HC Deb 29 July 1931 vol 255 cc2321-418

17. "That a sum, not exceeding £4,261,000, be granted to His Majesty, to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1932, for Expenditure in respect of the Air Services, namely:

2. Quartering, Stores (except Technical), Supplies, and Transport 1,721,000
5. Medical Services 302,000
6. Educational Services 484,000
7. Auxiliary and Reserve Forces 599,000
9. Meteorological and Miscellaneous Effective Services 245,000
10. Air Ministry 656,000
11. Half-Pay, Pensions, and other Non-Effective Services 254,000

Motion made, and Question proposed, "That this House doth agree with the Committee in the said Resolution."


I do not think there need be any apology for returning again, after a few weeks, to a consideration of the Estimates of the Ministry of Health. The many social services that are administered by the Department intimately concern the great majority of the people of the country and involve the expenditure of large sums of money of ratepayers and taxpayers alike. The most recent return of the cost of social services gives an approximate figure of some £400,000,000, and a very large portion of this amount is to be found in the Vote of the Ministry of Health, a considerable amount of which is expenditure devoted to Old Age Pensions, Widows' Pensions, Housing, National Insurance and matters of that kind. Certainly, in examining these Estimates and in scrutinising the balance sheet of the Department, one cannot disguise for a moment that the cost of ill-health, a great deal of which is preventible, is a very heavy sum which both the nation and industry has to pay, and I am certainly keeping that very important aspect of national health affairs well before mc. On the other hand, the Minister himself reminded the House only a very short time ago that even in this connection times are hard and extravagance in the social services often comes hack on the poorest in the community. Therefore, there is a great necessity for careful administration and prudent economy.

I desire to draw particular attention to certain grave and disturbing aspects of National Health Insurance, and particularly to the heavy sickness and disablement experience which has now prevailed for a considerable period. In fact, to quote one of the statements authorised by the Minister of Health, there has been in recent years a rise in these two particular connections so continuous in its operation and of such magnitude as to occasion grave concern among all engaged in the administration of these benefits. This matter is not only of national importance, but is giving considerable anxiety to the societies themselves and to all those who desire to see national insurance maintained on a safe and stable basis. This National Health Insurance system is a contributory one, but any excess in claims which has to be dealt with calls for additional contributions from the State. This social system, in my opinion, is one which has proved of great worth and use to the nation. It will always be associated with the name of the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George). It was due to his initiation, courage and foresight that this great and beneficent system has become a permanent part of the social service of the country. The total amount paid out of these funds during the year of which we have the last particulars, including the Exchequer contribution from the Ministry of Health Vote, was some £35,000,000 and medical benefit cost some £8,700,000. Of that sum the insurance doctors received some £6,256,000 and nearly £2,000,000 was paid to insurance chemists for drugs and appliances.

There was paid in sickness benefit some £11,250,000, in disablement benefit some £5,350,000, and in maternity benefit another £1,440,000. Medical treatment and attendance has now been available to the insured people practically for 20 years. During that period no less a sum than £100,000,000 has been spent on it, and undoubtedly during that time, and perhaps as a consequence of it, in part at any rate, there has been a general improvement in the public health. The decline in the general mortality rate has been one of the most satisfactory features of the century. Medical science has progressed a very long way in recent years. Many diseases have been successfully grappled with, and a very great deal indeed has been attained by medical research. Yet, notwithstanding all this, very considerable expenditure of money and considerable effort on the part of social workers, the medical profession, nurses, approved society administrators and all those who have taken part in this great health movement, there has been a marked and striking increase in the claims of insured persons for sickness and disablement benefits and in the consequent expenditure on these benefits. This very alarming rise in the sickness and disablement benefit claims has been going on, so far as I have been able to ascertain, since 1925 and, whilst it is true that there was some improvement in 1928 as compared with the high rate in 1927, this improvement was not maintained, and the position in 1929 was substantially the same as in 1927. Last year there was some improvement, though not a very considerable one, but when you remember that in 1929 there was a serious epidemic of influenza you cannot draw very much encouragement from the figures of 1930. Certainly, no one who has studied the matter would desire to say that the problem is by any means solved or that further immediate steps to deal with the matter are not very urgently needed.

There are three grave and arresting factors in the present situation. The first is the adverse experience which the approved societies have suffered, and the claim experience in respect of married women. In fact, the societies have been affected so seriously in this connection that the valuers have in some instances quite recently warned societies that, unless the conditions improve to a marked extent, the whole of the present surplus will be exhausted within a few years in providing ordinary benefit. A number of societies which specially cater for married women, having regard to the unfortunate experience they have sustained, will have to cancel their additional benefit schemes altogether—a very serious thing indeed. It is in fact already the experience of a number of societies that they have to cancel their additional benefit schemes altogether. The Government actuary in his report to the House a short time ago came, after a very patient examination, to the conclusion that the claims of the unmarried women had risen by no less than 60 per cent. so far as sickness benefit was concerned, and the claims of married women had actually risen by 106 per cent. and, as far as disablement benefit was concerned, Sir Alfred Watson said the claims of unmarried women had risen by 100 per cent. and the claims of married women had risen by no less than 159 per cent.—a very striking figure, at any rate from the point of view of those who originally made their calculations under the Act and especially as far as the finance upon which the scheme is based is concerned. That is one serious factor in the situation, and another and also very curious feature is this, that among males it is the younger insured persons rather than the older whose burdens cast upon the funds of the various approved societies have increased in recent years. One would have expected, owing to sickness and advanced years, that exactly the opposite would have taken place.

The third factor, which is also serious and a very curious one, is illustrated in some figures which have been published by one of the largest of the approved societies in the country, is this, that the excessive claims, as far as a large proportion of insured persons are concerned, are more in the North of England than in the South, and it is a very difficult thing indeed to see why a clerical worker of a given age in one part of the country should on the average have a materially longer sickness claim than a clerical worker of the same age and sex in another part of the country. It is a very curious thing, requiring explanation, why a woman factory worker in one area suffering from, say, a digestive disorder should on the average remain on the fund longer than a woman factory worker in another area incapacitated by a similar trouble. These figures which have been presented to the Ministry of Health are very extraordinary and illuminating. This is the result of the examination: The relationship between the average duration of a claim in an area, in the north of England and that of a claim in an area in the south of England is.…:

Cause of incapacity.

Excess per cent. of the northern area over the southern area.

Rheumatism 50
Nervous and mental disorders 41
Digestive disorders 21"
Those are very remarkable and difficult things to explain. I want at once to say, in order that I may not be misunderstood, that obviously in connection with a very large portion of the population such as is covered by national health insurance, unemployment and bad health must be considered contributory factors, but let no one think that it can be claimed that this great increase of claims is due to deterioration in the national health. The Minister, who has also, as I hope to show, gone a considerable way in endeavouring to remedy this trouble, has himself pointed out that it cannot for a moment be assumed that the great majority of these claims are in any way due to such contributory causes as epidemics and unemployment. I would like to read this passage from Memorandum No. 329, issued by the Minister of Health, which has been made particularly available for approved societies. This is a very significant statement, which is made, of course, with the authority of the present Minister of Health: These facts "— that is, the Government Actuary's report, of which I have already given some quotations— suggest that the increase may have been due not so much, if at all, to an increase in the amount of incapacitating sickness as to economic or other causes not dependent on state of health. If, over so long a period, there has been any corresponding increase of ill-health, there is no apparent reason why it should have manifested itself chiefly in illnesses of short duration, and not to a corresponding extent in cases of serious sickness, causing prolonged incapacity. Secondly, there is no apparent reason why such a change in general health should have affected women to an appreciable degree more than men, married women more than single women, or young people more than old. Thirdly, there is no collateral evidence indicating that the general health of the insured population was appreciably, if any, worse in 1927 than in 1921.

The position is all the more serious because, as has been so wisely pointed out in many of the communications which have been addressed from the Ministry of Health to approved societies, every payment of sickness or disablement benefit to an insured person who is not incapable of work diminishes the fund that would otherwise be available for the benefit of other members of the society.

In case this view which I am endeavouring to point out may be controverted—and I do not want anyone to rely on any statement of mine in this connection—in order to show the un-fortunate number of improper claims that are being made at the present time I should like to refer first to a statement which was made quite recently by the very experienced insurance Controller, who, I think, has the complete confidence of the approved societies. Sir Walter Kinnear went to the annual conference of the National Association of Trade Union Approved Societies, which met at Scarborough a few weeks ago, and he said this: A year ago a group of societies submitted for an examination a stated proportion of all their members in receipt of benefit. It was found, on the most conservative calculation, that 12 per cent. of all those persons were capable of work although still in receipt of benefit. 12 per cent. of the money spent last year on sickness or disablement benefit would amount to nearly £2,500,000. What a splendid specialist and consultant service they could have had if that money has been saved!

I see in the House this afternoon the hon. Member for Westhoughton (Mr. Rhys Davies), who, as everybody in the House knows, is the Secretary of a very important approved society, and I was very glad myself that he spoke out very plainly indeed, as I would have expected him to do, at the annual meeting of the delegates of his society only a few weeks ago. I have before me a report which appeared in one of the well-known insurance papers of the country: Mr. Rhys Davies, M.P., who is Secretary of the National Union of Distributive Workers' Approved Society, with 40,000 members scattered all over the United Kingdom, did some plain speaking at the annual delegate meeting of that society held at Southport on 4th April. He said that National Health Insurance finance was being sorely tried by doubtful claims, and unless an improvement took place the scheme must ultimately fall into the same chaos as the Unemployment Fund. About 5 per cent. of the insured population studied the rules and regulations as if they were crossword puzzles, but managed to substantiate claims that were never intended to apply. That small proportion had developed what he would terra a benefit-claiming mind. He appealed to all concerned to do all they could to avoid the catastrophe that might befall the scheme by making it clear that only genuine claims would be tolerated in future, otherwise we might have to resort to the German system of compelling every insured person to pay for his first medical certificate and bottle of medicine.

When we have views of this kind coming from very different quarters indeed, one does ask the questions to-day, What is going to happen; is there anything that should be done that is not being done; or can any other steps be taken to prevent what is the very real danger of the national health insurance system degenerating into the unfortunate financial condition of our unemployment insurance system? To refer to the words of the Minister of Health himself, I want to complete my observations on this matter by asking this question: What steps are being taken to repel—and now I quote the words of the Minister of Health himself—"the continued advance of a tide of unjustified claims to sickness and disablement benefit?"

Since we discussed this matter last in the House of Commons the Minister of Health has taken at any rate two very important steps, and I think he has taken them, if I may respectfully say so, in the right direction. He has first endeavoured to strengthen the safeguards to be adopted by societies in connection with the supervision of claims, and he has very strongly urged upon approved societies the importance, in the first place, of maintaining an efficient system of sickness visitation, and, secondly, an early reference to the regional medical officers for examination of claims. I must say that when I read the other day the Memorandum which was issued under the authority of the Minister of Health to the approved societies of the country, I thought it illustrated the fact that at any rate the Minister of Health was now pretty well seized of the very serious position of affairs in this connection. One of the directions or pieces of advice which the Minister of Health has evidently felt it most necessary to bring to the notice of the approved societies is one which illustrates the urgency of the position and what I hope the societies will themselves feel to be the necessity of dealing with the situation much on the lines recommended by the Minister and his Department. He says this: Societies will, as a result of their experience, he aware of the usual duration of incapacity due to the commoner illnesses, and subject to consideration of the information gained from a sick visitor's report or as a result of communicating with the member's doctor, they should not hesitate to refer to the Regional Medical Staff claimants whose incapacity is certified as continuing beyond the expected period.

Then he says this—it is the first time that the Minister or the Department have taken such a course— It is, however, felt that societies will welcome more definite guidance as to types of cases in which a reference at a particular stage of the claim is ordinarily to be recommended, and as the result of the consideration given to the experience of the service as a whole, the Departments are in a position, and think it desirable, to give an indication of the action which they think societies should normally take on claims in which the cause of incapacity, stated in the medical certificate, is one of those specified below.

He then makes this suggestion: Where incapacity is certified as being due to any of the following or similar conditions,"—

In the list he specifies catarrh, chill, cold, debility, dyspepsia and other conditions— an immediate visit by a sick visitor should he made and, unless the visitor's report justifies delay, the member should at once be referred to the regional medical officer.

As the hon. Member for Denbigh Boroughs (Dr. Moms-Jones) knows, there is so much danger lurking in certified cases of that character, so far as the funds of the approved societies are concerned, that it is necessary that the approved societies should, without any loss of time, see that the sick visitor immediately visits the cases, and if he is not satisfied as to the bona-fides of the certificate which the medical man has given the case should at once be referred to the regional medical officer. Anyone who peruses the instructions given by the Minister of Health in this regard will see that a very strong line has been recommended.

The Minister of Health has taken certain steps with respect to the medical men, and I am in full agreement with him there. Some advice and, if necessary, some reminder is required in that connection. I notice that in the communication which the Minister of Health has made to the medical men he has reminded them of the fundamental principles upon which National Health Insurance has been founded. He has told them: The payment to each claimant in a year of a single week's benefit beyond that to which he is properly entitled, would have the result of speedily bringing a large proportion of all approved societies and branches to a state of insolvency.

I think that was a very necessary reminder to the medical men. The right hon. Gentleman's Memorandum explains at length the principles on which the system is founded. He points out that there is not an unlimited fund, that contributions are made by the employers, the employés and the State, that if excessive claims are made the people who will suffer will be the insured people, and that in certain cases if there is insolvency a further levy will have to be made upon the insured members of the society. Since we last discussed this matter some months ago the Minister of Health has made an amending regulation so far as the change of doctors is concerned. In place of the former period of 14 days' notice, insured persons are now only permitted to transfer on one month's notice at the end of four stated periods—March, June, September or December. That is an alteration which has been made for very obvious reasons. I do not know whether anyone will challenge that step, but I think that anyone who has been associated with approved society administration during the last two or three years will agree that the change is very necessary.

I should like to ask the Minister of Health whether he proposes to take further steps. Useful and desirable as the steps that he has taken may be, it is difficult to feel confident that sufficient has been done to rescue the National Health Insurance system from its present position. The approved societies in certain cases where their funds are adversely affected have the right to apply to what is called the Central Fund, and I should like the Minister of Health, if he can, to tell the House what is the position of the central fund and how long he thinks it will be able to sustain the claims that are being made upon it by the societies. There can be no doubt that, unless there is a complete change in the situation, there is very grave danger that the National Health Insurance system will degenerate into the unhappy and disastrous position of the Unemployment Insurance system. I think everyone will agree that the present situation calls for the vigilant attention and co-operation of the Ministry, the medical profession and the approved societies. I would like the Minister to say what is the position of the third valuation of the societies. That has a very important bearing upon the situation. I hope he will be able to make some statement on the subject and also say whether he contemplates some further step in connection with this very urgent matter.

One would think, having regard to the large sums of money which have been paid by the State and by the employers and the industrial classes in these directions, that we should have found by this time considerable relief in the number of people applying for Poor Law assistance, but the Poor Law figures at the present time contain certain very disturbing features. A large number of people not confined to one quarter of the House or to one kind of society, have often represented to the people of this country that if we only embarked upon these great systems of widows' pensions, National Health Insurance, and Unemployment Insurance it would be reflected in the number of people applying to the Poor Law authorities for assistance. Nevertheless, I find that, during the first quarter of the present year, according to the returns of the Ministry of Health, more than 1,000,000 persons were in receipt of relief. On the 6th June, nearly 1,000,000 were in receipt of relief. I think the whole cost of the administration is something like £40,000,000.


Can the right hon. Gentleman say how that compares with the previous years?


There may be a certain reduction—the Minister of Health will have the figures—but nothing like what one would have expected, having regard to the very large sums of money expended in other directions. The present poor law figures stand at a number which has not been reached since March, 1930.


Will the right hon. Gentleman give us the classification in regard to those who are receiving benefit? He mentioned the case of the younger members. Has he any such classification in regard to the Poor Law?


I have some Poor Law figures, and I think it is very serious from the paint of view of the finances of the country that the total number in receipt of Poor Law relief is double the pre-War figures. I have a return which has been compiled from the Ministry of Health figures. It is a selection which has been made of the number of persons relieved in one day in June, 1931, in 47 selected areas. On that particular day there were 551,710 persons relieved, which is 9.6 per cent. more than in June, 1930. On looking at the list of selected places I find that in Derby the increase in the rate per 10,000 of the population as compared with a year ago was 110, in Liverpool 107, in Manchester 128, in Sheffield 114, in West Ham 71. I should like to know whether the Minister has any estimates of the number of employed persons who have been transferred from the Poor Law lists to the Employment Exchanges, in consequence of the relaxation of the benefit conditions under the Unemployment Insurance Act, 1930.


Or vice versa.

5.0 p.m.


That would be a very interesting statement to get. It would be interesting to know whether it has diminished the demands on public assistance administration or, on the other hand, is it true that in certain industrial areas the number of recipients of relief is now larger than immediately before the Act was put into operation. If the Minister could make such a statement it would be very interesting. Could he give us any estimate whether the Anomalies Bill, which I understand has now become law, will increase or not the number of people who are going to apply to the Public Assistance Committees? I do not know whether the Minister will be able to make any statement about the scales of relief, but in this respect I was interested to observe the position of the West Ham new guardians, My right hon. Friend the Member for Edgbaston (Mr. Chamberlain may have some faint recollection of the West Ham Guardians. Having regard to my right hon. Friend's experience in that respect, it is interesting to note the official statement issued by the present Minister of Health, that the number of persons in receipt of outdoor relief in West Ham is substantially the same as in the days of the appointed guardians and that the amount of relief given is approximately the same, although it may be a little more. I was particularly interested in the statement of the Minister that the new guardians continue the practice of their predecessors of dealing with each case on its merits, after a thorough investigation of the circumstances.


That is Poor Law.


The hon. Member has not followed me. It is the statement made by the present Minister of Health on the administration of the West Ham Board of Guardians, people selected by the Minister to dislodge those who were called the Appointed Guardians.


It does not really matter who is administering relief. It must be administered in conformity with the principles of the Poor Law, and that is that every case must be dealt with on its merits.


That is a most interesting statement. The hon. Member must have a short memory—


The crux of the position lies in the discernment of the merit.


I know the hon. Lady was not in the House in the days of the administration of my right hon. Friend the Member for Edgbaston. She must read up the Debates for those days, and she will learn that everything was ascribed to the persons appointed by my right hon. Friend, they were the blackest of fellows, especially chosen for their cruel task. They starved the inhabitants of West Ham, and there was great indignation about 11 o'clock at night on the occasions when we discussed this matter. Therefore, it is interesting to know that things are going on in West Ham in just the same old way. The only other point I want to put to the Minister of Health is this. With the rise of sickness claims and national health insurance there is a great drain, not only on national health insurance funds but so far as Poor Law is concerned on the finances of local authorities, and I want to ask the Minister of Health what preparations are being made by local authorities for the winter. It is going to be a very grim winter, and the Minister of Health has certain responsibilities in the matter. I do not know whether hon. Members have read the report of the Committee presided over by Lord Chelmsford, which was set up at the earnest request of the Liberal party, who said that if only this Committee was appointed a large amount of work would be found which could be put in the hands of local authorities at an early' date. The Commitee hag just reported, and they say: The general conclusion at which we arrive is that there is no great volume of work to be found immediately within the schemes which have been submitted to us. That is the end of that.


Oh, no.


I should like to hear from the Minister of Health whether he is taking adequate steps in this matter and whether he is thinking of the necessitous areas in the country. I notice that a deputation went to him the other day, and no doubt he will be able to tell us what he proposes to do. In the days of my right hon. Friend the Member for Edgbaston, we had the Lord Mayor's Fund and the unemployment figures in the necessitous areas were only about half what they are to-day. The only thing of which I have heard is that this deputation has waited upon the right hon. Gentleman. I have endeavoured not to be unduly critical of his administration. In many respects, I think the right hon. Gentleman has learnt from his predecessor. He has undoubtedly learnt a good deal since he became Minister of Health. We are all glad of it, and we hope that he will be able to give us some further information on these very important matters.


I do not think the House will quarrel at the length of the speech of the right hon. Gentleman for West Woolwich (Sir K. Wood), or that he devoted the greater part of his remarks to the administration of national health insurance. He avoided however in his speech two or three very awkward corners in relation to the administration of this scheme upon which I hope to have something to say before I sit down. I am afraid that the right hon. Member is the only Member of Parliament who takes very much notice of my speeches. I feel a little conceited that he attaches so great importance to what I say. But I notice that it is only on this particular subject he heeds my speeches. I adhere to everything I said in that speech, and I have no hesitation in saying again that my first concern about the national health insurance scheme is that it shall he maintained financially sound, and I should strongly criticise anybody, including a Conservative Government, who did anything at all to endanger its financial stability.

The first awkward corner which the right hon. Gentleman avoided was that the first serious blow at the finances of this scheme was aimed at and delivered by his own Government. I agree with practically everything he said about excessive claims, but let me remind him once again of figures which have become too familiar to him, and which perhaps may be carved on his tombstone when ha has passed away.

The right hon. Gentleman's party were responsible for what is called the Economy Act of 1926. Let us see what the approved societies have already lost on account of that Act alone. The State grant was reduced by that Act by £2,800,000 per annum, and the approved societies were compelled by the Government of the right hon. Gentleman to accept liability, for the first time, in respect of the cost of medical benefit, which amounted to another £1,900,000 per annum. That is a reduction in the income of approved societies of £4,700,000 per annum, and that reduction in the income per annum has been going now on for five years. The approved societies, therefore, have lost in income, consequent upon the action of the right hon. Gentleman's party and Government, up to date a sum of £23,500,000, sufficient to put all the approved societies in a sound financial position. The right hon. Gentleman does not know perhaps that as a consequence one or two small societies have reached a stage, according to the last valuation, when it will be almost impossible for them to pay the statutory benefits. The Minister of Health, quite rightly, is practically forcing them to join another larger society in order that they may meet their legal liabilities.

Before I come to the wider aspect of national health insurance let me tell the right hon. Gentleman of another awkward corner that he avoided. He never said a word in criticism of the medical profession—he only read what the Minister of Health has said about them. He is obviously a politician. I want therefore to say a word about the medical profession in connection with the administration of national health insurance, and without being conceited I think I get a little nearer to the problem than the right hon. Member. He avoided also the dentists, the opticians and the surgical appliances makers, all of whom seem to have their eyes keenly fixed on the funds of approved societies. The light hon. Gentleman was inclined to blame the 17,000,000 insured persons. I shall hope to prove that some of the blame rests with other people.

I have endeavoured to give a little attention to the scheme in our own country and also to similar schemes which are in operation abroad, and I regret to say that all such schemes, wherever they exist, are at the present moment on their trial. The first scheme of this kind ever established was at the instigation of the great German statesman, Bismarck, when he introduced his national health insurance scheme in order apparently to try and stop the onward march of social democracy. It failed. That scheme to-day, unfortunately, is in a very bad way financially, and for very much the same reasons that our own scheme is beginning to decline in financial stability.

I am satisfied that the standard of honour in relation to claims from the insured population, from the medical profession, from the dentists, from the opticians, and also from some Governments, must be raised and improved, otherwise this scheme will ultimately fail in its objects. People have changed their attitude completely since the War in relation to public funds, and in relation to friendly society funds and approved society funds—and, I suppose I ought to add, in relation to Tory funds, too.


Wait until the standard of physique is improved.


The hon. Member has made a suggestion which of course, must be considered. The industrial depression and the consequent unemployment must in fact weigh above all with anyone who takes these problems into consideration, but I would remind those who are not so intimately in touch with this question as some of us, that there are approved societies—I have said this before—comprised almost entirely of members who suffer very little from bad conditions of employment or from low wages, or from unemployment, but m which there is still an increase in the average rate of sickness claims. The reasons are deep and profound. I am not therefore going to say that the doctors or the insured are entirely to blame. Let me give the case of my own society, and the right hon. Member for West Woolwich will agree with me that it is the best managed society of the lot. The average number of days of benefit paid away to males in my own society grew in the three quinquennial periods from 3.86 to 4.35, and then to 4.90. That is to say, that there has been an increase in 15 years of approximately one day in the claims for benefit in respect of every male member of the society per annum. If you have an increase of only one day's claim over the whole of the insured population per annum, the increase in the amount in benefit is simply colossal.

Some people will argue that these little items do not matter. But when a scheme is based on actuarial considerations every decimal point must be taken into account, and when you have one claim out of every 100 unjustifiable, it upsets the whole of your financial calculations. I have been a propagandist for about 30 years and I have been an administrator for about a quarter of a century. I confess that the gulf between the administrator and the propagandist in relation to these funds is almost unbridgeable, I like to be both on occasions, but I have to deal with the funds of my members, and consequently have to look after them. The most remarkable thing of all that emerges is this, that every attempt that has been made by the approved societies to reduce the average duration of sickness has, lo and behold, met with exactly the opposite result. Take one illustration. We were told when dental benefit was established that the rate of sickness benefit would decline almost automatically. In fact just in proportion as we have provided dental benefit there has been an increase in the claims for sickness benefit. I am not complaining, but that is a fact which faces every administrator of an approved society.

The right hon. Member for West Woolwich put forward another important point. It would have been very interesting, as he said, if we could have had the returns of the third valuation of approved societies before us to-day. I feel sure that the right hon. Gentleman the Minister may have had something very interesting to tell us on that score. I have secured a return of 66 trade union societies which have received individually their returns for the last valuation period. The returns of these trade union societies are not quite as bad as the right hon. Gentleman would have led us to suppose from the general argument that he put forward to-day, but what is termed the segregated approved societies are never-the less in a bad way. The miners' societies, for instance, must be, by comparison, in a bad way financially. Where there is a long dispute in any one industry the society concerned is bound to suffer in consequence of that dispute, because there is no contribution income coming in. The Minister will know how very important this question is in the case of the segregated societies. I am very much afraid that they cannot carry on much longer on the present basis. Then there are approved societies which cover few but married women, and they are obviously in financial difficulty as well. In my own society we had to separate the women from the men for valuation purposes. It may interest lady Members of the House to know that the majority of the women voted in favour of a separate valuation for themselves.

I am glad to see some medical men present. They are daily dealing with the very serious problem that troubles approved societies. The right hon. Member for West Woolwich skated over this subject very delicately. The Minister of Health has issued instructions that insured persons shall not change their doctors as often as hitherto. The point at issue is this: I have no doubt at all in saying that there is something fundamentally wrong in the relationship between the medical profession, the Government Department and the approved societies. The point that arises always in my mind in dealing with medical certificates—they are written, of course, in very legible handwriting—is, why cannot doctors call diseases by English names, or by Welsh, instead of indicating them in Latin and Greek terms which are beyond our comprehension? There is no doubt at all that some members of the medical profession do issue certificates that are absolutely unjustifiable. I would add, however, that I have reason to pay tribute to the high skill and genius of the medical profession in this country. No man has more reason to pay that tribute than I have. But the high standard of their professional skill somehow does not percolate into their business and administrative work.

That leads me at once to a point on which I want to touch. The doctor has no relation to the amount of benefit paid away on his certificate. If we could bring home to the medical profession the amount of damage that may be done to the funds of approved societies by issuing certificates where they ought not to be issued, then the medical profession would come up against the same problem as we are faced with every day.


I do not think the hon. Member is quite correct. The medical profession is subject to a penalty in the event of any excessive certification.


If the hon. Member has been in panel practice I am sure he will agree with my statement, which I make in the very best spirit, because what I want to see is greater co-operation between the medical profession and the approved societies. It is a fact that the issue by the panel doctor of a medical certificate has no relation at all to the amount of money paid away on that certificate. Until we can bring home to the medical profession how adversely loose certification affects the funds of approved societies, we shall never get out of this difficulty. That is a point that ought to receive the attention of the Minister of Health. Take the anomalies that arise. I forget how many panel doctors there are, but I believe the number is about 15,000. The approved societies, however, at the instigation of the Minister of Health, pay the fees of regional medical officers in order to scrutinise the certificates issued by the 15,000 panel doctors. That is a legitimate complaint. Whereas the funds are used in the first instance to pay about £8,500,000 per annum to the 15,000 panel doctors, we have again to pay medical inspectors, as it were, to see that the 15,000 do their work properly. That is a very unfair financial arrangement.

The same remark applies to the regional dental officers. It is well known that the funds of approved societies have also been unduly damaged by unjustified dental claims made upon them and the consequent pressure by some of the medical profession. On the whole, in cool judgment, I have come to the conclusion that there is no way out of these difficulties until the doctors are in some way employed by the State. I hope I am not saying this in any spirit which will arouse antagonism. The medical profession is unlike other persons who serve the health insurance scheme. Doctors are paid their fees per capita per annum from the general fund. They serve the approved societies, but the societies have little say as to the terms of their engagement except through the insurance committees. There must, in my opinion, be a change in this arrangement. The Minister will find some useful information on that point in what has transpired in other countries very recently.

But let me turn to something else. These schemes, as I stated, were first established in Germany. They have now spread nearly all over the world; and although we are complaining that the scheme in our own country is suffering from pressure of all kinds, and that the funds are not as healthy as they might be, it may be a consolation to us to know that exactly the same problems arise in most other countries in the world. I would like to thank the International Labour Office for providing the very best information available regarding this type of social service in foreign lands. Austria has had a scheme for a very long time, and this is what is said about Austria: In Austria the sickness funds are being particularly affected by the depression, which has diminished the contributions received and increased the expenditure on behalf of insured persons who have become unemployed and are compelled by deprivation to apply to the funds. Very largely that is our case too. As far away as Brazil a scheme of this kind is in operation, and this is what is said about the Brazilian system: It is proposed that a revision which is necessitated among other things, by the very high costs of the benefits in kind (medical and pharmaceutical benefit) should endeavour both to increase resources and to reduce charges. The voice of Brazil probably will help the Minister to try to bring about a better understanding between our medical profession and the approved societies. But the best illustration of all of what is occurring to these schemes elsewhere is the latest report that comes from Germany. The scheme there covers about 5,000,000 more people than our own. It is an older scheme, and they have had, therefore, more experience of its administration. I think I am right in saying that in May of last year no Member of the Reichstag of any party would face the question of increasing claims on health insurance because of fear of political consequences. The Reichstag was dissolved, and I understand that President Hindenburg issued an edict to the effect that very insured person, as from July, 1930, in order to save the funds of the society, should pay 6d. for his first medical certificate and 6d. for his first bottle of medicine. I am informed that even that small contribution has had a wonderful steadying effect upon the number of claims received. That is an astonishing state of affairs, but we have to face the facts. The right hon. Member for West Woolwich should not always blame the insured population. His whole argument was that the claims were excessive. I wish to bring home to the right hon. Gentleman at the end of every paragraph, and at the beginning of every chapter, that it was his Government which began to undermine the financial solidarity of this scheme by the Economy Act of 1926. I put that point in wherever I can.

In order that the House may understand that the problems of national health insurance with which we are confronted to-day are not peculiar to our own country, I wish to refer to the fact that in the small state of Luxembourg last year there was a dispute, which divided the doctors and the approved societies on questions connected with the fixing and payment of medical fees. We have not come to that position yet. The doctors and ourselves, on the whole, are on very friendly terms, and if we could get over this one point, of what we term loose certification, I think that possibly the funds of the societies could again be soundly maintained. The most remarkable case from a foreign land however is that from Russia. It may be interesting if I read a few words which have reached me as to the position of health insurance and kindred systems in Russia. It is said: There is a desire among the ruling circles in Russia to increase the relative amount of benefit granted in cases of permanent incapacity at the expense of the benefit in eases of temporary incapacity and to improve the medical service for the benefit of the insured. I conclude by putting the matter thus: I am very anxious that there shall be no suspicion that the approved societies are checking unfairly the certificates of the medical profession; but when it is found that the approved societies, according to the Minister's own statement have referred to the regional medical officers thousands of cases and that upon second examination it has been found that in about 58 per cent. of those cases the persons concerned are capable of work, then I think the approved societies are entitled to ask the reason why. Perhaps the Minister will be able to enlighten us on that issue. I feel sure, in spite of all that has been said, in spite of all our criticisms of doctors, dentists, opticians, of the insured population and of Governments, we still possess in this country a health insurance scheme which is financially the soundest in the world. It is because I wish to maintain it in that position that I have spoken so much about it this afternoon.


This Vote which embraces the Ministry of Health, deals with a very large subject involving many points of view and it seems a pity that we should have to deal with the affairs of a vast Ministry like this at the very tail-end of the Session. The importance attached to national health insurance is clearly shown by the fact that it has been practically the only subject discussed this afternoon on this Vote. I listened with interest to the right hon. Gentleman who was associated with the Ministry of Health under the last Administration and who will, I hope, be in a higher sphere under the next Administration. I am sure that that is the wish of almost all Members of the House who have observed the great diligence and energy which he has shown in this Parliament. I also listened with interest to the hon. Member for Westhoughton (Mr. Rhys Davies) who is an authority on the branch of national health insurance with which he dealt. The right hon. Gentleman and he were, as far as I could see, in considerable agreement on several points. The question of excessive claims for sickness benefit under the national health insurance system is probably, apart from the question of the deficiency on the Unemployment Insurance Fund, the most serious matter with which Parliament and the Administration have to deal at present. As far back as 1925, warnings were given in regard to this matter. I do not agree with the hon. Member for Westhoughton that the state of things in this respect is really any better this year than it was in the peak year of 1929, if allowance is made for what I may call the very serious epidemic which took place in this country in the years 1928 and 1929. That was the most serious epidemic since 1919 and the House will appreciate that one would naturally expect to have a smaller amount of claims, proportionately, this year than in those other years.

What are the causes for the present state of things? I compliment the hon. Member for Westhoughton on the courage which he showed in blaming everybody. He blamed the medical profession, the insured persons, the approved societies, the opticians, the chemists, the makers of surgical instruments—I do not think he left anyone out. I suppose that the hon. Member was on pretty safe ground in making the sweeping charge that the standard of honour of all these classes of people had been very much reduced. I agree with him in this sense, and I feel sure that the House will take this statement in the spirit in which I make it. I am convinced that there is a tendency among all classes of the population, insured and others, to try to got as much for nothing as they possibly can. That applies to all classes of the community, and I do not think that insured persons are more guilty in that respect than any other class of the population. I would say that one of the main causes, apart from a certain slackness, is a kind of grasping tendency which all classes of people seem to be adopting in these days in all parts of the world from Brazil to Russia. Apparently people in all climes show that peculiarity as far as health insurance is concerned. That is illus-strated by the quotations given by the hon. Member.

I submit to the House that, unquestionably, the next great factor in this matter is the serious economic position in the world and, especially in this country, the unemployment position. I do not think it possible for a man who is a long time out of work to be really healthy. I am not now engaged in panel practice, but I had many years' experience of it, and I consider that one great cause of the present position under this scheme is the economic depression which is affecting the physical and mental health of the insured population. If the House agrees with me that that, to a great extent, is one of the causes, then I do not think that they will agree with the hon. Member as regards the medical profession, or consider that the medical profession, in the circumstances, is so much to blame. There is no more difficult problem before the medical profession at the present time than this question of sickness claims among insured persons, and the members of the professions are as much alive to their responsibilities as the approved societies.

The medical practitioners in this matter are in a position which is, if possible, worse than that of the Liberal party in this House, as holders of the balance. They have to hold the balance between the State or the approved societies on the one side and the person who is ill or supposed to be ill on the other side. There is no more difficult position in which any man can be placed, than the position in which the medical man finds himself on frequent occasions in regard to this matter. I hope the House will permit me to speak in rather plain terms on this matter. Supposing that, as often happens, the question of debility arises. This is a most elastic term. It may mean anything from congenital laziness to a serious state of ill-health, but when you meet a real case of debility there is no other term that will fit it, and a medical man is bound as a matter of conscience and honour, to certify that a person suffering from it is unfit for work. The hon. Member for Westhoughton suggested that too much medicine was taken, but I would like to know what he would say if he himself—


May I point out that I never said anything of the kind? What I said was that the more medicine that was taken the greater the claims on the funds.


I would agree that there is too much medicine drunk in this country, but I should be sorry for any man who started preaching in this country that it should not be drunk at all. I know of no superstition or tradition or habit or whatever you like to call it, of which it is more difficult to cure the population of this country than the tradition that a bottle of medicine is a cure for all evils. No doubt the Ministry of Health are quite cognisant of the various points which have been raised regarding the increase in sickness claims and have gone into the matter very carefully. There is no question that the increase has been very much larger in the ease of women than of men, and I suggest that there is one cause for that effect. A woman may still be able to do housework in her home, although she has been certified as incapable of following an outside occupation. From many years' experience I know that very often where a certificate has been given, showing that a woman who is an insured person is not fit for the occupation in which she is insured, she is engaged in active work in her household—work which, in many cases, would be quite as arduous as the occupation in respect of which she is receiving benefit. How you are going to deal with that is a problem, but there is a very great leakage under the Act on the question of women certified as unfit for normal employment, who are drawing week by week national health insurance benefit, and being engaged in occupations of a household character which, in my submission, are equally as arduous as the work for which they are certified as physically incapacitated.

With regard to more early notification to the regional medical officer, I think the right hon. Gentleman suggested that in the case of those insured persons who are notified as suffering from a cold, chill, or catarrh, an inspector of the approved society should have the right to enter the household and make inquiries.


That was not my opinion; it was a direction given by the Minister of Health in a recent Memorandum.


I am sorry if I misunderstood the right hon. Gentleman, and I am more sorry still to find that a recommendation of that sort could be made by a responsible Government Department. An inquisition of that character, where inspectors of approved societies are allowed to inspect certificates which have been given by duly qualified medical practitioners, and start making inquiries, as it were, behind the back of the medical man, as to whether these illnesses were genuine, would, I think, be intolerable.


That is what they do every day.


The right hon. Gentleman suggested that it was in relation to these particular ailments which have been mentioned. May I suggest that I do not think that any medical man has a right to put a thing like a cold on a certificate of an insured person? I do not agree that an inspector of the approved society should start dissecting and analysing a certificate, but I suggest that the Ministry should state categorically that no insurance certificate should be accepted for such a thing as a cold or a chill. I think the phraseology should be more specific in its character. After all, a cold is a very wide term, but, as has been mentioned, it is a symptom, and of a very vague character, I do not think that certificates such as that should be accepted, but that more definite phraseology should be used in respect of some of these ailments. I would like to say, as I said at the beginning, that medical men at the present time are faced not only with a feeling of the most serious responsibility, but with very great difficulty in regard to their interpretation of the regulations as to whether a man or woman is able to follow his or her occupation. I submit that in difficult circumstances they are doing their very best.

I should like to call the attention of the Minister to the research board investigations which are in the hands of the Ministry, or which they assist, and the recent suggested discovery in regard to supposed tests for cancer. I feel sure that everyone will rejoice, from whatever quarter they may come, whether in this country or any other country, in any tests which may be found to be absolutely complete and which will render the diagnosis of this very serious malady more easy, more accurate, and more certain. But I should like to submit to the right hon. Gentleman and the hon. Lady that when some discovery of this sort is announced from a foreign country, they should look here at home, where investigations have been made for 15 or 20 years, and where reports have been sent to the Ministry on exactly the same lines as the discovery that has recently been made in Holland.

If my information is correct, investigations have shown that the tests which have been found in regard to the diagnosis of this complaint have already been discovered and reported to the Ministry of Health in this country, but that no special subsidy at any rate has been given in order to encourage some of these pathologists and investigators to go on with their work. I think it is unfortunate that Votes of the character of this Vote should be taken so late in the Session, because I do not know that there is any Ministry in this country which embraces more directly or indirectly every section of the inhabitants of the country than does the Ministry of Health. We would like to have further opportunities for discussion, and we look forward to hearing from the Minister a review, which I hope will be a little more complete than the review which he gave the House last year.


We have so far listened to what is one of the most interesting discussions that this House has had. It has been a discussion which embraces, as has already been said, a vast portion of the population, affecting almost everybody more or less in their everyday life, and raising topics which are more understandable of the people than perhaps some of the abstruse subjects which necessarily come before this House.

I wish to ask the Minister if he will deal with one question on the subject of maternal and child welfare centres. In December of last year he issued a pamphlet to the local authorities urging them to take up the matter of maternal and child welfare, a subject which was very dear to the heart of his predecessor, and I am glad to find that the right hon. Gentleman has himself taken it up with such a zest. I think the House and the country would like to know how far the local authorities have acceded to his requests that there should be more spirit and energy thrown into the provision of these centres. He has not yet been able to bring before the House a scheme for dealing with that question of maternal mortality and morbidity, but I think the local authorities can do a great deal by advice to expectant mothers and help on the healthy rearing of their children. Anything that he can do in that direction will, I am sure, be welcomed heartily by the people of this country. Any indication he can give us that this Memorandum issued to local authorities has increased the number of welfare centres and the interest in this subject, will be received with the greatest pleasure.

The Debate this afternoon has been concerned more particularly with the question of national health insurance, and I should like to congratulate the Minister on the issue of memoranda both to the approved societies and the medical profession, which deal very faithfully and very frankly with the situation. I have no doubt that during the Debate to-day we shall hear more than one apology for some of the allegations which have been made against the medical profession. I approach this subject with the very deepest respect for the medical profession; indeed, I want to adopt words contained in the Memorandum issued to the profession, in which the Minister says: It must be noted that it is nowhere suggested in this Memorandum that insurance practitioners as a whole have been responsible for the general result. On the contrary, the strongest evidence adduced respecting the issue of certificates of incapacity to persons who were not incapacitated is that derived from a comparison of the results of the work of different practitioners. Therefore, there is no need for the medical profession to be troubled when this matter is discussed, as no doubt it will be discussed to-day and in future, because the Minister has come to the conclusion that there is a state of affairs which demands some explanation, and because he says, "There may be a misunderstanding or lack of knowledge on your part as to the principles of national health insurance. May I bring to your notice some of the results of the experiments and examinations which have been made, and let us see whether there is something inherently wrong in the system itself, or whether there is something wrong with the health of the people of this country." I think the right hon. Gentleman is justified in doing that, because, after all, this scheme costs a great deal of money. A sum of very nearly £9,000,000 is spent upon medical treatment and medicines for the insured population of this country. It is a vast sum to be spent on, I believe, some 15,000 medical practitioners who come tinder the Act. Therefore, we are entitled to ask this honourable profession that they should give a service that shall be reckoned as worthy of an honourable profession, with full honesty and due regard to the insured persons. We want them to apply that skill which they have attained by their training in the fullest possible manner.

I was rather interested to hear my hon. Friend the Member for Denbigh (Dr. Morris-Jones) refer to some of the causes of incapacity which are stated upon certificates, and he used that word which has become almost as blessed as the word "Mesopotamia," namely, the word "debility." Everybody knows, of course, that debility is not a disease but a symptom, and no reasonable person in the examination of a claim in its early stages would be disposed to say that debility was a wrong cause of incapacity to give. It merely confesses that at the moment the practitioner is not able to diagnose the actual disease. The patient is debilitated, but in the course of a few days the practitioner ought to be able to determine what is the real cause of incapacity or to cease giving certificates under the heading of "debility." That would not be my complaint against the medical profession. There is loose certification certainly among some members of the profession, and quite recently I saw a certificate which contained these initials "I.D.K.," which I believe meant "I don't know." When a professional gentleman descends to that sort of thing, I think we have cause of complaint.


Does the hon. Member object to the medical profession being honest occasionally?

6.0 p.m.


I should have said that that was hardly honest and was a little misleading, because I am only surmising that I.D.K. means "I don't know." If it means something else within the vocabulary of the medical profession, the doctor in question ought to have at least the common understanding that he is dealing with mere laymen, and should have put upon the certificate some words to convey the real condition of the patient. There was a case of a doctor who put on the certificate "Je ne sais pas." That sort of thing means that some members of the medical profession are not applying their minds to health insurance in the serious way they ought to do. Some of these things are very distasteful to the profession. There was another case of a certificate, in reference to a person who was incapable of work some weeks, saying that he was suffering from abrasion of the ribs, and it appeared that during the time he was upon the funds, he engaged in a heavyweight boxing contest and had laid out his opponent in the fifth round. That sort of thing is, of course, unsatisfactory, but I do not claim that it is a typical sample of what is being done. On the contrary, very excellent service is given by the medical profession, as a whole, and if we had this good service performed by all the panel practitioners, I doubt very much whether we should be here to-day complaining that there is an excess of claims over the expected.

My hon. Friend the Member for Westhoughton (Mr. Rhys Davies) always speaks with a frankness born of true knowledge and experience, but I think that in his endeavour to hit back at my right hon. Friend with regard to certain actions that were taken during the life of the Conservative Government, he rather misled the House. He was disposed to ascribe the paucity of funds for distribution by way of additional benefits to the action of the Government, and to say that all would be well if we had that money back again. If, however, I understand the Memorandum that has been issued to the societies, the gravamen of the complaint is that the expected is 100 and that the actual is greatly in excess of 100, and whatever might have been the money in the hands of the societies for disposal, whether the result of the economy Act or otherwise, you cannot get away from the fact that, if 100 per cent. was the expected, and if you have got into the neighbourhood of 159 per cent. in excess of the expected, there is something rotten in the state of Denmark which must be looked into.


Is it not possible that the actuarial calculations were altered consequent upon the reduction of the State grant from 1926 onwards?


The actuary who made his report some time ago said that the figures were in excess of the expected, and presumably the expected must have been the basis upon which the Act was framed. I want to deal with some of the points in this Memorandum, and to join, as I hope the Minister will join, in an exhortation to the medical profession, not to condemn them, but rather to ask them whether they can find out the cause of these extraordinary results, and whether it is in fact due to the bad health of the people, or to some other cause. The hon. Member pointed out that it had been necessary—I think that he called it one of the anomalies—in the health insurance scheme, where you are paying large sums of money to the medical profession to look after the health of the people, to spend a large sum of money on a service to look after the medical profession to see that the scheme was carried out. There had been a system of the visitation of the sick in operation long before health insurance under the old friendly societies. When a man was at home sick, it was sometimes the friendly inspiration of the visitor which led him to go back to work probably earlier than he would have done, but not against medical advice. There came a time in 1921 when the suggestion was made that it would be good to have some medical advice as to whether the certificates were given in proper order and for a longer duration than was really necessary.

In the Memorandum issued by the Ministry of Health, on page 12, the figures of references and examinations are set out. In 1922, in England and Wales, 113,000 cases were referred for examination, and it gradually rose until in 1930 no less than 531,000 cases were submitted. There are some significant results from these references. Of the cases that were submitted for examination in 3922, 40 per cent. were found to be still incapable of work. Sixty per cent. of the cases declared oft, either because they did not attend for examination or because they were found by the medical referee to be capable of work. One would have thought, if certification was going on in the very best way, that as you began to increase the number of the references, the number of persons found incapable of work would be increased also, and that the number of persons found to be capable of work would have got leas. But that was not so. I find, according to this return, that when 531,000 persons were referred for examination, only 34 per cent., as against 40 per cent. in 1922, were found incapable of work. That justifies the Minister in saying in his Memorandum: Had those who ceased to draw benefit represented those only about whose fitness for work there was room for a legitimate difference of medical opinion, together with those who might have regained their working capacity between the date of the last intermediate certificate issued prior to reference and the date when they ceased benefit after reference, it is difficult to believe that the great increase of references would not by now have been accompanied by a substantial increase in the proportion of those referred who were found to be incapable of work and continued to draw benefit after reference. He went on to say: When all weight that can reasonably be claimed for them has been given to the factors of lapse of time, and of differences of medical opinion, in respect of persons referred who cease to draw benefit, the results of these investigations make it difficult to resist the conclusion that a substantial proportion of those who at any particular time are receiving sickness or disablement benefit are persons who are not incapable of work. That seems a serious and grave indictment to make, whether it be against the insured person, or against the medical profession, or against the societies. I am not attempting to lay a charge at the door of any one of the three, but I say that such a memorandum deserves the earnest attention of this House as the great platform from which views may be expressed, and from which it should go out with a very loud voice that something has to be done to repair this state of things. It is not only a reflection upon the medical profession, but a reflection upon the moral honesty of the people. If there be a good and honest reason why these things obtain, then let us know it, and I am sure that the Minister of Health will be only too anxious to withdraw the allegations which are contained in the memorandum.

Arising out of the examinations which have been made, one thing stands out pre-eminently among all others. That is the fact that the increase in the sickness experience is greater among married women than any other class. While the expected is 100, the actual for sickness benefit is 106 per cent. above the expected, and for disablement benefit 159 per cent. above the expected. Such a state of things means that if married women were to stand alone, their scheme would be insolvent. I am sure that it gives the Minister grave concern as to what is to be done with this particular portion of the insured population. What is the difficulty with regard to married women? When the Irish Free State was set up there was a separation of that portion of the health insurance members resident in the Free State, and the Government there had then to consider the problem of the married women. There had been a suggestion, in the years prior to the separation, of a scheme of what was known as the marriage bonus, under which when a woman ceased work on marriage there was a payment of part of the reserves given to her, and her insurance ceased; if, again, she went into the employment market, she had to start again as a fresh insured person.

That scheme was never adopted in this country. On a woman ceasing work to become married, she was allowed benefit for six weeks in one year should sickness take place, and maternity benefit during a period of two years. An unfortunate position has arisen from the experience in regard to some of the women. I do not know whether the feminine mind is such that a woman is never quite sure about the experiment she is undertaking in marrying, and is not sure whether she will return to work or not, but in many cases she does become a casual worker. That is the real difficulty of the situation in regard to married women. She may be in work for a day or two as it suits her, and at other times if sick she is receiving an amount which is equivalent to, and sometimes greater than, the amount she would be getting from her casual work.

That matter has been considered by a body outside, and they say that if you are to put the scheme with regard to married women on a satisfactory basis, you have to do something to meet the situation, and if married women are to be accepted as an insurance proposition, there are three courses open, namely, to increase the contributions to meet the risk, or to reduce benefits, or to deal with the matter somewhat on the lines of the present system, that is to say, when a woman marries, she must pass out of insurance, and if she subsequently enters the employment market, she must requalify for benefit. During the time of requalification a limited sickness and maternity benefit would be provided. In that way, she will start on level terms with the unmarried woman or the widow who is in the labour market. I hope that the Minister will consider that particular point. There is no doubt that the married women's side of the health insurance scheme is not a satisfactory or a healthy proposition at the present time.

Another point which deserves the attention of the Minister is the effect of a high sickness experience and a low contribution record. It must be a tremendous factor in the success of a society that when it has a high sickness experience the contributions shall be sufficient to meet the strain, but you cannot expect that in a period of great unemployment. In 1928 the right hon. Member for Edgbaston (Mr. Chamberlain) introduced a Measure which wiped out penalty arrears. Up to that time members had to suffer a reduction of their benefits in proportion to the number of arrears which they had and that was known as the penalty arrears system. Under the Act of 1928 there was a special concession of the extension of the life of the membership if the member had gone through a prolonged period of genuine unemployment, so that his insurance could run for two years and nine months. No payment in respect of that was made to the societies by the State, but it Was suggested that out of what was known as the unclaimed stamps account, a grant of £500,000 should be made to the Societies to help them to carry the burden. As a matter of fact, the liabilities upon the societies in respect of that burden amount to something like £680,000—in 1930 it was more than that, and for 1931 the figure promises to be higher still. It was contemplated that the amount would be £680,000, leaving a deficiency of £180,000 a year to be borne by the societies, but in point of fact there is a greater deficiency to be borne by the societies.

At the end of 1930 we were faced with a difficulty which was brought prominently before this House by certain hon. Members from the Clyde area. An hon. Member opposite made a bold effort, which was successful, to see that the insurances of these people should not be put in jeopardy without some effort on the part of the Government. At the last moment, in December, 1930, the Government brought forward what was known as the prolongation Act, which to that extent gave a subsidy in favour of insured persons in order to tide them over until the end of 1931. But what I want the Minister to apply his mind to is this serious question of the arrears. We cannot keep the societies on a solvent basis if we put upon them the responsibility of providing full benefits for their members while at the same time they see the contributions declining. This is a matter which has to be met, and I hope the Minister will do something to meet the situation. I am sure the Minister is cognisant of the urgency of dealing with the subject of prolongation and the condition of those persons who, but for some assistance from the Government, will pass out at the end of 1931. The country and all who are concerned with this matter ought not to be left in a state of suspense till the very end of the year. I hope the Minister will deal with this matter in his reply. The number of persons in arrear is increasing; there is no question about that. It must be evidence from the way the figures of unemployment have gone up.

Apart altogether from the subject we have been discussing, which is the drain upon the funds of approved societies through a sickness experience which was greater than had been expected, there is no more important matter to consider than the position of those persons who, if no assistance is forthcoming from the Government, will find their health insurance in jeopardy. The present drain upon the societies imposes a burden which is not borne by some imaginary person or body; it is a burden which is borne by the members of the society. If they have paid in contributions proportionate to a particular risk, they are entitled when sickness comes upon them to have the benefits promised paid in full. If, on the other hand, the funds of the societies have been drained by keeping in benefit numbers of man and women in respect of whom no contributions have been paid, we shall not be able to meet, as we ought to meet, the moral contract between the insured person and the State, of those insured persons who have made the necessary contributions. Therefore, I join in the exhortation for better administration, a more careful issue of certificates by doctors, and a greater realisation of what depends upon the issue of a certificate. All Members of the House, members of approved societies and members of the medical profession should join in seeing that this scheme, above all schemes, shall not get upon the slippery slops of Unemployment Insurance, but maintain, as it has maintained for nearly 20 years, a state of proud solvency.


I am glad the question of the medical profession has been raised this afternoon. It is about time we came to grips with this subject of sickness experience. When this question was discussed on a previous occasion, I gave expression o the view that what was then said about sickness experience was grossly exaggerated. We did not take proper stock of the abnormal conditions obtaining during the past four or five years. A reduced standard of living must have the effect of producing a considerable amount of illness. I think the medical profession will say that a good deal of the increase of sickness is due to the reduced stamina of the people. Unless there is a marked change in our economic conditions, I feel that sickness experience will become even worse, and therefore it is exceedingly important that societies should retain all their funds. I shall deal presently with the effects of the Economy Act, 1926, and shall ask the Minister what he intends to do in that respect. I have no complaint about the general administration of this Department, because I believe it has been very excellent indeed; my complaint is that the Ministry are endeavouring to force societies to adopt methods of sickness visitation, and do work which doctors will say is work which they alone ought to do. If the figures produced here, though I do not accept them in their entirety, are correct, they stow that doctors have failed lamentably in carrying out the work of certification.

It is a curious thing that a layman, a sick visitor, should be called upon to decide when a person's case should be referred to a regional medical officer. Recently the Ministry of Health issued a Memorandum on this subject. In 1922 the number of cases referred was 130,000, whereas in 1930 the number was no less than 573,000. A large number of these persons are clearly entitled to be on the funds of their society. I know men of decent character, men who would not dream of malingering, who have been referred, willy-nilly, to the regional medical officer. His report has been that the case ought never to have been sent to him. I know of cases sent to the regional medical officer in which the patient has been dead the next week. That shows that proper care was not taken before the case was referred. Sick visitors, however estimable they may be in their general character, are having cast upon them a responsibility which is too grave for them. At the same time, there must have been something wrong with the diagnosis in the first place.

Except in rare instances, it should be the duty of the panel doctor to decide whether a person is entitled to be on the funds or not, yet the Ministry are trying to force the approved societies, at great expense, to increase their sickness visitation. I tried the other day, by means of a question, to "draw" the Minister on the subject of sickness visitation, but, as is usual, I found it very difficult to do so—to get the answer that I wanted. Even when one puts supplementary questions, one gets an answer that is entirely different from what had been expected or hoped for. This after-noon, therefore, I want to ask the Minister a very plain question: Is he entirely satisfied with the medical service under the National Health Insurance Acts, and, if not, in what way does he suggest that it should be improved? That is the thing to which we have to get down. This "scrapping" has been going on for the last 10 or 15 years—charges made against the medical profession, retorts by the medical profession, who place themselves upon a pedestal and refuse to come down from it. It is my belief that the Ministry are not satisfied that the medical service is what it ought to be. That is the root of the matter. If this malingering is going on to anything like the extent suggested the responsibility for it should be put on the societies; if the doctors are afraid to put people off the funds when they ought to be off, they should be freed from that fear by a different form of service.

May I help the Minister by reminding him of his own circular, to which reference has been made this afternoon? It gives details of investigations on behalf of the National Health Insurance Joint Committee. In 1929, 88,903 persons were referred to the regional medical staff. There was about six times that number in the first instance, but those were the cases picked out. There was this amazing result—a state of things which, if it is true, must make the Ministry alter the system under which it is loft to laymen to refer these cases to the regional medical officers—that of the 83,903 cases, 58.5 per cent. ceased to receive medical benefit. On examination by the regional medical officer, those persons were, presumably, declared to be found not incapable of work. [Interruption.] At any rate, they went off the fund. I want hon. Members to understand that there is a difference between the practice of approved societies and the practice of the old friendly societies. Under the old friendly societies a man had to be capable of following his occupation, which is an entirely different thing from being able to work. A man may be a miner or a coal porter and not capable of following that occupation, but if he can do any light work they are entitled to put him off the fund.

There is a marked difference now in the practice of approved societies. No fewer than 88,903 persons were referred to the regional medical staff in 1929, and 58.5 per cent. ceased to receive benefit. The figures were: In 1921, incapable of work, 64.45; not incapable of work, 35.55. In 1922, incapable of work, 68.09; not incapable of work, 31.91. In 1923, incapable of work, 73.92; not incapable of work, 26.08. In the first six months of 1924, incapable of work, 75.74; not incapable of work, 24.26. Does that show proper certification on the part of the doctors? The report of the Ministry in connection with the 1929 cases is: A substantial proportion of insured persons claim or continue to claim benefit who, on reference to an independent medical referee, would be found not incapable of work. What have hon. Members to say about a statement of that kind? That is the conclusion of an independent examination of the work of medical practitioners who are receiving over £7,000,000 per annum from insurance funds, or an average of £500 per doctor per annum. What have the doctors done for an average salary of £500 in excess of what they were receiving from their ordinary practices before they took on their duties under the National Health Insurance Act? Medical benefit in 1929 cost no less than £8,760,000, or more than half the sums spent in sickness and disablement benefit, which amount to £16,600,000. Since the Act has been in operation, £10,500,000 has been spent in dental benefit. We were told when dental benefit was brought into operation that this would have an immense effect on the health of the people, but the result has been more and more sickness claims. In spite of all these huge payments, sickness increases, lax certification increases, and payment to doctors increases.

I want to call attention to this point: If medical practitioners were doing their work properly, there should be no need for elaborate schemes of sickness visitation which is advocated by the Department. In any case, it should not be the duty of a body of laymen to refer doubtful cases to the regional medical officers. This should be the work of the panel doctor, unless the Minister is prepared to argue that a layman is more qualified than a doctor to do this class of work. I find on pages 10 and 11 of the National Health Insurance Report a list of the cases upon which the sick visitor is expected to report. Paragraph 38 states that: Societies will, as a result of their own experience, be aware of the usual duration of incapacity due to the commoner illnesses, and subject to consideration of the information gained from a sick visitor's report, or as a result of communicating with the member's doctor, they should not hesitate to refer to the regional medical staff claimants whose incapacity is certified as continuing beyond the expected period. Therefore, it will be seen that the layman has to decide in these cases. He has to call in the doctor and he has to decide, after a cursory glance at the patient, whether he should report to the regional medical officer or not. I think that is a most fantastic scheme. This attitude seems to suggest to me that the medical service under the National Health Insurance Act requires to be strengthened at the source, and it looks as if the doctors are unable to carry out their duties efficiently because of the fear of losing their panel patients. There would be a good deal less malingering if only the doctors had the courage to do their work properly. In regard to eases awaiting admission to the hospital, the report says: In cases of hernia and similar chronic conditions, the delay in admission to the hospital is often protracted, and as many of these persons are found to be not incapable of work during the waiting period, reference should be made at a very early date if it is known that the patient is awaiting admission to hospital, and is not confined to bed. With regard to post-operation cases, the report states: Members who have been operated on in hospital should be referred after a suitable period of convalescence. The time required for convalescence will vary, of course, with the nature of the operation, and the general condition of the patient, but reference will usually be desirable on the expiration of four weeks after discharge from hospital in cases in which the sick visitor's report (which will always first be obtained) does not indicate that this course would be inexpedient. The person undergoing the operation has to wait for the sick visitor to decide whether he ought to go to work, or whether he should remain on the funds a little longer. The position is an impossible one, and, whether we like it or not, the Minister ought to come down definitely and say whether the Government are satisfied with this service or not. I suggest that the Minister should consider the suggestion made from time to time by members of the Labour movement and many of the approved societies for a long time past that the time has arrived for establishing a national medical service which shall include the dependants of insured persons.

There is a matter upon which I would like the Minister to give us the fullest possible information, and that is the effect which the Economy Act, 1926, has had upon the recent valuations of approved societies. The right hon. Gentleman the Member for West Woolwich (Sir K. Wood) frequently criticises the Government in regard to this particular work. It may surprise the right hon. Gentleman to know that the financial loss under the Economy Act has been no less than £4,700,000. The proportion of the expenditure of approved societies which has been met from the Exchequer was 40 per cent. in 1921, and 17.6 per cent. in 1930–31. There was no excuse for this raiding of the funds of the approved societies. I find in a statement made to the Press when the Economy Bill was before the House that the right hon. Gentleman the Member for Woolwich stated:

  1. "(1) That no existing benefits would be interfered with.
  2. (2) That extension of benefits would still be possible.
  3. (3) That in all probability the amount of the surpluses, especially on the third valuation, would remain undiminished."
Nobody but the right hon. Gentleman the Member for West Woolwich could have imagined such a thing, having regard to the fact that the funds of approved societies were to be reduced by £4,700,000 per annum. In paragraph 31 of the first report of the Actuarial Committee it was estimated that societies representing 10 per cent. of the insured population would be eventually thrust into deficiency by the proposals of the Economy Bill. We know now that certain societies have not been able to continue their additional benefits, and it is extremely doubtful at the next valuation whether there will be any additional benefit at all as far as some of these societies are concerned.

The reduction in State grants and additional charge for medical benefit thrown upon approved societies amounts to £4,700,000 per annum, and, obviously, that must make a great difference to the approved societies and to additional benefits, and I ask the Minister at the earliest possible moment to restore the amount which was stolen from approved societies by the last Government. I ask the Minister to face this question and face the medical profession, and let us have a system that will really be in the interests of the insured persons of this country.


I do not propose to follow the hon. Member for Southampton (Mr. T. Lewis) in his references to the last Administration, but, as one who was not a Member of the House in 1926, and who, therefore, has no direct responsibility for what happened then, I may remind the hon. Member and the House that, while it is easy to say now that what was done in 1926 was wrong, it is just as well, if we are going to discuss this matter accurately, that we should take into account the circumstances of 1926. In order to do that, we must go back to the origin of our National Insurance system. The basis of that system was that there should be contributions by the three parties, the State, the employers and the employés, and, on the actuarial calculations which were made at the time when the scheme first came into operation, it was computed that certain benefits could be given. Going forward from the origin of the scheme, from 1911 to 1926, it was then found that those computations were correct, and that the State, which was one of the three parties to the system of insurance, and which, by way of experiment, had agreed in 1911 to make certain contributions, was in a position to say that the scheme had reached such a position that it was possible for the State to reduce its contribution.

It is a matter of argument whether or not the State should be the only party whose contribution should be reduced, but one effect of the State reducing its contribution to the Insurance Fund was that it had thereby other funds available for social services and for the general purposes of the State. In my judgment, it is not a question whether, to use a word which is not very pleasant, but which the hon. Member used, funds were stolen by the Conservative administration. I would point out that the decision to alter the basis of the contribution by the State was a decision of Parliament, and I have no doubt that at the time the whole of the circumstances were taken into account. To-day there is quite a different position. If the hon. Member objects to the State at any time altering its quota of contribution to the system of insurance, that would mean that what Parliament did in 1911 must stand for all time, and I am sure that even the hon. Member would not accept a proposition of that kind. It is always possible for Parliament to review the situation with regard to National Health Insurance or any other matter, and to say whether or not it will continue a certain payment, or reduce it, or make such changes as Parliament at the time thinks proper.

As I understand the situation to-day, however, it is not so much a question whether the contribution by the State or by the employer or the employé is right or wrong. The question which arises is that there has been, and is likely to be, a very heavy sickness experience, much heavier than was contemplated when the scheme was put into operation. There is this heavy claim upon the National Health Insurance Fund, and there is also the difficulty, which hon. Members must acknowledge, that a large volume of unemployment involves, not only an added burden on the National Health Insurance Fund in additional claims, but a corresponding reduction in the income of the societies concerned. That is the problem which Parliament will have to face, and Parliament will have to decide, it may be this Session or it may be in a later Session, whether or not the system of insurance as we understand it has to be further supplemented by State aid.

I would remind the hon. Member for Southampton that Parliament in other ways has shown its concern for the stability of our National Health Insurance Fund. Members in all quarters of the House are very anxious that we should maintain at its fullest capacity and its greatest usefulness the National Health Insurance system, and every Member of the House, I care not where he sits, is desirous that there should be no question of the National Health Insurance Fund getting into anything approaching the very deplorable condition into which the Unemployment Insurance Fund has got. I am glad to see the hon. Member for Gorbals (Mr. Buchanan) in his place. It was very largely due to his pertinacity and the pertinacity of his colleague the hon. Member for Camlachie (Mr. Stephen) that last Christmas, just before the vacation, we had the National Health (Prolongation of Insurance) Act, which, as has been pointed out, extended benefit to perhaps the most deserving section of the insured community, and I think that the hon. Member for Gorbals and the hon. Member for Camlachie may well claim credit for having compelled the Government to introduce that legislation, which was favourably received in all quarters of the House, and was put through very expeditiously, because everyone realised its necessity. At the time when that legislation was passed, as a result of which the State was to make certain contributions on behalf of people who were no longer in a position themselves to pay, amounting to 36 contributions for a year, the Minister was not in a position to say anything with regard to the cost. It was not known how many people would be affected, or how much would be required of the State to make good the deficiency. The estimates varied, I think, from £80,000 to £130,000, and the numbers from 60,000 to 100,000. I should like to as kthe Minister if he is now able to give us any information with regard to the number of people affected by that Act, and as to what steps are to be taken to deal with the same situation which will arise, unless something is done in the meantime, on the 31st December, this year.

Another point on which I would also like the Minister to be good enough to give us some information is as to the question, which is of interest to every Member of the House, of maternity and child welfare. The statement of the Minister, when last this Vote was before the House, that there was a toll of something like 3,000 women who died in childbirth every year, is an appalling record, and I, for one, should be very glad to know what steps are being taken in that matter. One would expect that the Minister of Health, no matter to what party he may belong, would be very anxiously concerned as to the gravity of such a position, and I am sure we shall welcome any news that he can give us to the effect that this problem has been taken up by the local authorities, who are very greatly concerned. We shall be very glad to know that some of the recommendations at any rate of the Departmental Committee which considered this question have been put into effect.

I want now to deal with a matter which has not as yet been dealt with. We are discussing the Vote for the Ministry of Health, and, although the activities of the Department are so varied and interesting, it seems to me that we should pay some attention to the Vote itself. We are discussing, not only the many matters which are involved in the work of the Department, but a survey of the cost. I remember the Minister saying, when last this Vote was before the House, that his Department was inevitably a Department that spends money, and he went on to say—this is his phrase, and not mine—that the Department would be described by one newspaper, which he named, as a spendthrift Department. He was careful to add that he believed that the expenditure incurred by his Department was expenditure which was wisely incurred, and which resulted in increased benefit and well-being for the country. It might be suggested that the doctrine that his Department is inevitably a spending Department, and certainly the suggestion which he himself has made that this country could afford to spend whatever it desired to spend, is a very dangerous doctrine, and I am sure he will forgive me if for a few moments I look at one of his Estimates with a certain amount of kindly suspicion.

The Minister, in introducing the Estimate, referred to the fact that the net sum involved by his Department was £19,600,000, and he pointed out that that represented an increase of £392,000. He immediately went on to emphasise that the increase was largely accounted for by the increased subsidy for housing. It is very difficult for the average Member of this House to keep himself informed as to the cost of the activities of any Department, no matter how well disposed and industrious he may be, but I have tried, so far as I have been able, to find out something as to the cost of the right hon. Gentleman's Department, and, if the House will bear with me, I will submit the results of my, perhaps, rather scanty activities for its consideration. I find that the administration expenses—salaries, wages, travelling expenses, and so on—amount, in found figures, to £2,000,000. Housing grants account for £12,750,000. The National Health Insurance Fund takes £6,000,000. That is for England and Wales. Then we have what seems to be a comparatively small sum of £110,000, when one considers that it covers grants for sanatoria, training of midwives and health visitors, grants to port sanitary authorities, and a few other items of that kind. That is a total of £20,750,000. The figure mentioned by the Minister was £19,600,000, and the difference of £1,200,000 or so is accounted for by appropriations-in-aid.

This expenditure, however, of £20,750,000 docs not represent the complete picture. For instance, the Registrar-General's Office cost £328,000, and I would like to know if I am correct in assuming that the cost of the census this year is nearly £250,000. Then there are Old Age Pensions, for which no less a sum that £38,250,000 is required; the Widows', Orphans' and Old Age Contributory Pensions scheme accounts for £10,000,000; and the Scottish Department of Health for £2,750,000; so we see that we are discussing, not an expenditure of £20,750,000, but these other items as well. Disregarding the Ministry of Labour Votes, it would appear, so far as I have been able to ascertain, comparing like with like, that there is an increased expenditure of £3,000,000 as compared with the previous year, and that year was £6,000,000 more than the year 1929–30. Having regard to the vast amount of money which we are spending every year in respect of pensions, I would like to submit this point to the Minister. His Department is responsible, as I have said, for the very considerable sum of £38,000,000 in the one case and £10,000,000 in the other case this year. Would it be possible for the House to have a statement covering, say, the next five years, showing the actual cash liabilities to which we are committed?

7.0 p.m.

We hear a great deal on all sides about economy. If we are committed by Statute to certain obligations, the sooner we know what they are the better. I, therefore, ask the Parliamentary Secretary if she will issue a statement showing, as far as possible, the liabilities of the State in respect to pensions so far as her Department is concerned, The present Government are, of course, not entirely responsible, as preceding Governments have their share in it, but we are to have an opportunity in the Recess of perusing the report of the Economy Committee and, in order that we may better appreciate that report, it would be useful if Members had in their possession particulars of the statutory commitments of the State in respect to pensions. Another great commitment is that on housing, and I would very much appreciate, as I am sure would other hon. Members, a simple Statement showing the contribution which the State has made in respect to housing. I see in the last report of the Ministry of Health a figure of something like £1,000,000,000 in respect to certain housing expenditure. I would like a statement of this expenditure, including subsidies, grants to local authorities, and loans to owner occupiers. I am sure that hon. Members would be amazed if we had in simple tabular form—not a statement prepared in a partisan way to show that one Government has done more than another, but a straightforward statement showing what the nation has contributed to the housing problem in the last 10 or 11 years or since the end of the War. It would be very interesting and instructive to all Members of the House.

There is one other point I wish to make. I have taken the trouble of comparing the cost of the administration of this Department with past years. I do not like taking the Estimates of the previous year, because they have a very vicious habit of becoming the Estimates for the following year, but I picked up haphazard in the Library the Estimates of 1924–25, and I thought it would be a fair test to see to what extent the administrative expenses of the Department have increased in seven years. I found that the administrative expenditure of the Ministry of Health in the current year's Estimates was £1,982,000, whereas in 1924–25 it was £1,337,000, which shows an increase of £645,000 or nearly 48 per cent. I shall not trouble the House with the figures with regard to the administration of the Welsh Board of Health for the same period, but I shall give the percentage. The House will find that there is an increase in the cost of administration of the Welsh Board of Health of 60 per cent., and in the case of the Scottish Board of Health of 47 per cent.

Those are figures and increases that ought to give us pause. I am not putting them forward in any niggardly or parsimonious way, but merely for this purpose. If we are increasing expenditure over a period of seven years by something like 50 per cent., we are entitled to say that we ought to have increased efficiency, or improved services, or more services. It may be that the administration of the Ministry of Health can justify this increased expenditure by showing that we have not only increased efficiency in the Department but improved services and more services. This may be the fact, but the House is entitled to ask the Minister if he is satisfied that this increased expenditure in the last seven years is expenditure which has been wise and reasonable. He has a multiplicity of duties to perform, and it is impossible to expect any Minister or Parliamentary Secretary to pay attention only to the cost of administration, but I should be glad if the Minister of Health could give us any information he has as to whether the increased expenditure on the administration of his Department has been wise expenditure and has resulted in improved services.


The figures in the Ministry of Health Vote are such that every Member of the House ought to face up to the position whether, in fact, they ought not to be more. I do not know of any Vote in this House which can be applied to greater and more humanising purposes than this Vote of the Ministry of Health. If I wanted to give in a sentence the epitome of all the speeches to which we have listened this afternoon, it would be something like thtis—instead of it being £19,600,000, it ought to be increased by £4,700,000 which failed to be appropriated to these funds as an effect of the 1926 Economy Act. Much has been said this afternoon about the anticipated difficulties of approved societies when they get their valuation returns out for the last quinquennium; much has been said about increased sickness and disability experience and of the heavy drain on the funds of approved societies. I share the apprehensions in that respect, and look round for the causes of it. You cannot rule out the fact that unemployment has a two-fold bearing on the state of funds of approved societies. You get no contribution when the man or woman is not working, and you get the standard of life in the home lowered to such an extent that it tends to increase the prevalence of sickness.

Taking that into consideration, one must consider the effect of the reduction in the appropriation. I would be disposed at this late stage to cut our losses, and try to forget the iniquity of taking some £2,750,000 a year out of the appropriation to the funds of approved societies, which was done under the 1926 Economy Act, if it were not for the fact that to-day we are living in the same atmosphere of 1926 with regard to economy. We are having committees appointed and inquiries on the question of economy, and coming out with reports which can only postulate one thing, that the funds are in a parlous state, that we must either increase the contribution of the members or we must cut the benefits. The House of Commons must make up its mind that there is another way of meeting this difficulty. If the amount which was appropriated formerly to approved society funds was restored, we should not be in this position of having to talk about cutting the benefits to any section of approved society members.

We were favoured a little while since a report of the Government with Actuary in connection with the position of unemployment. He, quite properly, reminded us that these two Acts went side by side. He said in his report: Both schemes had a common origin in the National Insurance Act of 1911. As originally designed, the State grant to unemployment insurance was one-fourth of the total, while in health insurance the State had to bear two-ninths of the expenditure in the case of men and one-fourth in the case of women and, in addition, the cost of central administration. I invite the House to go back to that as being fundamental. The burden of all the speeches this afternoon has been apprehension as to the solvency of approved society funds. Every speaker, without exception, has agreed that we, who represent approved societies and who have the knowledge and understanding of the position, want at all costs to avoid a descent on the slippery slope down which the Unemployment Insurance Fund has gone owing to abnormal experience. The first thing the Ministry and the Government have to do is to face up to putting this fund back again on its original basis for solvency before they talk about cutting the benefit of approved society members. Lest there should be any misunderstanding, I quote again from the report of Sir Alfred Watson, the Government Actuary, who crystallises the position thus: The total Exchequer contribution in respect of health insurance for 1920–21 was £10.3 million, or 40 per cent., while in 1930–31 the total Exchequer contribution was £6.7 million, or 17.6 per cent. I want to emphasise the fact that we stand in a different position as regards the administration and solvency of this fund from that in which we stand in relation to the unemployment position. Happily, there is, in regard to national health insurance funds, a very close administration of those funds in well-defined groups which are called approved societies. Each society vies with the other to do the best it possibly can for its members and to conserve its funds and administer them properly and sympathetically, but I know of no approved society, or group of societies, which would do other than follow out the original conception underlying the Act, that benefits should tend to increase rather than diminish. We all remember the original slogan of the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) of "9d. for 4d.," the conception being that, when you are getting benefits to-day at their minimum, they must tend to increase, and they will increase. There will be additional benefits. I am very jealous lest we should go back on the covenant we have made in respect to National Health Insurance benefits.

A great deal has been said to-day about the doctors. I should be the last man to want in a general way to say any-thing derogatory of the doctors, but they should feel, no less than the administrators of approved societies, their responsibility for establishing the soundness of the scheme. I agree with my hon. Friend the Member for Westhoughton (Mr. R. Davies) when he says in scathing terms to his own trade union confreres, "I am not standing for the man who is monkeying about." There is a genuine feeling that we ought, also to say we are not going to stand for the doctor who is monkeying about and helping people to get benefits to which they are not entitled. I should like to feel that the doctors are with us in this matter. When I think of the doctors and their methods of certification, I cannot help thinking of the experience which is patent to every Member of the House as to the difference between a doctor's certificate when I want to establish a claim under the Pensions Act and the type of certificate you get when it is a case of a claim for benefit under an approved society. There is a wide gap there. It seems to me that the medical profession can do, under the terms of certification, exactly what you are prepared to pay them well enough to do.

I hate to think that the medical profession are mercenary, but I cannot help feeling that they are a bit. I do not know whether we ought not to get a method where we pay them on results and give them a special bonus for declaring people off, or whether we can get a similar code instituted to that which applies in a pension case that we want to fight. In any case, the remedy for the position and for the risk of insolvency of approved societies, whether in bulk or whether in respect of any particular membership, lies first in the necessity of the State keeping faith on the original basis of the scheme. The hon. Member for Westhoughton referred to schemes in other countries and to the difficulty which is common in most countries. I would say, with some experience, that if we had the restoration of the amount of money that has not come into appropriation since the 1926 Act, it would make all the difference in the world.

The hon. Member for Mitcham (Mr. Meller) talked about the case of married women. He even hinted that approved societies were up against it to such an extent that they would have to adopt some other method. I want to put the plain question to the Minister whether there is any urge from his Department, whether he contemplates making any order or regulation or promoting any Bill to degrade the benefits of members of approved societies? I feel very keenly on this point that, as long as the State is not doing all it originally convenanted to do, there is no case for cutting benefits. I think much more can be done by closer administration. Much more can be done, as has been shown, by reference to the regional medical officer. There is something wrong when you refer 100 people to the medical officer, and half of them take fright and declare off. Is the Minister prescribing any method for referring these cases? I agree with the hon. Member for Southampton (Mr. T. Lewis) that it is not good enough to treat all members on a level basis and say, if they have been on so long, it must be a case to be referred to the regional medical officer. There ought to be some justification. I do not think I agree with my hon. Friend that the sickness visitor's report is perhaps quite good enough as a ground for referring a case to the regional medical officer. I think there should be some better basis than that to warrant sending so many cases. The number has certainly gone up with a tremendous leap. It has jumped from 113,000 in 1922 to over 500,000 at present.

I hope that we shall not degenerate, so far as the administration of National Health Insurance is concerned, along the lines of degeneration which set in with regard to Unemployment Insurance when the Exchanges treated every man as one who had to be challenged. It will be much better to administer the fund in a proper manner, and to assume that the title stands good until we see some evidence that it is not good. I am all for the urge that every measure of co-operation should be made under this Act before you get to the point of cutting benefits. It is contemplated by some societies, especially in regard to married women, that there shall be some degradation from the standard of benefits. I want to urge the Minister to take what steps may be necessary to obviate approved societies having to take such a step as this, because the moves are undoubtedly with him and his Department if the original idea of additional benefits and improved benefits is to obtain.

Many reasons have been adduced as to the causes of increased sickness. There is one which has not been mentioned which, I think, would obtain very largely, with regard to disability, at any rate. The improvement in mortality has a cumulative effect in increasing the number of disabled people on the fund as the years go by. The older a man gets, up to a certain point, the more the cumulative effect will apply, I should imagine, on increased sickness and on disablement Unlike most insurance, it pays approved societies if people die at the right time, because that is a release of funds and a release of liabilities.


Surely, if people die, you lose their contributions. Why is the society better off?


Experience will show that you are better minus the contributions than minus the liability of paying the disablement benefit which obtains in a good many cases except, of course, that we have the limit of age under the Acts now reduced by the incidence of the Widows', Orphans' and Old Age Contributory Pensions Act, which brings it down to 60.

I should like to say a word about arrears. There is no doubt that the approved societies' funds have suffered. The fund has been well administered, but the preceding Chancellor of the Exchequer could rob it, and even the present Minister is imposing on it the cost of the growing arrears in respect of unemployment. Everyone concerned with approved society membership throughout the whole series of prolongation Acts from 1928 to the present Act was expecting from the Ministry of Health some return to meet the cost of those arrears. The position is still obscure, and I hope that the Minister will tell us what he really proposes to do to help the approved society with respect to the cost of the arrears in reference to members who have been unemployed. These are all points bearing upon the solvency of the fund. All Members of the House are proud of the fact that the general position of the National Health Insurance Fund is as good as it is compared with the parlous position in which the unemployment fund now stands. Before we cut benefits we should explore every avenue for keeping the fund in its present state of solvency. I notice in going over the details of the Estimates that while increases are made, and quite properly made, in regard to housing, reductions are made in respect of the amounts for appropriation in respect of approved societies, I hope that when the Minister replies he will give the House an assurance that he will, in his administrative capacity and otherwise, see that benefits to all approved society members, women included, are conserved and improved, and that the necessary reliefs are given to approved societies.


Before we leave the very depressing though interesting subject which we have discussed all the afternoon, I should like to say a word about the excessive claims of married women. I recognise that that is a grave new phenomenon which requires careful inquiry. I should like to put forward one explanation. I do not suppose that it is a complete explanation, but I am quite sure that it is a possible one. In every time of depression in industry, when there is privation in households and members of households are out of work, it is the married woman who feels the pinch. Anyone whose social experience does not enable him to verify that remark may refer to Mr. Rowntree's study of poverty in York which is one of the greatest descriptions of poverty-stricken conditions ever produced in this country. He calls attention to the fact that wherever there is unemployment, low wages and difficulty, it is the married woman who feels the pinch, for the very obvious reason that she is the person who has to expend the family income and make it go as far as possible, and naturally, being the person with the responsibility, she leaves herself until the last. The decreased state of health of married women through that cause is one of the reasons for the increase in their claims.

I rose to draw attention to quite a different sort of wastage from that which we have been discussing this afternoon. I wish to speak of the wastage going on in housing subsidies. The Vote with which We are dealing to-night accounts for over £12,750,000 spent on housing grants, about £1,000,000 more than last year, and it is a steadily rising increase. It is a unique time for considering that question for two reasons. First of all, the Greenwood Act is a year old, and I suppose that local authorities hitherto have been almost entirely absorbed in considering the destruction of insanitary property, the acquisition of land and the erection of new houses. Now is the time when they should face up to the problem of what they are going to do with the new houses when they are built, and how they are going to see that they get into the hands of the persons for whom, they were intended. I suggest that there are two factors which make this a unique time for trying to see that housing subsidies in future shall benefit those for whom they were intended by Parliament, and to get back to decreased but economic rents.

The two factors are, first of all, that building costs have come down so considerably that economic rents are very little more at present than the full subsidised rents fixed some years ago under earlier Housing Acts. The second factor is, that under the Greenwood Act a set of admirable regulations have been issued by the Ministry which lay down the principle, I believe for the first time, that it is the clear intention of Parliament that the grants under the new Act shall benefit those who need rent relief, and that rent relief shall be given only to those who need it, and only for as long as they need it. Presumably that is the clear intention of the Act. It is the duty of the Ministry not only to lay it down, but to see that it is carried out.

I would suggest that the same intention that housing subsidies should only benefit those who have an economic need for them is really implicit in all housing Acts. The very title "Housing of the Working Classes Acts," surely, implies that the economic status of the tenant is supposed to be a factor, and that Parliament did not really intend to grant the subsidy all these years by Act after Act merely in order that relatively well-paid people should enjoy a trip to lovely Lucerne, or should be able to indulge in the purchase of that little motor car on which their hearts were set by economising in their rents at the expense of the public purse. Notoriously that has been the actual effect of a large part of the housing subsidies in the past. Now that the demand for public economy is so imperative, and also at the same time it is being more generally recognised that we must deal with the needs of those tenants who are still living in foetid slums or over-crowded houses because they cannot afford the rents of houses previously put up, is it not worth considering how we can combine the two policies, first, of ensuring that the subsidies only benefit those for whom they are intended, and, at the same time, seeing that even a larger and larger supply of houses is provided of the kind adapted to the needs of those who most need housing relief?

I will show how the circumstances of the present time can be made to apply in securing those two ends. Let us assume that some municipality nerves itself to take the bold course of deciding that in future the rent of all the new municipal houses shall be the full economic rent and that the subsidy shall be used for the sole purpose of granting rebates upon rent to individual tenants on the ground of their needs. It is not an extravagant assumption, because quite recently, by a unanimous resolution, the Manchester Corporation requested its housing committee to consider that very proposition and to report upon it. Housing rents vary considerably in different localities and for different types of houses on different sites in the same locality, and it is difficult to generalise. I will take a simple instance to show how it would work out if the Manchester proposal were carried out. The rents of Manchester were lowered quite recently to meet the change in economic circumstances and the lower building costs. At present the rent of an ordinary A3 three-bedroomed kitchen house, I understand, varies from 8s. 6d. to 10s. 3d. net, but the vast majority of houses are of the more expensive type. Last March the Ministry informed me that the full economic net rent of a three-bedroomed kitchen house of this type was 10s. 6d., that is to say, only 3d. a week higher than the higher rate of rent charged in Manchester for the houses erected with the benefit of the Wheatley subsidy. Hence if Manchester took this step of restoring economic rents, it could be done with no great shock to public opinion or breach in established custom. Those relatively well-off people whom Manchester has been accustomed to allow to occupy those new houses would find that they were not much more highly rented than their neighbours who manage to obtain possession of a municipal house built at a more expensive period. The full amount of the subsidy of those new houses would then be available to meet the needs of the really poor tenants who require rent relief.

How could this be done? The Greenwood Act and the regulations under it expressly contemplate that the subsidy should be used in giving grants to individual tenants, based either on the number of their children or upon the amount of their income, or upon a combination of both factors. It also contemplates other alternatives, such as charging what are called differential rents, that is, renting certain groups of new houses at one rent and other groups at a rather higher rent. I want to suggest three things, first of all, that the method of rent rebates attached to individual tenants and not to bricks and mortar is not merely an alternative way of carrying out the golden rule of the Greenwood regulations, that rent relief shall be given only to those who need it and only for as long as they need. It is the only way of carrying out that golden rule. Secondly, I suggest that the subsidy to be used in that way shall not be merely the difference between the Wheatley subsidy and the Greenwood subsidy, a paltry average sum of 1s. per house, but that the rebate system should apply to all the new houses under whatever Act they are built, and that it should absorb the whole amount of the subsidy. Thirdly, that policy should not merely be indicated as possible in the Ministry of Health's regulations, but it should be pressed upon local authorities as the only way in which local authorities can carry out what the Ministry has declared to be the clear intention of the Act.

Take the first point. I say that it is the only way of carrying out that golden rule. Supposing a housing authority adopts the plan of differential rents, and supposing they say, "Yes, we are going to see that houses go to those who really need rent relief, but we will do it by charging low rents to poor tenants," and they select their tenants on the ground of poverty. Take a tenant whose income is £2 10s. a week and who happens to have three children of school age. He is a very suitable tenant to have the benefit of a low-rented house. Six years hence that tenant may have received a rise in wages, and his three children may all be wage-earners and his income may be quite easily anything from £5 to £6 a week. Clearly this would not be a needy case for rent relief. That is not an abnormal case, but an ordinary and usual case. The truth is that the factor of family dependency is a more important factor in determining capability to pay rent than either of the other two factors of rates of wages, or employment and unemployment.

All three factors, family dependency, rates of wages, and employment and unemployment are continually changing, so that no system which merely selected tenants originally on admission on grounds of poverty can possibly economise in the use of a subsidy. Again, sup-posing it is assumed, as some local authorities prefer to do, that the mere fact that a tenant, has been a victim of an over-crowded or an insanitary slum is in itself a proof that he needs rent relief. Nothing could be more untrue or dangerous. A recent inquiry conducted by the Liverpool University into the conditions of the working people of Liverpool revealed this rather remarkable fact, that of all the over-crowded tenants of Liverpool houses, only 30 per cent. of the families were below the poverty line. Over 50 per cent. were so far above the poverty line that it might reasonably be assumed that they could afford to pay considerably higher rents than they were paying. Most surprising of all, almost the largest group of seriously overcrowded tenants were those whose families could claim two or more wage-earners in regular work. The explanation is obvious. The families where there tends to be the most over-crowding are families where there are several adult children. Yet those families who have grown up in poverty frequently cling to their slum or overcrowded tenements because they have become accustomed to have a large margin of pocket money made available by paying low rent, or because they want to live near their work or because of a mixture of both motives. That is not a preference that ought to be indulged at the public expense.

The only way of carrying out the golden rule of the Ministry is the method of rebates attached to the individual tenant. How can the money be used in that way? If the amount used for rebates is small—the difference between the Wheatley and the Greenwood subsidy is 1s. per week per house—the amount will be negligible and the economy will also be negligible. But supposing the standard rents are fixed at the full economic rental, we shall have available an additional subsidy amounting to 3s. 9d. in the case of a Wheatley house and 43. 9d. or 5s, a week in the case of a Greenwood house, an amount sufficient to allow rebates varying from 1s., 2s., to even 2s. 6d., the test being the size of income per head of the family, after deducting the amount of rent. One of the advantages of this plan would be that it would make it possible, without allowing any sponging on housing subsidies, to permit, as has been done in the past, a considerable number of tenants who have been living under undesirable conditions, who are not extremely poor and do not require rent relief, to pass into the new houses and when they do so, their rent will automatically adjust itself to the level of their capacity to pay. In other words, the difference between a flat rate subsidy attached to the house and a rebate granted to the individual tenant is that the same sum of money can be used over and over again as the particular tenant ceases to need it, and it can be transferred to a different tenant or a different house.

May I deal briefly with the objections that I have heard raised by members of different local authorities to this plan? The first objection is that the grant of rebates to individual tenants on the ground of the number of dependants or poverty, or both, is a measure of public assistance that is unsuitable for a housing authority, and that such rebates ought to be given, if at all, by the public assistance committee. That argument shows such muddle-headed thinking, that it almost makes one despair of those who use it. What is any form of housing subsidy but public assistance granted to an individual tenant. Bricks and mortar cannot benefit by subsidy. It must be the tenants who benefit. The fact that the subsidy in past years has been regarded as attached to the house and not to the tenant has been one of the most vicious parts of the whole system, because it has confused the public mind. It has enabled many people to think that if they accept a corporation house, subsidised out of public money, when they are perfectly well able to purchase or to rent a house for themselves, they are not, as they are in fact, cheating the poor and using money which was never intended for them, but that they are doing something perfectly legitimate. It is the duty of the Ministry to present to the country more clearly than they have done hitherto the right view in regard to this matter, and not merely to state, in rather vague terms, that it is permissible to use the subsidy for individual rebates. They have laid down the rule that it is the clear intention of Parliament that relief should be given only to those who need it, and they ought to see that the local authorities obey that rule and adhere to it. If the local authorities decline to adopt a method which really does ensure that, it ought to be in the power of the Ministry to see that the local authorities do obey the clear intention of Parliament.

There is another respect in which I feel that the Minister ought to give us more assurance than in the past as to what steps he has taken to prevent the waste of housing subsidies. When the Greenwood Act was passing through the House, I pointed out the grave danger that there seemed to be of profiteering among landowners because of the system adopted of granting a high subsidy where houses were built on land of a specially costly character. I see already in connection with certain local authorities that there is a strong tendency on the part of the landowners to charge excessive prices for land because they see quite plainly that the local authorities have a diminished inducement to buy land cheap because they can obtain a higher rate of subsidy if they have to pay above a certain price for the land. Not long ago there was a case in Liverpool where the city council passed and sent up to the Ministry of Health a proposal for paying over £2 a yard for a certain site, not a very eligible site in my opinion, on which to erect a block of tenement dwellings. I am glad that the Ministry of Health, this extravagant Socialist Ministry, turned down as too extravagant a proposal put forward by the strongly Conservative Liverpool City Council. The result was that after considerable squeezing the landlord offered his land at 10s. a yard less, a very considerable saving was effected. I would ask the Minister to give us an assurance as to what steps he is taking to economise in the use of the subsidy. He knows very well the great need there is for urging local authorities to greater activity in securing a larger number of new houses. I wish I could believe that half as much scientific thought and attention and pressure from the Ministry was being given to the question of urging the local authorities to make good use of the subsidies that they have and to see that they are not wasted by giving them for the benefit of people who do not need them and using them for the more structural aspects of the housing problem.


The first part of the Debate was principally devoted to a discussion of the question of sickness benefit paid by approved societies. Several hon. Members have touched upon various other points. The hon. Member for Faversham (Mr. Maitland) asked me why our expenses had gone up so formidably during the past seven years Both sides of the House were responsible for the increased expenditure. First of all, we had the Wheatley Act which necessitated considerable expenditure in increased staff. Then further officers were needed under the Conservative Pensions Act of 1925. We have since developed that Act, and on each occasion whenever we have made developments in regard to pensions or housing, an increase in the staff of the Ministry has been necessary. The hon. Member for Faversham also asked me whether I could make a clear statement in regard to the future course of pensions and housing. Both those subjects have been dealt with in reports and Estimates, which I shall be glad to hand to the hon. Member.

The hon. Member for the English Universities (Miss Rathbone), in her very interesting and suggestive discourse, urged that the local authorities should ensure that the poorest tenants were helped. It has been the object of every Minister of Health worthy of the name, and it ought to be the object of every local authority, to see that houses are provided at rents suitable for the very poorest of the population. That is the central problem in housing, and one to which we have devoted our very best attention. Each locality has its own problem to solve. It has to cater for its own class of population, and it has its own differences to adjust as to the different classes of houses required. It would be highly undesirable at this stage to force local authorities into one particular line of action. All the proposals that are put before the Ministry are considered on their merits, and such criticism or advice is given to the local authority as may be appropriate in the circumstances. The developments and experiments that are taking place in Manchester, to which the hon. Lady referred, are very interesting, and I hope that we shall have similar interesting experiments in different parts of the country, from which perhaps a general policy will be evolved. At the present time we must give the local authorities considerable latitude.

I come to the question of the approved societies and sickness benefit. I suppose we look upon this matter from slightly different angles. There are a good many angles from which we can view the problem. The administration of national health insurance is a very important part of the functions of the Ministry of Health, and it is our duty to watch the health of the population and to make every allowance for the increased sickness in time of unemployment. The hon. Lady was right when she said that times of unemployment and stress pressed most hardly on the mother in the home. In considering this problem, we have to take into account the point of view of the insured person, the professional view of the doctor and also the fact that the insurance societies have their eyes fixed on the sole interests of their members. I am not saying that these different views are irreconcilable, but they do need to be balanced against each other.

8.0 p.m.

I think that the hon. Member for Mitcham (Mr. Meller) was a little hard on the medical gentleman to whom he referred. The doctor who wrote "I.D.K." on the certificate is a person I regard with some liking after all. It was very much the same thing as when a general practitioner says that he requires a second opinion. I am certain, knowing a little about the society to which the hon. Member for Mitcham referred, that if that certificate came in, it was received in exactly that sense as a request for a second opinion, and that the second opinion was hurried to the bedside of the patient. Again, I cannot see that there is the slightest harm in the visitor asking for a second opinion. When the visitor calls to inquire into cases certified as colds, chills or debility and thinks further inquiry is necessary, I cannot see that there is anything in the least derogatory even to the strictest medical etiquette for the visitor to say that he would like a second opinion. All that happens in such a case is that the regional medical officer is brought in. Of course, the doctors have their points of view and their susceptibilities. Then there are the business susceptibilities of the insurance societies. Then there is the point of view of the approved societies, who, I understand, when they drink the health of their members do it with these words, "A healthy life and a sudden death." It is the business of the Ministry of Health to try to assimilate all these points of view, and to judge with the utmost possible care all the evidence that comes before us. After long and careful reports we have come to the conclusion that, making every allowance for the effects of unemployment and depression, the whole of the sickness claims made on the approved societies cannot be altogether accounted for by these causes.

The right hon. Member for West Woolwich (Sir K. Wood) paid us a great compliment when he occupied so great a part of his speech in reading long extracts from our report, and this relieves me from the necessity of going over it in too great detail. He pointed out in our own words—and very excellent words they are—that the incidence of sickness showed some anomalies. If we were dealing with general bad health, one would expect the older part of the population to show it most, but in the case of young people the increase of sickness is greater than in the old. You would also expect more prolonged illnesses, whereas, as a matter of fact, you find that the larger number of increases are in the case of short illnesses. Our last circular went out on 31st May last. We are holding conferences with the approved societies. The right hon. Member for West Woolwich (Sir K. Wood) asked what further steps we were about to take, but as the circular only went out in May last, it is rather early to suggest any further measures. The question of the central fund has been referred to during the Debate. The central fund is not in a very good position. It reached a maximum of over £1,500,000, but it has since been seriously depleted owing to the necessity of having to make grants to societies who were in a deficiency through causes beyond their control. That is a very serious matter, and the financial position of the fund is engaging the earnest attention of the Minister. It is possible that a levy may be one of the subjects to be discussed, but whether it will be necessary to make a levy is a matter for further consideration. It is being anxiously discussed, but I cannot give any more definite information at the moment.


Are we to understand that the levy is to be something in the nature of a pool?


No. The third valuation is now almost completed, and we expect the full report will be issued in the autumn. We have not yet a complete analysis of the third valuation, but, so far as it has gone, the figures are coming in rather better than were anticipated. At the same time, a number of societies, particularly those with a separate fund for women, show that their disposable surplus has been reduced.


Will the Parliamentary Secretary tell us something more about the levy before she leaves that subject?


There is no levy yet. It is one of the possibilities we are discussing with the approved societies. With regard to the third valuation, it is true to say that a number of societies have found their disposable surplus reduced, and some of them have been compelled to curtail the additional benefits they have previously provided. It is clear that the financial basis of the insurance scheme will need careful examination, and it is a matter which will have the attention of the Minister in the near future. With regard to the prolongation of insurance, we are now in conference with the approved societies, and my right hon. Friend hopes to be able to announce a decision on the matter very soon.

I think I have dealt with most of the points which have been touched upon during the Debate. Approved societies, like the rest of the community, are feeling the combined strain of unemployment and trade depression. But they are giving the matter their very careful attention, and it is hoped that it may be possible to improve their administration in some minor points.


Will the hon. Lady deal with the question of research upon which I made some observations earlier in the Debate?


The hon. Member referred, I believe, to a very recent discovery with regard to cancer. That is being, I understand, discussed by the Cancer Committee, and obviously I can say nothing of value on that matter at the present moment.


The House is indebted to my right bon. Friend the Member for West Woolwich (Sir K. Wood) for raising the question of general interest which has been the subject of Our discussion this afternoon. Everybody has their own point of view about it. The discussion has been interesting for several reasons, partly because it has given an opportunity for the expression of views which have thrown a very interesting side light on some political opinions. For instance, the hon. Member for Westhoughton (Mr. Rhys Davies) said that the increased claims upon the societies were illustrative of the fact that people had changed their attitude towards public funds. That is a statement which is more often made from this side of the House than from the other. There is undoubtedly an increased tendency on the part of the public to look for some sort of assistance and help from public funds instead of depending, as our fathers did, upon their own exertions. There was an interesting clash of opinion between the hon. Member for Southampton (Mr. T. Lewis) and the hon. Member for Camberwell North West (Dr. Morgan) as to the benefits of nationalisation. The hon. Member for Southampton wants nationalisation of the medical services, but he does not want nationalisation, as the hon. Member for Camberwell pointed out, of the approved societies.


I never said so. I reserved my answer.


The hon. Member knows that that will not do. The hon. Member for Camberwell North West is a doctor, and he wants nationalisation of everything except the medical service. He showed that plainly by his question. It was indeed a most interesting exchange of question and answer between two hon. Members, who I have no doubt on the public platform have expressed themselves in favour of universal nationalisation, as long as it was not of themselves. A little later the bon. Member for Greenwich (Mr. Palmer) referred in terms which are more generally used on this side of the House than the other, to the Unemployment Insurance Fund. He hoped that it would not be allowed to get on to the slippery slope that was leading to disaster. It was interesting to hear that it was on this slippery slope. We all thought that since the genuinely seeking work Clause has been abolished everything was satisfactory in connection with unemployment insurance. Apart from these expressions of opinion on smaller points, there has been a general measure of agreement as to some of the main facts which are causing a little disquietude in all quarters of the House. Everyone will agree that it would be a great disaster if the National Health Insurance scheme became merely a form of public assistance—and it is not too late now to save it. It may be too late, and it is therefore much better to advertise the troubles which are causing uneasiness at this stage rather than wait until it is too late and then bewail the fact that disaster has overtaken the fund.

I am sorry that the Parliamentary Secretary was not able to give us a, little more guidance upon some of the definite questions which were put to her. She took refuse in the old worn formula that the subject was engaging the earnest attention of the Government. Of course it is. She said that conferences were being held and committees were being appointed—everything was in the future, but nothing definite in answer to the pointed questions which have been asked. The hon. Member for Southampton said that what he wanted to know was whether the Minister was satisfied with the present position of the National Health Insurance Fund and its administration, and, if not, what was he going to do?


What I asked was whether the Minister was satisfied with the medical services.


I think his question was a little wider than that, but, even so, the hon. Member has not had an answer.


I quite agree.


There were other questions, equally pointed and clear, which the hon. Lady entirely evaded, except to this extent that she said they were the subject of consideration by the Minister. It may be convenient before we part with this subject to summarise the facts which are not in dispute so that they may be known in the country. There is no doubt that the additional benefits of some societies are in jeopardy. Some societies are even getting to the position of being in a deficiency. The duration of sickness claims is not responsible for this position. Broadly speaking, the duration of sickness claims has not increased. There is, equally, no doubt that a substantial number of people are making claims upon the fund who have no moral or legal claim upon it. It has been put as high as 12 per cent. by a representative group of approved societies, but whether it is 12 per cent., or a little more or a little less, there is no doubt that a number of people are making claims upon the fund who have no right to do so. Although it is easy to exaggerate, undoubtedly it is a position that ought to engage, and I have no doubt has already engaged, the attention of the Minister.

The next question is that the increase in the claims is more largely felt in the case of married women and young men. I am not sure which causes me the graver disquiet, but I think the fact that the young men are making increased claims is the more serious development. Then there is a fact which has not been sufficiently recognised, and that is that the growth in the number of the sickness claims is out of all proportion to the deepening of the industrial depression. Undoubtedly it may be due in some part to the unhappy increase of unemployment, but it is a fact that the increase in sickness claims is not to be accounted for wholly by the increase of unemployment.


The hon. and learned Gentleman has made a statement which rather disturbs me, and it affects a great mass of people. He referred to the days when people were willing to do for themselves things that they now want done by others. Before these claims get through, who certifies the claims? That information ought to be kept in front of us if we are to debate the matter properly.


The hon. Gentleman has not had the great advantage of hearing the views expressed by hon. Members on both sides of the House who are intimately acquainted with this question. [Interruption.] The hon. Member displays some irritation which makes me think that he ought to be a claimant upon the fund. [Interruption.] The hon. Gentleman is angry with me for speaking about this subject in terms which I thought represented the measure of agreement between Members on both sides of the House.


You are suggesting that there is some foul thing going on with certain people.


I am not suggesting anything foul. My very next sentence, if the hon. Member had not interrupted me, would have been a statement that in spite of these undoubted facts, which no one will deny, it is very easy indeed to exaggerate the fact, if it be a fact, that a certain number of people are making improper claims, just as it is easy to exaggerate the fact, if it be a fact, that many members of the medical profession are perhaps a little too easy-going in the granting of certificates. The hon. Member appears to be anxious to place all the emphasis upon the defects of the medical profession.


No; you are.


I have not referred so far to the doctors. I should have come to that subject in the ordinary course of the few remarks that I desired to offer. A question which the Parliamentary Secretary did not wholly face to-day is, what is the Minister going to do about this position? He has, as my right hon. Friend the Member for West Woolwich pointed out, called attention to the necessity or desirability of the doctors being perhaps a little more careful. But I think the position calls for something more definite and more drastic than a mere suggestion of that sort. The hon. Member for Westhoughton has two remedies. His first suggestion was that the doctors should be brought more in touch with the consequence of their certificates, that they should be made to realise how much money depends on the grant of a certificate. I am not sure that that is the right way to enable the doctors to do their duty. I think a doctor should use his medical skill by addressing his mind to the condition of the patient, and not to considering what may be the consequence, great or small, of granting a certificate. It is quite enough to diagnose the patient's condition without diverting his attention to considering what may be the consequence upon some fund about which he knows nothing. That suggestion of the hon. Member was less helpful than some put forward.

The next suggestion, which no doubt finds a greater measure of agreement among hon. Members opposite than on this side, was that the medical service should be nationalised. I shall not be expected to agree with that, and I do not believe that any doctor sitting on the benches opposite will agree with it either. Imagine 16,000 medical men nationalised as a State service. Imagine the questions that would be asked in this House as to the way in which these State servants were carrying out their duties. I do not envy the task of the Minister of Health if that proposal is ever adopted. Two other proposals which have been made are rather more helpful. One was that a little more attention should be given to the system of sick visitation which obtains in many of the best conducted societies. A great deal undoubtedly could be done if that was stiffened up, and if societies were not merely persuaded but induced to introduce a more comprehensive and carefully organised system of sick visitation.

The other suggestion which I think is likely to prove even more useful in discovering the cases of improper claims was that the operation of the regional medical staff should be speeded up. Its usefulness, as everyone knows, is to some extent diminished by the fact that there is a certain tardiness in its operation to-day. If the second medical opinion could be called in a little earlier, possibly the right; diagnosis would be made so as to prevent anything in the nature of an improper claim being made on a society, but whether you ascribe the undoubted increase to the tendency on the part of some people, married women and young men chiefly, to make a claim which they ought not to make, or to the easy going character of the medical profession, undoubtedly the one tendency acts and reacts upon the other. If there are people—human nature being what it is, there will be people—who will make a claim which they ought not to make, if they find a medical man easy going they will be encouraged to make such claims in greater numbers. Similarly, if a medical man finds a great many claims coming along, he naturally passes a greater number of claims, human nature being again what it is.

Medical men are the kindest-hearted people in the world, and I believe that most of us, if we were medical men, would prefer to take the risk of passing persons about whom we were not perfectly satisfied if they were ill, rather than take the risk of refusing them a certificate. We would run the risk of passing a wrong claim rather than the risk of rejecting a right claim. We shall not get very much assistance in this question by attempting to distribute blame amongst the classes who make these claims, or amongst the doctors. Let us try to discover some system, some improvement in the operation of this fund, such as a better and more efficient visiting or a quicker operation of the regional medical staff. Let us try to improve the system, and then we shall reduce to a minimum the improper claims which are causing disquiet to-day. I was sorry to hear the Parliamentary Secretary say that a levy upon the central fund is under grave consideration. The central fund is the fund of all societies. If it be a fact that laxity of administration in some of the less well conducted societies is causing the difficulties, the result of making a levy upon the central fund will be to make the good societies pay for the lax administration of the bad societies. You will be getting very near the proposal of pooling when you have a levy on the central fund.

The central fund exists for well-defined purposes, and the Minister ought to be quite certain that he has exhausted all the possibilities of improving the administration of the societies in relation to claims, before he allows the levy which the hon. Lady says is under discussion. Frequent references have been made to the Economy Act. If there be spilt milk, there is not much good in crying over it. The withdrawal of State contribution effected by the Economy Act may have been right or it may have been wrong, but, if the withdrawal or reduction of that contribution had never been made, the ills—if they be ills—which we have been discussing this afternoon, would have been just as great. A greater State contribution might have cloaked these evils, but it certainly would not have ended them. The effect on the funds of these societies would have been inevitable, though it might have been postponed, if the State contribution had been continued at the old level. I do not want to go back on a controversy which is closed at any rate for the time being, but I venture to suggest that the Economy Act has nothing to do with the question which has mainly engaged the House this afternoon.

In spite of the very pointed questions and suggestions addressed to the hon. Lady I did not observe any indication on her part, as representing the Ministry, of paying back the money which was taken away by the Economy Act. The hon. Member for Southampton (Mr. T. Lewis) in addition to putting certain questions, made that suggestion. The hon. Member for Greenwich (Mr. Palmer) made the same suggestion in still more direct terms. He told the hon. Lady that she could not reduce benefits, and must not increase contributions, and that the only way out of the difficulty was to pay back the money taken away by the Economy Act. The hon. Lady made no response to that suggestion. I remember hearing the Minister of Health make many an acid speech about the Economy Act but I do not discover any anxiety on his part to prove that the words uttered four years ago were well-founded—words promising that, at the earliest possible moment, the mischief which we were supposed to have done would be repaired. The hon. Lady studiously refrained from dealing with that question and as I have mentioned the hon. Lady I may close by recalling to the attention of the House the difference between the expectations which were held out by her and her colleagues and their performances. Her words no doubt are well remembered: We will deal with the people who are suffering from hunger and cold, from want of boots, from want of milk, from want of clothes. These are things which a Labour Government can cure within three weeks of coming into office."—[OFFICIAL REPORT, 1st May, 1929; col. 1601, Vol. 227.] If the increase in the claims upon this fund is due to the fact that industrial depression has increased unemployment it is the hon. Lady's fault, according to her own admission because she said she could put it right in three weeks. If she provided the milk, the hoots, the clothes and the coal which she promised to provide within three weeks of coming into office, all the industrial depression in the world would not have brought about that increase in the number of claims upon the societies which is making them so anxious. I hope that the hon. Lady's experience will produce fruit and that hon. Members who sit behind her will be less reckless in their promises at the next General Election. If they address their minds to the improvement of the National Health Insurance Fund instead of promising the moon to their constituents at the next Election this Debate will not have been a waste of time.


We have had an interesting Debate on the subject of health in its relationship to national health insurance, but I think we might profitably discuss the question of health also in its relation to housing, water supply, sewerage and the like, and deal with some of the causes, as well as the effects. I want to draw attention to what I regard as one of the most fruitful causes of ill-health and, in particular, to what I consider to be the shortcomings of the Ministry in this respect.


Hear, hear.


I am pleased to hear the approval of the hon. and gallant Gentleman, which is very helpful. Reports are continually being sent in by medical officers of health drawing attention to lack of water supplies and proper sewerage schemes, and I submit that where new housing schemes are being laid before councils and before the Ministry, it should be the Ministry's duty to see that proper and efficient schemes of this kind are being provided. Some time ago the attention of the Ministry was called to the case of a town which was being developed on what were regarded as real up-to-date town-planning lines. It was advertised in these words: "Come to the new health resort, Kinmel Bay." There were picturesque posters showing what a wonderful place it was. In that place there is no main sewerage scheme whatever. Over 300 houses have been built and each one of them has nothing but a cesspool. Here is a case in which a proper scheme is essential to protect public health and prevent disease. Surely the provision of a main sewerage scheme in a town of that size where the houses cost up to £1,000 each, a town which is supposed to be a health resort, is a work on which unemployed labour could profitably be employed, and steps ought to be taken by the Ministry to deal with it. It may be said that the local authority has the duty of providing such a scheme. I have seen dozens of schemes in my time, and have passed dozens of plans for the laying out of estates and in every scheme—

Mr. DEPUTY - SPEAKER (Mr. Dunnico)

Is the scheme to which the hon. Member refers a scheme subsidised by the Ministry of Health?


Yes, in some cases these schemes are subsidised.


The hon. Member can only raise a point of that character if the Ministry are directly responsible.


I need not confine mysef to any one scheme. I can find several. I only mentioned one to illustrate my point and I pass to another. That is a scheme of the Branston Rural District Council, near Burton-on-Trent. This scheme was approved in November, 1929, nearly two years ago, and not a single piece of work has been commenced on it to this day. I took the opportunity to confirm this as late as Monday night, and in that case, where 300 houses have been built, there is no sewerage scheme, although the district council has been pressing the Ministry of Health to get on with the job. It was approved on the 5th November, 1929, and not a single thing has been done. The same principle applies in this case as in the other. This is a matter of public health, and surely, in the general lay-out of this estate, it is one of those burdens that the Ministry should see is not placed on the backs of the ratepayers. At least a plan should show where the sewers are to be laid, so that when houses are built it will be known where they could be connected up to them; and the general health of the people would to that extent be safeguarded.

The more I see of the Department in dealing with these matters, the less I like it. While we have unemployment and these practical schemes are put up to the Department, I cannot understand what it is that is preventing us getting along and trying to absorb some of the unemployed in this useful work. If an outbreak of disease occurred in either of the places that I have mentioned, heaven knows what would happen. If it is not the duty of the Ministry of Health, and if it is not the duty of the local council, whose duty is it to attend to these matters and protect the health of the community? In regard to water supplies and some of the old systems of sewerage at which I have been looking, I do not wonder that in many cases the medical officers of health, one of whom, in a case that I know of, has the magnificent salary of £20 a year—

Lieut.-Colonel FREMANTLE

Who built these houses?


They have been built as an overflow, by private enterprise, chiefly, at Branston.


The hon. Member is criticising the Minister for what is not a matter under his jurisdiction.


I cannot understand, where public money has been expended on the building of these houses, why we should not insist on certain conditions being carried out.


A few moments ago, the hon. Member was criticising the salaries of medical officers, and other matters under the control of local authorities. He must keep to matters directly under the jurisdiction of the Minister.


The salary of these medical officers of health is in part paid by the Ministry, and the local authorities cannot dispense with their services without the approval of the Ministry. Surely on some portion of this Vote we should be able to discuss the duties of the medical officers of health. There was a direct connection between the Ministry and the duty of the medical officer to report to the Ministry in order to draw attention to the shortcomings of these authorities, and as a consequence the central health authority should themselves be fully cognisant of the facts that I have tried to enumerate here, and should take immediate steps to see that the abominations that exist in these areas as a consequence of these hundreds of cesspools are removed.


I wish to bring to the notice of the Minister the questions of nursing homes, radium, and pure milk. In regard to nursing homes, in the latter part of 1927 a Bill was passed making it necessary for these various homes to register, and in some cases an alarming state of affairs was brought before the notice of the Ministry, which made them introduce the Measure which is in force to-day. I understand that the local authorities are largely responsible for the administration of this Act. However, I presume that it is their duty to report on its working to the Ministry, and we should like to know how that Act has been functioning and whether we can really say now that these various homes, for the closing of which the Bill was introduced, no longer exist.

With regard to radium, we have heard recently a good deal about the lack of supplies in this country. I believe there is a body of trustees administering this matter, but we should like to know whether the price at which we are buying radium is reasonable and that there is no ring being formed and this country penalised in having to pay very large sums for this necessary commodity.

Thirdly, with regard to milk supplies, we have heard on various occasions in this House about pure beer, but we do not often have a discussion on pure milk. It is obvious that this question is one of the very greatest importance to the health of the nation as a whole. I represent a milk-producing constituency, and so it is fitting, perhaps, that I should raise this subject. The Ministry of Health, I know, take a very great interest in the subject, and only a few months ago produced a memorandum, entitled "Bovine tuberculosis in man, with special reference to infection by milk"; and therein a statement of the case has been made which shows that this subject has the attention, consideration, and sympathy of the Ministry.

I wish to put to the Minister a few questions in regard to this matter. I do not think I need elaborate the facts in any detail, because a very few facts will show the House what an important matter it is. It has been calculated that some 38,000 people die in England and Wales each year from tuberculosis. It is said that 80 per cent. of those people who are suffering from tuberculosis get it from milk. Some say that 30 per cent. and some say 40 per cent. of all the cattle in this country are infected with it. Lord Moynihan, in the House of Lords a few months ago, stated that £250,000 is spent in this country every day on the treatment of tuberculosis. Those few simple facts, I think, reveal the importance of this matter. There are some alarming figures given in this memorandum, on page 12, as to the percentage of milk samples found to be tuberculous during a certain period. Of the samples examined in Liverpool over 7 per cent. were found to be tuberculous; in Birmingham the figure rose to 7.6 per cent.; and it is an almost equal figure in various other towns.

Another matter which undoubtedly concerns this question of milk is that of the varied significance of the terms employed in designating the different grades of milk. The Parliamentary Secretary to the Ministry of Agriculture a little while ago pointed out that the various terms, Grade A and Grade A, TT were very confusing. The ordinary man in the street imagines that if he is purchasing Grade A milk it is necessarily free from tuberculosis, but it is not. Unless it is marked Grade A, TT, there is no stipulation that it is free from tuberculosis or is produced by a herd of cattle which has been properly examined. Therefore, it is quite clear that the need to-day, to quote from an article in the "Observer" a few weeks ago, is not for the abolition of existing grades, but for a complete change in the misleading nomenclature. Buyers would then be able to tell from its official designation whether the milk belongs to the first or the second grade, and doctors would have confidence in urging parents to give their children more milk, because they would know what they were getting, and farmers would profit from this increased confidence as much as the children. I hope that that matter will receive the attention of the Ministry. Various authorities are at work to-day trying to eradicate bovine and human tuberculosis. Much valuable work has been done by Dr. Griffiths, whose work is mentioned in this report. Various Members in all parties have been interested in the work of Dr. Spahlinger, and I should like to know whether we have the sympathy of the Ministry in this matter. I know that experts disagree upon this question. What reform was ever introduced and ever became successful on which the experts did not disagree at some stage of its production? I would like to draw the attention of the Minister to the Norfolk test. Some years ago tests of the Spahlinger method were made in Geneva, where they proved to be 100 per cent. right. That was not considered sufficient to prevent people in this country investigating the method more carefully, and a few months ago a test was made in Norfolk. Many people, not merely amateurs, but properly qualified medical men and women, have come to the conclusion after the closest examination of these tests, that they were completely satisfactory.

There have been discussions, disputes and suspicions as to what the Spahlinger formula is, and it is the object of all of us in this House who take an interest in this matter, and of Mr. Spahlinger himself, that this formula should be given to the world as soon as possible. I am certain that if it is, very valuable and wonderful results will accrue to the people of this country and the world generally. I believe that the result will be the prevention of tuberculosis in children and cattle. The Government of Northern Ireland have specially voted a sum of £10,000 out of public funds in order that experiments can be carried on with Dr. Spahlinger's bovine vaccine. All who are interested in this matter, and, Mr. Spahlinger too, are anxious that the full light of publicity and investigation should be brought to bear on it. I am certain that when the results are brought before the world, his name will be linked with that of Jenner, Lister and Pasteur, and that this great man will reap his just reward in contributing something to the real benefit, happiness and health of mankind.


I want to refer to a question raised by the hon. Member for Mitcham (Mr. Meller), namely, the question of maternal mortality. I am very interested in the Memorandum which was sent out by my right hon. Friend to the local authorities in December, 1930. My hon. Friend the Member for Sunderland (Dr. Phillips) asked my right hon. Friend a few weeks ago how many replies he had received to his circular. He replied that something like 139 local authorities had replied, that 102 proposed to make improvements in their maternity services, and that 13 have the circular still under consideration. That leaves something like 330 authorities which are not prepared to make any advance in what we all agree is one of the most tragic problems with which this country has to deal. That is entirely unsatisfactory. I have no wish to criticise or blame my right hon. Friend or his administration. Indeed, it has been within my knowledge over a period of 10 years that this particular problem has his warmest sympathy, and I know that he will give all the help he can. Ten years ago he was the chairman of the Consultative Committee to the Ministry of Health, and he called special attention to the problem at that time. The Act of 1918 gives us practically all that we need to deal with this terrible question.

I need not recall to the House the facts with regard to maternal mortality as outlined in the interim report of the Departmental Committee set up by the right hon. Gentleman the Member for Edgbaston (Mr. Chamberlain), but so astounding is our delay in dealing with the problem, that it will not hurt to remind the House once more that for every 250 births, the life of one mother has to be sacrificed, and that every year 3,000 women in England and Wales die in childbirth. The worst part of the problem, although in a way the most hopeful, is that 50 per cent. of those deaths are preventable. It is tragic because a death which might have been prevented is a great stigma upon the Community, and it is hopeful because if the right methods are set into operation, this great problem of maternal mortality will be amenable to treatment. If any blame can be laid at anyone's door, it is at the door of the Ministry which preceded this. I have taken the trouble to apply to friends of mine on some of the authorities whose names are given in the paper circulated by my right hon. Friend, asking them why they are not prepared to go ahead with the extension of their maternity services. Over and over again I received the same reply, that they are held up by reason of the block grant which was introduced under the Local Government Act of the right hon. Gentlemen opposite. They canont expend any fresh money. Their financial arrangements were set out for five years, and the whole of their work is stereotyped and held back in this important particular until they get the next quinquennial assessment.

Lieut.-Colonel FREMANTLE

They were given an extra £5,000,000 a year in order to help them.


That money is hopelessly inadequate to meet the needs of the situation, as any doctor in the House must be prepared to admit. I would even say to my right hon. Friend that I do not altogether agree with the statement in the Memorandum he sent out that a general practitioner can undertake the ante-natal work which is necessary. [Interruption.] Why not? That is my opinion, and I think I am entitled to that opinion, having regard to the reports of the British Medical Association, the Commission which considered the question of the training of midwives, and the report of the Commission set up by the right hon. Member for Edgbaston. Over and over again we see it stated that these preventable deaths are due to the fact that specialist help is not available. [Interruption.] Well, I ask you to read the reports if you do not agree. It is obvious, as the result of investigations of recent years, that from pregnancy right on to the time after child birth, and through the period of lactation, these mothers of the nation have a right to the services of specialists—gynaecologists and obstetricians.

I would call the attention of the hon. Lady if she is going to reply to the position in rural areas particularly, and would suggest that there are certain things which might be done administratively to prevent maternal mortality there. For one thing the first opportunity should be taken of providing a decent water supply to the rural areas. I would raise this question in connection with education, but it is much more important as regard child-bearing mothers. [Interruption.] Hon. Members opposite and in other parts of the House do not seem very sympathetic to-night. The idea of a pregnant mother carrying pails of water a quarter of a mile to her house ought not to cause a smile. There is no point in the right hon. Gentleman opposite appearing so beneficent if that sort of thing makes him smile. I do not know that the telephone service has anything to do with my hon. Friend, but perhaps she can pass on the fact that babies are not born at any special time at night, and if the telephone service is cut oft after a certain hour those who have charge of maternity services in the area are not get-at-able. I am glad to see in the Estimates a suggestion that a certain amount of extra money should be given for the training of midwives. That is a move in the right direction, but I shall not be satisfied, of course, until we have a national maternity service. I do not know whether that would require legislation and therefore would be out of order in this Debate, but whether that requires legislation or not we could effect a great deal towards providing a national maternity service if the right hon. Gentleman would persuade the local authorities to get on with their job.

I have had put into my hands to-day the report of the Battersea municipal authority, which does excellent work in this direction. During the past nine or 10 years they have had a maternity ward and a borough maternity hospital. During that time the figures of maternal mortality have fallen to .91, as compared with a general rate for London of 3.35. We can get the same results everywhere if the work is put into operation. In an East End maternity home dealing with 2,000 cases a year only 4 per 1,000 mothers die. If we want an example from a rural area, I suppose one could find nothing very much more rural than the bush in Australia. In Victoria, Australia, the general death rate is 5.59 per 1,000, but the Bush Nursing Association, which is an excellent association of trained nurses and medical men, have dealt with 2,270 cases in their maternity hospitals in four years and have had no deaths whatever to record.

The report to which I have referred came at an opportune time and yet at an inopportune time. It opened people's eyes to the tragedy of the position of affairs in this country, but it came at a time when hon. Members opposite had introduced the Local Government Act and made it absolutely impossible for further money to be spent or for authorities to go ahead. I do not know whether my hon. Friend can do anything, but I hope he will continue to stir up the authorities. I know his great interest in the matter, and perhaps when he replies he may be able to tell us whether he has been able to do anything with the friendly societies, whether he has been able, as he once expressed it at a conference, to get together under one great umbrella, the insurance societies, the friendly societies, the local authorities and the doctors, and all others interested in these services, in order to provide a national maternity service.

9.0 p.m.


I am very sorry that I missed the opportunity of intervening earlier on the question of National Health Insurance, and I crave indulgence while I put before the Minister a some what special point. I have just come from a meeting of the British Medical Association at Eastbourne, and I think I am the only Member of the House who has sat in that medical parliament and in this Parliament. I want to put before the Minister an earnest appeal to reconsider certain points of prime importance in National Health Insurance. I am sure non. Members will agree that we ought to make the medical service under National Health Insurance approximate as closely as possible to the conditions of private practice. The more we depart from those conditions the greater the dissatisfaction that will be felt by those who have to suffer. The latest regulation concerning the opportunities to insured persons of changing their doctors is seriously disliked by the medical profession, which has to work the service. A unanimous resolution was passed at the representative meeting protesting against that particular restriction.

Hon. Members may not realise that under that regulation a poor man cannot change his doctor without giving three months' notice—in fact, he has to give one month's notice and then there is three months longer to wait, so that there is really a period of four months before the doctor can be changed, and during that period he has to pay the fees of the man whom he has chosen, which is a very unjust part of the regulation. The psychological effect of a free choice of doctors can hardly be over-estimated, and I am sure the Minister has not considered that aspect of the question sufficiently. That there should be a free choice of doctor is surely one of the most important points in the relationship between patient and doctor, and it is one of the facets of the problem which will be disastrously affected by the introduction of a State service. Let us keep to free choice of doctor as long as possible. The main objection to the free choice of doctor comes from the approved societies, and I ask the Minister to give an ear to the other side of the question as well as that which he has obviously been considering.

I ask the Minister's attention to another part of the National Health Insurance Service, and that is the difference in the treatment of private and insured persons represented by limitation of panel prescriptions. I admit that the right hon. Gentleman is in no way responsible for one of the chief Causes of this limitation to be found in the agreement made in 1927 by the then Minister of Health by which the chemists on the panel have first call on the drug fund. That arrangement has been characterised by the British Medical Association as dangerous, and it has been described by panel committees as being against public policy. I hope the Minister will be prepared to revise that arrangement. The hon. Member for Camberwell made a very valuable contribution in some letters to the "Times" in which he pointed out the absurdity of a resident on one side of Edgware Road being entitled to certain medicines while a resident on the other side of the road would not be entitled to those medicines. These irregularities of practice are extremely unfortunate and they lead the panel patient to think that he is not being treated as other private patients are being treated.

I urge the Minister not to be too severe upon the panel practitioners who are trying to give as good a service to panel patients as to their private patients, and they are being penalised for doing it. I would like to point out that the dissatisfaction which is felt by insured persons, and by the public generally, with the National Health Insurance Act is a real thing, and I can give instances to illustrate this dissatisfaction. One is the enormous rise in the number of attendances at voluntary hospitals, which show a remarkable increase during the last 12 years.

A great proportion of my own patients are dissatisfied with their treatment under the panel doctors, and I know that at the hospital with which I am associated the figures show that the patients include a large proportion of insured persons. My experience is confirmed by the figures in connection with other hospitals. This means that while many people pay their contributions to the National Health Insurance Fund they are ready to pay another fee in order to receive hospital treatment. My own hospital dealt with 50,000 out patients last year, and I believe a similar number was dealt with in Guy's Hospital. No doubt there is a real dissatisfaction with the conditions imposed on patients under the National Health Insurance Act, and many of the reasons for this dissatisfaction could easily be removed. Lord Hewart, the Lord Chief Justice of England, has described the Health Minister as a pure despot. I invite him to exercise his despotism in rectifying these defects.


I desire to call attention to another side of health work, and that is the question of national parks, which, I understand, now come under the purview of the Minister of Health. A committee was appointed in September, 1929, to deal with this question and it reported on 23rd April this year. I want to ask the Minister if he can say what steps the Government propose to take to carry out some of the recommendations of that committee. The committee came definitely to the conclusion that action was necessary looking to the future, and that the public should not be deprived of some of the great benefits and rights which they possess at the present time. It is interesting to note that the Town and Country Planning Bill deals with a certain number of the recommendations of that committee in quite a satisfactory way. In their report the committee point out the generous attitude which landowners as a whole display towards the public in giving them access to their land, and they allude to the access which is possessed by the public to Crown lands and land held under the National Trust. They also point out that there are 1,600,000 acres of common land which cannot be built upon and are available to the public at all times. There is a danger unless steps are taken that the public may lose some of their rights. The committee, while appreciating the splendid work being done by the National Trust, feel that some of the work is far beyond the activities of the National Trust, and they think that it is necessary to stimulate a certain amount of activity among local authorities, which can only be done by a national committee in which the Government are interested.

No doubt it would be the desire of any such national committee to work through the National Trust and other bodies doing the same kind of work. The committee made two definite recommendations, and I ask whether the time has not come when the Minister can take definite action. The two alternative schemes recommended were (1) assuming a sum of £100,000 was available for five years and (2) assuming that only a sum of £10,000 was available for five years. In the first case, it is recommended that there should be appointed two executive authorities, one for England and Wales and one for Scotland, and the duties of those authorities would be to inspect various areas which are suggested as national parks, to stimulate co-operation with local authorities and landowners, ascertaining the various opportunities which were available, and making various recommendations to the Government. They suggest that there should be a consultative council as a liaison body to work in co-operation with other bodies. In the scheme where there is only £10,000 a year available for five years it is suggested that two advisory committees should be formed, one for England and Wales and one for Scotland, and that those two bodies should perform the same duties as in the larger scheme making recommendations for grants through the Ministry of Health and work very much on the lines of the Royal Fine Arts Commission.

I realise that some of the duties which these executive authorities would have to carry out would in the long run require legislation, but I suggest that there is no reason at all why the two schemes—I hope the larger one will be adopted—should not be taken in hand at once, and why the Minister should not ask suitable persons to act on these executive authorities, so that they could tackle immediately the national problem of parks in a voluntary way without the necessity for any compulsory powers or legislation for a considerable time to come, though that necessity might arise at a later stage. I would urge the Minister, if he cannot make any definite announcement to-night, to say that ho intends at an early date to take action on these lines and to make the appointments recommended.

Coming from the general to the particular, I should like to call attention to a specific example of a proposed national park which is to some extent in danger at the present time. It happens to be a place that is well known to me. In the Midlands we have our municipal parks, and we have in South Staffordshire 200 acres at Kinver Edge. That is a very fine memorial park on the smaller scale, but the place that is most favoured in the Midlands is the area of Cannock Chase. It was formerly a Royal forest between Stafford, Tamworth, and Walsall. It comprises 10,000 acres of high moorland, with beautiful, unspoiled wild scenery. Perhaps I can best give just a picture of what it is like by quoting two lines from the Staffordshire song which says: And it's oh! to race on Cannock Chase, 'Midst the golden gorse and brown. That will give a picture of what Cannock Chase is like at its best, and it is very much hoped that nothing will take place which will interfere with it. It is accessible to many millions of the industrial population in that great area of the Black Country between Birmingham and Wolverhampton, and other spots in the Midlands, and it is well provided with transport facilities; but there is one danger which may arise there, and in other places too, and that is that underneath this beautiful unspoiled scenery there is a large quantity of very valuable coal. It is not suggested that any national park should be developed in such a way as to interfere with coal mining. That would be extremely foolish, and it would be impossible to ask that it should be done.


It could not be done without legislation, and the hon. Member cannot anticipate anything which involves legislation.


I think you will see, if you will permit me to finish my argument, that what I am suggesting would not really require legislation at all. I was going to suggest that the Minister should be good enough, in his capacity of taking a general control of and interest in national parks, to get into touch with the authorities on the spot, point out to them the dangers that might occur to Cannock Chase, and ask whether it might not be possible to approach their coal mining operations on lines which would not interfere with the appearance of Cannock Chase. There is a very strong local committee of a representative nature, and its honorary secretary, Mr. Leckie, has quite recently addressed an appeal to the papers pointing out that, owing to the boring that is taking place on the top of Brindley Heath, in the very centre of the Chase, there is very grave and imminent danger to the amenities there. All that I am asking the Minister to do at the present time is to get into touch as quickly as he can with the local representatives of the coalowners, and use his persuasive powers to point out to them what may occur, and I feel sure that they will be susceptible to any reasonable appeal that may be made to them in that connection. To sum up, I would ask the Minister to do two things—to take up this case locally, and to act in a national way by the appointment of the committees to which I have referred. In doing that, I believe he will be taking really forward steps to preserve for all time some of the most glorious examples of the work of Nature in this country, and will confer on millions of our fellow-citizens the indefeasible right to enjoy the sunshine and fresh air on soil which is their own national property.

Lieut.-Colonel FREMANTLE

In the large number of suggestions that have been made this evening, there is one general line along which one distinguishes a really dangerous division of opinion, which I should like to ask the Minister to emphasise on the right side. I am afraid that, as always happens in these discussions on the Health Estimates, as in the case of certain other social services, there is one answer that can be made to the criticisms that are put forward, and that is that those criticisms generally depend on the axiom of the inexhaustible purse. Many of the measures which have been suggested, and of which everyone would approve if there were an inexhaustible purse, are really entirely out of the picture at the present day on the present Estimates, because there is no inexhaustible purse, and proposals have to be limited to the measure of the capacity of the Treasury.

Therefore, our reply to a certain number of the criticisms of the late Government would naturally be that, if it be thought that the difficulties of the insurance system are due to the insurance system having been deprived of something like £5,000,000 a year, it is up to the present Government to supply the £5,000,000 a year; and that, if the difficulties in regard to the maternity service are, as the hon. Member for East Islington (Mrs. Manning) said, due to the Local Government Act depriving local authorities of the power of expansion—a point which, obviously, is not entirely true as such—if that were so, it is up to the present Government to supply the deficiency. Sufficient for the day is the evil thereof, and sufficient for the year 1928–29 were the finances thereof. We made them sufficient, and it is up to this Government to make the finances of the year 1931–32 sufficient for their needs. That criticism, therefore, does not apply to the present day. At the present day it is up to us on this side of the House generally to offer our assistance where we can to the right hon. Gentleman in the extraordinary difficulties with which he is faced, and in regard to which we agree with him that it is the desire and determination of the whole House to maintain the efficiency of these services within the limits of the exhaustible purse.

I want to put forward, as a very small contribution, a suggestion as to the lines which, it appears to me, must be followed if we are to ensure economy and efficiency. That is the real problem. We meet with it in several of the questions that have been raised to-day. That is the difficulty of the desire for expansion and the necessity for expansion. We have had innumerable committees. The committee, to which reference has been made, set up by my right hon. Friend the Member for Edgbaston (Mr. Chamberlain) to explore the ground of maternal mortality, definitely suggested expansion of the maternity services in various ways. The hon. Lady the Member for East Islington made a very good suggestion, although she did not recognise how good it was, when she gave an illustration of the extraordinary means being adopted out in the bush in Australia, where by personal service, without, I presume, any constructional expense and other building of hospitals, but by the bush nursing association and such means, they were able to reduce maternal mortality to almost nothing. That is just an illustration of a fact which does require to be borne in mind.

There is far too great a tendency to think that the real progress of expansion must be in bricks and mortar and that you have to have something large, striking, and expensive if you are to get a move on. That is an echo of the various reports which we have had. We have a suggestion to that effect in regard to maternal mortality and it is suggested in the case of mental hospitals and mental deficiency, which is a matter on which I should like to have an explanation from the Minister in view of the Act recently passed. We have it again, as regards the development of local government hospitals and the vast expenses which are to be incurred in expanding and providing greater accommodation in the hospitals. But because we have a limit to our finances we may have to go much more slowly in these matters than is often suggested. It may seem from that that we are going to reduce efficiency or progress, but that is not necessarily the case. It must be recognised that these buildings are useless unless you have the personal services to fill them, and personal services are perfectly useless, buildings or no buildings, unless you have, equally, assistance given by the individuals themselves, with information and understanding to make use of what is provided for them.

The personal service is of overmastering importance, and therefore it seems to me that in this time of straitened finance, when the Minister has to cut down and keep the services at a minimum, he is not necessarily reducing the progress if he is trying to make the most use of the services which do exist, voluntary, official or otherwise, and is trying to develop the maternity services, the nursing services, home visitation of the sick, aftercare and pre-care and all those different points which are being worked at by the associations connected with these services in the promotion of the health of the people. There is great need of that, and it would be perhaps useful if the community as a whole were to have a short armistice from building, and if efforts were devoted to the expansion of the personal services. These things do depend a good deal on the actual policy laid down by the Minister and supported by this House.

I will not attempt to go into details, but I could give cases where the machinery at the present moment is being used to press material development at great risk to existing services. I know, personally, of one small hospital in a town in Kent where they have been told they must expand from 12 beds to 25, and they say that may break up the present excellent hospital, and it is doubtful what will become of it. I have also heard the same thing happening in regard to the expansion of local government in my own county. One of the voluntary hospitals is threatened because it cannot meet the needs of the county authorities on its voluntary basis. I want to ask the Minister what is being done to make use of the voluntary hospitals in the combined scheme under the Local Government Act, 1929? We must put away from us all prejudice in the matter if we are to give the best services to the sick. We must use the existing hospitals, whatever the future may be.

Therefore, we ought to encourage the use of both official municipal and voluntary hospitals. It may be said that that is not being done. I heard of a big industrial town where an absolute rift between the municipal and voluntary hospitals is growing. In London things are going in such a way that the voluntary hospitals are likely to be put on one side entirely, and the municipal hospitals will suffer until they have developed overlapping services. We are at the parting of the ways. It may be necessary one day for us to be on the basis of an official hospital service, but I do not believe it, and I hope not. At the present time, in the interests of the sick poor, and owing to the exhausted purse, I ask the Minister, while it is not too late, to see that officialdom meets with voluntaryism, with all their rival prejudices, and that he creates opportunities and possibilities of combining them. Lot him do that before this cleft becomes too wide, in order that we may make the best of an extraordinarily difficult financial condition of affairs, so that it will be totally unnecessary for him to carry out his threat that he would die in the last ditch before he would economise. He has got to economise, and the last ditch has been filled in by the Chancellor of the Exchequer, so that the right hon. Gentleman is not able to die. We ask him, therefore, to make the best of these economies.

The MINISTER of HEALTH (Mr. Arthur Greenwood)

I rise as one with long life in front of me, and not likely to have to die in the last ditch. My memory goes back to the first discussion we had on the Estimates of my Department when the right hon. Gentleman the Member for West Woolwich (Sir K. Wood) came down to the House bristling with indignation, filled with passion and contempt and all kinds of conflicting emotions, and quite certain that I should be the worst of all Ministers of Health. This afternoon I sat here and preened myself while the right hon. Gentleman threw bouquets at me minute after minute, and I came to the conclusion that, after these unfortunate forecasts, the right hon. Gentleman has come to see the light. He has realised that, after all, this Government and this particular Department is not quite as bad as he tried to lead the House and the country to believe.

A good deal of our attention to-day has turned upon the system of health insurance. The hon. and learned Member for Fareham (Sir T. Inskip) spoke almost entirely on this question, and asked what we were going to do. Then he made two suggestions as though they were entirely new suggestions, and something which had emanated from a master mind. They were two suggestions which we had actually put into operation, and are working at as actively as is possible in the circumstances. He wanted more attention paid to sick visitation. Why, half the complaints we have had to-day have been that there is too much. Some of my hon. Friends have made that kind of suggestion. The second suggestion was that there should be greater use of regional medical officers. That, again has been one of the complaints, that we are making too ready use of regional medical officers. So I think we can say we are doing all that the hon. and learned Gentleman has suddenly discovered that we ought to do, and we have been doing it most of the time.

There has been on some sides of the House, perhaps, a little too much emphasis on improper claims. There is not the slightest doubt that there are improper claims. Swinging the lead is not a new device invented in the last year or two, and, under any system, you will find people who make improper claims and who, by doing that, are robbing their fellows. I would gladly sweep all those people out of benefit, but we have to be careful that in tightening our administration we are not going to deny the just claims of sick persons. It is easy to become a little too stringent, but it is much easier to become a little too slack. Improved administration and greater co-operation between all the agencies concerned are having a very substantial effect. In 1930 the total expenditure of all approved societies on sickness and disablement benefit was £2,000,000 less than in the previous year. It may be that 1930 was a lighter year for sickness, but I think part of that saving was undoubtedly due to improved administration and to more effective cooperation between the panel doctors, the regional medical officers and the approved societies. The improvement of last year has continued during the first half of this year, and the sickness claims for the quarter which has just finished are the lowest recorded for any quarter for several years past. So that the steps that have been taken are now beginning to prove effective.


Can the right hon. Gentleman be a little more detailed? What is the percentage of the last quarter compared with the Actuary's estimate?


I could not say about the Actuary's estimate, but for the second quarter of 1931 cash issues amounted to £5,250,000, as against £5,500,0001 last year and £5,750,000 the year before.

May I say a word about the Economy Act. It has been brought into the discussion on one side and the other and we are told that, if it had not been passed, the evils with which we have been concerned to-day would not have been appreciably affected. But there is another aspect of the problem, and that is the disposable surplus of the approved societies, and the question of this legislation has a bearing, therefore, on the third valuation. It is all very well for hon. Members opposite to say we are crying over spilt milk, but they spilt the milk, and it was not their milk. [Interruption.] This is the very smart and flippant reply that we get in Debates of this kind. We have never received any assistance from hon. Members opposite when we have been wanting to do anything of that particular kind, but we could always get it if we are pursuing a most drastic policy of economy at the expense of the masses of the people. I should be a proud man if I were able to undo the evil that they wrought.

May I turn to the speech of the hon. Member for Brigg (Mr. Quibell)? Kinmel Bay is no creation of mine. It is rather like that Peacehaven near which the right hon. Gentleman himself lived for so long. These monstrous growths upon the face of the earth are places of which no one can approve, and it is clear that there ought to be no large-scale development for residential purposes without effective sewage disposal and adequate water supply. The impression that Members would obtain from my hon. Friend's speech was that nothing has been done and nothing is being done, and, indeed, he implied that nothing was ever likely to be done. He is one of my severest critics. Let me give the figures for the development of water supply and sewage disposal during the last two or three years. I take England and Wales as a whole, urban and rural, and I will give three years—1928–29, for which the right hon. Gentleman was responsible, and 1929–30 and 1930–31 for which I take some responsibility. In the case of water supply, the loans sanctioned in the first of those years, in the last year of the late administration, were £1,650,000, in the next year £2,350,000, and last year £3,160,000,

As regards sewerage and sewage disposal schemes, the loans have increased even more considerably. In the last year of the late Government's term of office it was £3,600,000, in the following year £5,800,000, and last year £8,000,000. I come now to the rural areas which my hon. Friend seems to think we have entirely ignored. With regard to water supply, the figures have risen in rural areas in the last three years from £161,000 to £608,000, and for sewerage and sewage disposal from £635,000 to £1,700,000. Those are very considerable increases which have resulted quite definitely from the Government policy by an improvement in the grants for accelerated work. That shows that, in that sphere of the Department's activities, we can claim pretty substantial progress.

The hon. and gallant Gentleman the Member for Chippenham (Captain Cazalet) raised several separate questions.


What about Kinmel Bay?


Kinmel Bay is now finished with. The hon. and gallant Gentleman referred to the question of nursing homes. It is very difficult for me to give any figure about that. They are administered by local authorities and our direct contract with them is primarily in regard to the surveys that we are making from time to time.

On the question of radium, as hon. Members know, a fund was established, partly from voluntary sources and partly from a grant from the Treasury, which is administered by a Trust set up by Royal Charter and by the Radium Commission, which is the body which is responsible for allocating and apportioning the radium. I think that I am right in saying that before very long practically the whole of the fund at our disposal will have been expended upon radium and the radium allocated by the Commission to the best of its knowledge of the circumstances. On the matter of milk supply which the hon. and gallant Member also raised, the whole question of milk policy is one that always troubles successive Ministers of Health and successive Ministers of Agriculture and Fisheries from two rather different points of view. The question is now under active consideration by my right hon. Friend the Minister of Agriculture and myself. It is also true there is another difficulty in the way of dealing with it, and that is that I am afraid we cannot deal with it without legislation.

With regard to Mr. Spahlinger and his work, to which the hon. and gallant Gentleman also referred, I do not want to enter into a long controversy about the question, but I can speak upon this matter for all my predecessors during the last nine years. Our attitude has always been that we are quite willing either to co-operate with Mr. Spahlinger or to test any vaccine or serum he might produce. That offer still stands. If there have been difficulties, they are not all on one side. That offer has been repeatedly made, and it is an offer by which we still stand.

The hon. Gentleman the Member for London University (Sir E. Graham-Little) raised again three points dealing with national health insurance. I suppose that national health insurance is about the foremost and most complicated question with which any administration has to deal. Here are the doctors on the one hand, here are the approved societies on the other hand, and here are other people interested, and between them they do not always quite see eye to eye. I am not myself ever likely to believe that they ever will see eye to eye. We have not got rid of the free choice of doctor. We have partly, as a result of the investigations which have been made, limited the rapidity with which an insured person can run from one doctor to another, which is an entirely different thing, and has been done in the interests of the medical profession as well as in the interests of the insured person, and by that we stand. I am satisfied that in the long run it will be found to be in the interests of the medical profession, and while annual conferences will have their fling and kick up their heels and pass their resolutions, I am still not satisfied that the medical profession—[An HON. MEMBER: "At Scarborough?"]—I am referring to the conference of the British Medical Association, a fairly respectable body. I am not satisfied that they would feel so strongly as to take very strong action about it. It may be true that the arrangement which was made in 1927 is not as advantageous as medical men think it ought to be for the insured person, but that question raises a good many others which cannot be dealt with in to-night's Debate.

In connection with institutional services, you have a conflict of opinion. Doctors say that they do not want to have to deal with this matter if they are under the control of approved societies, and approved societies, on the other hand, say that they do not want to deal with it unless they have a finger in the pie. Between the two of them we seem to have got a reasonable working scheme which will not, of course, completely satisfy everybody, but which does happen to succeed in working pretty well. I was astonished to hear the hon. Member for the University of London appeal to me to use to the full the despotic powers which the Lord Chief Justice believes I possess. It is an astonishing proposal to come from a person like him, more especially when from time to time I have taken quite a small part all my attempts have been opposed by Members on the other side.

The hon. Member for East Wolverhampton (Mr. Mander) referred to national parks. I think that it is one of those questions in which there will be no difference of opinion on any side of the House as to the desirability of definite action on those lines. I cannot say anything to-night except that the question of the report of the committee is under the sympathetic consideration of the Government at the present time. It is a question which will involve, I imagine, legislation, and although I should personally be delighted to go down and use the very email persuasive powers which I possess upon the mineowners at Can-nook Chase, I am not sure that past experience shows that mineowners are so amenable to reason as the hon. Member appears to think. I fear that even there it might require legislation, possibly.


Will the right hon. Gentleman be good enough to do what he can in the matter and get into touch with the local committee, who feel very keenly on the subject?


I will certainly get into touch with them to see what can be done. I will do that with pleasure.

One or two hon. Members raised the question of maternal mortality, and questions were asked as to how far we had gone with appeals that have been made to local authorities. I should like to give the House the latest figures which I possess. Hon. Members are aware that some months ago I circulated a full Memorandum to local authorities making many definite suggestions for attacking the problem of maternal mortality, and asking them to take the necessary steps. On 21st July, out of 396 local authorities, replies had been received from 216, of whom 128 had actually adopted proposals, and, in many cases, were bringing them into operation, or had constructive concrete proposals before them. In some cases the Department has made further suggestions for the improvement of their services. The replies which have been received are being followed up with a view to ensuring that effective action will be taken.

The replies which we received up to the end of last month have been analysed, and they show that 31 authorities are establishing or extending ante-natal clinics, 16 arranging with private practitioners for routine ante-natal examination in suitable cases, 17 are improving their arrangements for the supply of midwives, 14 are arranging consultative services for doctors who need assistance, 20 are providing or extending hospital accommodation, and 37 are arranging various types of auxiliary services. I should imagine that that represents a greater development than at any similar period in the history of the maternal services of the country, and I hope that hon. Members will do what they can to persuade local authorities to develop this tremendously important service, because, although it may be that times are hard for local authorities, I am satisfied that that kind of expenditure brings a very substantial reward in its train.

The hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) faced us with a conflict between voluntary hospitals and municipal hospitals. My own impression, taking the country as a whole, is that it is not a conflict so harsh and so clear-cut as the hon. and gallant Member would think, although, as in London there is ranged on one side the voluntary hospitals and their supporters, and the public hospitals and their supporters on the other side. It is perfectly clear that in our existing hospital system, whether public or voluntary, we have not more than enough to satisfy our needs, and to pretend that we can dispense with either form of hospital is ridiculous. I have no doubt that for a very long time the two kinds and types of hospitals will go side by side. I would say, and I say it in all friendliness, that the voluntary hospitals must realise that the big local authorities will desire to develop their own provision in regard to hospitals, while working in cooperation with the others. I hope that there will be sufficient good will on both sides among the voluntary hospitals and the public authorities to make the maximum use of the existing hospital accommodation.

The hon. and gallant Member referred to my threat to die in the last ditch if

there was economy in the social services, and he said, quite solemnly and seriously, that economy in the social services there must be. This year's Estimates of my Department show no economy in the social services. They show expanding social services, and one of the pleasantest recollections of this year of my office is that the local authorities, hampered and trammelled as they are by hard times, many of them suffering financially from legislation for which I was not responsible, notwithstanding these difficulties, and irrespective of the political party in control, they have steadfastly gone on their way developing their essential services. When the money for this year is expended, I am satisfied that we shall find the public service of this country healthier and more vigorous than it was at the beginning.

It being Ten of the Clock, Mr. SPEAKER proceeded, pursuant to Standing Order No. 15, to put forthwith the Questions, That this House doth agree with the Committee in the outstanding Resolutions reported in respect of the several Classes of the Civil Estimates, and of the Navy Estimates, the Army Estimates, the Air Estimates, and the Revenue Departments Estimates.