§ Dr. MORRIS-JONES
I beg to move, to leave out from the word "That," to the end of the Question, and to add instead thereof the words:this House appreciates the progress made by local authorities since the passing of the Local Government Act of 1929 in coordinating and improving their public health services and, while recognising the need for economy in local expenditure, is of opinion that the development of these services should steadily continue as and when circumstances permit.When the fortune of the Ballot gave me the privilege of initiating a Debate on this occasion, I felt that I ought to raise this question which, I know, is a subject-matter of concern to the House generally, and which I have no doubt will elicit from the Minister concerned a reply of interest to hon. Members. The Local Government Act of 1929 in its scope and magnitude, in the vast number of interests which it touched and in its effects on the prosperity and wellbeing of this country was one of the greatest Measures ever passed by this House. Whatever anyone may say of the faults or deficiencies of that Act, it must be admitted that it is a great monument to the energy, skill and administrative ability of the right hon. Gentleman who is now the Chancellor of the Exchequer and who was then the Minister of Health, the right hon. Gentleman who is now Postmaster-General and who was then Parliamentary Secretary to the Ministry of Health, and also that great Department over which the right hon. Gentleman the Member for Sevenoaks (Sir H. Young) now presides. It was one of the longest Bills ever presented to this House. The Act has 138 Clauses and voluminous Schedules and the provisions dealing with the public health services of this country alone, occupy many pages.
On reading through the Debates which took place during the various stages of 678 the Bill's progress through this House one cannot help being impressed by the complexity and far-reaching character of its public health provisions. One of the big achievements of the Act was the transfer of the Poor Law services of this country to the present authorities. On one given date—I think it was 1st April, 1930—at a time when 1,000,000 persons were getting Poor Law relief in this country this great change was carried out, and I think the persons thus concerned were hardly aware that a change of such magnitude had been made. The new authorities, on the appointed day two years ago, succeeded in taking over their new duties without failing to relieve any known case of destitution. When one hears persons finding fault with this Act and its working, one cannot help feeling that a tribute of admiration is due to the national and local administration of this country and to the organising ability which could achieve a transfer of such a character, on such a scale, and with so little disturbance to those concerned. I question if any other country in the world could have achieved anything like that change in that manner.
The main objects of the public health provisions of the Act were to achieve, eventually, improved and efficient public health services in this country and, in the second place, to secure economy. These objects were to be achieved by an amalgamation of areas throughout the length and breadth of the country, by the absorption of various services then carried on under the Poor Law, and by co-ordinating these, as it were, into one public health service under the county council or county borough council of the area concerned. This is of course in relation to that section of the population which requires some form of public assistance. Naturally it does not affect the fortunate people who are in a position to pay for whatever services they get. When one considers the complicated nature of these services, and the difficult questions involved in the prevention and treatment of sickness in the ordinary way, the care of the child from birth up to the age of school entry, the treatment of fevers and the prevention of infection from fevers, the care of the mother before and after childbirth, the prevention and treatment of tuberculosis, the prevention and treatment of venereal 679 disease, the prevention if possible and treatment of lunacy, one realises the immensity of the scope covered by these provisions of the Act. All these services, in so far as they were covered by the Poor Law, are intended eventually to be transferred to the care of the local authorities.
The question of housing also enters into the consideration of this Measure, but I do not intend to occupy the time of the House on that question, because I understand that another hon. Member may raise it at the conclusion of this discussion. The second object of the Act was economy, and this is certainly not a negligible factor. Looking back over the records of the last 40 years I find from such figures as are available that expenditure on local administration, which was £36,000,000 in 1891, is to-day close on £300,000,000. All that expenditure, of course, is not for public health services. I have not been able to secure the exact figures for public health administration, but a very large part of the sum I have mentioned would come under that head. I wonder if the Minister can tell us, in the first place, how the amalgamation of areas is proceeding and how many county councils and county borough councils have submitted schemes. On 1st April of this year these bodies were supposed to submit schemes, subject to agreement among themselves and among the individual local authorities for which they were responsible. Anyone acquainted with local administration must be aware of the difficulties involved in this matter. In the county of Denbigh, which I represent along with my hon. Friend the Member for Wrexham (Mr. A. Roberts), there has been great activity in this matter. Having pretty well reached agreement the authorities there have submitted or are in the course of submitting to the Minister a scheme which will involve the abolition of four rural district councils. The committee which was entrusted with preparing that scheme has worked very hard and has visited, I do not say every parish, but every local area and every local authority in the county. When one realises what has to be done in this respect in the county of Denbigh and in the Principality of 680 Wales, one must be impressed by the geographical difficulties involved in such reorganisation.
There is also the question of local sentiment, which is not a small matter. There is a goad deal of rivalry between one local authority and another, and it is no small matter to have submitted an agreed scheme. It will involve some hardship on some local authorities. I have in my Division an urban area which under this scheme will have to take over a place of mushroom growth of which the House may know, called Kinmel Bay. I do not want to dwell on that matter except to emphasise that that is a place which has been exploited by a certain land company which was unknown until they arrived on the scene. There is a population of close on 1,000 people, and they have no facilities for sewerage, lighting or roads, and the adjoining local authorities have undertaken the burden of looking after the mushroom growth of this adjoining parish. I hope that the Minister will make inquiries into these rapidly-growing areas which are exploited by people who after-wards leave the inhabitants in the lurch, and without any means of redress. Many of them are people who have reached the stage of life when they desire some comfort and peace in their old age, and they suffer great hardships in such places. I have no hesitation in mentioning this place Kinmel Bay to the House. I hope that the Minister of Health, in the reorganisation of areas, will deal sympathetically with such places.
Schemes were supposed to be submitted under the Act for the absorption of Poor Law institutions. Some of them were to be absorbed, others were to be altered and made more adaptable to modern conditions. Some of them were to be declared redundant, and some were to be used for a different purpose. That movement was undoubtedly long overdue in the interests of public health. The then Minister of Health mentioned in the House one Poor Law institution in a rural area the inmates of which were composed of seven people who were acutely ill, 55 infirm and senile people, six epileptics, eight certified lunatics, 18 certified mental deficients, nine uncertified mental deficients, one able-bodied man, and three healthy infants. Is it possible that any group of human beings who were less 681 than supernatural could look after a conglomeration of cases of that kind in a few wards of one institution? Can the Minister tell us whether this institution is still in being or whether some steps have been taken to deal with it? I understand that in the London area very much progress has been made in dealing with Poor Law institutions. I see from the figures of the last report of the Minister of Health that 37 Poor Law institutions have been appropriated for use as hospitals and nine of them for use as children hospitals or convalescent homes.
The case in the country is far from satisfactory. Only 19 out of 79 county boroughs have submitted schemes for the reclassification of their Poor Law institutions, according to the last report, and not one county council outside London has been able to appropriate a single Poor Law institution for the purpose of a general hospital under the control of the local authority. The intention of the Act was that all local authorities should, as far as possible, provide all the assistance which was necessary on medical and health grounds under powers that they possess under other Acts than the Poor Law Acts. The Local Government Act empowered them to make a declaration that such and such health services should be provided otherwise than by way of Poor Law relief. Are the local authorities making any of these declarations? As far as I read the Act, the power is not limited to a declaration at the time of taking over the Poor Law services. I am under the impression that some local authorities believe that these declarations are supposed to be made previous to taking over the Poor Law functions. I understand that that is not so. The Act is elastic enough, and the Minister will agree that it was intended to be elastic enough, to allow of a continuous policy.
Has any county council or county borough yet transferred the health functions of the public assistance committee to the public health committee or to the maternity and child welfare committee? I know that the time has been short, but the whole intention of the Act was that in a certain time, the sooner the better, the county council should take over these public health functions and transfer them to their health depart- 682 ment. I do not suggest that we should have too much departmentalism in the public service. Medical officers in charge of such services should work as a team. You cannot isolate one service and one man to look after it. There is permission under the Act for medical officers to consult with the specialists of the large voluntary hospitals. I am rather afraid that so far not much in the way of consultation goes on. I hope that the Minister will tell us that the provisions of the Act dealing with this matter are being carried out, and that arrangements are being made for continuous consultation. I have no doubt that the tendency of the Ministry of Health is to get whole-time medical officers under their control as far as they can. Personally, I aim a great believer in the general medical practitioner. I believe that the general medical practitioner has served the country well, and will continue to serve lit as long as any one of us can foresee, and I hope that the Minister will discourage any tendency to relegate, as it were, the treatment of disease to the hands of the officers of the Ministry. If you have a medical officer in charge of a maternity and ante-natal clinic, a large number of expectant mothers would undoubtedly prefer to go to a private medical practitioner. We have to remember that, after all, these general medical practitioners when called upon will have to attend to the mothers in the emergency of their confinement.
I see that some local authorities—county councils and county boroughs—are suggesting doing away with the old Poor Law medical officer. I should be very sorry if that came about. One or two authorities have suggested that visits to patients' homes should be made by their own institutional medical officer, and I see that one authority has proposed, or has had under consideration, the setting up of a panel, something like that under the National Insurance Act, whereby a sick person in receipt of parish relief will be able to select any doctor from the panel in the neighbourhood. I do not think that that will lead to efficiency or economy. The old parish doctors contain among their class the ablest and most conscientious general medical practitioners that the country has. They regard it as a privilege and a pride to look after the poor. In many 683 areas they are the only doctors there, and attend the rich and the poor, and they live and die—many of them die, I am sorry to say, prematurely—among the population whom they serve. I am very glad to see that, under the Act, a doctor can only be relieved of his office with the consent of the Minister, and I trust that the Minister will reluctantly give his consent, unless, of course, there are medical grounds for doing so.
I come to the second main function of the Act which is that of national economy. I do not know whether it is too soon to know what the result so far has been. The House will remember that a very great change was made by the Act. Grants from the Government were changed from a percentage basis to a form of block grants—consolidated grants. One would like to know what effect the crisis of last September and since has had in regard to public health services, whether the Minister considers that there is a reasonable standard of efficiency and progress maintained without excessive or unreasonable expenditure? We remember that there was a circular No. 1222, issued to local authorities on 11th September last at the time of the great national crisis. Of course, those authorities were enjoined to economise, and everyone admits that it was necessary to do so. It was the belief of the supporters of the Act that the changes produced by the Act would lead to greater economy in administration by avoiding the duplication of service. Is it too early for the Minister to be able to tell the House so far what is the result of the Act in regard to those particular economies?
As a medical man who has been in practice for many years, I know the importance of an efficient public health service. As a Member of this House and a citizen, I also consider that we must have due regard to the cost of national and local government administration. I take the view that the total expenditure of this country is far more than we can afford. While I take the view that expenditure on health services must not be curtailed at the cost of efficiency, I also hold the view that it must be examined thoroughly in view of the state of the national Exchequer. I find, upon looking into the figures of the reduction 684 in rates, for instance, that local authorities have been able to arrive at a fictitious reduction in many cases, but that, owing to increased assessments, the amount actually expended by many local authorities at the present time is greater. in 1931–32 than in the previous year.
It has been said that this Parliament is a reactionary Parliament. I do not believe it for a moment. It might be fairly said that the last House was a profligate one. I think that the last House spent money at the time without any regard as to where the money was to come from.
Lieut. - Colonel WATTS - MORGAN
Will the hon. Gentleman tell us if that is part of the Yellow Book or the Green Book?
§ Dr. MORRIS-JONES
I can assure my hon. and gallant Friend, if he is rather anxious about the expenditure which his party has always supported, that it comes from neither book. I am not quoting any books at the present time. I am only expressing my own opinion that if the government of this country had been left to the party of which he is a member, there would not be very much left for public health services. It is clear that hon. Members are rather unduly sensitive about that. I thought they had become hardened to it before now, because only the other day they went so far with regard to unemployment insurance as to support a non-contributory Measure. I do not think that this House is reactionary in regard to public health. I feel sure it would support the right hon. Gentleman in any measure and all measures that may be required to retain for this country a model public health service of which we have been proud in the past, and of which, I feel sure, we can still be proud. I hope that the Amendment which I have the privilege of moving will enable us to get from the Minister some further interesting information, which, I feel sure, he will be able to give us.
§ Lieut.-Colonel FREMANTLE
I beg to second the Amendment, which has been so ably proposed by my hon. Friend. I would like to endorse very much the general tenor of his proposals, and remind the House that we have to justify any procedure in this House on the 685 general lines of the mandate given at the last General Election. It was on that mandate that the Government took office, and on which the Government have acted, and it is in the light of that that we have to justify and support the administration of His Majesty's Government. It was a doctor's mandate that was given to the Government, and although we do not hear very much of the medical side, that side is obviously implicit in the doctor's mandate. When the hon. Member for Bridgeton (Mr. Maxton) was speaking in the Debate on the Address, he spoke of the long-suffering working class, and hoped that we should getfor the first time in this country, an opportunity to build a decent State on a decent foundation,and that the Government wouldstart to build up a new social order on foundations of human decency, fair play and common justice."—[OFFICIAL REPORT, 10th November, 1931; cols. 80–81, Vol. 259.]There could not be a better statement of our aims on this side of the House. It is we, after all, who remember, in the main, the long-suffering working class. Members opposite represent a minority of the long-suffering working classes. We represent the majority of them, as well as other classes, and we, Conservatives, Unionists and Liberals are responsible for a long list of reforms which have improved immeasurably the welfare of the working classes. That which we are discussing this afternoon is only one at the end of a long chain, and no one, however keen he may be on the Socialist programme, can deny the fact that Socialists have not had time until quite recently to initiate reform, that reform has therefore been initiated by Conservatives, Unionists and Liberals, and no one can assert that the condition of the working class is not immeasurably better than it was 100, 50 or even 30 years ago. As regards this particular Measure of local government, after all it was first the Public Health Act, 1875, a Conservative Act, which laid the foundations. It was the Local Government Act, 1888, which introduced county councils, and it was the Local Government Act, 1894, a Measure of a Liberal Government, which introduced parish councils. So that the whole structure is definitely directed to the ideal of the hon. Member for Bridgeton. It is in that light that we have to measure the results of the Act of 1929.
686 There are four lines of thought in considering that Act in these difficult times. First, we are all agreed that we must maintain the efficiency both of our institutions and their personnel. We cannot allow any economies to reduce that. In the second place, in view of the necessity for economy, we want to make better use of such facilities as we have, to get a better output from them by reorganisation. In the third place, we ought to revise the traditions or the groove into which administration may have sunk in the light of experience. Fourthly we want to advance, if slowly, on the agreed path. What has been the effect of the Local Government Act, 1929, up to date? One has to face the fact that one cannot as yet measure its results by any definite figures, although not long ago the late Minister of Health and others supporting him were trying to measure their efficiency by the decline in the mortality rates. The figures for 1931 are definitely disappointing. That is obviously not due to this Government, though it might be due in some part, if we could measure it, to the Local Government Act. However, we cannot measure the efficiency of that Act by immediate statistics. The birth-rate in that year fell from 16.5 to 15.8, which is the lowest point yet, and I regret to say that the death rate went up from 11.5 to 12.3, and infant mortality rose from 60 per thousand to 66 per thousand. Of course, one might in a ligthhearted way say that was obviously due to the late administration, but I should not use any such criticism, any more than I should use any such argument conversely about the work of our own party; but we have got to face the fact that we are not living in times when we can confidently believe that we are always going to improve. Things have improved enormously of recent years, but the figures of last year are definitely disquieting.
§ Lieut.-Colonel FREMANTLE
Of course. Certainly everybody must desire that there shall be the people necessary to carry on our institutions, including this House. The Local Government Act, 1929, was not designed to increase the birth rate, or to decrease it, but the hon. and gallant Member is falling into a terrible 687 error if he thinks we can view with any satisfaction a constant decline in the population of this country. Fears have been expressed as to the future of our Poor Law institutions, and we might have expected to see some decline in their efficiency as the result of the enormous task of transferring them to new authorities. Let hon. Members think of the task of the London County Council alone in taking over, on the appointed day, the work of 25 boards of guardians, taking over 35 separate infirmaries and 28 mixed institutions. It was a gigantic work, and yet, as my hon. Friend has said, we have not heard of a single case in which anybody has suffered, or in which the efficiency of the institution has suffered. As a nation we owe a tremendous debt of gratitude not only to the London County Council but to all the local authorities—and their officials—throughout the country, and the Government Departments, for the splendid work they performed in carrying through the transfer. It was voluntary work at its very best—work which is little known and little rewarded, except in the feeling the members of those authorities must have or having rendered valuable service to the country. As regards the fears that have been expressed, we feel confident that those fears have not been realised.
Regarding the second point, whether we have better results from this rearrangement, as I say it is too early yet to speak of them, but I think those who have worked professionally with the local authorities or are otherwise in close touch with their work recognise that great advantages are accruing on the professional side of the work of the institutions. Take the appalling waste which arose from having isolation hospitals all over a county. There were one or two efficient institutions in the boroughs and larger urban districts, and then a host of little institutions under different district councils that did their best—and a very fine best it was—to make some provision for isolation cases, but they were wretched arrangements from the point of view of the comfort of the patient, and wretched from the point of view of resources. As a result of the Local Government Act a reorganisation has been undertaken. Perhaps the Minister will be able to tell us how far that reorganisation has gone, 688 though I do not think he will be able to tell us very much, because it requires a very great deal of time to come into effect. I hope the reorganisation will be carried on because there will be enormous advantages if we can bring it into effect in the next two or three years.
As an extreme case let us take the provision of smallpox hospitals. We all know how inadequate have been the arrangements for dealing with a small-pox epidemic. At any time it may be upon us, and the arrangements are grossly inadequate. That raises the further question of vaccination, which is the subject of other laws as well as of arrangements under the Local Government Act. It is quite clear that in the revision of our machinery for maintaining the public health we must revise the vaccination laws and the whole of the vaccination machinery. To what extent is the transfer of powers under the Local Government Act preparing for such a revision of the vaccination laws and their administration. The question of vaccination is a large subject and I will not go into it now, but I do hope that the county councils, in taking over powers to deal with smallpox, sanitation and vaccination, will prepare sound schemes which will enable us to deal with the appalling anomaly which exists at the present time—this hypocrisy under which we are supposed to have a system of compulsory vaccination when only one-third or one-fourth, or less, of the population now growing up are vaccinated and protected against the dreaded disease of smallpox.
Another point we have to consider in developments under the Local Government Act is the threat to voluntary institutions, voluntary hospitals and voluntary agencies engaged in health work. The more we co-ordinate municipal work, the more we regularise the official system, the more difficult it is to fit in the voluntary system with it, and yet all of us appreciate the enormous advantages of the voluntary system where it is properly supported in connection with hospital work. Even the most extreme Socialist recognises that for the present the voluntary system must remain. At the present time, when we have to consider both efficiency and economy, it would be perfect madness to contemplate, even in the more distant 689 future, any interference with the efficiency of voluntary hospitals and other institutions. Over and over again one is met by the statement that the work of raising money for voluntary hospitals and other institutions is degrading, and that they ought to be on the rates. It is said that the burden is partial in that it falls upon certain benevolent people only rather than on the great mass of the people. That is perfectly true, but we cannot have a voluntary system that will bear equally on everybody all round.
The advantage of the voluntary system is that those who give generally help to see that results are obtained from their contributions, and that is why we find voluntary hospitals securing general help.all round from the community in the provision of amenities for the patients, with the result that similar municipal hospitals have a much duller and less appetising air about them. We must recognise that the voluntary system is essential both to economy and to efficiency. The very fact that people associate themselves together in a society to raise funds for a particular institution and to see that it is carried on is admirable publicity for this work and helps the public to understand and to appreciate the institutions which are provided for them. In London we see the problem in its most acute form, though we get it reflected all through the country. In London everything has been done by the officials to try to work in with the voluntary hospitals, and yet the voluntary hospitals feel that by degrees they are fighting a losing battle, that it is more and more difficult to hold their own against the municipal side of hospital work. Perhaps the Minister can reassure us on that point.
I have been in close touch with the 13 teaching voluntary hospitals in London, and they have been seriously perturbed by one fact. In the Local Government Act provision was made for a London Voluntary Hospitals Committee to be in constant consultation with the London County Council, but there are 150 hospitals represented on that committee, and the 13 teaching hospitals feel they have not had their interests adequately considered. There was an idea that the London County Council were going to set up a central teaching hospital which would compete with the voluntary teaching hospitals which have been the founda- 690 tion of British medicine. I do not believe that is intended by the London County Council, but they are intending to carry out the splendid scheme introduced by the Government before the last one for a post-graduate teaching centre in London.
As regards ordinary teaching there is a definite part to be played by the voluntary hospitals and a definite part to be played by the Poor Law hospitals. How shall these two be brought together? There must be some clear understanding of their relative functions. On the one hand, you have the voluntary hospitals, which must do the main work of teaching and research and which I do not think can be properly carried out by municipal institutions. The municipal hospitals ought to be working in cooperation with the voluntary teaching hospitals, with a view to effecting greater economy. The municipal hospitals have a large range of clinical quarters in their medical schools which should he of great advantage to the rising medical profession, and the nursing profession. The ordinary voluntary hospitals take one-fifth of the cases in London, and they would willingly help the Poor Law infirmaries if arrangements could be made to do so. That would be an advantage to the hospitals and to the municipal institutions. I believe it would also be a great economy and would help cooperation between municipal and voluntary hospitals, which we all wish to see. As regards the grouping of laboratory work, I think there is a great future for co-operation between all our laboratory services.
We have been looking forward to the first revision of grants under the Local Government Act. Grants were made for three years as from the appointed date, the 10th April, 1930, to 1933, and then the new bodies will start under grants for four years and afterwards for five years. I fancy that the Minister of Health is busy with his staff preparing for the consideration of those grants. We are all very much concerned as to what those grants will be, in view of the financial stress of the country. We are all concerned with what is called a fiscal clause, which gives power to reduce grants to those authorities which have not looked after this kind of work properly. The Minister is using those 691 powers not to penalise authorities but to keep them up to the mark, and that can be done by sending round experienced inspectors from the Ministry of Health. I believe that that inspection has gone on to a considerable extent. If that work is to be spread over a long series of years on account of the limited staff employed at, the Ministry of Health, I am sure that it will be extremely valuable in obtaining information, after visits to those local authorities who have found great difficulty in performing their task as we wish them to do it. I hope it will not be necessary to reduce the grants, and that the power given in Section 104 of the Local Government Act will be found useful in bringing authorities up to the mark. I believe that that is a great constructive Measure, and, if we do not constantly revise those grants, we must proceed on new lines which may prove to be a saving in expenditure in the end. The arrangements should be freely examined from time to time, and in the working of the new Act I believe we have a very great advance which will be shown in the gradual improvement in the figures of actual sickness in the near future.
§ Sir WILLIAM JENKINS
The hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) said that at the last election the Government received a doctors' mandate. To-day we may truly say that we are discussing a doctors' Motion, because the argument of the hon. Member for Denbigh (Dr. Morris-Jones) was that he was greatly concerned to protect the general medical practitioner, and it seemed to me that he was more concerned in looking after the general medical practitioner than he was about the health of the people.
§ Sir W. JENKINS
The hon. Member for Denbigh referred to the enormous expenditure of the last Government upon these services, but may I point out to hon. Members that the hon. Member for Denbigh supported that Government.
§ Dr. MORRIS-JONES
I must be allowed to correct the hon. Member when he says something which is not a state- 692 ment of fact. I was opposed to the medical administration of the last Government.
§ Sir W. JENKINS
I think the records will prove that the action of the hon. Member was taken in order to prepare his way for sitting on the opposite side. The Act of 1929 was passed to co-ordinate and improve all public services, and, in doing so, had to remove local prejudices against a central authority. While some progress was made in 1930–31, the whole of the progress is now retarded by the economy schemes submitted by the Government. We on this side disagree with the methods adopted to economise on public health, social services and education. These services should not suffer, as the vitality of the nation depends on our activity in this connection. All the authorities are now warned not to develop any schemes that will warrant Government grants.
The great thing about the Local Government Act of 1929 was that it put all health services under one control, and one is bound to support that kind of scheme. It deals with school treatment, maternity welfare, Poor Law and public hospitals. Clause 13 of the Local Government Act of 1929 gave county councils and county borough councils power to take over Poor Law institutions, and to consult representatives of governing bodies and medical staffs of voluntary hospitals. Every effort has been made to get agreement between national hospitals and voluntary hospitals, but in the depressed industrial areas the voluntary system has failed, and more and more comes the responsibility for rate-aiding these institutions. People in those areas used to contribute one penny, twopence, and in some instances threepence a week towards voluntary institutions, but because of depression they are unable now to make a contribution of 3d. per week. They are reducing their contributions to one penny in a number of instances, and in many cases they are unable to make any contribution at all.
Another important matter is raised by Clause 16, which makes it compulsory for local authorities to recover, where possible, the cost of treatment. Here, again, there has to be a full inquiry as to the means of the patient. I think there is a danger in connection with this 693 matter, particularly in distressed areas. We should see that no preferential treatment is given, and I am afraid that in some instance preferential treatment is given because the people in the hospitals look upon the patients from the point of view of their ability to pay. This seems to me to be another means test in another form.
§ Sir W. JENKINS
That may possibly be so. I should like to refer to what the hon. and gallant Member for St. Albans, an ex-medical officer of health, said in regard to ill-health and the nation in a report which he made in 1927. In that report the hon. Member gave the figures of loss of patients' work, less efficiency due to ill-health, care and treatment in institutions, care and treatment at home, loss of work by those attending the sick, public health services, school heath services. All this, said the hon. Member, involved a loss of over £291,000,000 per annum. That is a very serious matter, and one which should be very carefully considered. There are other losses not enumerated which increase that total very considerably. Sir Walter Kinnear, the Controller of Health Insurance, has stated that practically three-fifths of the burden of incapacity is due to causes, many of which are susceptible to preventative and curative treatment, but, if there is not economy in this service, then this colossal loss and human suffering will increase and the nation will be poorer.
I looked at the Army reports for 1929–30, and there I saw the very significant statement that, as a result of the depression, more than half of the Army recruits were rejected for physical or mental reasons, and that 53.1 per cent. of them were physically unfit. That is a record not provided by those sitting on this side of the House but by the Government itself. Under Health Services, as stated by the hon. and gallant Member for St. Albans, we have ante natal services, midwifery, health visiting, home nursing, infant welfare centres, maternity homes, and hospitals. The local authorities have to take into consideration all these services. The hon. and gallant Member for St. Albans referred to one part of the report of the 694 Minister of Health, but not to the whole of it. Whatever he may say with regard to his own party, this is the first occasion on which I have heard him include the Liberal party with the Tory party. Hitherto all the benefits of which I have heard hire speak have been, as he said, due to what the Tory party has done, but since the Tories have joined hands with the Liberal party he now mentions the Liberal party as well as the Tory party. The Minister of Health report on infant mortality for 1930–31 says:It is pleasing to note that the year 1930 shows the lowest figures recorded since statistics began to be compiled.It was down to 60 under one year of age per thousand births; in 1928 it was 65; in 1929 it was 17.74 per thousand births. While there has been this gradual decrease, local authorities are told by the two hon. Members who have spoken and who are medical men, "You must economise," because the Amendment says that these services are to continue only "as and when circumstances permit." Until then I suppose everything has to remain at a standstill. On Thursday last the Minister of Health, in answer to a question by the hon. Member for Plaistow (Mr. Thorne), gave the total number of men, women and children in receipt of Poor Law relief on the last Saturday of the month in a series of years. I mention this because it has its effect on the children, inasmuch as they are not getting what they should be getting in the way of maintenance. In September, 1931, the number of people receiving relief was 1,005,813; in October, a month later, 1,050,342; in November, 1,089,023; in December, 1,127,006; in January, 1932, 1,188,628; in February, 1,219,701; in March, 1,220,000. This last is an approximate number. But all the figures show an increase every month compared with 1914, when the total was 643,000.
§ Sir W. JENKINS
I do not know. I have taken these figures from the report of the Ministry of Health. I have not taken the whole of the months. I have taken the 1914 figure for March. There may have been decreases during the other months of that year, though I do not know. I quote the statistics for com- 695 parative purposes. They represent an additional burden on local authorities. This burden has to be borne by the rates. The result of it all is that the social and health services must suffer until, as the Amendment says, "circumstances permit." Yet the Government will continue to grant exemptions of rates by 75 per cent. to breweries which have made such fabulous profits in the past, and to other industries which have been able to show profits. Why should these industries not wait until circumstances permit "? No, it is the poorest who must make the sacrifice every time.
I see in an interim report of a Departmental Committee of the Ministry of Health for 1930–1 an important statement. The committee arrived at the conclusion that of the deaths brought under their notice not less than one-half were preventible. A number of recommendations were then made, and these will be found in page 76 of that report. The present economy means continuing this loss of life. The late Minister of Health, Mr. Arthur Greenwood, in December, 1930, circulated a memorandum to local authorities in connection with that report. He made definite suggestions for tackling the problem, and the local authorities were asked to take the necessary steps. In July, 1931, out of 396 local authorities, 216 had sent replies, and of these 128 had actually adopted proposals. I am anxious to let hon. Members know that, in spite of some condemnation yesterday of the late Minister of Health, the results show that he was very active in dealing with the health of the people.
The replies received from local authorities by the end of June, 1930, showed the following results: Thirty-one authorities were establishing or extending ante-natal clinics; 16 authorities were arranging with private practitioners for routine ante-natal examination in suitable cases; 17 authorities were improving their arrangements; 14 authorities were arranging consultative services with doctors who needed assistance; 20 authorities were providing or extending hospital accommodation; 37 authorities were arranging various types of auxiliary services. According to the Amendment these again must wait "until circumstances permit." I wish also to call attention to the report of the Ministry 696 of Health giving statistics of blindness. On 31st March, 1929, there were 52,727 registered blind persons in England and Wales. The last return shows a total of 56,853, an increase of 4,126, or nearly 8 per cent., which is a very serious matter for local authorities, as they have to deal with this enormous increase. Is it due to under-feeding? I know men in my own area who were quite strong and healthy until 1920, when they become unemployed and lost their little cottages. They had been working in the mines, some of them, under very difficult conditions. To-day some of these men are practically blind and unable to follow their occupation.
It is pleasing to note that the number of children blind at birth shows a reduction. We can attribute that fact to the public health and clinical work. If we had not acted in that direction, I do not think we should have had this decrease in numbers. We have no right to economise if it is likely to result in the birth of blind children. I hope we are not going to retard this humane progress. We are unable, under the Blind Persons Act, 1920, to provide workshops for these people who are blind, entirely because of our financial condition. Voluntary efforts are failing, and it is now a very urgent matter. We are not in a position to give the assistance that we would like to give in order to provide work and training for these people. In my opinion the Government should economise on non-essentials, on things that can afford to wait without any loss to the nation. It is often said that the greatest asset in any country is its people. It is our duty, then, not to curtail any wise expenditure on the health of our people.
It is sometimes said that we have been wasteful upon local authorities. I want to give a few instances of things that I know in my own area, instances showing how local authorities are penalised by the enormous amount of money that has to be spent in repayment of loans and in interest upon those loans. Take the county of Glamorgan. For educational purposes the loans for elementary education are £78,985. The grant that we get from the Board of Education is £17,497. The net charge upon the county is £61,488. As a result of the block grants the position is this: A penny rate now, instead of producing £10,500, produces 697 only £5,112. The cost for the repayment of capital and interest on elementary edlucation loans is a rate of over 1s. in the £. In the case of higher education we are getting from the Board of Education 50 per cent. of what we expend. That represents a twopenny rate. We have other services in the county where the repayment of loans and interest represents a 5½d. rate. So we start off with a rate, in repayment of capital and so on, of 1s. 7½d. This does not include the Poor Law cost and the repayment of the Goschen loan, which, again, is a very substantial sum.
Glamorgan County Council has made application to the Minister of Health and to the Board of Education. As a rule, when it is a question of giving grants or permission to do anything, the Board refers the local authority to the Minister of Health. We have made application, and have said that it is absolutely essential that in the interests of the children there should be established two open-air camp schools. That has been suspended under the new order. Two nursery schools have been suspended, permanent clinics for cripples have been suspended. Who can get up in this House and say that a clinic to provide orthopaedic treatment for cripplied children should stand over "until circumstances permit"? No one can raise his voice here or outside this House and say that these children ought for one day to be prevented from having these facilities. Then there are the hospitals and workships for blind children in our blind schools, and the schools for mental defectives. We are told that they must all remain unattended to for the moment.
Then there are the school for crippled children and the extension of the medical services. In normal times the Board of Education say, "We are prepared to support you, and want you to provide medical men." We have done a good deal in our own county, but we are told now that we must not increase the cost, and we cannot increase our rate because we are a distressed area. Because of that we are not able to give to the children and women in our county the necessary facilities; we cannot find the means to meet the cost. We are unable to deal with the provision for backward children in elementary schools, and the authori- 698 ties are enabled only to improve their black-listed schools, and with not all of them are we in a position to proceed, because the Board tell us that the others can wait for some little time. Another service, directly under the Minister of Health, which we have been compelled to suspend for the time being owing to the cost, is the putting into operation of Section 60 of the Local Government Act, 1929, and transferring the maternity and child welfare service to the county council in the part of the county which is under the jurisdiction of the county council for elementary education. This transfer would have the effect of placing children under supervision, as regards their physical welfare from birth to the time when they leave school. At present the medical service of the education committee does not get hold of these children until they come into the schools, by which time much physical discomfort and deterioration may have ensued, unless it has been arrested by the child welfare service of a district council, and the district councils are unable in most cases, because of their financial difficulties, to do anything.
Then we have the mentally defective children in the county of Glamorgan. We have accommodation at Drymma Hall certified for 79 females and at Hensol Castle for 100 males, but accommodation is needed for approximately 2,500 cases. At present we have about 100 cases detained under orders in institutions all over the country, and we have other defectives sent to places of safety, and some of them in Poor Law institutions, which is very degrading. We ought not to allow that to continue for one day longer; the Minister should look into the matter very carefully and not allow these children to go into the Poor Law institutions. Then there is a large number of urgent cases for whom institutional treatment cannot be found. Are these to wait for the Wood Report, when the requirement of the county is for 2,500 places, until "circumstances permit?"
I come to the urban district council of Glyncorrwg, an area which I know very well and for which I have been a Member for many years. It is a purely industrial area, without any amenities or parks or any satisfactory clinics. They have one nurse for the whole area and one part- 699 time medical officer, and they are unable to do anything because the charges upon them for loans and repayment of capital and interest are a very heavy burden. On sewers and sewage disposal only the rate is 2s. 9¾d. for repayment of capital and interest, and it means 6s. 7¼d. per head of the population. If we take the whole of their expenditure on loans under various items it means a 3s. 11¾d. rate before they start upon any services at all, or an amount of 9s. 4½d. per head of the population.
I would like to mention the Neath Rural District Council, who again have very great difficulty because of the enormous amount of money that has to be provided out of the rates to pay their loan charges. For sewerage in the Neath rural district the rate is 1s. 3d. in the pound, and they have a water undertaking, which is one of the finest in the country, but it means a 3s. 7d. rate to pay the loan charges and interest. That makes a 4s. 10d. rate out of a 17s. or 18s. rate. How can these authorities provide for the people when they have such a heavy burden and the Board are still saying, "We cannot give you any further grants"? The Neath Borough Council have a loan repayment charge on their general account of 1s. 8d. and on elementary education of 5½d., which makes a rate of 2s. 1½d. There is a number of things in the town that they need and are anxious to get, but they are unable to do so because of these additional charges.
There is one matter in connection with the county where I think the Ministers of Health and Transport could do something to help the men who are now receiving unemployment benefit. Take the by-roads in all the distressed areas of Glamorgan-shire. I do not know whether the Minister of Health can do it, but there is something to do in connection with the health of the people on the by-roads and by-streets, where they have not been able to get proper roads, with the result that these by-roads have in them pools of stagnant water, which is detrimental to the health of the people. Most of them are undrained, and that is a matter of public health and therefore one for the Minister of Health. The local council cannot do it. The hon. Member for Den- 700 bigh said that some people had been exploiting. The landlords have not made the roads properly in the beginning, and the result is that they cannot get the roads made, and that would he one way in which the National Government could provide employment for men who are willing and anxious to work instead of receiving unemployment benefit. At least, they could have their unemployment pay augmented. Surely the National Government, when they have all the talents and when, as the hon. and gallant Member for St. Albans said, they are working together with all the brains pooled, ought to be able to devise a scheme to help the people where there is so much suffering, where the women and children are suffering, and where we want more clinics and better accommodation for the people. Surely they ought to be able to provide some means.
I have seen roads and streets in a terrible condition, and it may be well that you should occasionally hear some of the Welsh names. The Minister of Health may he able to pronounce them as well as I can after he has been at the Ministry for some time. Take the by-roads in places like Cwmllynfell, Cwmturch, Rhiwfawr, Ystalyfera, and Resolven. There are industrial areas which have only got access by the main roads, and all the by-roads are detrimental to the health of the people. I hope the Minister will give us some hope to-night, that he will say something that will benefit us and the people, and that he will not wait until "circumstances permit," but will assure us that we shall get all the assistance possible.
§ Captain GUNSTON
The hon. Member for Neath (Sir W. Jenkins) has made a very interesting speech and suggested various measures by which we might alleviate the difficulties especially in the poorer areas of the country, but I think we had better not ask what the Minister can or cannot do in regard to various anomalies and difficulties, but rather if he thinks, after the passing of the Local Government Act, 1929, the position has materially improved. The hon. Member who has just sat down gave us a very interesting case with regard to pools of water in some very unpronounceable places in Wales, but under the Local Government Act those roads are now to 701 be taken over by the county council unless they are delegated to the local district councils.
My hon. Friend the Member for death (Sir W. Jenkins) was referring to by-roads, apart from the main roads and the classified roads.
§ Captain GUNSTON
It is a small point, but it is a matter for the county council. I would like to ask the Minister if he can give us some information as to the results of the working of the formula. He will remember the great Debate which took place in this House with regard to that most, complicated and ingenious formula. I see in his place the Parliamentary Secretary to the Ministry of Health, and I remember some of the speeches that he made, in those days when he was not so enamoured of the formula as I was. Perhaps when he replies he will be good enough to say how the formula has worked and whether the fears of the local authorities with regard to it have or have not been realised. Speaking from memory, I believe the late Minister of Health, Mr. Greenwood, told us that on the whole the formula had worked very well, and I think we are entitled to have a few words from the Minister as to how the financial part of the Act has worked.
I have risen really to ask a few questions about Section 2 of the Act, which refers to registrars. I once brought in a Private Bill with regard to registrars' fees, but that Bill was lost in the other place, and the then Minister of Health incorporated it in the Local Government Act. I believe the appointed day with regard to these registrars of births, deaths and marriages was the 1st April, 1932, and the reason why the coming into operation of that part of the Act was so long delayed was the taking of the census. The Minister will remember, with regard to the registrars, that when we went into it we found an enormous number of anomalies and that they were paid by fees which had no relation at all to the work performed. The House felt that these men, who were really public servants, should get a decent salary and should be put on a proper basis, and I want to ask whether the schemes which had to be prepared by the county councils and the county borough councils have reached the 702 Ministry, because I think they were due by the 1st. April of this year. I want to ask him whether lie has exercised his powers under the Act to increase the fees by 50 per cent. He will remember that these fees had not been increased for 100 years, and, owing to the lowness of the fees, it was impossible for these men to get proper remuneration. I should like to hear whether, under the schemes which are coming into operation, it is proposed to increase the fees, so that these men may at least get proper remuneration for their devoted work which they have carried on for many years.
With regard to maternity services, I think that the whole House, in those long discussions which took place on this tremendous Measure, was agreed as to the necessity of reorganising the medical services in the country districts, and especially the maternity services. Those of us who live in the country were very much struck by the fact that, while we were very short of accommodation in voluntary hospitals, there were many Poor Law institutions which were half empty, and which people did not want to go into because they feared the stigma of the Poor Law. The idea under the Act was to get away from that stigma and reorganise our hospitals so that they could become specialised institutions. We were very anxious that in each district of a county is should be possible to have a specialised maternity hospital. Everyone knows that the difficulty has been to get a poor woman—for example, a farm labourer's wife—into a specialised hospital in time, and we felt that in the country districts the wife of an agricultaral labourer is entitled to as good treatment as the wife of an artisan in a town, where these facilities exist. Could the Minister tell us what efforts the county councils are making to reorganise their health services, and especially maternity services, in the various institutions which are now under their control?
I should also like to ask a question with regard to the guardians committees. The Minister will remember the great Debates that took place on the question of the abolition of the guardians, and the fact that the Minister of Health at 703 that time met the wishes of the country Members by the system of guardians' committees. I should like the Minister to let us know if that system is working well, and if the former guardians to a great extent make up the present guardians' committees. I should also like to hear how the very interesting experiment of co-opted members is working. There was a good deal of doubt at the time on the question of co-opted members for these committees, but it was felt that by that means we might attract into local work various people who did not want to go through the turmoil of an election. What is the proportion of co-opted members on the guardians committees in the country as a whole?
In conclusion, I should like to re-state my faith in this great Measure. I think that the Government of that day had great courage in reforming our local institutions and the Poor Law, because such Measures are not popular Measure, or Measures which appeal to the sensational Press and get good publicity, but they are necessary, and I believe that this Act will go down to history as one of the greatest Acts that has even been passed through the House of Commons. From time to time, of course, it will be necessary to review it and see how it works. To-day we have one of our first opportunities of reviewing that great Measure, and I hope that the Minister will be able to give us a little more information as to its working.
The hon. Member for Denbigh (Dr. Morris-Jones), in moving his Amendment, has, I think, endeavoured as far as he could to cover over the attitude of the National Government regarding the public health services since they took office. He said that the Local Government Act, 1929, afforded possibilities for the general improvement of our public health services. I do not think that any one of us would deny that the Measure itself did offer possibilities of improvement in the public health services, and I would go so far as to suggest that, immediately it got into the hands of the authorities who had to administer it, there was an endeavour to reorganise our hospital services and improve our general public health services. This went on for a short period, but, when the National Government took office at 704 the end of last August, they immediately issued instructions to local authorities to put in force drastic economies in all their public health services. The result has been that ever since this Government came into office, our public health services have been deteriorating and have been retarded. This is the most important subject that has been debated in the House of Commons for some time; there can be nothing more important than the general health and happiness of the community as a whole; and it is very largely on the administration of our public health services that thousands of men, women and children who at the moment are not enjoying good health depend for the improvement of their health.
The Amendment was moved by a Liberal and supported by a Tory and the hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) claimed that the party which he represents had given, in the interests of the general community, reform after reform in the public health services. I want to say very frankly that the Conservative party have never given anything but what was forced upon them in connection with the public health services, and I think that the Liberal Member who moved the Amendment was very lax in his defence of the Liberal party in not stating that fact.
Since the National Government, who, we have just been told, are a pool of all the intellect of the House—I suggest that it is a very stagnant pool, that it is either standing still or preventing things from moving speedily—issued their economy instructions, public health administration has been seriously retarded. I have here some figures relating to the West Riding of Yorkshire, a very large industrial area, where, as the Minister of Health will admit, health administration is a very important matter. Since the National Government took office last September, that is to say, during the last six months, there have been savings in nearly every branch of their administration. On the salaries of health visitors there has been a saving of £1,330; on rents of child welfare centres, £250; on equipment of child welfare centres, £1,040 and £1,300 has been saved by not proceeding with 10 child welfare centres. On one of our maternity hospitals, near Mexborough, there has been a reduction of £4,240; on a further maternity home at Skipton, a reduction of £2,560; on tuberculosis treatment there 705 has been a reduction of £1,290; on ultraviolet ray treatment, £600; on maintenance in sanatoria, £3,890; and on X-ray mobile units, £2,050.
In regard to the provisions which are to be made next year, the Government have sent out economy circulars which, particularly in the case of authorities which have preponderating Conservative majorities, have been accepted and interpreted in the spirit in which they were sent out, and for the forthcoming year further reductions are contemplated in the public health services of that important West Riding county area. They are suggesting a further cut of £27,491, after the 10 per cent. already provided on the ordinary estimates, in the general health services of the area. In the training of health visitors there is to be a reduction of £380; on doctors in emergency cases for maternity, £500; on tuberculosis dispensary rents, £250; on travelling expenses, £150; on extra nourishment for tuberculous patients, £400; on provisions in sanatoria, £150; on domestic renewals and repairs, £170; and on structural alterations, £100. The chairman of the public health committee informs me that a proposal for the erection of a free sanatorium with 100 beds has been postponed, that the provision of a recreation hall in an existing sanatorium where there are 300 patients has been postponed, and that the general cuts in the estimates this year, apart from the cut of 10 per cent. that was made when the economy circular was sent out, amount to a further 15 per cent. of the sum proposed in this year's estimates of the West Riding County Council for general public health services. We are finding, also, that it is more difficult now to give relief in the way of free milk at our clinics to mothers and babies, however necessitous the cases.
I want to make an appeal to the Minister of Health. We desire to see established once more the privileges of administration that we enjoyed during the time that Mr. Arthur Greenwood was at the Ministry of Health. We want to see those services re-establislhed to the full. It is no use Members on the other side of the House patting themselves on the back for the economy cuts that they have made in the public health services during the last six months, and the contemplated cuts during the next 12 months, and at the same time trying to 706 make the general public believe teat all is well and that nothing has happened. I am afraid that, unless there is a very serious change in the administration of our public health services, our death rate and our infantile mortality rate are likely to increase. I think all of us feel proud that for the last 50 years the figures have been on the decrease, and it will he very reactionary of this Government to bring about further reductions on these services which will be likely to reverse that position. These clinic and maternity and child welfare services are tremendously beneficial to thousands of women and children, and we hope that the Government at an early (late will withdraw that economy circular and open up a path once more for a real administration of our public health services, so that we can aim at bringing happiness and good health to the general population.
§ Captain ELLISTON
The hon. Member makes a great mistake when he claims for his own party a monopoly of interest in what concerns the public health. I wish to join with those who have paid a tribute to the remarkable and patriotic work done in connection with local authorities since the Local Government Act has been in force. It has been a particularly difficult time, because it has coincided with extreme financial difficulty and depression. I should like to call attention to what has been done by the public health departments of our local authorities to effect their economies in such a way as to maintain a maximum of efficiency with a minimum of expenditure. This has been done without any of those reckless economies against which local authorities were rightly warned by the Ministry in the early days of the crisis.
I know that in the case of Blackburn there has been no break of essential health services during this difficult time. On the contrary, in some departments of the work of the local authority there has been increased activity. For instance, in connection with maternity and child welfare work there has been increasing use of the clinics, and the opportunity has been taken by medical officers and health visitors to impart an enormous amount of valuable instruction in matters of domestic economy and nutrition. The 707 importance of that can be appreciated when we remember that in that borough of 125,000 inhabitants over 25,000 are unemployed. It is a very significant thing that the use of those centres has tremendously increased in this time of unemployment. That may be explained, perhaps, by the fact that the mothers who in normal times would be in the mill are now able to take their children to the clinic and to seek advice, or again it may be that in an especially enlightened community they appreciate the enormous value of the work done by the clinics.
Another point in connection with the work of our public health departments is the great vigilance with which medical officers in all parts of the country are watching for the early signs of malnutrition or failure in health of the people on account of the difficulties of life at present, and they are able, when they see dangerous conditions developing either among the mothers or the children, to arrange for a supply of milk or for meals which enable them to make up the shortage of their domestic budgets.
The Amendment expresses appreciation of the progress achieved by local authorities in co-ordinating and improving the public health services. We all realise how very much has been done in the great towns in connection with the co-ordination of hospital schemes, and there is no doubt that those local authorities are deserving of the highest praise for having accomplished so much in so short a time. But I feel bound to ask whether any comparable general advance has been made in the county areas. I am hoping the Minister will be able to tell us that the county councils are well on the way towards that grouping of areas which would ensure efficient administration and enable the appointment of experienced, whole-time medical officers of health. I feel very strongly that we must have a lead from the Ministry in the matter of the co-ordination of hospital services in these county areas. The county councils require some guidance in tackling the very difficult problems that arise under the Local Government Act. We could have no finer example of what can be achieved than in Aberdeenshire, where we have a university, a voluntary hospital, a great 708 city, the county of Aberdeen and the adjoining county of Kincardineshire joining forces to form one of the finest possible health units that could possibly be conceived, and, with the assistance of the Ministry of Health, we may yet see our own county councils in England dealing with the problem on the same bold and courageous lines.
The next point we have to ask ourselves is: Are we spending our money in these hard times to the hest advantage? Experienced workers in public health administration have very grave doubts, and it is a matter of remark that, in spite of the increasing expenditure on maternity and child welfare work during recent years, the children who are entering the schools to-day are still showing a disappointingly high percentage of defects. I find among men who are skilled in public health work a feeling that time and money are being wasted by continuing the systematic and routine inspection of thousands of school children. They believe we have now sufficient knowledge and experience of the general conditions existing among those children and that the time has come when we can cut out that expensive work and concentrate on the children who are known to have defects. Those experts in health matters also believe that now is the time when we have to concentrate on ante-natal work, on the health of the pre-school child, and on the health of those young people in the transitional period between leaving school and entering industry, and that by developing those services without any further expenditure we can get higher efficiency and more important results.
Another matter of special interest to the public health service is that of research. They doubt whether the money that is being spent on research—it is not too much—is being spent in the best way. There is a general feeling that we might have less laboratory and more field research into those ordinary practical problems which are met with every day in the public health departments. There is a general belief that nutrition is the basic problem affecting the health of the people. It is suggested that better housing means worse food and consequent impairment of health and increase in the incidence of sickness. Surely that is the 709 sort of matter that calls for early investigation so that the workers in the field of public health service may understand better the significance of the conditions they see in their clinics and in the hospitals later on.
I believe all those engaged in public health administration are impressed with the importance of the greater education of the people in health matters. There is a feeling among many men in local authorities that we are doing everything that can be done as regards the personnel and the equipment of the public health services, and it is now up to the people to do the rest. But, before they can take advantage of these services that are provided for them, the people must understand the significance of those services and how they can benefit. I feel certain that the development of this public health education in one of the most economical and effective measures that could be supported by the Ministry of Health. I should like specially to ask the Minister whether he can assure us that in this matter his Department is getting loyal co-operation from the Board of Education. I feel that the House would desire, through the Minister, to acknowledge with satisfaction the work that is being done by local authorities in connection with health. It is very remarkable that they have been able, by tightening up their organisation and asking sacrifices of public officials, to maintain so high a standard of efficiency at such a very difficult time.
§ Mr. LANSBURY
There are one or two questions which I should like to raise in regard to this Amendment. First of all, I should like to say that, if there are any people deserving of congratulation on the passage of the Local Government Act, 1929, it is Lord Passfield and his wife, Beatrice Webb. If we are going to throw bouquets at one another, I think it will be admitted that the minority report of the Poor Law Commission sketched out the proposals in that Act, and it was generally recognised how much the country was indebted to those two good people for the proposals that they made 30 odd years ago.
§ Mr. LANSBURY
We voted against it for very good and sufficient reasons which were stated at the time. The benefit of speaking in this House, as I have been reminded during the last few days, is that there is a record of what you say. I am willing that the statement which I have just made shall be judged by our speeches and our actions during the passage of the Act through the House of Commons You may support a principle, but you may disagree with how the principle is being applied. For 30 years we have wanted to break up the Poor Law and to deal with it in a, certain way, and the one thing which we very much wanted to do was to take the unemployed, all the able-bodied people, out of the Poor Law, and it was because that was not done in the Act that we voted against it on the Third Reading. That fact is on record. But in so far as the Government of the day in 1929 adopted our proposals and obtained the co-ordination and the unification of local government services we were very much in agreement.
I notice that the Postmaster-General, who can tear an argument to tatters as well as the wisest and best of us, is very much shocked at that statement. Not only did I sign the Minority Report which was devoted to this matter, but I also happen to have done six weeks' imprisonment in favour of that principle. We went to prison because we maintained that London should be unified for the administration of public assistance, and about that there cannot be any question, because not only do the records of the OFFICIAL REPORT prove it, but the records of Pentonville Prison will prove it too. I should not have said anything about the matter but for the fact that the two hon. Gentlemen who opened the Debate wanted to divide the honours between their respective parties. I do not think that on the question of the abolition of boards of guardians and the unification of the work of boards of guardians and the bringing of it in alongside the rest of local government there was ever much difference of opinion among those who had had any hand in administration of this kind.
I repeat to the hon. and gallant Gentleman that the may look 711 up the Official Report, and he will see why we voted on certain occasions against that Bill. Although we did not actually vote against the Third Reading we voted in favour of a considered Amendment to the Third Reading which stated our point of view. No amount of argument can get over the fact that anything that is of any value in the Act of 1929 is contained in the Minority Report of the Poor Law Commission. I believe that if the Chancellor of the Exchequer were here he would pay the same tribute of respect to Lord Passfield and his wife for the great work which they did in creating public opinon so that this sort of thing might be done. The fundamental blot upon that Act from our point of view, apart from the fact that it did not take the able-bodied away from the local authorities altogether and treat them as a national problem, was the question of finance.
I do not at all accept the view which the hon. and gallant Gentleman the Member for one of the divisions of Gloucester (Captain Gunston) put forward. I do not know at all how far Mr. Arthur Greenwood would say that the formula on which the financial assistance is based is one which does not need any amendment. I believe that when the five years are up we shall find that it will need a very great deal of amendment, and I will tell the House why. Take a district like the one from which I come. We have numerous duties to perform apart from the removal of the Poor Law service. We all admitted at the time that we should not pay more than they pay in rich boroughs, but the Bill made no provision for this, and that was the occasion on which I voted against the Bill of winch I have been reminded just now. The fact is that when we come to new expenditure we have so much less rateable value from which to draw. About that there is no question whatever. You have taken a considerable proportion of our rateable value away by the de-rating part of those proposals, with the result that what new expenditure we have had to embark upon during this period has had to be found out of local funds. I am sure that when the time comes to reconsider these matters one of the things with which you will deal and change will be the financial arrangements.
712 The reason I am not in any mood to congratulate anybody is that in a period like the present it seems to be absurd to say that you ought to economise on any public health services. In spite of national need and money stringency or anything that you can advance, I maintain that a period of great unemployment is exactly the period when there ought to be more money spent upon health services. At such a time the more needy people are not able to provide for the medical and other services they require. In spite of what has been said since both by the Prime Minister, and, I think, by the Minister of Health, bodies like the London County Council and our borough councils have carried the spirit and practice of economy in health services much too far. I cannot say that here and there so much less money is being spent, but I can say that over the whole field, speaking generally, there is less activity in public health services. That is especially true in London and in districts like mine where the rateable value is now even lower than it was before because of derating. Where the means at disposal are really less we find that the health services are lessened. There can be no question about that fact. When people glory in the fact that expenditure is so much less than it was so many years before, or a year before, it really means that children and women, and others, are having to go without necessities.
I am waiting to see the next year's report of the medical officers of the London County Council. When the year through which we are passing has ended we shall have the report of the Medical Officer of the Ministry of Health and the report of the Medical Officer of the Board of Education. I am certain from only looking at children in school now that the reports will show a very marked difference in the physique of the children. That will be seen to be due to unemployment partly, to the fact that there is not so much money going into the home, and also to the fact that there is less public assistance going to the children. In my district, up to a certain period, when we were supposed to be shovelling out public money lavishly, and without any regard as to where is came from—hon. Members may say whatever they please about it— no child went into school without a proper pair of boots on its feet or without a 713 shirt and other reasonable clothes upon its back. You can go into the schools now and see the sort of boots and shoes and clothes the children are wearing. There is not a single social worker in the East End of London who would not corroborate what I am saying. I do not think that that is true economy or anything upon which to congratulate our-selves at all. It is exactly the contrary. I repeat that during a period like the present there ought to be more public money spent in this sort of way than at any other period, and it ought not to be a question of saying, "Let us wait for a more convenient season."
That brings me to another point. Her Majesty the Queen has taken a great interest in maternal mortality, and great hopes were raised in the country that the question was to be dealt with effectively. I know that Mr. Greenwood intended to introduce a Bill, but that was a Measure which he was told could not be brought forward because of financial stringency. I ask the Minister to say, when he comes to reply, whether there is any possibility of our getting that particular Bill this year, or whether he can give us any new figures about maternal mortality. It may be that local authorities may have taken such action that the latest figures show a reduction. I have not seen any figures recently, but when the figures were last published the present Prime Minister and the Minister of Health and others joined in saying that we must make a great effort to save mothers in the future. I would like to know whether anything is being done about the matter.
I wish also to say a few words about hospitals. Every voluntary hospital in London, I believe, is more or less in a bad way. They are living, as it were, from hand to mouth. I am always willing in regard to some of the work of the London County Council to say what I really think about it. On the education side some of their work—I am saying "some" because I do not want this statement to be thrown at me—is magnificently done. in regard to the Poor Law hospitals, they are doing a very fine piece of work in making it all a sort of public service without any sort of stigma of pauperism about it at all. They are trying to create, although they have not got it yet, a real municipal health and hospital service. I should like to ask the 714 right hon. Gentleman what is happening in regard to the proposals put forward by his predecessor for the co-ordination of the work of the voluntary hospitals with the sort of municipal service that the county council is setting up. It is a fact that in certain districts some of the hospitals are terribly overcrowded, while many municipal hospitals are almost empty. There is no earthly reason, once the Poor Law stigma is removed, why anyone should be ashamed or afraid to go into a municipal hospital. I would like the right hon. Gentleman to say what advance is being made along that line. I want to see a national medical service throughout the country, and whilst that is coming on I should like to see, especially in London, real co-operation and co-ordination in the work of the voluntary and municipal hospitals.
To-day there is a different attitude of mind on the part of the masses of the people towards going into hospital. In the old days they were frightened from going into a hospital, but that fear has been overcome, and it is a very excellent thing that it has been overcome. I hope that the right hon. Gentleman, even in these days, will lend the weight of his authority and the experience of his Department to bring about greater cooperation between the voluntary and the municipal services. Fundamentally, all these services fail in one thing. It is true that during a period of unemployment more health service is needed from the community for the individuals. On that there can be no two opinions. Even in good times, when trade is booming, there is still the problem of the persons in slum dwellings or in overcrowded homes who are taken out and upon whom a great deal of money is spent, be they boy, girl, man or woman, in order to cure them, say, of incipient phthisis or rheumatism or some other complaint that has been caused through over-crowding, or, as one hon. Member behind me said, from malnutrition. We are not going to get over that and we shall not properly deal with it until we have thoroughly dealt with the housing problem. I understand that we cannot discuss housing on this Amendment and I do not wish to pursue the subject further except to say that we spend millions of public money in patching people up and sometimes curing them, and then we send 715 them back to conditions which recreate the disease of which we have almost cured them. In spite of all the appeals for economy and in spite of the demands made for limiting expenditure, I hope the House of Commons will face the fact that it is much better, as an old German doctor said to me in Germany, 30 odd years ago, to spend money in keeping your people healthy than in spending money trying to cure them, when they have been suffering from preventable diseases.
§ Sir KENYON VAUGHAN-MORGAN
I share with the right hon. Gentleman the Leader of the Opposition admiration for the services rendered by the great municipal hospitals of London, but I do not think that he or the House will overlook the debt which those municipal hospitals, through their medical officers and staff, owe to the voluntary hospitals in which they received their training, nor the spirit which permeates the great voluntary and teaching hospitals of London, through which and by which the medical officers and others have had so much assistance and the community so much gain. The hon. Member for Neath (Sir W. Jenkins) made a remark which leads me to believe that he has not an appreciation of the value of the voluntary hospitals, nor that confidence in their administration which their proud record entitles us to accord them. The voluntary hospitals perform and have performed for many years the greatest service to the health of this country and the progress of medical science, and the two lion. Members who belong to the medical profession who have contributed to our Debate this evening paid their tribute, very properly, to what we owe to the great teaching hospitals and the voluntary institutions as a whole.
A criticism was made this afternoon which those of us who are interested in the subject have heard many times and which has been answered on many occasions, that whereas in the past the voluntary hospital has been able to rely successfully on the benevolent efforts of private individuals, at the present time and more probably in the future the source from which that benevolence has been derived may become slower in its flow and smaller in its volume. That such a tendency exists is undeniable, but when 716 we look at the course of the contributions to voluntary hospitals over recent years, and during the difficult periods through which the country has passed in the last two years, in particular, it is gratifying to see that the flow of that generous contribution has not fallen off. To-day the voluntary hospitals receive a revenue of £13,500,000 per annum, and, although we do not know what may be their fate in 1932, up to the latest period for which we have records that generous flow has been consistently maintained and has steadily increased.
Let us bear in mind that the revenue for the maintenance of voluntary hospitals is no longer dependent solely upon the generous gifts of the wealthy or the well-disposed. It is now what may be described as a great national cooperative effort. It derives from those who are attracted by the opportunity which the hospital presents of relieving distress and doing good. It derives from the wealthy and the well-disposed, and it derives very largely from those who having received the benefits of the hospitals avail themselves of the opportunity of contributing to their maintenance, according to their means. In addition to that valuable class of contributor we have the great organisations. such as the Hospital Savings Association, which last year had 1,000,000 members and contributed £500,000 in revenue. Organisations of that kind are of untold value to the voluntary system. Not only do they contribute to its maintenance and welfare but they accord to the patient who may have occasion to use the hospital that very feeling to which the right hon. Member the Leader of the Opposition has referred, namely, that the hospital is no longer a place to be dreaded or avoided but a place to which he contributes and which is his own if he should need it. To that great tendency the future of the voluntary hospitals may well owe much. In view of the great services rendered by the voluntary system it is to be hoped that nothing will ever be done by the great municipal hospitals, however valuable their own part may be in the complete health services of the country, to impair the services rendered by the voluntary hospitals.
A further point on which the hon. Member for Neath touched was the old 717 complaint, often answered, that discrimination is exercised in the hospitals in regard to the patient, the patient's surroundings and the patronage by which the patient may be given an opportunity of access to hospitals. Those who are familiar with the administration of our peat hospitals are well aware that no such subservience to subscribers exists and no such preference is accorded to one patient over another. To the medical officer, the surgeon or the nurse the patient is a patient, quite regardless of his circumstances outside. He is judged by only one thing, his need and the service which the hospital may be able usefully to render. When the Minister of Health replies, will he be good enough to report on the present relations and the future prospects of that co-ordination between the two branches of national service, the voluntary and municipal hospitals, and will he be good enough to- deal with the question of the intended establishment of a home for the post-graduate course in London? Will he also assure us, if he is able to do so, that nothing will be proposed by the Ministry of Health in the direction of promoting efforts which may cut at the root or impair the opportunity for usefulness of our great voluntary hospitals? Having said that, may I again pay my tribute to the valuable services now being rendered by the municipal hospitals, and my confident belief that there lies between the municipal and the voluntary hospitals a great service in the future to toe benefit and the welfare of the nation and its public health.
§ Mr. HICKS
I regard this Amendment as somewhat foolish. To start with, it congratulates local authorities upon doing their duty as regards public health. I do not believe that there is a local authority in the land that is doing its duty. I want to bring the House down to realities. We can all pay our tribute to -the heroic services of those men and women in our hospitals who look after the sick and wounded—I wish that they had not half as much to do—but I agree with the right hon. Member for Bow and Bromley (Mr. Lansbury) that the money would be much better spent in preventing disease than in establishing large institutions to cope with diseases after they have been contracted. The 718 duty of local authorities is to get at the causes of ill-health. What are the most fruitful causes of disease in a locality? In the main, I think, municipal authorities are just "come-a-day, go-a-day, and God send Sunday," and "Let us get over the job as easy as we can." No hon. Member who is responsible for this Amendment has given us any evidence that local authorities are tackling this problem with vigour, courage and foresight. There is no department of public life where the presence of the dead hand is so evident as in our local authorities, with their old traditions, their ancient formulae, with their cob-webbery of regulations, with property owners sitting on the council, with red tape, legal red tape, which checks and destroys bold municipal initiative and impairs steady progress.
On the top of all this there is the financial difficulty, made enormous in most instances by the appalling unemployment and the relief of distress that has to be given in various industrial localities. And to crown all is what I regard as the insane economy policy of this Government. If there was any enterprise in municipal authorities it would be very effectively held down by national restrictions. While we are anxious to express appreciation of any person who is doing good work, we must try and get a proper perspective and have regard to the size of the problem and the steps that are taken to grapple with it. We must see how municipal authorities are handling it. Good health is important to everybody. The nation which is truly great is that nation which has the largest percentage of healthy and happy men, women and children. Instead of the Government being at the head of a national crusade to deal with the root causes of poverty and disease, radiating its energies and determination in all directions, it is checking and hampering the movement. I have not been a Member of this House very long. I was in the last Parliament, but far from there being any general evidence of initiative in dealing with these grave problems it has been conspicuous by its absence. This House of Commons is more in the 719 nature of a money-changing chamber than a chamber for dealing with these matters.
While good health is important to everybody it is everything to the working men. It is their capital. The only commodity they have to sell is their labour. The working man has no capacity to draw rents from property; at least he has no standing. He cannot draw rents from property; he is unable to draw interest from shares. He has no dividends to draw from investments. The only thing he has is his health, and, therefore, good health to the worker is the greatest thing of all. Take that away and his opportunity of obtaining a livelihood is considerably diminished. The diseased or crippled worker is a bankrupt worker; perhaps hon. Members will understand me better if I refer to it in that way. Good health is his capital. It is essential and imperative in his case, but it is just the workers who are subjected to conditions which make good health a chance in some instances and almost an impossibility in others. If I were asked what are the root causes of bad health, I should turn to the reports of our medical officers of health—hundreds of them are available—which tell us that they are bad housing conditions and poor living. We shall all agree about that. I submit that to aim at the prevention of disease is a much greater job than tampering with its effects. Nearly every Department regards itself as justified if it has taken some action to deal with some part of this problem, but, I submit, that as far as the general problem of health is concerned it is substantially let alone.
We must strike at the root causes of ill-health. What municipal authority is doing this? Perhaps those who are responsible for the Amendment will tell us. It is common knowledge that of all breeding grounds of ill-health and disease slums are the worst. Dangerous epidemics usually begin and spread from slums. Public officers with monotonous repetition and statistics after statistics tell us every day and every week of the death-dealing nature of slums, and call upon local authorities and national representatives to deal with them. Infant mortality in a garden city is about 35 per 1,000, but in the slums it is over 120 per 1,000. That fact alone shows that slums are not 720 healthy places, that they are one of the causes of disease and death; and, if we are to congratulate municipal authorities upon doing their work in a progressive way, we have to ask them what they are doing to tackle the causes of disease. Most municipal authorities are lethargic until someone challenges them. Doctors keep pointing out that overcrowding, lack of sunlight, damp rooms, the lack of proper sanitation, dirt and squalor, which are characteristics of all our slums, create conditions which are veritable hotbeds of fever, tuberculosis, rickets, and influenza. We all know that if one person gets a cold in a house then all of them get a cold; if one person gets influenza, every other person in the house gets it. If one gets a disease they all get it, and if one gets tuberculosis there is a danger of it extending to the rest of the family.
What are municipal authorities doing in tackling these causes? What is their contribution towards dealing with 'this problem? When we are paying our tribute to the splendid service which ministers to the people when they are ill, and no one will desire to qualify it, I submit that the better way is to tackle the problem the other way round. We are all conscious of this. We know that these things will continue to exist unless we take steps to deal with them. Money spent on curing disease would be much better spent in trying to prevent disease. To all intents and purposes our local authorities are doing nothing, or practically nothing, in slum clearance. What they are doing is a mere fleabite; it is not tackling the problem seriously at all. There are millions of our fellow citizens clamped down in these slums. The Lord Bishop of Southwark said that there were over 9,000,000 of our citizens, more than one-fifth of our population, clamped down in slums. He was not too generous in his figures, because there are 2,000,000 of our children, the boys and girls of a great Imperial race, who are being robbed of air and sunshine. We congratulate local authorities on the steps they are taking to deal with this problem.
I cannot deal with some of the remedies which require consideration on this Amendment—they will come up under the second Amendment—but let me say that to-day millions of our people are fester- 721 ing and rotting in slums. I say to those who have power and authority that for every life which is lost and which could be saved, there is a responsibility on their shoulders. We have no moral right, no ethical right, no political right, no right at all to be indifferent to any effort that can be made to deal with some of these problems of poverty in our slums and to give our people a better environment. Take this great City of London. Take places like Battersea and Bermondsey. The East End of London is one huge slum. There are slums in Battersea and Bermondsey despite the heroic efforts of the right hon. Gentleman the Member for Bow and Bromley and the hon. Member for Bermondsey (Dr. Salter) to introduce a little sweetness into those municipalities. Go through these districts and you will see than our people are condemned to live under conditions which give them no possible chance of fighting effectively against disease. There are hundreds of thousands of workers in London housed under conditions of that kind.
I ask hon. Members to read the reports of medical officers, of religious bodies, of independent social investigators on this subject. Men and women of the highest public character and record of service have made investigations in our various boroughs, and they have presented us with staggering reports on the abominable conditions in which many of our fellow-citizens live—conditions of filth, disease and overcrowding, with one family or two families in a room. When we have as many as eight or nine individuals living in one room, how can we congratulate our local housing authorities on their enterprise I If we do so, it must be with our tongues in our cheeks. For all that is being done to deal effectively with this problem, some of these housing authorities might as well be dead. It would be a good job indeed if they were, in order that we might then centre the responsibility upon some body which would tackle it in the right and proper way. I ask the Minister to spur up local authorities who are not dealing with their jobs as they ought to. The health of the people is more important than the dignity of municipalities or local authorities. That is the spirit which ought to prevail, and I ask the Ministry of Health to direct its attention to dealing with causes as far 722 as possible, instead of having to deal always with the effects of those causes.
§ Sir H. YOUNG
I heard the speech of the Leader of the Opposition with very much pleasure. I did not know that I was going to have the happiness to-day of congratulating the official Opposition on another of those conspicuous conversions which have recently been so numerous in their annals. If I understood the right hon. Gentleman's references to the great Local Government Act of 1929—and I listened carefully to his account of the history of the matter—he was in favour of the Measure in the old prison days and he is in favour of the Measure now, but there was a brief and not so recent interval— —
§ Mr. LANSBURY
I hope that the right hon. Gentleman will give the full history. I am one of the five signatories of the minority report which proposed the unification of local government services. That happened 30 years ago. I think that that might be taken into account, and if the right hon. Gentleman listened to me just now, as I think he did, he knows that if pointed out that it was only certain portions of this Act that I voted against and would still vote against.
§ Sir H. YOUNG
As regards his conversion to the whole Measure we congratulate the right hon. Gentleman:And, with the morn, those angel faces smileWhich we have loved long since and lost awhile.Part of this Debate has consisted of a resolute attempt on the part of some Members of the official Opposition to represent that unwise restrictions are being placed on the public health services, in the interests of economy. For that suggestion there is no shadow of foundation of any sort or kind. The first argument used in favour of that contention was a misquotation of a circular on economy issued at the time of the nation crisis to local authorities. I propose to give the actual words of that circular and to ask the House whether there is anything in it to which the greatest advocate of the efficiency of the public health services could possibly object. The words of the circular are:His Majesty's Government would not, however, contemplate that local authorities should embark on a wholesale and ill-considered course of cutting down expenditure, 723 whatever be its character or its purpose. Such a policy seems to them neither necessary nor advisable.Is there in that any reckless disregard of the efficiency of the services in the interests of economy? Further down in the circular we find the special reservation, that consideration is to be given particularly to whether a service is required on urgent grounds of public health. It is the policy of this Government, as it must he the policy of every Government which has the welfare of the country at heart, to consider public health as a matter of urgent national importance and to regard that economy as a false economy which would reduce the efficiency of the essential services.
The other argument used in favour of this contention from the official Opposition has been the misrepresentation—I do not suggest that it was intentional misrepresentation—of the facts of the case. It is not the fact that there is a reckless and wholesale restriction of the development of public health services or that those services are not being maintained on a basis of full efficiency and reasonable progress. I shall give some facts to show how little there is in the suggestion which has been made to that effect. I have had the advantage, of course, which hon. Members opposite have not had of being able to see the whole field of the figures at once, and I have taken pains to get an estimate of all the schemes of development in matters of public health before the Ministry at the time of the oncoming of the effort for economy. These amounted roughly to £1,000,000 worth and of that not more than £150,000 worth had to be abandoned as not essential. I ask the House to compare that figure with the observations which have been made and to say if that is not the amount which they would have expected from any reasonable administration in view of the urgent financial necessities of the case and their relation to the necessities of public health.
Let me go into the matter in a little more detail in order to show how unjustified is the contention of the Opposition. I do not believe that many words are necessary for me to persuade the House that there is no contradiction between the interests of economy and the interests of public health, but that the two are 724 one and the same. That money which is spent on essential and urgent services of public health is money spent in the interests of economy, to save waste and to save larger expenditure hereafter. That is the principle at the bottom of all sound administration—that money spent on necessary services of public health is a good national investment. Of those services I would put the following in the forefront, at the present time, and under existing conditions, speaking with full knowledge and with the best advice available as regards the needs of the nation. I would put first the service of maternity and child welfare—there will be no disagreement on that—and the service for dealing with the great scourge of tuberculosis. I take these two as examples of outstanding urgent public health services and I propose to give one or two facts to show that in those services there is none of that reckless abandonment of public health work which has been suggested from the benches opposite.
About tuberculosis I may say in passing that we have now an important new weapon in the fight against that great white scourge. Since the initiation of the new system of local administration, owing to the co-ordination of public assistance with public health services, we can now follow up cases when they leave the sanatorium. We can effect a more perfect co-ordination in that respect, so that the fighting effort against the disease can be more effectively brought to bear. Let me take, as a test of the maintenance of the effort for the public health services, the treatment facilities available for tuberculosis. At the end of December, 1930, the number of beds available was 15,972; at the end of December, 1931, the number available was 17,609. There is no evidence there of relaxation of effort. In regard to the other great service which I have mentioned, namely, maternity and child welfare, at the end of 1931 the number of infant welfare centres in England and Wales was 3,043 compared with 2,935 at the end of 1930. Again an increase. No evidence of relaxation of effort there. The number of ante-natal clinics in England and Wales at the end of 1931 was 1,262 compared with 1,101 at the end of 1930. I assert without fear of contradiction that if the House looks into the actual figures and facts and the record of work done for the essential ser- 725 vices of public health, they will find no evidence whatever of that slacking of effort which has been suggested this afternoon.
The right hon. Gentleman the Leader of the Opposition raised the question of maternal mortality. We all know the whip of failure which is urging us forward in connection with this matter. It is the failure to secure a reduction of maternal mortality, and that reduction is the goal which we have set before us. I know that a scheme was put forward under the late Labour administration for the service to which the right hon. Gentleman referred, but he will forgive me for saying that I think that scheme was typical of the complete lack of touch with realities in administration shown by the Government of which the right hon. Gentleman was a Member. It would have placed a burden on the country's finances of a nature which the country was totally unable to bear at the time. I contend also that it was not well conceived to get the best possible use out of the public money which would have been so largely required to finance it. But because that is a frank impossibility at this time, does it mean that we are to relax in the effort of the war on maternal mortality? On the contrary, to get rid of illusions will enable us to proceed in the most practical way and to get the best use of the resources available.
We have already sent a circular to the local authorities for this purpose. There are services for promoting the welfare of mother and child before, at, and after birth which local authorities can render. They do not all render it. What can be done is to stimulate the local authorities to come up to the standard of the best, and until we make the best use of the powers we have, it is waste of time to give new powers. That is what the effort of the Ministry will be under my direction with the consent of His Majesty's Government. Further effort will be made to persuade the local authorities—those that need persuasion; there are many who do not—to improve and strengthen their maternity services. Stress must be laid on the importance of educating the women themselves to take advantage of the services. It is no good providing services if people do not know enough to take advantage of them, and you must go from 726 the provision of the services to the provision of education to make people appreciate their value. Particular attention must be paid, of course, in the interests of economy to those areas in which the mortality among mothers is the highest. It is there that we must direct the biggest effort. It is in this direction that we must look for the really successful advance against this great foe of the human race.
I should like to pause at this point to congratulate my hon. Friend the Member for Denbigh (Dr. Morris-Jones) on the use that he has made of his good fortune in the Ballot by introducing this topic and on the extremely thoughtful and informing speech which he made. I listened with consternation to the expert knowledge which he conveyed of these regions of administration. It is most interesting at the beginning of this important reform in administration to stand before the House and to give some account of the advance which has been made in the working out of the many far-reaching and far-regarding schemes that were laid down in the Local Government Act, and to point out, what experience shows to be the case, the verification of the high expectations which were formed at the time the Act was passed. I think the report to be good. As far as good expectations ever found their fulfilment in this bad world, I think that in this case there has been a measure of fulfilment of expectation which is above normal.
The co-ordination of public health and public assistance—that is, the old Poor Law—is already yielding most valuable and interesting and important results, both in efficiency and in economy, which is part of efficiency. I think that I see a stimulus to the activity of local authorities, and I think that I see it resulting from the fact that they are freer in matters of finance in the sense that they are more masters in their own house. That is the result of the block grant system which gives them a security and control which were lacking from the old percentage grant system. Let me, in passing, make a reference to the sum, with which hon. Members will be well acquainted, of £5,000,000 of new money which was put into the scheme, that is £5,000,000 increase in Exchequer money which was made available for local authorities at the time of the institution 727 of the block grant system. That money has for its specific purpose the promotion and extension of such services as those which we are considering to-day. I refer to this in order to show that in the general scheme of our finances there is no need for an immediate grip of parsimony such as there is in some other national services, because there is this margin in the block grant for the development of such services as those to which I refer. When I speak of the extension of the maternity services and the effort to be made to secure a better standard in those services among local authorities, I am relying upon the margin which was provided by this £5,000,000 to make possible such extension and development.
That is one benefit from the new scheme, namely, a greater sense of freedom and initiative for local authorities. I find another benefit closer than that. That is an ability on. the part of the Ministry of Health to concentrate with a more single mind on its more proper work. The appropriate sphere for the action of the Ministry of Health in this regard is to be the clearing house of knowledge and information and not, let me assure the hon. and gallant Member for Albans (Lieut.-Colonel Fremantle), the arbitrary tyrant, but the clearing house of knowledge and information and the source from which counsel and advice can proceed in order to place the local authority, which is in its nature local, in touch with the best examples and best knowledge available for their service. The Ministry has another great function. It has, to a large extent, to be the staff brains of the whole national health services. I am not meaning to claim any monopoly of brains for the Ministry of Health or for the Minister in relation to the national health services. I carefully say the staff brains, whose function is to provide the staff work for the national health services, that is, the kind of work which can best be done by a central staff.
I would invite the attention of the House to special inquiries which we carried out quite recently in the discharge of these staff functions into tuberculosis, cancer and cerebrospinal meningitis. They are characteristic of the good work which can be done by the central body for the help of the local authorities, 728 in putting the best knowledge at their service and enabling them to direct their own efforts in their contest with these diseases into the best channels. Another characteristic bit of staff work of this sort at the Ministry of Health is in connection with the important matter of nutrition. This is a modern science on which floods of fresh light are being cast every day, and it is difficult even for the medical officers to keep up-to-date with the latest information. In order to help them we have instituted a new standing advisory committee to concentrate and to bring to bear the latest information on the subject of nutrition for the benefit of the medical profession and the public as a whole. The practical lesson, of experience is that this is not. very important for the middle and upper classes where there is a varied diet, but for the wage-earning classes, where diet is not so varied, it is most important that this modern knowledge as to the sources of health in nutrition should be brought to bear. The Committee have brought out two reports, one on diet in Poor Law children's homes, and the other on the vitamins, where the uninitiated can follow the natural history of these difficult subjects from Vitamin A down to Vitamin D, and even to Vitamin E and its function in promoting the fertility of rabbits.
Let me turn to one or two of the questions which were put to me in the course of the discussion. I shall have answered some in what I have said already. The hon. Member for Denbigh asked what progress was being made with the classification of institutions, and in particular the transfer of hospitals from Poor Law conditions to the new status of the general purposes hospital. That is a problem which cannot, possibly be dealt with effectively in a short time. It must take time, and in particular necessitates a general survey of accommodation before action can be taken. But I can say that the progress has been good and certainly satisfactory, particularly in London. Sixty-eight institutions have been appropriated for special purposes, that. is, from general Poor Law purposes to special purposes following on a scheme of classification, according to our last report. Since that report, 11 more have been appropriated. 729 There is nothing to complain of in the rate of progress there.
Let me state my experience of the extraordinarily beneficial effect of the transfer from Poor Law status to general public status in the case of these hospitals. It is acting as a remarkable stimulus upon the institutions, since it makes them, as it were, equals of the greatest and most famous hospitals in the land. I find something beautiful in the new courage, the new enterprise which this sense of full status has given to these institutions. It is a matter in which we can all take pride that the ranks of those famous institutions, whose names are so well known to us, are now being joined by hospitals all over the country. Let me say a word as to the co-ordination between the old voluntary hospitals and the new public general hospitals, about which I was asked by several hon. Members. It is the policy of the Ministry of Health to co-ordinate that co-operation between voluntary and public hospitals in every possible way. The necessity of the voluntary hospitals as a part of our national hospital scheme is, of course, recognised as an essential part of the structure. Both the voluntary hospitals and public hospitals have their own useful fields of activity. I know of no sense of hostility or antagonism between them and, indeed, there is no reason why there should be. The only rivalry is as to which can treat their patients best. As regards co-ordination of their functions. That is the task of the Ministry of Health. The Ministry of Health must see that the two divisions in the hospital structure shall each pay due regard to the opportunities and possibilities of the other and that each shall be duly fitted into the structure.
The hon. Member for Denbigh asked me how the area review was proceeding, the review of boundaries. It is proceeding as fast as the difficulties will allow. There are of course great difficulties, because the idea is so novel. We have to reconcile old traditions, old prejudices, and in some cases old antipathies in order to carry out arrangements desirable in the interests of economy and efficiency in the modern world. On the whole, progress has been satisfactory. Nine reviews have been completed and four more inquiries have been held which will lead to a decision very shortly. In addition to those 730 13, 15 others are in course of being arranged and, as regards some others, it is necessary to give those extensions of time which the Act contemplated would be necessary. The progress is considered to have been satisfactory upon the whole. The hon. Member for Denbigh asked me how many exclusive declarations have been made since the last report. It is the policy of the Ministry of Health to encourage making such declarations where it is possible in order to complete the process of segregation of activity which is the primary object of the Local Government Act. Here, again, a careful survey of all the services necessary was made, and in many cases a survey of the institutions must proceed to a fairly complete stage before a declaration can be made. Therefore, we shall not expect many declarations just yet. The number made last year was five.
I was asked some questions by the hon. and gallant Member for Thornbury (Captain Gunston) in regard to the working of the formula. So far the formula has worked with surprising smoothness. I say "surprising", because anyone acquainted with that marvellous product of the human mind could not imagine anything that would suggest more complexity of administration. It is, however, related to the practical life as well as to the theoretical life, and it has been found in practice to work out without difficulty so far. As to the question of registrars, about which he asked, schemes of reorganisation were due to be submitted by this month. They are very complicated schemes and postponements, for which provision is made in the Act, have had to be given in most cases to allow consideration to be given to the schemes. Three or four schemes are, however, actually in operation. The power to increase the schemes has not yet been considered. As to the question in respect of the co-option of guardians, I would refer him to pages 195 and 196 of the last Report of the Ministry of Health, where he will find an analysis of the situation in respect of the co-opted members of guardians committees.
Finally, the hon. Member for Fulham East (Sir K. Vaughan-Morgan) asked me a question as to the present situation in regard to the post-graduate school. That is a typical instance of how the voluntary hospitals and the public 731 hospitals can discharge complementary functions in the whole scheme of hospital accommodation and medical education. I am glad to say the postgraduate school has now actually come to birth, and it is a birth which we believe to be of very great promise for the future of medical science, medical education, and the health of the people. It has come to birth at the London County Council Hospital at Hammersmith. It will be, therefore, a school in connection with a public general hospital, the only one of the kind. The present stage of its evolution is this: The charter has been granted and the governing body set up. At present the actual organisation of the school and a scheme for the provision of buildings for the school are being worked out. That stage is being gone through now. The hon. Member will see things are in train, and before very long, we hope to see this school with all its promise for the future, with all its promise for the co-ordination and fulfilment of medical knowledge, an established fact.
I believe I have dealt with all the matters raised in the course of this Debate, and have given the House ground for dismissing whatever fears may have been caused to them by the criticisms of the official Opposition by showing that there is no disregard of essential public health services at the present time. On those interesting questions raised by the opener of the Debate, I believe I have been able to show the House that the high hopes which were formed of the Local Government Act at the time of its introduction are now from the experience of administrators being brought into actual fruition.
§ Dr. MORRIS-JONES
In view of the full explanation of my right hon. Friend, with the permission of the Seconder, I beg leave to withdraw the Amendment.
§ Mr. DAVID GRENFELL
I regret that the Minister was not given an opportunity to follow all the speakers on this side of the House who were prepared to take part in the Debate. The right hon. Gentleman commenced his speech by humorously twitting the right hon. Member for Bow and Bromley (Mr. Lansbury) on his alleged conversion to the Act of 732 1929. He did scant justice to the right hon. Gentleman. When the time comes to assess the errors and the rectitude of my right hon. Friend, it will be found that he has been most often on the side of the angels arid has been a leader in the march towards happier and healthier social conditions. Like other apostles he has lived among the people, he has challenged authority and he has been to prison. He has gained experience from contact with his fellow-men and is here an example of the vitality and health which he desires other people to enjoy.
I wish to comment on one or two points made by the Minister himself. He claimed that there had been an increase in the number of child welfare centres. We do not grudge him whatever credit is due, but really the figures, as they were given to us, are not so satisfactory as they appear at first. sight. An increase of 108 in 3,000 is just over 3 per cent., and is not a very great acceleration having regard to the importance of this work. As to maternal mortality, I do not blame the present Minister and those responsible for this very difficult matter. This is the most perplexing obstacle to modern science that this country has now. Strangely enough, in this roost highly-civilised country, with our medical science at its highest point of efficiency, this disease is more prevalent than in countries medically and scientifically much more backward.
The right hon. Gentleman referred to the need for the study of nutrition. This, it is said, is a modern science which does not concern the middle and upper classes, who always have a variety of food, but is very important for the working people whose means are more limited and whose range of diet consequently more restricted. I hope no one will take offence when I say that we are a little tired of that sort of comment. We represent the working people, and we know that they are not getting the quality of food that they require. One gets a little tired of hearing about the need for more knowledge, more science, more study for the working people. Why not try them with more food, with a little more play and with wholesome food? The hon. and gallant Member for St. Albans (Lieut.-Colonel Fremantle) and the Mover of the Amendment know quite well that if a 733 better standard of life were maintained the standard of health would be considerably improved in a very short time. But they come here in no mood to criticise or to condemn. They came here to-day with congratulations for the Ministry and for the profession which they adorn. It occurred to me that they were reversing the old phrase which we have heard so often, and were praising with faint damns. The Minister was not a bit disturbed by anything that was said by either of them, and no one minds what was said by the two hon. Gentlemen representing the medical profession. They have not given us the benefit of their medical knowledge. They know we are not doing anything like the work we should do about preventible disease. After all, it is much better to prevent disease than to try to cure it.
This Debate has centred around organisation and inquiries and research. We have heard a great deal about the rival merits of voluntary and municipal hospitals, about organisation and about medical services. It sounded to me like the old-time recommendations of poulticing, binding and wrapping up, and bloodletting, which were the stock recommendations of the medical profession a generation or two ago. When will the doctors in this House and in the country give us a clear lead? Why not get down to the cause of disease, bad housing? An hon. Member referred to the development of a housing estate in the county he represents, and I am glad he did call attention to it. It is not the only case, and I hope his words will be heard out-side this House, because thousands of jerry-built houses are being erected. Then there is also the question of existing houses—old houses, condemned houses, dark, leaky houses, houses with bad floors and houses with imperfect chimneys, houses in which it is a punishment to live. There are thousands of such houses. Speaking personally, I would much prefer to go to a clean, dry, prison cell for 12 months than endure the housing conditions which I see in some parts of the country. These bad houses should be done away with, the slums should be cleared away, and new houses built. That will make for a sturdier race. Tit rural constituencies there are school buildings in which it is a punishment for the children to have to 734 remain for four or five hours a day for five days a week. Children there acquire the seeds of diseases and illnesses which affect them for the remainder of their lives.
Children also suffer from poor and insufficient food. The hon. Member for Ebbw Vale (Mr. A. Bevan) gave figures the other day to show the disparity in height and weight between children living in depressed industrial areas and those under happier conditions. At 12 years of age there was a difference of two inches in height and of seven or eight lbs. in weight, and a difference also in vitality and energy. I do not think it, matters very much how many inches a man has when he has finished growing, but it does matter very much if his lack of inches is clue to under-feeding having sapped the body of its vitality. It is a crime that young people should be denied the chance of growing up strong and healthy and be condemned to a life of semi-invalidity, a life of physical inefficiency because of lack of sufficient food. There are ample statistics to show the prevalence of rheumatism, and while no one will say that, rheumatism can be traced to any one cause it is known to be due to improper food and improper conditions of life, and to be more widespread where conditions are bad. Chest troubles are widely prevalent in this country, partly on account of the climate, but mainly because of under-feeding and lack of care in the years of childhood. Preventible measures ought to he the subject of special addresses for the instruction of Members by the hon. and gallant Member for St. Albans, who knows so much about this subject but is so unwilling to give the information which the House requires. Nothing gives me greater joy than to see schoolchildren nowadays, because of the change in the methods of instruction, the change in the relations between teachers and children, and the improvement in school buildings. Everything is so much better now than in the days when I went to school. But we can do still more to improve the conditions of children, which will lead to happier manhood and womanhood.
I come now to a subject which I have sought to discuss in this House. I am not sure whether it is in order to-night, hut I would like the Parliamentary 735 Secretary to listen to me. The subject is the widespread prevalence of industrial disease. I live in a part of the country where there is a greater variety of industries than can be found, possibly, anywhere else in the world, in a similar area. Those industries include coal mining, steel manufacture, tinplate works, spelter and lead and copper smelting; and there are railway works and docks, and pitch and fuel making industries. I would like to know that the children who have been given a good start in life under conditions prescribed by the Ministry of Health will not, when they go into industry, be subjected to unhealthy conditions.
§ Mr. SPEAKER
The Home Office, and not the Minister of Health, is responsible for industrial disease.
§ Mr. GRENFELL
I agree, but the Minister did make reference to inquiries into the incidence of cancer, tuberculosis, cerebrospinal meningitis, and other diseases, and the Ministry, in its coordination of medical services and medical research, might make inquiries into this subject. I believe a large number of those engaged in these industries become a burden on national health insurance and on other public services on account of the circumstances connected with their employment. Is it not possible for an inquiry to be made into the incidence of cancer in industrial districts to see whether or not there is any connection between the conditions in certain industries and the other conditions which give rise to cancer? It might afford an important clue. I know it is very often a subject of amusement, but there are people who believe that the presence of petrol fumes in the air is responsible for cancer, and others who believe that the use of tar to spray roads is responsible for cancer. If there is any doubt as to the effect of tar and petrol fumes, why not make an examination, perhaps jointly with the Home Office, to see whether they have any connection with the cancer which is known to be incidental to fuel making and one or two other occupations. We have our responsibilities to the people who sent us here, and there is no more important responsibility than looking after the health of the nation. I am not satisfied that we are doing as much as we might do. The Minister ought to take 736 his responsibilities more seriously, and not be lulled into satisfaction by speeches like those of the two hon. Members who spoke first in the Debate. There is ground for commendation, but, there is also ground for criticism, and I hope the Minister will meet us on this ground, not be content with small accelerations in the services, with small improvements here and there, but go on to a thorough overhaul of our medical system in order to secure the utmost efficiency.
§ The PARLIAMENTARY SECRETARY to the MINISTRY of HEALTH (Mr. Ernest Brown)
I would like to say a word or two in reply to the hon. Member for Gower (Mr. D. Grenfell). No such lighthearted view of the problem is taken by the Minister as he would scorn to suggest in his last few sentences. If the hon. Member will study the last report, that for 1930, issued by the Chief Medical Officer of the Ministry of Health, he will find, on page 105, a most valuable section dealing with the problem of cancer, and on page 123 he will find a section dealing with rheumatic diseases. So far from being lax in this matter, the Ministry is thoroughly alive to the need for research as well as for action in connection with these diseases. As to his desire to place a halo round the head of his own leader, of course we have no objection to that.
§ Amendment, by leave, withdrawn.
§ Main Question again proposed.