The number of claims has also risen by 41 per cent. 134 Therefore, the duration of claims must be the same, which tends to discountenance the allegation of malingering. The Parliamentary Secretary should bear in mind the effect of the Contributory Pensions Act. When this came into force in 1926 an opportunity was given to all persons who had been insured for two years to re-enter insurance as voluntary contributors, and a considerable number did so. Without doubt the greater number of them were elderly people, whose sole object in becoming voluntary contributors was to obtain pensions, but those persons also became eligible for sickness benefit, and that must have some effect on the rise in the number of claims.
If we look at Table B, on page 7, we do not find anything very alarming about the increase of sickness claims. In the case of sickness among men the average duration decreased in 1927 as compared with 1921. The sickness among unmarried women decreased. In the case of married women, the average duration only slightly increased. In the case of disablement, there has been an increase, but even here the duration has actually decreased in the case of married women. A big point has been made about the number of people who went on disablement benefit but came off it in a few weeks after their claims had been tested. I think doctors will tell you that in the case of a serious illness it is quite a common thing for the illness to be of six months' duration, and just to run a week or two into the next period, the disablement period, and that the man then goes off. I resent the suggestion that they go off benefit because the pay has come down to a half. I say that in a large number of these cases they go off benefit because they have reached the end of the illness. The end of the illness has to be reached at some time, has it not? It is just the same in regard to the Saturday business. People think it strange that men should go off the fund on Saturdays when their work commences on Mondays. Do they think a man will go off the fund on Friday night if he is resuming work on Monday? It will not be found that putting off men on a Friday instead of a Saturday will reduce the sickness experience very much. The most serious aspect of the affair relates to married women, but I do not want the Department to be 135 stampeded by that, because the married women form a very small section in relation to the whole membership. Men form 66 per cent. of the membership.
To sum up: Having regard to all the circumstances of the past two years I do not think the expert advisers need get panicky over the report of the Government Actuary. We must remember that there are enormous funds. In spite of what my hon. Friend the Member for Westhoughton (Mr. Rhys Davies) said, the funds of National Health Insurance are indeed enormous. The second valuation showed that nearly £16,000,000 was retained as non-disposable surplus. The surpluses were somewhere in the region of £43,000,000, and nearly £16,000,000 was retained out of that sum. Before the ordinary reserves need be used that £16,000,000 can be drawn upon. The third valuation is now in progress and I hope the fullest possible amount will be made available for additional benefits and that no attempt will be made to curtail them on account of the present record. If an excess of 7 per cent. over expectations in two years is to be used as an excuse to curtail benefits, it is only reasonable, when the experience for 12 years has been 25 per cent. under expectation to say that that should have warranted a reduction of contributions. In my final word I would suggest to the Minister that it would be a helpful thing if he would at the earliest possible opportunity restore the sum of £3,000,000 per annum filched from the funds by the late Chancellor of the Exchequer.
§ Lieut.-Colonel FREMANTLEWe have heard a great deal about excessive claims for insurance benefit, and I do not want to go over the ground again, more especially as we have been much relieved to hear that the question is under further examination and in view of the very reassuring statement in the well informed speech of the hon. Member for Westhoughton (Mr. R. Davies) that the experience of the first three months of this years suggests that this phase of things is coming to a natural end, though I doubt very much whether such a steady rise, going on year after year, will be terminated so quickly as he suggested. I feel that it is necessary to reply to one or two remarks made by the last speaker and one or two others, and to try and 136 bring the Committee to a full and reasonable view of the question. I have read a great deal about it, and would lay emphasis on the views of some of the regional medical officers, and more especially one opinion from one of the chief medical schools in London, which takes a detached line, wishes to make the scheme run smoothly, and is used to dissecting and analysing such records. This review of the factors in the situation shows that there are to blame both those who take advantage of the scheme as receivers of benefit and those who take advantage of it in the administration of benefit. Both among medical men and insured persons there are a certain number who have less conscience than others. An hon. Member put the number of malingerers as high as 1 per cent., that is to say out of 17,000,000 persons there would be 170,000 potential malingerers. I should not have put the figure as high as that, but we must all recognise that there are malingerers.
Ordinary human beings try to get the most out of a State service; in fact, it is not the case that they try, but that it comes natural to them. As my friend the regional medical officer says in his review, that state of affairs is not confined to any one class. Among the more leisured classes, if a claim is put in under a fire insurance policy it is made as big as possible, the argument being that the insurance companies have large funds out of which to meet claims. It is the same with an insurance scheme of any kind. If an ordinary individual seeks benefit he says, "I may as well get my money's worth"; and no one is so much responsible for the prevalence of this idea as the original author of this scheme, the right hon. Member for Carnarvon Boroughs (Mr. Lloyd George) who managed to send the cry "Nine-pence for fourpence" throughout the whole of the country—a most immoral doctrine. That immoral doctrine had its vogue, but now the disadvantages of it are recoiling upon the insurance scheme. Individuals naturally want to get their money's worth; they do it naturally, unconsciously. That is the worst feature of the ease. If there were a deliberate attempt to defraud the scheme I do not think there would be much difficulty in detecting and preventing such definite frauds. It is not fraud either on the part of the benefit taker or the doctor. 137 Though there are people who are wilfully fraudulent, the main trouble is not deliberate fraud, it is the unconscious aspect of the affair. And that is the case with the medical men. I ask hon. Members who have been trying to make the doctors the scapegoat to recognise that the facts of the case are the other way round. Here is one of the most vivid descriptions that I have seen as to how this affects the individual:
The patient, feeling desirous of a rest, goes to his panel doctor and practically says, 'I do not want a precription but only a certificate.' The doctor, knowing the immediate result which a refusal would bring about, rarely dares to disoblige. It is no trivial annoyance for an angry patient to remove his name from the doctor's list, because it does not stop at that; he tells his friends and acquaintances and the doctor gets a bad name in the neighbourhood, which is detrimental to his income.That is the way in which this regional medical officer sums up the situation. Naturally, it is his business to please his patients, whether they are private or panel patients. I remember one doctor summing up a long practice in this way. He said, "My practice is to give the patient the benefit of the doubt, and if, after some time, there are still doubts, then I give my partner the benefit of the doubt, and in the last resort I refer the case to the regional medical officer and give him the benefit of the doubt." That is the way medical men carry on a very busy practice, and they have a rule-of-thumb method of carrying out their duties. That is very serious. Although there may be a setback in the first three months of this year, I believe the real fault is inherent in the system, and it is due to the fact that it is a Government system supported by the doctrine of hon. Members opposite that the nation has a bottomless purse and the Government always have the idle rich to draw upon.Contrast that with the old system of the friendly societies, as summed up in the reports of friendly societies over and over again. The old friendly society system induced a spirit of loyalty among the members. The general principle which they proceeded upon was that a person should not be a burden on friendly societies for a longer period than he could help, and in that way they helped the funds of the societies. Although they were not able to help the actual adminis- 138 tration, there was a natural tendency among the members to make the best of things, and to come on the funds as little as possible. It is owing to the attempt to systematise and rationalise the charge, in the broadest sense, on the whole system of government, with national resources behind it; it is owing to an effort to spread the principle so as to go into every nook and cranny, and relieve every form of hardship in every form of sickness; it is owing to those causes that you have done away with the voluntary principle which in former days attached itself to the separate and independent entity of the friendly societies. The consequence is that now you have an endless claim upon what is regarded as a bottomless national purse.
That is the philosophy of the whole thing, and it is very serious. It is not due to the fault of any one person or another. We cannot reverse the hands of the clock. We have to try and encourage the old spirit which formerly attached to friendly societies. We may think that the nation was misguided in 1911 when it decided to entrust the administration of the health insurance societies to friendly societies in the form of approved societies, but there you had a combination with the larger number of insured persons. You have to cultivate the spirit of loyalty with friendly societies on the one side and with medical men on the other side in order to get through this difficulty.
I want to end my remarks with this point. It has been suggested that it is no use trying to coerce a body of professional men, most of all medical men, because they have always got you in the end. You have to equip them well, and, when you come to technicalities, the scheme they devise is the best. The Minister of Health has been extraordinarily sympathetic towards medical men in understanding their difficulties and helping them through. There is now a scheme under which a medical practitioner whose action is called into question can submit his case, first of all, to the judgment of the regional medical officer, and then to a jury of professional medical men; consequently, those medical practitioners will be judged by their own profession and this will have the greatest effect upon them.
139 9.0 p.m.
It is suggested that medical men are too lenient in these cases because they do not want to let their profession down. The last thing we want to do is to cover up the misdeeds of those who are letting us down. According to the opinion expressed by the British Medical Association who represent about two-thirds of the profession there are a few doctors doing bad work, but the same men would be bad under any system. The chief difference between private practice and insurance practice is that there are penalties in the latter if they do not thoroughly examine the patients and are inclined to give certificates for sickness benefit without discrimination. Those are the people we want to catch. The Minister of Health is trying to devise a method by which these people can be caught and penalised, because we have no use for them. Those are the opinions of those who speak with the experience of the British medical organisation, and they represent the opinion of the medical men who have to deal with this subject.
We have to consider one other point which has caused a good deal of trouble in the Press, and which has been brought up against the medical profession. I refer to excessive prescribing. Two particular cases have been brought to the notice of the Minister of Health, and he referred them to the referees. In one case, the referees upheld the decision of the Minister, and in the other case they did not uphold his decision. It was shown, however, that excessive prescribing did exist. Some of those who wish to support this idea of giving the benefit at any price have taken up the line that medical men are justified in prescribing to any extent so long as they are doing what they consider is best for their patient. In this particular case it was a firm of four men, who, as reported by the referees, were all men of very high principle, who wished to do their best for their patients; but the amount of prescribing in that case could not possibly be countenanced by any body of medical men, and there is no question that they were deliberately and definitely paying no regard to the limitations of an insurance system, and were not getting the effect that could quite well have been obtained by any ordinary medical man with more careful prescribing.
140 This question of excessive prescribing is obviously a very delicate one. The ordinary doctor, certainly in my day, was brought up to be fairly regardless of cost in regard to prescriptions, dressings, equipment, and so on, in the hospital, but it was a very different matter when he had to provide these things for himself in his his own private practise. The natural tendency is for a man to use these things without regard to cost, and that tendency must be restrained, but without damaging the effect of the advice. The only way to do that is to take the profession generally into confidence and get them to work with you, and I believe that good machinery has been devised now which will meet this case.
Then we have to watch the tendency, which is liable to be a fatal one, on the part of the people, to fall back into the arms of State in order to get everything done for them. The idea is futile in matters of prevention of ill-health, with which I am more particularly concerned, that the State can do things for you. Prevention is only possible so far as the community will do its part. So much is that the case that individual families and persons can generally do their own part regardless of what the public authority can do; they can live healthy lives, and can largely prevent sickness by their own efforts. If, on the other hand, they are taught simply to rely upon a public authority, a very serious condition will arise. A very remarkable statement was made last November at the National Conference of Friendly Societies by the chairman, who said:
There is in evidence, however, another development less desirable in its reaction upon the life of the nation. Useful though these schemes of national health insurance are, there is a very real danger in their over-development. Any scheme, however good, which removes the incentive to provide for the future, and encourages all and sundry to look to the State to make provision for that future, forgetting all too often that they themselves are the State, must tend to weaken the national fibre, which thrives and develops in an atmosphere where thrift is practised and where self-reliance and independence are fostered.I cannot believe that excessive prescribing is in any way associated with the increase of sickness owing to the industrial difficulties through which we have passed. We have seen the death-rate figures steadily coming down year after year from 1921, and an even more definite 141 indication in regard to health conditions is the fact that infant mortality has steadily gone down. It is quite true that there was a small rise in this very accurate index of the health of the nation during 1924 and 1925, when the Socialist party were in office and when the country was recovering from that in the following year, but the decline after that continued, the figures being 75, 70, 70 and 65, respectively. Yet another index of sickness is the tuberculosis death rate. The number of deaths from pulmonary tuberculosis has gone down from 33,000 to 29,000 per annum, and the number of deaths from other forms of tuberculosis has gone down from 10,000 to 7,000. It cannot be admitted that there is much difference between the sickness rates and the death rates, and I do not believe that there is any real increase of sickness among the people.With regard to the Local Government Act, there are many points that might be brought forward, but I hope that later on, when the Act comes further into operation, we may be able to have a useful statement from the Minister as regards the progress of schemes, and to discuss them. What I have already said in regard to the value of the voluntary friendly societies in the matter of health insurance applies also to this question. If we try to systematise these schemes into a whole system on official lines, I am afraid that here again we shall fail; but if, on the other hand, we try to help to get effort and resources from whatever direction, by enlisting good will in the neighbourhood and district, I think we shall be able to make a real advance. It may not be possible to see on paper in what way a national official scheme can be fitted together with the voluntary societies, the voluntary hospitals, and all the voluntary effort that has been the basis of health work in this country.
Some of the very best and most useful work done throughout the country is done by voluntary societies and voluntary hospitals, and, as the scheme provides for the working together of the voluntary associations and bodies with the official, I hope that every effort will be made to encourage these schemes in the future administration of local government and of the health services of this country, not least in connection with the post-graduate hospital which has been so 142 warmly commended on every side, though I think a little without regard to the difficulties that there must be in enlisting the forces of voluntary skill, experience and efficiency which are at present associated with all the different medical schools in London and throughout the country, and which have nothing to do with this new hospital that is being set up. I hope that this new postgraduate hospital, founded with such excellent intentions after so many difficulties and failures, will culminate by managing in some way, though it is difficult to realise how, to enlist the best sympathies and efforts of all the 13 medical schools in London, and that we may hope for the creation of what may be, and one hopes will be, the greatest post-graduate medical school in the world, and certainly in the Empire, and a great help to post-graduate instruction for the medical men of this country.
§ Mr. PERRYOne remarkable feature of the Debate has been the perfect unanimity with which the medical profession in all parts of the House has rushed to its own defence. I do not intend to deal with the excessive rate of sickness and disablement benefit. I want to put before the Committee a plea for an additional benefit to be considered and, if possible, sanctioned by the Ministry for approved societies. We have been, told that the late Chancellor of the Exchequer made a raid on the funds of approved societies, but his action has not reduced in one single instance the amount of benefit payable. Every Member of the House, and every official connected with the administration of approved societies, knows perfectly well that, when the next valuation takes place, the effect of that raid, in addition to the different allocation made for medical benefit, will make a tremendous difference in the amount at their disposal and will have a very serious effect upon the policy of additional benefits.
In spite of that, I want to make an appeal to the Ministry to sanction the inclusion in additional benefits of treatment at British spas for those who suffer from rheumatism and allied diseases. The treatment at British spas is second to none in the world. The greatest difficulty at present is that it is beyond the means of the vast majority of the workers. The tribute that has been paid to the In- 143 surance Act is very consoling to those of us who fought so hard in the memorable by-election at Manchester, when the late Mr. Masterman was unsuccessful in coming back to the House. It justifies our policy up to the hilt. If it were possible to bring this course of treatment within the reach of insured persons, we should be conferring a still greater boon upon them.
During the last five years those who represent the British Spas Federation—Buxton, Bath, Harrogate, Cheltenham—and the rest—[An HON. MEMBER: "Baden-Baden!"] I have never been there. My home is at Stockport, which is not exactly a spa, and not at. Baden-Baden. Those who are responsible for the policy of the British Spas Federation have played their part in drawing up a scheme for the consideration of the Ministry and of approved societies. They have come to an agreement with that very powerful trade union, the British Medical Association, in regard to a scale of fees, under which exactly the same medical service and treatment that are now given to private patients would be available for insured persons. It is approximately 18s. a week for the baths and course of treatment. The medical fees work out at 7s. a week, or a guinea for a course of three weeks' treatment. At the moment no hostels or institutions are provided.
The object and intention of those who are trying to formulate this scheme has been to place insured persons in an exactly similar position to private persons. I believe arrangements have been made whereby, at a cost of 35s. a week, good, high class accommodation can be provided for those who are attending and taking treatment. That means that at an approximate inclusive cost of £3 or three guineas a week, if approved societies were encouraged to make this one of their additional benefits, treatment at our English spas similar in every way to that enjoyed by those who have the means to undergo it would be at the disposal of insured persons. My appeal, which will be supported in many quarters of the House, is that this scheme, which has been well considered and discussed by the representatives of approved societies and agreed upon by the British Medical Association and strongly urged by the British 144 Spas Federation, should have every encouragement given to it by the Ministry.
The hon. and gallant Gentleman who spoke last referred to the Local Government Act of 1929. I wonder how many Members have had complaints brought to their notice about officials who have been displaced by this rationalisation of local government and who feel very unfairly treated by the county councils who have taken over the administration of larger areas. I am told the Ministry of Health has no power in the matter.
§ The CHAIRMANI was just going to rise to that point. I think it is not in order.
§ Mr. PERRYI trust the point may be considered in some future Debate. I do not join in the pessimism that has been expressed in some quarters on account of the increase in the number of sickness claims, but I think the Committee will be making a great mistake if they fail to realise the importance and the danger of what is actually happening. There is no doubt that the actuarial report, compared with previous figures, demands serious attention. I do not think anyone who has had anything to do with the administration of national health insurance will raise any complaint as to the basis upon which the actuary's report has been made. I cannot join with my hon. Friend below the Gangway in his denunciation of the experts. I think the whole basis of our friendly society work would have been wrecked years ago if it had not been built on a sound actuarial basis.
I should be the last person in the world to criticise the actuaries who are responsible, but there is some substance in the complaint that has been made about slackness. I wonder what would happen if a Member on these benches had to make the admission which the hon. and gallant Gentleman has just made in regard to his distinguished and honourable profession. I hesitate to believe that members of such a distinguished profession have not the courage of their convictions when it comes to a question of signing a certificate for incapacity for work. That allegation was made earlier in the Debate by the hon. Member for Westhoughton (Mr. R. Davies)—than whom nobody can speak with greater experience of approved society administration—in regard to the young doctor 145 just coming into practice. I do not think there is the slightest substance in that. How can a young doctor start in practice in present circumstances? He comes from the university where he has worked hard and qualified in his profession, but where does he start? He cannot open a shop or take a house and put up a plate outside and ask his patients to come to him.
§ Mr. PERRYWhat happens? Practically all the workers over the age of 16 years are already insured and definitely attached to their panel doctor. It is not unreasonable to assume that if a panel doctor is attending an insured person he also gets persons not insured in the same house. It is all very well for hon. Members to shake their heads, but I suggest in actual practice it cannot be done when all workers over 16 years of age are already covered by insurance. There may be some of them not linked up definitely to a panel doctor, but other persons who are not insured are usually covered by the same doctor, and it is ridiculous to talk about young men coming up and jumping into the profession like that. It does not work out in that way.
§ Mr. PERRYNot many of them are paying Surtax. Then, when you are dealing with the question of certification, the Ministry might well consider whether the present procedure of dealing with medical practitioners who fail to honour their obligations is quite correct. When a complaint is made against a doctor and you find it is fully proved, what happens? You have not got to decide whether he has been guilty of an omission or offence, but whether his retention on the panel is likely to be prejudicial to the administration of medical benefit. In 99 cases out of 100 the doctor says he is very sorry, and will not do it again, and that is the last you hear of it. I suggest that in any new Regulations some provision might be made for dealing with offences of this kind.
I have one other suggestion to make. I was very glad an hon. Member referred 146 to the voluntary visitation in the old friendly society movement. I suggest that the intensive visitation and personal contact between members of the old friendly society movement was the greatest check against possible malingering. If that practice could be developed, we might expect better results. There is another point which might well be borne in mind. I was one who, many years ago, had to help to carry out one of these investigations as to the causes of excessive sickness, and we found—I was not much surprised, having spent many years working in the cotton mills in Lancashire—especially among the young girls of 20 to 22 or 23 years of age, that their early introduction into industrial life had had a very marked effect upon their health, and the sickness claims were excessively heavy.
We also found in some towns, although insurance was provided to a greater extent than in any other part of the country, that we could tell where the workers were paid very low wages by the low value stamps. There were thousands of persons working at a rate of less than 12s. a week. In those towns, strong in the old friendly society movement, and stronger still in the old sickness and burial society movement, we found persons working at a rate of 12s. a week, but when they were sick they got, in some cases, two sums of 6s. a week from sick and burial societies, and an additional 7s. 6d. from the State. Thus they got 19s. 6d. for being ill and 12s. for working, and we were not surprised that if they were ill they took a long time to get better. Those who were concerned in the administration of approved societies can fully confirm that statement. While the situation does not give cause for very great alarm, this is a matter which cannot be lost sight of either by the Ministry or by those who are responsible for the administration of approved societies.
§ Mr. WOMERSLEYI, like the hon. Member who spoke last, have sat for something like five hours listening to this very interesting Debate. We have had speeches from Ministers and ex-Ministers, from doctors representing all three parties, and from officials of approved societies, and, perhaps, it will be just as well if there is a word or two from a common or garden Member who is neither an ex-Minister, nor a doctor, nor an official of an approved society.
§ Mr. J. JONESA pawnbroker.
§ Mr. WOMERSLEYA very honourable profession, as, no doubt, the hon. Member opposite has found out, and will do so again unless he practises the barometer trick. There was a certain gentleman whose death was certified as being due to practising the barometer trick, the glass constantly going up and down. I hope we shall not hear of any such cases in our debates. I should like to say a word or two on the question of malingering, because in my early days I belonged to a friendly society, and I am very proud of that fact. We did not hear much about malingering in those days because every member was a sort of private detective, and if a man was caught out after 8 o'clock at night when he was on the sick list he was reported next morning to the secretary. I do not say that that is necessary, because I do not believe for a moment that there is so much malingering as some people try to make out. I will give some figures in proof of that statement. A man does not malinger unless he is going to get material benefit from doing so. What is the position now? I have been working out a few figures. An unemployed man with a dependent wife and four children, and drawing unemployment benefit, will receive 34s. a week. He falls ill, and then goes on the National Health Insurance, and with his wife and four children he gets 15s. a week for 26 weeks, and then it drops down to 7s. 6d That is not much temptation for a man to malinger.
Again, if he happens to be so sick that the doctors cannot save his life, and he dies, the widow is ever so much better off, because she gets, with her allowance under the Widows' and Orphans' Pensions Act, 24s. a week. It is a very peculiar system that a man who is sick and really in need of more money to provide the things which a sick man requires, is actually getting far less than a man who is out of work and on unemployment pay. I am not going to say for a moment that in my opinion the case has beer made out that there is a great deal of malingering. It may be that many more people are taking more medicine than they did in the old days, before the Health Insurance Acts were extended to include such people as shop assistants and so on. Then a different system grew up amongst employers and 148 employed. In the past, before they were compelled to be insured, it was the general custom among employers to pay full wages to employés when they were sick for a certain number of weeks, and then two-thirds, and so on for a considerable time. Many of the employers, having to pay the contributions week by week, came to the conclusion that anyone who was sick on their staff must claim health insurance benefit. There is no doubt that when employés who have been sick cone back to report that they will be able to return to work some employers say, "Now, do not come back until you are absolutely certain that you are fit for work. It is no use coming back and after a day or two having to go back upon sickness benefit." Therefore, some insured persons do take a few days longer than they used to do in the old days, but it is in the best interests of the insured persons themselves and of the people who employ them. We have to use a little bit of common sense in dealing with them.
As I listened to the Minister of Health deliver his speech this afternoon, I closed my eyes for a short time and I could have imagined that it was the late Minister of Health who was addressing us, except that the voice sounded different. It was the same sort of speech. He gave us details of what his Department were doing. He talked about housing and the wonderful things that were being done in that direction, but he did not give any dates as to when these things started. He told us about the alteration in Poor Law relief. There was just one point at which I felt that I must interrupt him. I did so, but he did not give me a satisfactory reply at all. He referred to a certain circular which had been issued. As one who has had something to do with administering the Poor Law along with my other duties as a representative of a local authority I cannot for the life of me see what difference there is between the present instructions received from the Ministry and those under which we have been working all along. It all depends upon those who are administering them; that is the real point at issue. As my mind goes back to some of the Debates which have taken place in this House during the last four or five years and I think of the thunderings we heard from the 149 benches opposite when those who are now in office were in opposition, it makes me think that to-day's little Debate has been like the good old-fashioned prayer meetings which I used to attend in my youthful days. It has been so very nice and so very happy. There has been nothing at all coming from those who were the thunderers of the old days.
The hon. Lady the Member for the Sutton Division of Plymouth (Viscountess Astor) quoted from a speech of the Parliamentary Secretary, and with some effect too. I remember that speech. I really thought that the hon. Lady was going into hysterics. What she was going to do when she came into office has already been quoted, but I am sorry to say that it has not happened. [Interruption.] We do not expect the hon. Lady to go into hysterics. She will go into the doldrums when she realises what little she has been able to do after making such lavish promises. I suggest to the hon. Lady and to many of her followers sitting behind that when they go back to the electorate they will not have a very easy task in explaining why they have not kept their promises.
§ The CHAIRMANI have been looking for some reference to these matters in the Ministry of Health Vote.
§ Mr. WOMERSLEYI am dealing with points which were raised earlier in this Debate. You, Mr. Young, did not happen to be in the Chair at the time that those points were raised. You are in the Chair now and I must obey your Ruling, and I shall certainly do so. The point to which I now wish to refer is one on which I am sure I shall be in order, as it deals with the question of administration. The difficulty which I am experiencing in my constituency with regard to approved societies is that they want to pick and choose those whom they will take into membership. I have at the moment a case in mind where two members of the same family were accepted by an approved society, but the youngest member of the family has been refused. The father of the family resents this very much, because he does not want two or three persons coming to his door for the cards. He wants to do all the business with one society, and he also objects to having to enter the youngest member of the family as a Post Office contributor for some reason or other. We know that before the amending Act 150 was passed many people objected to being Post Office contributors. They did not get anything like the same benefits as those who were contributors to an approved society.
The late Government when they brought in their amending Act in 1928 realised the position, and, I am glad to say, amended the law so that Post Office contributors should receive all the benefits in the way of medical treatment and so on. I want to see the time when these contributors may get even the extra benefits which the friendly societies now give. At the same time, I do not think that it is fair that these approved societies should have the right to pick and choose and take the best lives and leave those lives which are not very good to be dealt with through the Post Office contributory scheme.
One of the speakers this afternoon referred to the fact that on many occasions after referees and controllers had given decisions the matter was brought to the Minister and the Minister overruled their decision, and that it was heartbreaking work for referees and controllers to carry on. Surely the hon. Member has been sufficiently long in this House to know that sometimes a Member of Parliament receives a letter from a constituent and that he sees the Minister and talks nicely to him and the Minister perhaps gives way. That is how these things are done sometimes. I suggest that it would be a bad job for Members of Parliament, at any rate, if the Minister did not reserve to himself the power to overrule the decision of referees and controllers. Nothing has been said during the course of this Debate.
§ Mr. WOMERSLEYThe hon. Member who has said "hear, hear" has said the least, and, if he had got on to his legs and spoken, we should have known nothing. The hon. Member cannot have it all ways.
§ Mr. WOMERSLEYIn the last Debate on the Ministry of Health Vote a question was raised by the hon. Member for Norwich (Mr. Shakespeare), who asked that something should be done in regard to a certain matter. The matter has been 151 mentioned by the Minister, and I am sure that I shall be in order. It was the question of draft rules and orders in regard to the Poor Law issued on the 11th February, 1930. The hon. Member for Norwich referred to the new regulations issued in order to govern the public assistance committees as the successors of the old boards of guardians. The question was in respect of relief work, or test work, or task work as some people call it. The hon. Member for Norwich quoted an instance relating to his own city where there was being imposed a certain form of test work which he considered was by no means a fair one. He wanted a reply from the hon. Lady, or from the Minister, on the matter and desired some action to be taken. I should like to ask the hon. Lady to tell us exactly what is the position as regards this test work?
I spoke on the matter on that occasion and pointed out all that we had been told when the present Government were in opposition and what they would do if they came into office. The circular which has been issued says that some test must be imposed on able-bodied men. I agree that it is necessary that there should be some sort of test. What I object to is that people when they are out of office tell us that they would not have a test, and when they get into office they continue the system of tests. I condemn some form of tests. If they are useless tests, it is doing no good but certainly doing a good deal of harm to the man who is put upon such test work. A man likes to feel that if he has to do a task he is doing something that is of use to the community among whom he lives. That is what the Parliamentary Secretary to the Ministry of Health said. It was only on the 31st March that she said it, but I did expect that we should have heard something more about it. She said:
As regards the question of test work, I cannot discuss individual cases without notice, but will answer to the best of my knowledge as to the law and the circumstances. As a matter of fact, a very considerable number of guardians give relief without any test work at all. We have issued a circular on the matter which states that it is desirable that some form of occupation should be given to able-bodied men. We stated that we considered every local authority ought in the first place to make arrangements for test work, and that the arrangements should include due provisions for securing that work, training or instruc- 152 tion should be suitable to the physical capacity and intelligence of the individuals."—[OFFICIAL REPORT, 31st March, 1930; cols. 1,008–9, Vol. 237.]That is a good point, but it lays down very definitely that there must be some form of test work. The question is, what can you do in the way of test work that is suitable for the physical capacity and intelligence of the individual. It is the duty of the Minister of Health to formulate a scheme and put it before the local authorities; a model scheme upon which they can work. The local authorities have just taken over the duties of the old boards of guardians. The old boards of guardians, after many years of experience, were unable to find any real solution of the problem as to how they could prove that a man was prepared to work in order to earn the bread and other allowances that were made to him, without making it a job that was disagreeable to him. In my own town we tried a system which I think was fairly successful. We put down a slab-making plant. We took cinders from the electricity department, mixed them with cement, and made slabs that were bought by the corporation from the board of guardians, and used in the town where they were made. The men regarded that as doing something in the way of useful work, but we were told that we were robbing other workmen who had been engaged in making slabs. That is the difficulty you are up against every time.I remember a speech that was made on this subject by the present First Commissioner of Works. He laid it down very clearly, in spite of speeches that he had made outside this House, in spite of the great hopes that he had held out to these people, that under no circumstances would he allow a man who was physically fit and able-bodied to receive relief without offering him some work and expecting him to do it. He said that if he would not do it he would compel him or would leave him to starve. That is what the right hon. Gentleman said. I do not think that it is necessary to quote the whole of his words.
§ Mr. TINKERIn fairness to the right hon. Gentleman the hon. Member ought to quote more. The right hon. Gentleman was referring to test work generally.
§ Mr. WOMERSLEYI will quote more from the speech of the right hon. Gentleman. He said: 153
As I go round, I am challenged by the authorities to say what I would do with these men.He was referring to able-bodied men.I was asked yesterday what would I do with the men who wilt not work. My policy with the man who will not work, when there is decent, honourable work at proper wages for him to do"—
§ Mr. WOMERSLEYI was prepared to hear those cheers from hon. Members opposite. I said that I would read it, and I am doing so.
§ Mr. MUGGERIDGEIt has spoiled your point.
§ Mr. WOMERSLEYLet me continue the quotation:
My policy with the man who will not work, when there is decent, honourable work at proper wages for him to do, is to let him go without food.
§ Mr. TINKERThat is the point.
§ Mr. WOMERSLEYI hope that point has sunk in deeply.
I would not bother about it, but I would apply that test to all classes and not merely to the class we are discussing.So would I. Let hon. Members realise that, and let them realise also that they have not a monopoly of the workers or of the work-shies; neither have they a monopoly of sympathy with the poor people of this country.The point here is,said the right hon. Gentleman,that it is not decent work you are offering men to do. You have no right to say to a man that he shall break stones or saw up wood merely for the sort of dietary I have read out."—[OFFICIAL REPORT, 5th April, 1928; col. 2,175, Vol. 215.]Hon. Members opposite agree that the right hon. Gentleman used those words. That being so, I ask the Parliamentary Secretary to the Ministry of Health why it is that these things are being done now, when they were condemned by one who is now a member of the Cabinet.
§ Mr. DUNCANDid you find fault with it?
§ Mr. WOMERSLEYYes. I spoke in the same Debate and if the hon. Member for Clay Cross (Mr. Duncan) had been in the House he would have heard me speak on that occasion. I have travelled up 154 and down the country to observe these things, because I like to know what is going on. I addressed a large meeting about that time. I had a very hostile reception wherever I went. The only thing that aroused cheers was when I mentioned that the Government which I supported was abolishing the boards of guardians. When I made that announcemeat, the roof nearly came off. It was the most popular thing that I could have said, because the particular board of guardians in that district inflicted this test work. I have seen this work performed and I am not in agreement with it, but I challenged the right hon. Gentleman on the occasion in question, as I have challenged him since, to tell me what form of test work he could suggest, not for the man who has had a decent job offered to him—that is what we ought to be devoting ourselves to, how to find jobs, and not to the question of relief—but the man who would not work whatever was offered. Hon. Members opposite know that there are such men. What are you going to do with them? The right hon. Gentleman who is now the First Commissioner of Works said that he would leave them to starve. We heard a great deal on this subject from the Opposition when the late Government were in office, but it is astounding how little we hear of it to-day from the same party.
§ Mr. WOMERSLEYWhen they were in Opposition we heard a great deal about it, but now that they are in office we hear nothing of it. It is simply a question of Jack in office being a different fellow from Jack out of office. Now that they have assumed the responsibility; they know what the conditions are. The very Act of Parliament that was passed by the late Government, and condemned root and branch by the present Minister of Health and the Parliamentary Secretary, is now being quoted all over the country by speakers belonging to the Government party as a splendid Act, which they say they are going to make workable and to do all sorts of things with it. We heard to-day from the Minister of Health commendation of a certain feature of that Act. It is political hypocrisy. I feel sometimes that I would like the new Members to be able to go back into the past and to hear 155 some of their own leaders making speeches which they are contradicting by their own acts to-day.
§ Mr. LOVAT-FRASERI intervene in this Debate for the purpose of bringing before the Committee a matter with which I have deep concern. I am going to turn the attention of the Committee from the matters on which discussion has been taking place for some hours to another matter. I wish to bring before the Committee one of the results of the Local Government Act passed by the late Minister of Health, and that is the enormous decline in the number of women now engaged in the work of Poor Law administration. I asked a question of the Minister of Health earlier in the evening. I am approaching the matter in no party spirit, nor am I reproaching the Minister of Health, who has received the Local Government Act from his predecessor and has to administer it, but I do appeal to him to endeavour to mitigate an evil which, as I have pointed out, is resulting from the Act.
I would like to give the Committee some idea of how the number of women has declined. There were before 1st April no less than 2,330 women guardians devoting themselves to Poor Law work. There could be no doubt about the value of the work, especially where children were concerned. The majority and minority reports of the 1909 Commission both dwelt upon the great value of the work done by women. They varied, of course, in character, ability, and education, but the general work of the great body of women was admirable. May I ask the Committee to keep the number I have mentioned in mind—2,330. On the county councils and county borough councils, who have taken over the work of Poor Law administration, there are 260 women councillors. The Local Government Act provided that public assistance committees were to do the actual work of administration formerly done by the guardians, and the authorities in appointing these bodies may include not more than one-third co-opted members of whom some may be women. Out of 83 county councils, 52 have co-opted members including women, and 31 have refused to co-opt any. Of 62 borough councils, 42 have co-opted members and 20 have refused. Therefore, 156 94 county councils and county borough councils have co-opted women on their public assistance committees, but the result of that co-option has been very meagre. It has not been possible for me to get official figures. I asked the Minister of Health, but he said it was not possible, and my figures are taken from Press cuttings and unofficial sources, but I think they are reliable. The county of Cambridge has co-opted two women, Northampton four, Hertfordshire two—
§ The CHAIRMANI am not quite sure how far we can follow this up, because I understood that there was no power to make a responsible local authority co-opt women.
§ Miss LAWRENCEThe Minister gave the explanation that, having regard to the liberty which the Act gives the local authorities, he did not think it would be wisdom that we should enforce it.
§ The CHAIRMANI take it then that the Minister has power?
§ Miss LAWRENCEI think, if I may say so, that it is a proper criticism of our administration.
§ 10.0 p.m.
§ Mr. LOVAT-FRASERThe county of Devon has co-opted four women, Cornwall has co-opted the rather remarkable and large number of seven, the city of York four, and Darlington two. If you say that 94 authorities have co-opted an average of three members each, that makes a total of 282. If you add that number on the public assistance committees to the 260 women who have been elected to the new Poor Law authorities, the result is 542 women doing Poor Law administration work against 2,330 doing it before the 1st of April. Fifty-two county councils and county borough councils have refused to co-opt members at all, and consequently no women have been co-opted, and in some of our largest centres you have not a single case of a woman guardian, not a single woman previously engaged in Poor Law work has been called in to assist the new Poor Lam authorities to do what is essentially women's work. There are guardians sub-committees of the public assistance committees. They are the hewers of wood and the drawers of water for the public assistance committees. They will 157 have the duty of deciding what Poor Law relief is given, and help in conducting the workhouse. Membership of the guardians committee I regard as a comparatively small matter, but even there the appointments have been of the most meagre character.
I can give you one very remarkable instance. The county of Middlesex appointed five guardians sub-committees, and they have co-opted two women on each, with the result that there are now 10 women on the guardians committees. Before the Act came into operation on 1st April, the women engaged in Poor Law work in the county numbered 62. In some cases, the county councils have handed over the care of the children, with whom I am particularly concerned, to sub-committees, maternity and child welfare committees, education committees, and so on. The Local Government Act makes no provision whatever for the addition of women to help in the work of caring for the children. The National Council of Women sent a deputation to wait on the late Minister of Health, and it did me the honour of asking me to accompany it. We were received very civilly, and we were allowed to make some speeches. The Minister told us he considered he was giving a new argument to women in handing this work over to the county councils, because women could endeavour to become members of these bodies by pointing out that they would now be doing work which was very familiar to women. That was a poor argument. The fact that there are only 260 women members of these county councils shows how difficult it is for women to get on these bodies, and I call the attention of the Committee to this matter in the hope that the Ministry will view the position sympathetically and endeavour to make an improvement.
This is not a party question, and I appeal to hon. Members on the Conservative and Liberal benches to sympathise with my point of view as much as those who sit on my side of the House. Here you have a field of work being taken away from women when many of us have fought for years to obtain for women entrance to fields from which they have been excluded in the past. Here women have carried the field, and have done splendid work in it, and the result of 158 the Local Government Act coming into operation has been to filch from women that field of work in which they have done such splendid services in the past. I appeal to the Ministry of Health to drop the rather unsympathetic attitude they have shown to the representations such as I have made, and endeavour to counteract the evil which is resulting from the Act.
§ Major MUIRHEADI do not claim to have one-tenth of the experience or knowledge of the National Health Insurance scheme that many Members who have spoken to-day have. I would not intervene except that I have had a certain amount of experience in the administration of National Health Insurance business. I have acted as sick visitor. I am chairman of a local section of the Food Society. I am chairman of a finance committee of an approved society, and for some years past I have taken an active part in the affairs of the National Rural Approved society which co-ordinates the activities of 200,000 rural members. Everyone who has spoken to-day has been impressed by the fact that it is difficult to put your finger upon any one factor which makes for difficulty and for any one remedy. At the same time, it is essential that we do not allow any particular factor to be over-emphasised or wrongly emphasised. One or two of the references made to-night have tended in that direction. The Member for West, houghton (Mr. R. Davies) mentioned the financial situation brought about by the Economy Act. He mentioned it twice. That might impress people outside the House, but it has nothing to do with the increase of sickness and disablement claims.
The question of sickness and disablement claims is altogether different from the Economy Act. If the hon. Member tried to link them up, I should almost say that it amounted to what the Chancellor of the Exchequer would call organised conspiracy between the insured population to try and so increase their claims that they would bring about something to the discredit of the right hon. Gentleman the Member for Epping (Mr. Churchill). That had nothing to do with the subject under discussion. The Minister for Health twice in his speech laid emphasis on the fact that a large amount of these claims—he emphasised it 159 so much that he appeared to make it a predominant factor—was due to an in crease in early notification. He said that that was rather a good thing. The interesting point is this. The increase in sickness is for men 41 per cent., for unmarried women 60 per cent., and for married 106 per cent. When we come to disablement claims, the increase is 85 per cent. for men, 100 per cent. for unmarried women, and 159 per cent. for married women. So that by far the greater proportion of the increase is due to disablement claims rather than to sickness claims. Disablement claims are, as hon. Members will know, claims for benefit beyond 26 weeks of sickness, and therefore the point emphasised that the large amount was due to early notification rather falls to the ground in view of these figures.
Dr. MORGANIf the hon. Member will look at page 14, paragraph 19, of the Actuary's Report, he will see that the Actuary makes that point very clearly.
§ Major MUIRHEADI am not insinuating that it is not a point to be considered. I think it is.
§ Major MUIRHEADI do not want to quarrel with the Actuary; he would be a dangerous man to quarrel with. I am not trying to minimise that particular fact. I am trying to avoid over-emphasis by quoting the fact that a greater proportion of the increase comes from disablement and not from sickness. I hope that the hon. Member will not think that I am trying to rule that fact out of court. The question of the effect of unemployment was brought up by many speakers, but there again it is a case of not overemphasising. In the interesting address which Sir Walter Kinnear delivered to the Faculty of Insurance the other day he said:
It is impossible to measure the extent to which the growth of sickness claims has been accelerated by economic forces, but it is obvious from the figures that the growth has been out of all proportion to the increase in the burden of unemployment.I understood the Minister of Health to say that in the main this particular situation was one of administration. With 160 that, I agree; but, as a matter of fact, in the past the question of administration has been minimised quite incorrectly. In the report of the Royal Commission on National Health Insurance, 1926, we see that both the majority report and the minority report deal not too kindly with the question of administration. In reviewing the different circumstances between approved societies, the majority report says:The second cause of surplus which was constantly quoted in evidence was careful administration, particularly as regards the supervision of claims for benefit. Undoubtedly, good administration must be a contributing cause to a satisfactory valuation result, even if it is thought that, when compared with the other cause to which we have referred, it has been but a minor factor. We should like to make it clear that in advancing this proposition we are in no way lending our support to any suggestion that good administration is relatively unimportant. But we are inclined to think that even if it were possible hypothetically to assume a uniform standard of administration throughout all societies, the discrepancies which would have resulted would have been almost as great as those which have in fact emerged, and we are strengthened in this view by the consideration that there are prosperous societies in which administration is not strict and unfortunate societies which are unfortunate despite strictness of supervision.That is a lukewarm compliment to administration. In the minority report, I think, the words are scathing. The report says:We agree with our colleagues—meaning the majority members—that the effect of this incentive upon the valuation results is grossly exaggerated and that other factors, occupational and otherwise, are the predominating causes of the great disparities in the surpluses declared.They go on to say:Saving the funds by curtailing the benefits of the sick persons and forcing them back to work, or otherwise leaving them to starve, is not a feature that is either economical in the long run, or moral in a State scheme, but that it is present there is no doubt whatever.I am not unfair, therefore, in saying that the question of the importance of administration has in the past been rather minimised. I grant there are two sorts of administration. First of all, there is the official administration, the visible administration which one sees in the office, in the person of the Secretary and so forth. But there is another form of administration which I would emphasise. That is what I may call, for want of a 161 better name, the invisible administration—the check of one member upon another. Several speakers have referrd to the old friendly society spirit, in which this invisible administration in its very best form was implemented. Undoubtedly, in the days of the old friendly societies it was very strong. It can hardly be said that under the State scheme to-day it is anything like as strong as it used to be in the days of the old friendly societies; but it is appreciably stronger in those societies which were built up on the basis of the old friendly societies than in other societies. That old invisible administration, the check of one member on another, was not the hard brutal kind of administration which is referred to in the Minority Report as leaving deserving cases to starve. The people were too close to each other to allow such a thing to take place. Nowadays we refer cases of doubt to the regional medical officer, but the old check of one member on another was more effective than the best regional medical officer.The trouble, nowadays, in this as in many other things, is that not only are we getting away from the personal touch, but we are forcing ourselves away from it in many cases. That, I think, is a great pity. I may quote the case of the society with which I am connected. It is a characteristic society—the National Federation of Rural Approved Societies. It comprises some 10,000 members, living in the agricultural districts of Central England, and, in passing, I may say that when a medical practitioner recommends any ophthalmic surgeon and not an optician, the Society, without hesitation or question accepts that recommendation. We are very careful not to make ourselves technical discriminators in face of a medical practitioner's certificate; and I only mention that circumstance to show that it is not the sort of society which tries, by hook or by crook, to save a few shillings, here and there, in order to try to swell its balance. It is interesting to note, however, that in our recent valuation report the Government valuer showed that both in sickness and disablement for men the figure is below the valuation provision. In sickness for women it is also below the valuation provision, and only in the case of disablement for women is it higher. Even amid this big movement to increase claims 162 which is going on, this typical rural approved society still shows comparatively little difference.
I come back to the report of the National Health Insurance Commission. That Commission reported on the subject of approved societies in two senses. The majority reported in favour of the continuance of the approved society system. The minority report, in very definite terms, recommended the abolition of that system. Both sections of the Commission joined in recommending the partial pooling surpluses. Both with regard to the approved society system and the surpluses, the report created a feeling of uncertainty in the minds of a large section of the insured population—both those who hoped to get something, and those who thought they might lose something. Has the feeling created by that report got nothing to do with the present situation? I think it has. The year 1926 was a critical year from more than one point of view. It may be a mere coincidence, but the publication of this Report in 1926 did coincide with the great intensification of the claims for sickness and disablement benefit. I cannot prove this, but I put it forward as a suggestion. I cannot help thinking that in the minds of a good many approved societies there was a feeling, which was engendered by the terms of this Report, that perhaps very shortly the present system would go overboard. There was a sort of feeling of "Eat, drink, and be ill, for to-morrow we may have a different system." I think that is a spirit which has very likely got abroad, perhaps unconsciously, among approved societies as a result of the recommendations of the Royal Commission in 1926.
When we see an inequality anywhere, we immediately think it is an unfairness. We thing inequality and unfairness are synonymous terms. The moment we see an unfairness we immediately think the person who on paper is at the bottom of the list must be the man who has been unfairly treated. There is then a tendency to say that everything must be altered, and things are graded to a sort of drab level, which perhaps satisfies peoples' sense of fairness and equality on paper, but which in reality tends to stabilisation at a much lower level. I am trying to emphasise the importance of what I call the invisible form of ad- 163 ministration, by which members have a feeling of corporate loyalty to their society. They live close together and are well known to each other, and they utilise that loyalty, not to press hardly upon their neighbours, but to try to exercise a proper pressure to ensure that claims for benefit are not unfairly made or continued. I believe that that spirit of the old friendly societies still exists in a good many societies, but that it has declined or disappeared in others. If we want to remedy the present situation, I believe we shall do it better by trying to re-establish that old spirit of invisible administration in the societies Where it has declined rather than by trying to crush or penalise those societies where it still continues, to their great advantage.
§ Miss LAWRENCEThis discussion has ranged over two main subjects, namely, the question of increased sickness claims and the question of administration, but several Members have dealt with minor points, which I will deal with separately before I go on to the two main subjects of Debate. The right hon. Member for North Cornwall (Sir D. Maclean) asked that I should explain to him why the costs of administration had gone up so much. Taking the total increase of £216,573 for administration in England and Wales together, there were £50,000 in automatic increments, £18,000 due to the cost of living increase, £118,000 due to the administration of new services, £11,000 in respect of the increase of the whole time dental staff, and another £11,000 due to various increases in regard to the initial expenditure on medical staff. Thus the whole of the administrative increase is due either to the automatic increases or to new work.
There was a very remarkable complaint made by an hon. Member, who quoted from the "Daily Chronicle" a strange interview which an official of the Government gave to the Press. It was a remarkable interview, intimating that the friendly societies are this and that, and that all manner of strange things may happen if claims increase. It is even stranger that, after careful inquiries in the office, we cannot ascertain which Government official gave this information. I notice that the "Daily Chronicle" does not say that he was a Government 164 official of the Ministry of Health. There are many Government officials in the world; some occupy exalted positions, and some occupy humble positions. There is no indication whether the particular official who gave this strange prophecy with regard to friendly societies came from my Department, or whether he came from some other Department, but we have looked through our Department in vain.
§ Mr. T. LEWISWould the hon. Lady deprecate such a course if the official came from her Department?
§ Miss LAWRENCEI do not say that any official of our Department has any right to say what friendly societies might do, and I doubt whether it was an official of ours. I have no information whatever on the subject. I neither deprecate nor approve; I merely express my ignorance of the whole matter. I now come to one of the two main topics, namely, the question of the increase of sickness claims. I always admire the dialectical skill of the right hon. Gentleman the Member for West Woolwich (Sir K. Wood). He detailed this alarming increase in the claims of the friendly societies. He said that it surprised him very much, and that he could not be satisfied with the tentative and weak explanation given by my right hen Friend. He thought that there must be something behind it, and that it must be a question of bad administration, and of the panel patients being allowed to change their doctors too quickly. He so successfully gave the idea that he was attacking the administration of my right hon. Friend, that many Members forgot that the period of administration under question was his own administration. The Government Actuary's report covers the interval from 1921 to 1927, but the Committee would not have gathered it from the tone in which he made his speech.
It was under his administration that the men's sickness claims rose from 76 to 107 per cent. of expectation, and disablement claims went up from 54 per cent. to 100 per cent. It was under his administration that the regulation allowing panel patients to change their doctors at very short notice was put in. If I wanted to copy the right hon. Gentleman, I should simply ride away 165 with the statement that all these things of which he complained had happened under his own administration; but I do not think that would be altogether a reasonable way of dealing with this problem, and therefore I do not propose to follow him in the manner and the temper of his speech. This is really a very big and somewhat obscure question. It is not a new question. When I heard the right hon. Gentleman it seemed to me that he found himself between the horns of a dilemma: either he did not know that the number of claims was going up, which would be a very serious thing indeed for a Parliamentary Secretary to confess, or else he watched the rise helplessly not knowing what to do.
The truth is, these claims have risen steadily every year from 1921 to 1927. The year 1929 appears to have been the peak year. The numbers of claims have not been analysed for the two later years, but I will give some figures as to the total amount paid in benefits, and I would like to explain that in this total amount I am adding in for the last two years for the purposes of comparison the £2,000,000 representing a liability which was transferred to the Widows', Orphans', and Old Age Pensions Fund. The figures I am going to give are not the actual figures, but the actual figures for the last two years as they would have been if that £2,000,000 had not been transferred. In 1927 the amount rose to £18,135,000. In 1928 it went down to the extent of nearly £1,000,000—adding in the £2,000,000—and then rose again in 1929 to £19,600,000; but in the opinion of our experts that increase was wholly due to the lamentable influenza epidemic of the earlier months of the year.
§ Sir D. MACLEANDoes Sir Walter Kinnear's report apply to the same period?
§ Miss LAWRENCEThe speech of Sir Walter Kinnear was on the Government Actuary's report. We have not actually taken out the numbers for those years. All we have are the numbers for the years 1921 to 1927, and having no numbers for the later years I have given figures showing the amounts paid in benefit. The figures went down in 1928 and rose in 1929, but our experts believe that that was wholly due to the lamentable influenza epidemic, which was so bad that 166 it seriously affected the death rate for the year. The figures are dropping now in the earlier months of this year. Claims appear to have reached their peak somewhere about the year 1927, and to be stationary or dropping at the present time. The second thing about the excess of claims, and it is a very remarkable thing, is that the duration of sickness has hardly risen at all. The number of claims has risen, because there has been an increase in the number of claims in respect of short illnesses; they are responsible for the greater part of the increase. This is a very remarkable thing.
I ask the Committee not to pass any rough and ready judgment on this mass of very confusing statistics. The report which has been issued is one of the most valuable things that either the medical profession or the approved societies have ever had. We propose to follow up that report, and to give the information year by year. Originally, the approved societies and medical practitioners came hand in hand asking that the period within which a patient might change his doctor should be increased. It was increased, and now approved societies and the medical profession have rather changed their mind, and are inclined to think that a somewhat longer period of notice is necessary. The British Medical Association and the Consultative Council of Approved Societies have agreed to a scheme under which they will be able to review the case of any one of their professional brethren.
Dr. MORGANWill the hon. Lady consider the possibility of a doctor who is unpopular, not for medical reasons, but for other reasons, being dealt with unjustly by his colleagues, who differ from him not medically, but for other reasons?
§ Miss LAWRENCEI think the general medical opinion of the district is very much better and more acceptable for correcting any eccentricity in a medical man, because the representations of all the persons concerned are considered. The representatives of approved societies, the British Medical Association, and even the Minister of Health must have very good reason for going against the united opinion of the approved societies and the doctors. I do not know that I have very much more to say to the Committee on the question of these figures. We have put before the 167 House the first instalment of figures by which something like a reasonable judgment can be formed on these matters. It is not an easy or a simple question; it is a question into which many factors enter, and on which we want a good deal more light, and perhaps not quite so much heat as we have had hitherto.
§ Miss LAWRENCENow I come to the question of the administration of out-relief—
§ Sir K. WOODBefore the hon. Lady passes on, would she kindly give a little more information to the Committee about the new regulations in relation to the penalisation of doctors, and the method of dealing with that matter?
§ Miss LAWRENCEThe British Medical Association, the Conference of Panel Committees, and the Consultative Council of Approved Societies have agreed that, where there is anything abnormal in a doctor's certification, the panel Committee chosen from the panel doctors in his own area shall review the case.
§ Mr. McSHANEIs it not true to say that every one of those doctors who are going to sit in judgment is an interested person?
§ Miss LAWRENCEYes, in a way he is. If you take all the panel practitioners in the district, and ask them to look into the case of one particular panel practitioner, they have a common interest, if I may say so, in maintaining the professional prestige of their brethren, and they have also a pecuniary interest in not cutting down too much the fees of any one of their body. They will report to the Minister, and the Minister will have in reserve the usual powers, where a case is proved, of deducting something from the remuneration of the practitioner concerned.
§ Captain GUNSTONWould the hon. Lady say what action is going to be taken if it is found that a doctor has behaved wrongly? Is he going to be debarred from practice?
§ Miss LAWRENCEThe usual method is to make a certain deduction from the remuneration of the doctor concerned.
§ Mr. T. LEWISWill the approved societies or insurance committees have any part in this review?
§ Miss LAWRENCENo. It has been agreed that it shall be the panel doctors in the locality who will investigate such a matter. Now I come to the question of the administration of out-relief, and I do not know of any single thing that this Government has done that has filled me personally with more pleasure than the change which has been made in the administration of out-relief. [interruption.] No such change has been made since the Act of 1834, and I want the Committee to listen to what has been done. The Out-Relief Order of 1911 prescribed the house, in all ordinary cases, as the appropriate channel through which relief should be given. There were certain cases in which out-relief could be given, but the bulk of the out-relief given had to be given on a report to the Minister in every individual case, and the Minister could simply disapprove of the award. If he disapproved, the relief could not be given and the district auditor could, and did, surcharge. The late Minister announced at this box not very long ago that it was his purpose to return to the Order of 1911, and he did return to it in a great number of cases. He signified his disapproval of out relief to single men in union after union under the frightful penalties of the district auditor. That was done up and down the country and that was one of the most infamous things ever done.
Our circular does away, first of all, with the routine necessity of reporting cases to the Minister. We say the local authority should afford occupation, instruction, training and work as far as their local circumstances permit, and that that work must be suitable to the age, physical capacity and intelligence of the trainee. If that work cannot be provided, relief may be given unconditionally and the power of the Minister to deprive individual cases has gone. No Minister will ever attain be able to cut off single men from relief without procedure by Order. We have ended that utterly illegitimate exercise of the Minister's powers. We wrote to boards of guardians and pointed out that the 169 bad practice enforced upon them by the Minister was contrary to all the principles of the Poor Law. We told them that the general refusal of out-relief to particular classes, which was the policy of the late Minister, was contrary to one of the first principles of Poor Law administration and it was their duty to take each case individually. In union after union I have found that the treatment has become more humane and the unemployed are getting more money. The relaxation of the conditions of unemployment took a good many more men off poor relief.
Talking about Merthyr, an hon. Member behind me has told me that the chairman of the Merthyr Council was pointing with delight to the fact that poor relief had gone down by three shillings because of the men getting back their unemployment benefit from this Government. Poor relief has been lightened owing to the relaxation of unemployment benefit. That has spoiled a little the totals of poor relief figures, but that the men are getting better treatment is a perfectly clear and true statement.
Viscountess ASTORDid not the hon. Lady give a pledge that when they got into office within three weeks they would take it up as their first and most sacred duty to see that the harmless and innocent should not suffer any actual physical privation, and that they should get milk and boots. Have they got it?
§ Miss LAWRENCEIt was not three weeks, but six weeks before we got rid of the appointed guardians.
§ The CHAIRMANThe Noble Lady must restrain herself. The Minister gave way to her, and she must now allow the Minister to proceed.
§ Miss LAWRENCEI pointed out in regard to this matter of the Minister administering the Poor Law in this highly irregular way, that we had done away with that, and had drawn the teeth of any Conservative Government that may come along and try to limit out-relief in this way. There is no person who has studied the Poor Law but can see that unconditional relief to 170 the able-bodied is a new thing in the Poor Law, and a thing that has never been recognised since the Act of 1834. We have now allowed that, and have told the boards of guardians—and I think everybody will agree—that there should be training, or instruction, or useful work, as far as can be provided for these men. Test work is an ugly name, but work and training for occupations to occupy men and restore their moral and improve their condition is a, thoroughly good thing, and a thing of which every trade unionist will thoroughly approve. It is true that, with regard to any great new schemes of work, we have been hampered by the fact that we were dealing with a dying machine. It is impossible to make a dying authority undertake any new constructive piece of work, but we have now got a new authority. We shall now, I hope, be able to work these classes through an authority which possesses all the resources of an educational authority, and be able, up and down the country, to institute humane and reasonable forms of occupation for these men.
People talk about stone-breaking as if it was universal in all the 600 unions. There were, just before April, only 21 places where men broke stones at all, and some of them were doing quarrying work, which is highly appropriate for men of certain trades. I cannot think of a better job for a man accustomed to road-making than quarrying. Quarrying is quite different from that odious business of shutting a man in a cell. Quarrying work for men used to heavy labour is reasonable work. I do not believe that there is a single place left where a man is shut in a cell to turn a handle to grind corn. That was being done by the West Ham Guardians when we took over the corn-grinding stock. Stone-breaking is reduced to small dimensions, and I do not regard as abnormal or onerous quarrying work in the open air. We are rationalising the Poor Law. Hon. Members opposite laugh when I talk of the unemployed coming up to the guardians with the circular in their hands. Hon. Members opposite dislike to hear of unemployed and men on relief exerting the usual rights of human beings.
§ Mr. BRACKENIs it a fact that the hon. Lady promised that within three weeks of her accession to office she would abolish—[Interruption.]
§ Miss LAWRENCEI say that we have made such a revolution in the administration of out-relief as has never before been known in England. We have introduced an entirely new principle. We have recognised the right of the authorities to grant out-relief to the unemployed as an ordinary matter. We have done that, and we will go on and improve the method until we have changed the Poor Law from being a disgrace, as it was a disgrace a year ago, into being a humane, rational and reasonable method of assisting the poor.
§ Captain GUNSTONI think that the Committee must have been amazed that the Labour party can defend stone-breaking as normal work. I should like to ask the Parliamentary Secretary whether she will answer the speech which she made a little over a year ago that stone-breaking would be abolished when the Labour party had been in office three weeks.
§ The CHAIRMANThe hon. and gallant Member is dealing with an Estimate and not with a speech made a year ago.
§ It being Eleven of the Clock the CHAIRMAN left the Chair to make his Report to the House.
§ Committee report Progress; to sit again To-morrow.
§ The remaining Orders were read, and postponed.