MATERNITY SERVICES (SCOTLAND) BILL.

HC Deb 28 January 1937 vol 319 cc1099-154

Order for Second Reading read.

3 58 p.m.

The Secretary of State for Scotland (Mr. Elliot)

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

This Bill is intended to deal with a stubborn and intractable problem which, for long, has preoccupied those who are engaged in the public health service in Scotland. I refer to the problem of maternal mortality. In 1935 there was issued, under the auspices of a specially appointed sub-committee of the Advisory Committee of the Department of Health for Scotland, a report on maternal morbidity and mortality in Scotland. That was the report of a highly competent, technical committee which included among its members Professor Johnstone, Professor of Midwifery in the University of Edinburgh, Professor Hendry, Professor of Midwifery in the University of Glasgow, and Dr. Buist, Dundee, Chairman of the Central Mid-wives Board of Scotland. In a prefatory note to the report it is stated that these eminent gentlemen concur in the conclusions and recommendations formulated, and at the same time desire to record their conviction of the urgent need for improvement in the standard of midwifery in Scotland.

This Bill is for the purpose of carrying out, as far as possible, the recommendations of that report, and I believe that the House and, later on, the Scottish Standing Committee will find that it does so very closely. The object is to improve the standard of midwifery in the home in Scotland, and to secure adequate nursing and medical services for women who are confined in their own homes. The Bill is based on the recommendations of this report, and I hope very much that it will be found to be non-controversial, as it certainly is nonparty, for I am sure that right hon. and hon. Members in all quarters of the House will concur emphatically in the desire to remove the reproach under which we lie in Scotland in relation to maternal mortality. I hope that the House in general will assent to the recommendations which we are laying before it today to remove that reproach. We do not wish, of course, to paint too black a picture of the conditions out of which the Bill has arisen. It would certainly be wrong to spread amongst prospective mothers an impression that might give rise to a complex, a feeling of fear or panic with regard to confinement, for, after all, child-bearing is a normal function and it should not be associated with the atmosphere of dread of a major surgical operation. It is true that there is a death rate of six mothers for every 1,000 children born in Scotland. That indicates a greater degree of ill health, which we cannot properly measure but which we all know, even from our own experience of personal friends and acquaintances, is far greater than it ought to be. We believe that some of these lives could be saved and that much of this ill health could be prevented by properly co-ordinated arrangements for attending to the health of the women before confinement, during confinement, and after confinement in their own homes.

In short, the purpose of the Bill is to secure for every woman in labour in Scotland the same order of skill and attention as we would wish for any of our own people. The practice in regard to maternity in Scotland differs from that in England. Scottish doctors take a larger part in confinements than English doctors, and the midwives, of course, take a correspondingly less part. The Bill takes account of these conditions and differs from the English Bill. The scheme of the Bill is not limited to a midwife service but also brings in doctors and a specialist service. Every expectant mother who desires to be confined in her own home will be entitled to obtain the services of a midwife and doctor, and, what is more, if the need arises the doctor will be at liberty to call for the advice or help of an obstetrician of recognised standing. There may be districts in the Highlands and Islands where it will not be practicable to make specialist help readily accessible, but the intention is there and it will be carried out as far as is humanly possible. When a suitable period has elapsed after a confinement the doctor will visit the mother with a view to giving her advice as to any treatment she may need. We think that this post-natal examination is of the greatest importance as a means of preventing the development or the continuance of con- ditions that may give rise to ill health in later life.

Therefore, I ask the House to picture the midwife, the doctor and the specialist working together as a team. They will work under the general administration, guidance and oversight of the medical officer of health. His advice will be available to the doctor and the patients if any difficulty arises as to machinery or procedure. The scheme is founded on co-operation between the doctor and the midwife. It arises naturally out of the existing conditions in Scotland. But it is not necessarily the only method of ensuring an efficient maternity service. It may be desirable, as a result of experience, to modify the arrangements that I am now asking the House to assent to. It is true that the Scottish practice is for the confinement to be attended by a doctor, so we think it right that at any rate in the initial stages the general practitioners should be given a chance to show that the confidence placed in them is justifiable. We hope that with the arrangements of the midwife service and the advice of highly qualified specialists at call the doctor will not be required to go beyond minor assistance. It has been said that part of the high mortality rate in Scotland is in fact due to over-anxiety on the part of the medical man. The tendency perhaps has been to hurry the operations of nature. Confinement is not to be regarded as an operation in which the doctor has the whole work and responsibility, but as a natural event which he should supervise and guide if necessary, but one in which the patient is certainly going to play far and away the major part.

The local authority arrangements of the Bill I must deal with next. The arrangements that the local authorities will be required to make for providing this service will be subject to the approval of the Department of Health. That is set out in the first Clause. The local authorities in the first place commented rather adversely on that proposal, complaining that they were being put under the control of the Department of Health. I wish to make it clear that that is not so. These provisions are inserted in the Bill to ensure that not merely the Department of Health but, through the Department, the Minister, and through the Minister this House, can continue to keep an eye on the working out of these provisions. If the arrangements were left solely to the local authorities the Minister would have the defence that the responsibility was solely that of the local authorities and that he could not interfere. It should be possible to raise the matter administratively on what is the most sensitive point of all for a Minister, that of his salary, when the Estimates come before the House, and to ask whether in fact the arrangements which are being carried out are the most effective to bring about the desired result.

Mr. T. Johnston

Is the right hon. Gentleman wedded to the exact form of words to be found in Sub-section (2) of Clause 1?

Mr. Elliot

No, I have had discussion with the local authorities on this point, more particularly with the Glasgow Corporation, who suggested that they could with advantage modify these words. I have said that I would be most glad to have an Amendment drafted by them. It has been drafted by them and put up not only by the Corporation but, I believe, by the Corporation after consultation with some of the other great local authorities, and I am prepared to accept that Amendment substantially in the form in which it has been drafted. There will, of course, be elasticity for the local authorities in making their arrangements, because certain areas, such as the Highlands and Islands, have difficulties with regard to communications which will have to be taken into account. For the service of midwives it will be open to the local authorities to arrange with the voluntary associations which employ midwives or to arrange with midwives engaged on private work, or themselves to establish a salaried service of midwives. Before submitting the proposals to the Department the local authorities are required to consult the voluntary associations which employ or are willing to employ mid-wives in their areas, to consult with any organisation which has the right to speak for the midwives practising in an area. That is only reasonable. In fact very strong representations have been made to me on behalf of these voluntary associations. It is only reasonable that they should be taken fully along with this great effort, because they have rendered great service in the past.

The remuneration of midwives is, of course, a vital question for the midwives- themselves. But those are points which will arise for discussion in Committee. I think it is inevitable that when the scheme comes into full operation the handy woman will disappear from the scene in Scotland. I think that it is true that the, number of midwives in practice will be reduced by the operation of the provisions for compensation on retirement. Moreover, the midwives engaged by the local authorities will be paid either by those authorities, or by their own associations and will no longer have the not uncommon experience of rendering services for which they receive no fee. In fact the future holds for midwives brighter prospects of a reasonable livelihood than they have had before. When the full service is in operation it is clear that there will be quite a number of midwives who will not be absorbed into it. These cannot all make a living now. It is provided in the Bill that if a midwife gives up a certificate within three years after the Bill has passed she will receive as compensation three years' income, calculated on the average for the previous three years. Many midwives remain in practice after they have really become unfit, and in those cases the local authorities are empowered to call upon the midwife to surrender her certificate, subject to a right of appeal to the Department, and such midwives will receive five times their average income calculated on the previous three years.

The local authorities will be free to select their own types of arrangement for securing the medical services, so long as those services are adequate. In some areas the local arrangement will be with all the medical practitioners in those areas who are willing to undertake the service. In other areas the ante-natal and postnatal examinations may be carried out at the authorities' clinics, and arrangements may be made with all the practitioners or with a limited number. In such a case the arrangement will be to secure that the doctor attending the confinement will be advised of the results of the examination which has been carried out before.

Now I will come to the question of the mothers themselves. How far are expectant mothers likely to avail themselves of this service? The service is offered; it is not thrust upon anyone; it is not compulsory. But we do expect it to be taken advantage of generally. The fees will be graded according to the ability of the patient to pay, and no fees will be charged in the case of the necessitous mother. In the case of insured women, the wives of insured men, and women in a similar economic position, it is hoped that the financial arrangements will enable local authorities to provide a complete range of service at home at a fee not much, if at all, higher than is at present payable for the services of a midwife alone. This provision will enable women to authorise payment to the local authority out of the maternity benefit due to them under the National Health Insurance Act.

I have received representations upon that point, for there are views held both for and against this proposal. While I prefer the proposal in the Bill, I shall have an open mind on the subject and shall be prepared to listen to arguments for and against on the Committee stage. I do not think that anyone will expect me to go further than that at present. I would only say again that this is not a party matter, because there are views in favour of the money being paid to the local authorities strongly held by hon. Members on all sides of the House. I do not think that the maternity services will achieve the maximum effectiveness without the fullest cooperation of the mothers themselves. I have already stated how necessary is the fullest co-operation between all the team who will be working to assist the mother.

The finance of this Measure is as follows. Where the local authority makes arrangements with midwives in private practice, or has taken midwives into its employment, the fees and salaries will be fixed and paid by the authority. If arrangements are made with voluntary asociations for the services of midwives in the employment of the latter, the payment to be made to the association by the local authority will be a matter for negotiation between those bodies. The payment for services rendered by the doctors will be made by the local authorities in accordance with scales fixed by the local authorities after consultation with the appropriate organisations of doctors. It is not easy to forecast how much the improved service which we contemplate will add to the present expenditure of local authorities on maternity services. On a rough estimate, when the new services are in full operation the additional expenditure, after taking account of the fees recovered, may reach £120,000 per annum. When the Local Government (Scotland) Act, 1929, was passed the percentage grant was replaced by a block grant. It was also stated in the Act that, in the event of material additional expenditure being imposed on local authorities by the initiation of a new service, Parliament will provide further money in respect of that service. Clause 3 of the Bill gives effect to this clear intention and proposes a grant equivalent, approximately, to half the total additional expenditure of the authority.

I have had representations from certain local authorities that the sum proposed is not sufficient, but that goes without saying. They also represent that the intention of Parliament in passing the Act has not been fulfilled; and certain local authorities are not satisfied with the proposed method of distribution of the sums. The arrangements are set out in Clause 3. They are that the grant to each authority will be half the estimated additional expenditure and will be scaled up and down in proportion to the need of the area determined by the weighted population under the formula of the 1929 Act. Certain authorities complained that they were not satisfied with the treatment they had received. I hope that the proposal I make will seem reasonable to the local authorities. I shall be prepared to move an Amendment that the Bill should not come into operation until the day after the third fixed period begins, that is to say, 16th May, which is he day after the new block grants have begun to run. I have hopes from my discussions with local authorities that the proposals which we have submitted to them with regard to the amount of, and the weighted formula for, the new block grants will enable us to reach agreement with them. Therefore, if we calculate the grants under this Bill on the formula to which, as I say, I hope the local authorities will agree, and if we bring the Bill into operation the day after the beginning of the grant period for which Parliament will have provided an increased sum for these services, I hope the local authorities which made these representations will feel that both in the spirit and in the letter we have done our best to meet them.

Mr. N. Maclean

Will that not necessitate an Amendment of this Bill when it becomes an Act, because the formula in it is the formula that appears in the 1929 Act?

Mr. Elliot

I am advised that it can be done simply by saying that these things shall begin to run from the commencement of the Bill. The commencement, as the Bill stands at present, will be from the date when it receives the Royal Assent, but if we put in a fixed date it will run from that date. It would be anomalous if we allowed the financial and other calculations to depend on the arbitrary date on which the Bill receives the Royal Assent. It might be in the last block grant period or in the new block grant period. It might be according to the old formula if it received the Royal Assent before the third fixed grant period begins, while if it were delayed a few days it would be under the new formula. I do not think that important things like that should depend on a casual factor such as the date of the Royal Assent. Therefore, I hope to put a fixed date in the Bill, and I am sure that it will be more satisfactory to the House and the local authorities.

The local authorities will also receive Exchequer help in the amount of their liability for compensation of midwives who retire. That, of course, is a transitory liability limited to three years following the commencement of the Bill. In all cases one-half the compensation paid during that period will be borne by the Exchequer. There are, of course, a great number of points that will arise in the discussion of this Bill, but they are more points for discussion in Committee. For instance, the Universities and teaching institutions are concerned about the cases which will be available for the training of medical students and women in midwifery. Provision is included in the Bill that the local authorities and the Department, in exercising their functions, shall have regard to the desirability of maintaining facilities for teaching. The approved societies have expressed approval of the Bill, although some of them are a little apprehensive about some aspects of Sub-section (2) of Clause 2 dealing with the voluntary power to pay over a proportion or the whole of maternity benefit.

I hope that we shall be able to pass this Bill as soon as may be to the Committee stage. I have taken a little longer than my ideal time of 15 to 20 minutes, which experience shows is just the time that either Ministers or Members should take in discussion. I apologise to the House for having over-run my time very briefly. I will content myself with saying that it is not for lack of interest in the subject or of a desire to place it fully before the House and the country that I have curtailed by remarks to the business aspects of the question. Anyone who, like myself, has had some training in the practical aspect of this problem cannot help feeling that it is one of the most important which the House can consider, or in which the public health services can assist. Anything that we can do to forward the object which this Bill has in view will, I am sure, not be time wasted or labour lost.

4.26 p.m.

Mr. Johnston

We on this side of the House approach this Measure with sympathy, but our duty, naturally, is to apply our minds to a critical examination of many of the details. We trust that on the Committee stage the reasonable and persuasive attitude which the right hon. Gentleman has adopted to-day will be in evidence when he comes to examine our proposed Amendments. I am sure from past experience that that will be the case. I am glad that he did not attempt any facetious references to Sairey Gamp, and so on. The Sairey Gamps have really long disappeared from our health services in Scotland. Many undeserved epithets have been thrown at the "howdies" and the midwives in Scot-land, but those epithets will, I am sure, find no place in the discussions which take place here and upstairs. While by the sheer force of circumstances the right hon. Gentleman and the Government are being driven to make proposals in the direction of Socialism, they cannot help themselves—

Sir Samuel Chapman

It is social reform.

Mr. Johnston

It is Socialism, as I hope to show in a few moments. I know that that word stinks in the nostrils of the hon. Gentleman—

Sir S. Chapman

I do not know what the right hon. Gentleman means. I have used the phrase "social reform" for 50 years on platforms. I have always been a social reformer, and I am glad to hear my right hon. Friend introduce this Bill.

Mr. Johnston

I wish the hon. Gentleman well in his missionary progress towards the proposals which we on this side have been returned here to promote. I am sure that he is going into the Lobby to-day to vote for a municipal medical service under public authority, with mid-wives paid by public authority, and to secure a public health service among our women which could not be secured by the individualist effort which he has supported in the past. I desire, if I can, to avoid controversial matters. I am certain of this, that there will be general agreement that this Bill is rendered necessary by the remorseless development of the social conscience in recent years in Scotland.

The right hon. Gentleman said, quite truly, that we had a very high maternal mortality rate, but he did not explain why we were 15 per cent, worse than in England, nor did he seek to explain why also, in a model area in London, instead of having a death-rate of six per thousand, as we have in Scotland, they have got it down to 0.68. Nevertheless we welcome this Measure, and it goes very much further in the direction of Socialism than the corresponding Measure recently passed by this House for England. It is not only maternal mortality to which we have to pay attention here. In Edinburgh they followed up maternal cases after the women had left the clinics supposedly cured, and they discovered that there were 30 per cent, of those cases of women who had serious illness and remained seriously ill for long periods after they had been discharged from the clinics, so that we are facing not only a mortality rate of six per thousand, but also a very high sickness rate arising from our maternity arrangements.

I have said that we are laying the foundations of a new municipal service in midwifery, and I was very glad to see that the chief medical officer in Glasgow. Dr. MacGregor, was one of the signatories to the Minority Report on the Scottish Health Service, which declared that he was prepared to go very much further even than this Bill goes. He was not only prepared to have municipal mid-wives, but he was prepared to have a complete medical service with doctors and midwives in the employment of the local authority. We have not got that length yet, but the right hon. Gentleman has given us in this Bill at least municipal specialists to deal with the difficult cases, where there is an arrangement made to have hospital treatment for such cases; and with the exception of municipal doctors we have got pretty nearly everything in this Bill that we have been asking for in recent years.

A great deal, however, will depend—I hope that the Lord Advocate, who, I understand, is to wind up the Debate, will give particular attention to this point—upon the character of the Regulations which the Department is going to insist upon. It is all very well to say that the Department shall require an agreed scheme, but what is in the Government's mind as to what they intend to import into these Regulations? For example, we know that there are already two authorities in Scotland which run a most efficient system of home helps, but there is nothing about home helps in this Bill. It may be that the right hon. Gentleman and the Department intend to include home helps in the Regulations. If so, we shall be most delighted to hear it, but the right hon. Gentleman and the Government must really consider whether they are dealing effectively and completely with the maternity service if they are not going to provide for the necessities of a household when the mother is taken away, for example, to an institution for a lying-in period, leaving a young family perhaps to the care of a neighbour and the mother worried when she is away. Unless some provision is made in the nature of home helps, as they are called, I am afraid the right hon. Gentleman will not get the same ready acceptance of his offer to the women of Scotland to go for their lying-in periods into hospitals that he would otherwise get. I trust that the Lord Advocate, when he replies, will give us some indication of the Government's view upon that point.

There is another question that causes us on these benches very considerable concern. There is nothing here, of course, about malnutrition, but we know that Sir George Newman has laid it down that in his expert opinion every woman who is going to have a baby should have prescribed for her two pints of milk per day, an adequate cheese diet, an adequate supply of butter, fresh eggs, fresh fish, a supply of liver, and fruit and vegetables. That is the expressed opinion of the highest medical authority of the Department in England, and it is not a partisan view taken on these benches. What provision is going to be made in the Regulations for seeing that women—and unfortunately many of them are becoming under-nourished from long periods of poverty and underfeeding—are provided with the nutrition necessary to a mother in child bearing, so that the child, if not the mother, shall be given a chance from the date of its birth to grow up into a healthy and efficient citizen? It has been said, and I think it is justified, that motherhood is the most dangerous trade in the country. There is more sickness and mortality in it than there is in coalmining, and if that be so, surely the right hon. Gentleman, who, as he said in his closing statement, has himself some experience as a medical man, will agree that it is right and proper that the Scottish Standing Committee or this House this afternoon should consider whether or not we should insist upon having in the Regulations guarantees that the woman who is giving birth to a child shall be adequately nourished during that dangerous and difficult period.

There are one or two questions arising out of the Clauses of the Bill on which we should like some further explanation. The right hon. Gentleman told us that he was going to consult existing voluntary associations. I suppose that that is necessary in many rural parts of the country. These voluntary associations have grown up over a period of years, and some of them are efficient, and I think it is right and proper that they should be consulted, but I do not understand this point. In Subsection (9) of Clause 1, the Lord Advocate will find that when a new scheme is authorised by the Department and amendments have to be made in the scheme, neither voluntary associations nor any other body need be consulted at all. They are not mentioned in the Sub-section though they are mentioned in other parts of the Bill in the initial stages. When we consider how highly important it is that at any rate in the early stages of this Measure we should have the good will and hearty co-operation of everyone, I think the right hon. Gentleman ought not to lay his Measure open to criticism such as might arise on this Sub-section.

Now I come to another difficulty that we have. It says in Clause 1 that the period during which there shall be domiciliary treatment by a midwife is to be only the lying-in period. Why is that? In the English Bill a period of 10 days was prescribed as the minimum, but in this Measure, for some reason that I cannot understand, the domiciliary treatment is to be for not less than the lying-in period.

Mr. George Griffiths

It is 14 days in England.

Mr. Johnston

Well, I leave that point with the Lord Advocate. The right hon. Gentleman, when he came to the question of finance, said that he hoped the local authorities would be satisfied with his promise that this Bill would not be operative until after 16th May of this year, by which date the new block grants would be in operation. But what is happening here? As a result of the new block grants which the local authorities think they are getting, there is already a cut-in projected to some extent. I recollect that when the English Bill was going through the Minister of Health was able to give specific figures as to what each local authority was likely to be burdened with as a result of the Bill—he gave percentages—but the only Scottish figure that I have been able to ascertain with any degree of certainty is in regard to Edinburgh. I am told that, as the Bill now stands, with all this formula about weighted percentages, population, and all the rest of it, Edinburgh is entitled to get only about 27 per cent, of her expenditure from the national Treasury. It may be that under the block grants she will get more. Under the revised system, and if the Bill does not come into operation until after 16th May, will Edinburgh be guaranteed that she will get 50 per cent, of her expenditure?

Mr. Elliot

No. I should not like to mislead the right hon. Gentleman or the House. I think that actually, on the percentage of the expenditure, the percentage would not be increased. It might be very slightly diminished under the new formula; but what I say is that the new formula must be taken in conjunction with the new grants, which will in fact very substantially increase the resources open to all local authorities. As for the fact that some local authority may get less, that is true, but it is in order that some other local authority in much greater need may get more, and I am sure that we should all agree to that. This is a distribution of the money available according to the needs of the population.

Mr. Johnston

Could we have a White Paper or a statement printed in the OFFICIAL REPORT in answer to an arranged question, showing what each local authority in Scotland may receive as a percentage of its expenditure after the new block grant system is in operation? I do not think it is unreasonable to ask for that.

Mr. Elliot

I could do that as soon as the block grant and the weighted formula have been agreed with the local authorities. At present those matters are in negotiation, and it will not be possible to submit a statement showing what they will get until the percentages have been agreed with the local authorities. As soon as that is done I should be glad to submit it, but I am afraid I could not give a date for it. [Interruption.] In the case of some local authorities it will be considerably more than half, and in the case of other local authorities it will not be so much, because the money which otherwise would have gone to them will go to more needy authorities.

Mr. Johnston

Some local authorities will not get half?

Mr. Elliot

That is so.

Mr. Walker

We understand the Minister to mean that the total cost in Scotland will be met as to the extent of one-half by the Exchequer, but that the one-half may be distributed in a varying ratio among the local authorities?

Mr. Elliot

That is so.

Colonel Sir Charles MacAndrew

Surely that does not make any difference to the explanation given in the paragraph on the top of page iii of the Memorandum, where it says: Under this arrangement the grants will range from about 90 per cent, of the additional expenditure in the case of the poorest areas to about 27 per cent, in the case of the richest areas.

Mr. Elliot

No, it does not alter that; it is a perfectly correct explanation, but there may be a slight variation on account of the operation of the new weighted formula, which may not be the same as the old weighted formula. The operation of the new weighted formula will be, on the whole, to give greater advantage to the densely populated areas and the sparsely populated areas and the poor areas than to the richer areas, and I am sure that would be the desire of everyone in the House.

Mr. Johnston

The only point I am making is that we are in the greatest difficulty in understanding what is happening. I am anxious that every local authority should be encouraged to operate this Measure, and if after May they discover that instead of getting what they anticipated they are to receive very much less, and are eating into their share of the new block grant, there may be an attitude of mind which will tend to diminish operations under the Act.

Mr. Elliot

As my hon. and gallant Friend the Member for North Bute (Sir C. MacAndrew) has said, the explanation on page 3 of the Memorandum is substantially the explanation. I agree that nothing could be worse than that there should arise among the local authorities any feeling of bad faith. After these proposals were made the local authorities made certain representations to me. I have not been able to meet those representations along the lines on which they would wish me to meet them. I have met them in another way which, it is possible, may not meet with their approval, but I do not think any suggestion of bad faith will arise, because that explanation on page 3 shows that the grants will range from about 90 per cent, in the case of the poorest areas—and that may be altered—to about 27 per cent, in the case of the richest areas—and that may be altered. It may be as low as 26 per cent. But the grant will amount in total to approximately one-half of the cost of the new service in each year.

Mr. Johnston

I do not wish to pursue this rather difficult subject, but, to the best of my knowledge and belief, as the Bill now stands, without the added complications about the new block grant, Edinburgh imagines she is getting 27 per cent, of her additional expenditure, and not 50 per cent. I trust that before we come later to this Clause we shall have an adequate explanation of what every local authority is likely to get.

I turn to the question of midwives. In the English Measure there was an alternative pension system. Insead of saying that a midwife who surrenders her certificate will get a certain number of years' pension or, if she does not surrender it, or is discharged, will get another number of years' pension—which is to be the case in Scotland—I understand that in the English measure there was the alternative of an annuity system, giving a guaranteed payment for life to a midwife who gives up or retires.

Sir C, MacAndrew

The hon. Member will see that that is provided for in Clause 4 (4)—at line 25, on page 7 of the Bill.

Mr. Johnston

I am afraid I must have missed that. I will leave that point. Another point is that some midwives complain that the periods chosen for the calculation of their pension or gratuity were abnormal periods and unfair to them, and they ask the Government to consider making it a flat rate of five years, instead of three years in one set of cases and five years in another. A woman who has been removed from the roll of midwives and continues to act as a nurse to women in childbirth is liable on summary conviction to a fine not exceeding £10 if she receives any remuneration for acting as a nurse. I suggest to the Lord Advocate that the words "receives any remuneration" might be struck out. Remuneration may be furnished in other ways than by payments in hard cash, and if we want to make the system watertight it might be advisable to delete those words. I have exceeded my time and do not wish to stand in the way of other hon. Members who wish to discuss this matter. I can only say that we on these benches welcome the purpose of the Measure and think that on the whole it provides a basis upon which future Governments, or even this Government, may build in creating better standards of medical attention for our people. It has been a reproach to us in Scotland that our death rate should be higher than the death rate in other parts of the land, and any steps which this or any other Government can take to better the health of our people will have the greatest possible support from the Members on these benches.

4.54 p.m.

Sir Archibald Sinclair

I should like, in the first place, to congratulate the right hon. Gentleman on bringing forward this useful Measure, and to express the gratitude which I feel exists in every part of the House for the interesting speech in which he explained it to us. I was glad that he emphasised the naturalness of the condition of pregnancy and of the function of child bearing. It is one of the disadvantages of the efforts which we have to make to mobilise public opinion on this, as on other social problems, that the facts and figures which we have to bring out into the light of day may tend to create an atmosphere which the right hon. Gentleman described as one of dread, but I hope his speech and the passage of this Bill will do much to dissipate that atmosphere, and to give to the mothers of Scotland the assurance that they will have the support of efficient maternity services to help them through the time of their trial. The need for such services is clear. Maternal mortality in Scotland is not diminishing, and when we quote the figures of maternal mortality we are far from exhausting the evils to which the present conditions give rise; because apart from those who unhappily lose their lives, there are those who suffer from illness and prolonged ill-health and disability. Moreover, although the figures of infant mortality are going down it is an unfortunate fact that infant mortality among children of only one week old has shown a slight tendency to rise. I think all these facts prove clearly the need for such a Measure.

If a Measure is good I am not concerned with whether the right hon. Member for West Stirling (Mr. Johnston) chooses to affix the label "Socialist" to it or not. I was amused at his efforts to affix this label to the hon. Member for South Edinburgh (Sir S. Chapman) and at the hon. Member's sensitiveness in resisting the operation. It seemed to me that both hon. Members were a little out-of-date. Their political reflections have only matured to the point which my party reached some 40 or 50 years ago, when Sir William Harcourt said in this House "We are all Socialists now." It is just as possible for a sturdy individualist to advocate, to demand, such a reasonable measure of social organisation as this, as it is for a right hon. Gentleman, without having any aspersions cast upon his sincerity as a Socialist, to stand up for the liberty of the subject when he thinks it has been invaded by the action of the executive, as a certain right hon. Gentleman did in a still well remembered speech in this House some years ago. In the same way we should be able to support a measure of social reform without having aspersions cast on the consistency of our individualism.

Mr. Johnston

The right hon. Gentleman will forgive me for interrupting, but I think this is necessary for his political education. Will he not believe me when I say that the contract he has just made is at least 40 years out of date?

Sir A. Sinclair

That tu quoque does not help the right hon. Gentleman, because I have pointed out that we had reached that stage of education 40 or 50 years ago. He does not dissent from my argument as to the possibility of combining the principles of individual liberty with social organisation, and it is a fact that my political forerunners found no political difficulty in doing so 40 or 50 years ago. If this Measure is good, and it is, I do not care what political label may be affixed to it, let us judge it on its merits; and I think it is fairly clear from the attitude displayed in all quarters of the House that Scottish Members have made up their minds to welcome it.

The right hon. Gentleman truly said that one vital aspect of the problem of improving our maternity services would be the raising of the remuneration and the improvement of the conditions and status of the midwives of Scotland; that, of course, was one of the recommendations both of the report on Maternal Morbidity and Mortality in Scotland and of the Committee on Scottish Health Services, which reported last year. It is true that machinery is provided for raising the remuneration and improving the status and conditions of service of the midwives, but the right hon. Gentleman did not give us very much indication of how and when that was to be done. I hope that he will be able to give us very clear assurances and an indication that it will be the deliberate policy of his Department in administering the Bill.

There is a question which I would like to put to him. I observe from the Memorandum which accompanies the Bill that the estimated cost of the scheme is £120,000. As we are told that the Government will be paying 50 per cent, of the cost of the scheme, that means that the total cost of the scheme to the Government and the local authorities will be about £240,000. Would the right hon. Gentleman explain to the House why this scheme is to cost so much less than the scheme which was adumbrated for the maternity services in the report of the Committee on Scottish Health Services? That Committee worked out a scheme, the total cost of which was to be some £310,000, as the right hon. Gentleman will see if he refers to page 290, recommendation (5). Perhaps he would give the House some indication of the difference between the provisions of the scheme of the Bill as compared with the scheme of that Committee, and the reasons why the cost is now estimated at a substantially smaller figure.

The right hon. Gentleman referred to the difference of opinion which has been aroused over the proposal in Subsection (2) of Clause 2 of the Bill, that a mother may be permitted to pay her maternity benefit to the local authority. There is no such provision, of course, in the English Measure, but the suggestion is not necessarily the worse for that. We ought to take our own view of the problem and consider it on its merits. Nevertheless, it is a fact that in the English Measure, which was very carefully considered during its passage through this House, no such provision was included, and I therefore suggest that we should scrutinise the present proposals very carefully. The cash benefit is of immense importance to the poor mother, and is not, and never was, intended to be given entirely to the doctor and the midwife; it was always intended that some part of it should be available for the mother herself. I was very glad that the right hon. Gentleman indicated that he was going to preserve an open mind and listen to argument on this question, because I feel a certain amount of doubt about the proposal. In his speech the right hon. Gentleman asked this question: How far are expectant mothers likely to avail themselves of this service? That is a vital question. May it not be that if they are to be subjected to pressure from the local authorities to give up their maternity benefit they may be reluctant to avail themselves of the provisions of the Bill? Therefore we should consider very carefully the pros and cons of this proposal. It might be a wise provision that only half of the benefit could be transferred to the local authority, if the mother authorised that to be done.

There is one more point of detail, on which I do not want to say much, because it is a little outside the scheme of the Bill, but it is important in connection with maternity services; it is hospital accommodation. Not only the Committee on Scottish Health Services but also the report on Maternal Morbidity and Mortality in Scotland, on which report we are told the Bill is based, referred to the great importance of the provision of better hospital facilities. Can the right hon. Gentleman tell us whether this aspect of the problem is being dealt with at the same time as we are passing this Measure?

One last word, and that on finance. I was glad to hear the assurances of the Secretary of State that the new formula for the block grant would give substantial advantages both to the areas with congested populations and to the sparsely populated areas like the Highlands of Scotland. Unless that assurance turns out to be true in generous measure, it will be very difficult to make any progress with the Bill in the Highlands. The report of the Committee on Scottish Health Services which came out last year made a very strong point, first of all of the remarkable efficiency of the medical services of the Highlands and Islands, which they regarded as a pattern for services under similar conditions, and also of the inadequacy of the funds at the disposal of local authorities for the maintenance and development of their statutory health services. They made a recommendation to which we in the Highlands attach very great importance: A special supplementary grant of £50,000 a year (in addition to the other grants for Scotland as a whole, including the Highlands and Islands), should be made available for the improvement of local authority health services in the Highlands and Islands and for their co-ordination with the services provided under the Highlands and Islands Medical Service Grant Acts.

I would ask the Lord Advocate or the Secretary of State whether the Government have considered that recommendation and propose to give effect to it. Unless some such provision is made or unless the new formula for the block grant, by which funds to be provided under the Bill are to be distributed, turns out to be fully as generous as was indicated by the Secretary of State to us this afternoon, I am afraid that this Measure will remain a dead letter in the Highland counties of Scotland. I hope, therefore, that some reassurance may be given to me and to other Highland Members on those financial points. Subject to that, and to the other small reservations which I have made, I desire to assure the Secretary of State of my strong support for the Measure.

5.16 p.m.

Mr. Graham Kerr

I think everyone in the House heard with as much interest as I did the very clear exposition from the Minister of this extremely important Bill. As one of the representatives of Scottish Universities, I can assure him that the Measure will receive a very generous and very cordial welcome. There will be many points of detail which will have to be considered in Committee, and in addition, there appears to be one point of such fundamental importance that it merits the consideration of the House. Whereas the Bill has for its main purpose the improvement of domiciliary midwifery in Scotland, I have the assurance of many of those who are best qualified to speak on that subject that unless the Bill is amended in one particular respect, it will bring about, not improvement, but actual deterioration in the domiciliary midwifery of Scotland.

The Minister brought out very clearly what he regards, and what Scottish authorities in general regard, as the ideal system, namely, that every confinement should have at its disposal a team of three workers. There should be, first of all, the medical adviser of the patient to whom she is accustomed; then, during the critical period before and after the birth, she should have a highly qualified midwife in attendance. Finally, in case of emergency or of abnormality, there should be available the skilled specialist and obstetrician. We are all aware that many of our friends, including some distinguished obstetricians, look forward to the day when all midwifery cases will be treated in hospital, but that is not yet a matter of practical politics. Further, we have no convincing evidence that it would be an advantage in the present state of knowledge. I would certainly hesitate to put before the House anything in the way of statistics. Before now I have warned the House of our experience in biology that statistics can be extraordinarily misleading. There happens to be in this particular case some statistical information that is at least free from one of the great sources of fallacy in statistics, namely, the volume of the data on which they are based.

In 1933 there was published in New York a report upon the mortality in connection with confinement, and this report was based upon a total of 348,310 cases, a volume of data which I do not think the most pernickety statistician would consider insufficient. It showed that, of the cases dealt with in these splendidly equipped hospitals, the death rate was 4.5 per 1,000, whereas in the case of confinements in the patients' own homes the death rate was 1.9 per 1,000. Here, again, however, there is an important disturbing factor which warns us against taking these figures at anything like their apparent value, because, of course, in the hospitals at the present day you find a far greater proportion of abnormal cases, with particular dangers attached to them, than occurs among the cases not so treated. Therefore, I do not for a moment ask the House to take these particular statistical data at their obvious apparent value, but we are quite safe in taking them, with a great mass of similar evidence from elsewhere, as justifying us in saying that the day is not yet ripe, or anything near it, for the treatment of midwifery cases in general in hospitals.

The overwhelming majority of cases to-day are, of course, domiciliary cases, and I may say, speaking as a biologist, that to a biologist it would appear that to-day no more important task faces our society than the improvement of our domiciliary midwifery to the very highest possible level. When we consider the matter from that point of view, we cannot but remember one consideration that transcends everything else in importance, and that is the ensuring of the most efficient training that is possible in midwifery, for the midwife on the one hand and for the budding medical practitioner on the other. I have representations from the Scottish Universities and from the great maternity hospitals of Scotland to the effect that the present Bill fails to ensure this. The University of Aberdeen says: This omission will in the long run defeat the whole object of the Bill. The Glasgow Maternity Hospital, the largest of its kind in the country, and, incidentally, the largest training centre for midwives in Great Britain, says this: If the Bill in its present form is passed, the effect may be to wreck the outdoor or domiciliary service of the hospital, which is absolutely essential for the training of students and midwives. Again, the Dundee Maternity Hospital, an admirably equipped and efficient institution, which during last year was responsible for over 50 per cent, of the births registered in the city of Dundee, says, in reference to the adequate training of midwives: It appears to the directors of this hospital that the Bill as drafted would ultimately fail to achieve this result, since, through the destruction of the present system for their training, the number of properly qualified midwives would inevitably decrease, or, alternatively, the standard of their training would be bound to suffer. These are strong words. I suppose that most of us here are not inclined to attach too great weight to words simply because they are strong; it depends upon by whom the strong words are uttered; and the words I have quoted are uttered by some of those who are most competent in Scotland to utter expressions of opinion.

To come, in conclusion, to the practical point with regard to these remarks, what appears to be required in this connection, in order to carry out the main purpose of the Bill, is the addition of a new Clause which will render more precise the general instructions to local authorities to provide certified midwives, by ensuring that the means will remain available for their adequate training. It is not sufficient to say, as the Bill at present does in Sub-section (8) of Clause 1, that the local authority shall have regard to the desirability of maintaining any facilities and so on. I have not the least doubt that every local authority has full regard to the desirability of training, say, embryo surgeons in the facts of human anatomy, on which the whole of their practice of surgery is based; and, every local authority will agree as to the desirability of maintaining facilities for the training of surgeons; but those of us who have been in touch with medical teaching are well aware of the fact that the very greatest obstacles have been laid in the way of providing those facilities. It seems to me, therefore, that it will be essential that there should be added to the Bill, and I hope that we may perhaps hear from the Lord Advocate presently that the Government will agree to add a Clause worded in this way: In every area where there is a recognised medical school the local authority of that area and the Department of Health shall take steps to secure that adequate facilities are made available for the practical domiciliary instruction in midwifery of any person undergoing training with a view to becoming a duly qualified medical practitioner or a certified midwife.

5.25 p.m.

Mr. Leonard

The commendation that has already been expressed is entirely in accordance with my opinion with regard to the Bill. I appreciate that it is rather comprehensive in its scope, and while, perhaps, criticism may be directed towards it, I think I can agree with others that it is a step in the right direction. I shall not enter into any comments as to its being long overdue; it is sufficient for me that the Bill is here, and we are going to make the best that we possibly can of it. With regard to the scope of the Bill, I think it is well summed up in the four paragraphs (a), (b), (c) and (d) of Subsection (2) of Clause 1, which indicate the matters with which the Bill is expected to deal; but I have received some observations from those competent to touch on the matter with regard to the application of these four points and to the power of the Department to determine how they may be applied. While I recognise that time is a most important factor, and that speed is desirable from the point of view of the mother, nevertheless the position as regards administration must be considered, and it seems to be advisable from all points of view that, in the application of the activities set out in these paragraphs, permission should be given to authorities to move in stages or in areas, since the smooth running of the administrative machine is perhaps as essential as the speed of application.

I have one or two points to make, and in making them I hope I shall not deal with what the Secretary of State referred to as Committee points. I wish to deal specially with the provision made for consultation with bodies such as the Mid-wives' Association and voluntary organisations, and I want to say a word or two with regard to the proviso to Sub-section (3), that, where a voluntary organisation has been established for the purpose of co-ordinating the services provided by other voluntary organisations,, the coordinating organisation shall be consulted instead of the other organisations themselves. The only point I want to make is that I trust that, if the co-ordinating body is taken into consultation, there will be ample opportunity of ascertaining the views of the voluntary organisations whose work it is co-ordinating, on matters such as legislation, and that the voluntary bodies whose work it is co-ordinating will have within their structure avenues whereby the operative side, that is to say, the nurses working for the voluntary bodies, will be able to express their views.

I also notice that in Sub-section (5) provision is being made for consultation with any local organisation of medical practitioners, if any such local organisation exists. I have had certain statistics put before me with regard to the tendencies of doctors themselves, and it is no secret to say that a great number of doctors do not like to indulge, nor do they specialise in, this work. I was wondering whether it is not possible that, instead of consultation with a body of general practitioners, provision could be made that the consultations should be conducted with a panel of practitioners who have paid special attention to the subject. Sir George Newman said in 1933 that the expectant mother should become accustomed to a diet which includes ample milk—two pints a day—cheese, butter, eggs, fish, liver, fruit and fresh vegetables, which will supply her body with the essential elements. Such a statement cannot be placed on one side. I agree that expectant mothers may delay applying for the services contemplated in this Bill simply because of the need to use their money for services other than medical, and I urge that further consideration should be given to the possibility of providing free service at least for those within the field of Health Insurance.

Another point that perturbs me is that this of necessity creates the need for another form of means test. I should like to know whether the Minister has devised any formula to meet the question of need. What is the measure to be? Will there be a special formula brought into being for use on this occasion alone, or will some formulas which have been in use in order to determine need be used? The question of surrender of certificates and the compensation to be paid to mid-wives is connected with the question of administration. I am advised that Glasgow would prefer a five-year period from the point of view of administration alone. After all, it is possible that an authority might determine to indulge in a full-time midwifery service and, if that is the case, a large number will be required. I am aware that in maternity hospitals training is given to large numbers of probationary nurses or pupil midwives, but many of them will not be employed in this form of service. They are only there for the purpose of getting the certificate. So it will be desirable to extend the period of five years in order that the numbers will be available. In addition, it is desirable that the important matter of selection should have consideration in order that administration may be built up smoothly. With regard to the provision in Clause 6 prohibiting unqualified persons from giving service at birth or in the lying-in period, if it is true that that period has been extended from 10 to 14 days in the English Bill, I hope a similar alteration will be made in this Bill. I believe it is the general opinion of those competent to deal with the matter that on the tenth day certain difficulties arise which need to be intently watched.

There are two points which I have not yet heard mentioned. Persons working in certain institutions are exempt from any penalty if they act at a confinement. One such institution is a maternity home. There are maternity homes, some of them eminently respectable organisations, where there is no one qualified from the point of view of this Bill, except the matron, and I do not see why that should be allowed when penalties are imposed on people who are perhaps just as qualified as these nurses in maternity homes. The same applies to mental asylums. Why should it be necessary to make an exception in the case of births taking place in a mental asylum? Surely anyone in that position is as much entitled to qualified attention as anyone else. With regard to Clause 7, I should like to ask, for the advantage of the City of Glasgow, whether those who attend refresher courses will incur expense, and whether the expense incurred in the provision of refresher courses will rank for grant under the financial arrangements of the Bill?

I am glad that the right hon. Baronet the Member for Caithness dealt with the question of additional hospital accommodation. It may be required for antenatal and other purposes and it is a moot point whether this will receive any consideration in the Bill. I think it should receive consideration, if not in administration, at least in so far as capital charges are concerned. With regard to Clause 8, I should like to have some attention paid to the possibility of panels of doctors who specialise in midwifery work being consulted rather than general medical practitioners. The reluctance to employ women doctors is now a thing of the past. Not only women go to them, but there are men who prefer women doctors. I wonder whether it would be possible for women doctors to be brought into the consideration of this matter.

5.40 p.m.

Mr. Allan Chapman

I hope that if I exceed my Scottish quarter of an hour the fact will be indicated to me in as polite a manner as possible. There is such an air of unanimity this afternoon that it is rather difficult to find anything to argue about with hon. Gentlemen opposite, which is very satisfactory and is the greatest compliment that could be paid to my right hon. Friend the Secretary of State. The thing that stands out most in my mind is that the midwife is obviously the key to the success to the whole scheme, and I desire to touch on one or two points relating to the efficiency of midwives as affected by the Bill. In the first place, this question of compensation affects it. There are doubtless good reasons for having three years' compensation in the case of a volunteer relinquishing her certificate, but it seems to me that it is placing a penalty against efficiency. For this reason, that persons who ought to retire on grounds of age or infirmity, would get only three years' compensation if they volunteered to do so and, in the circumstances set out in the Bill, they would be inspired to try to carry on for another year or two until they were pushed out by the local authorities, thus qualifying for five year grant. A lot of difficulty would be removed if the amount taken for compensation was the same. Another point about this question of the efficiency of midwives is that it is essential we should attract the very best type to what is virtually a new service, and, although there are doubtless good reasons why it has not been brought about, I should like to have seen a uniform system throughout the country where the pay, the terms of service, the age limit for retiring were the same, and there was some sort of superannuation scheme as well. With the certainty of well-paid employment you are more likely to get the best type of people going in for this important profession.

I was interested to learn that some of those nurses who have their C.M.B. certificate but are not practising midwifery are already working for corporations such as Glasgow, but there is a small danger here, it seems to me, although the Bill provides against it to a certain extent. I understand that a certificate from the Central Midwives Board does not necessarily make a perfect midwife. Doctors and others to whom I have talked say that it is a question of long experience of actual cases that makes the midwife. I hope, before even a trained nurse who holds a certificate is released to deal with this matter, she will have not only a course of training but a course of dealing with these cases under supervision. There is also a very important problem involved in this question of training. It is unfortunate that one section of the community supplies the main experience for these trainees, but hospitals exist mainly for the benefit of poor persons and it is natural that they should seek experience for their trainees amongst the people they serve.

I hope the Lord Advocate will be able to tell us, on this important point, which is causing great anxiety among Scottish hospitals, that some form of compromise has been reached. It is clear that extern training is of equal if not greater importance than intern training in view of the main object of this Bill. There must be a world of difference between dealing with an emergency in the ward of a hospital where the experts are in the next room,; and dealing with an emergency in some unfortunate soul's back kitchen. Yet a person who would be very good within the hospital might be hopeless when faced with such an emergency. Therefore I support my hon. Friend very strongly on the point that the external training is extremely important, and urge that the difficulty should be met. It is my desire to see these mothers protected by requiring a certificated midwife always to be present when a trainee is handling a case, no exceptions being made. I think, then, there would be very little danger to the mother.

These observations are put in a spirit of inquiry, and I would not disturb the placid way in which this legislative child is being brought into the world this afternoon by following up the remarks of the right hon. Gentleman the Member for West Stirling (Mr. Johnston). I will leave his quip that we are on the road to Socialism, by saying that I do not regard Socialism and social progress as necessarily synonymous terms; not even when they were backed up by the jest of a Liberal statesman who made a remarkably inaccurate statement in this House over 40 years ago. I most heartily support the Bill, and believe that it is one of the most vital social Measures of our time. Quite apart from the more humanitarian side, if in the past every life has been precious, the trend of population being what it is, every life in the future becomes doubly precious. I join with hon. Gentlemen opposite in urging upon the Government Front Bench that there should be no false economy in this matter. The real wealth of the nation is its people. The urgent claims of other social services pale before this Measure, because it is one of the key Bills of social progress. I believe it will make a great deal of difference and trust it will make the statistics, which we have been reading from recent reports, look mediaeval in a few years' time.

5.48 p.m.

Sir Ernest Graham-Little

I regret to introduce perhaps a little element of disturbance in this placid atmosphere, but I think that an opportunity has been missed in framing the Clauses of this Bill. As the hon. Gentleman the Member for Rutherglen (Mr. A. Chapman) quite properly remarked, the key-note of the Bill is the midwifery service. As the Bill is said to rest upon the recommendations and authority of the very admirable report quoted in the Bill on Maternal Morbidity and Mortality in Scotland, it is a disappointment that the recommendations have not been more closely followed. I fear that there is a very considerable danger in regarding this Measure as a real contribution to the solution of a problem which has undoubtedly distressed and disturbed the medical profession more than any other problem of the present day. Maternal mortality is one of the very few domains of medicine in which the rate is increasing rather than diminishing. It is a very lamentable state of affairs, and no effort that can be made to bring about a solution of the causes of that mortality ought to be spared. What are the recommendations of this report? If hon. Members will turn to page 25 they will see that it is definitely stated that: Ante-natal, intra-natal and post-natal supervision should be afforded by the same medical attendant; where this is impossible the ante-natal record should be readily and immediately available to the attendant at confinement. If any progress has been made, or is to be made, in regard to this very terrible problem, it is in considering the circumstances which lead up to the confinement. Almost all the provisions of this Bill deal with intra-natal measures. That is too late. All the valuable time has been lost in the ante-natal period. What are the circumstances in the ante-natal period which are so important? Some of them have been stressed with great precision and propriety by Members on the Front Opposition Bench. There is no doubt at all that the nutrition of the expectant mother is one of the most important helps to her reasonably successful confinement. Some months ago an interesting lecture was given in which the mortality from maternity accidents in the Island of Lewis was reported, and the amazing fact emerged that the mortality in the Island of Lewis was less than the mortality in Paddington. The reasons suggested were that in the Island of Lewis, where there is a very small community, the feeding was stated to be relatively excellent, with fresh milk and food, and it made all the difference to maternal mortality. I do not think that aspect of the question need be argued because it is universally accepted.

But there are other suggestions in regard to the ante-natal period. There are medical diseases which only a medical man can discover during that period. There are physical disabilities which only he can discover. It so happens that during this very week I have had personal knowledge of two cases of well-to-do families in which the expectant mother had, in both instances, been found some time before confinement to suffer from physical disability which necessitated the delivery of the child by what is called the Caesarean operation. Such conditions cannot be made clear unless care is taken in the investigation of cases before confinement. There are other causes such as cardiac and pulmonary disease, tuberculosis, and, of course, the most important of all, venereal disease. If you are to give the mother who is the victim of venereal disease any prospect of having a healthy child and a normal confinement treatment must take place quite early in pregnancy. If it is given throughout pregnancy there is every prospect of the confinement being normal and of the birth of a healthy child. That is proved by statistics, with which I will not trouble the House at the moment.

I would like to support the plea made by the right hon. Gentleman the Member for Caithness and Sutherland (Sir A. Sinclair) for the provision of more maternity beds. That again, is one of the recommendations in this report which does not seem to have been touched upon at all in the Bill. It is a curious fact that mortality in well-conducted and scientifically -administered maternity homes has been very much less than confinements in the best circumstances at the homes of patients. I will give a concrete example from my own knowledge. Queen Charlotte's Hospital has been conducting in the past year a series of observations into the prospect of mitigating the mortality from that very terrible disease of puerperal fever. During that 12 months a new drug has been tried, and the remarkable result has followed, that the mortality has decreased from 22 per cent, to 2 per cent. That kind of knowledge or experiment can only be tried under very skilled observation and in well-equipped maternity institutions.

Another aspect of the Bill which I rather deprecate, and which has been so remarked upon by a previous speaker, is that it rather leaves the general medical practitioner out of the scheme. The colleges and universities have been very perturbed about the incidence of maternal mortality, and the General Medical Council a year or two ago circulated universities, which are principally responsible for the training of medical men, upon the enormous importance of increasing the opportunities for obtaining practical skill in London and elsewhere. Very elaborate changes have been suggested, and some have been made, in the medical curriculum to meet that need. If you diminish the sphere of activity of the general practitioner in this matter, you will diminish the urge for improvement in his education. I cannot help thinking that we are really approaching this matter from the wrong end. The real desideratum is to improve the scientific treatment of cases of impending disaster from maternal mortality, and it is from that angle we should approach it rather than from practically the last stage, that called the "intra-natal stage."

This report, which I cannot commend too highly, gives an indication of certain dangers which come from measures taken at the confinement itself by what is far too often the case, a relatively ill-equipped midwife. The tendency of the inexperienced person is to offer to do too much. Nothing is more disastrous than to do too much at a confinement. I was trained for part of my medical course at a great maternity hospital in Dublin, and it was the tradition and practice of the officers of that famous hospital to dissuade the medical student from interfering more than he could help. The real benefit of the ante-natal care is that it lessens the need to interfere. You know what is there long before the danger comes. It is from that point of view that I rather fear the danger of giving a false idea of security when no security exists. I would much rather spend far more money upon measures for the preparation and the preceding stages, and much less money on the actual operation of delivery, and make the operation of delivery a really normal physical process, which it ought to be, and which it very often is not. The real way of doing that is to prepare the patient beforehand, not a day or so before, but weeks and months before. It is from that point of view that I think this Bill will be somewhat of a disappointment to the medical profession.

6.0 p.m.

Mr. Guy

The intervention of an English Member and a doctor in the person of the hon. Member for London University (Sir E. Graham-Little) has presented a feature in the Debate which so far has been lacking. I should like to add my welcome to this very valuable Bill and my congratulations to my right hon. Friend the Secretary of State for his very clear explanation of its objects. As regards the need for the Bill, there can be no doubt whatever. Reference has been made to the report on Maternal Morbidity and Mortality—a most valuable report. It brings out a state of affairs which calls for a great deal of thought and care, and demands progress and performance. We have been a long time waiting for the Bill. The period of gestation has been prolonged. The English Bill got its Second Reading on 30th April last year. I am relieved that the Scottish Bill has seen the light of day, and I think that it is better than the English Measure. It is definitely a better Bill in so far as it covers ground that the English Bill does not cover. I think my hon. Friend opposite did not do full credit to the place which is given in this Bill to the medical practitioner in combining his services with the midwife in cases of confinement.

I regard the Bill as a turning point in the campaign for dealing with the grievous maternal mortality. It is high time that we reached the point of effective action, because the preliminary part of the campaign in arousing public interest in this question did more harm than good. I am particularly glad that my right hon. Friend referred to the danger of creating an undue amount of alarm in the minds of expectant mothers. As has been said, the process of childbirth should be a normal physiological function, and now that it is known that steps are to be taken to provide greatly improved medical and midwifery services, a great amount of the apprehension that has been rather unfortunately aroused ought to be allayed.

There is one point which indicates the measure of the problem with which we have to deal, and it was dealt with in the report to which I have referred, and that is the percentage of cases of maternal mortality which are avoidable. It is amazing—indeed, I go so far as to say that it is highly discreditable—that not less than 60 per cent, of the cases of mortality attributable to pregnancy are, in the opinion of the authors of the report, avoidable. In many cases it must be very difficult to apportion the blame. In some cases the fault rests with the patient, and in other cases, in fact in the larger proportion of cases, there has been some carelessness or some faulty diagnosis, perhaps some negligence on the part of either the midwife or attendant or the medical practitioner. It is because of the information which is now available, and in view of the fact that a proper scheme is to be elaborated for maternity services and I hope the training not only of nurses, and perhaps also of medical practitioners, that the maternal mortality will in due course be considerably diminished.

Reference has been made to ante-natal care. I agree with my hon. Friend the Member for the London University that that is probably the most important field for improvement and reform. In this connection I discovered in the report on Maternal Morbidity and Mortality that the figures in regard to expectant mothers show that in a large number of cases the health of the mother was adversely affected by the pregnancy, particularly so in the case of the mothers who died. The figures show that there was about 84 per cent, of good health before the particular pregnancy started in the case of the mothers who survived, but in the case of the mothers who died at childbirth the percentage of good health before pregnancy was only 71 per cent. With regard to health during pregnancy there was 75 per cent, of cases of good health among the surviving mothers, but the good health during pregnancy of the mothers who died fell to 46 per cent. That clearly shows that health not only before pregnancy but during pregnancy is very important in regard to the question of maternal mortality. Therefore, everything that can be done to protect the health of the expectant mother will be a valuable contribution towards a solution of the problem. It is on those lines that the machinery to be set up by the Bill should be of very considerable importance.

I am sorry that the right hon. Member for West Stirling (Mr. Johnston), whose flippancy in describing this Bill as a Socialist Measure amused me and other hon. Members on this side of the House, is not in his place, because I should like to remind him that in Edinburgh nearly 100 years ago we had the skeleton of this public health service in the appointment of the first medical officer of health, at a time when the Socialist party had not appeared. The right hon. Gentleman raised the question of malnutrition. That is one of the few controversial questions in this particular field of inquiry. The right hon. Gentleman can get no support from the report on that particular point. Those concerned in that report considered the malnutrition question, and they state that, so far as they can find out, it is not a factor in maternal mortality, but that the question of diet is of prime importance. The question of qualitative rather than quantitative nutrition is of very great importance. In the case of necessitous mothers who are attending a clinic, they are, or they should be, provided with both milk and food.

I agree with what has been said as regards the necessity of improving the accommodation in maternity hospitals. The Bill does not deal with that point. The question of maternity hospitals, in particular in relation to those cases which require special treatment—operative treatment—must not be forgotten, and I hope that due provision will be made. There are two questions which I should like to put to the Lord Advocate. The first is in regard to the Scottish figures for maternal mortality which have been given as about six per thousand births, compared with the English figures of four per thousand. On the face of them the Scottish figures are 50 per cent, worse than the English figures, but I have been informed that those figures are not strictly comparable. Can the Lord Advocate say whether they are strictly comparable, and, if not, what deduction should be made from the Scottish figures? A further question is in regard to the training of nurses, maternity nurses in particular, which, if this Bill is to be a success, will have to be dealt with on up-to-date, scientific lines. Some time ago we had an excellent, well-informed and reasonable report from the Black Committee on the training of nurses. That report came out before the report on the Scottish health services. Questions have been asked from time to time as to what are the views of the Scottish Office on that report. The time has now arrived when some decision should be taken. If consultations have taken place with the various nursing associations it is time that a decision was made. If there is to be a new scheme for the training of midwives and maternity nurses it should be launched and put into operation about the same time as the machinery of this Bill. I believe that when the Bill is in operation it will provide a very important contribution towards the solution of a grave social problem, and I wish it every success.

6.14 p.m.

Mr. Watson

I am very pleased that my right hon. Friend the Member for West Stirling (Mr. Johnston) claimed this as a small Socialist Measure. That statement created a little amusement on the other side of the House as well as on the Liberal benches, which are now empty. We were told by the right hon. Member for Caithness and Sutherland (Sir A. Sinclair) that 40 years ago an eminent Liberal statesman said that we were all Socialists. We who are Socialists have always been of opinion that there are Socialists and Socialists, and we are not prepared to recognise members of the Liberal party or the Tory party as Socialists. If this Measure is not a Measure of that description, why has it not been brought in long ago? We might have had this necessary little measure of social reform in the days when we were assured that individualism was everything, that individual enterprise was all that was required and that the local authority should do as little as possible.

Here we are asking local authorities to do a very valuable service. I am pleased that the Measure has been received with such enthusiasm by hon. Members opposite. I am not going to examine it in detail; that can be done when we reach the Committee stage; but I was interested in the assurance of the Secretary of State that he has an open mind with regard to several points, and I hope we shall have that same open mind when we meet the right hon. Gentleman in the Standing Committee upstairs. Very frequently we get the assurance of an open mind on the Floor of the House, but when Amendments are moved in Committee the mind of the Minister is usually closed on matters upon which we have had an assurance that he had an open mind. The right hon. Gentleman was more specific this afternoon and indicated several parts of the Bill upon which he was prepared to hear arguments. I hope he will be in the same mood in Committee.

It is not often that a Sassenach intervenes in these Debates, but I was pleased that the hon. Member for the London University (Sir E. Graham-Little) made his contribution. I was specially interested in his closing remarks. He asked that more attention should be given to women before the birth of a child than after. That is a very sensible view to take. In the Bill provision is made for local authorities to provide facilities on application being made for medical examination and treatment during pregnancy, and I hope it will mean that local authorities will see that the necessary nourishment is given to a woman where she requires it before the child is born. Unfortunately, in this country we have a considerable army of unemployed and also a large army of low-paid workers who really cannot afford to give that nourishment to their wives that is required before the birth of the child. Under this Measure it will be possible for local authorities not only to provide the medical examination which is necessary but also the treatment which will ensure the woman being built up physically before the child is born. From that point of view it is a most valuable Measure.

The hon. Member for the Scottish Universities (Mr. Graham Kerr) rather feared that the Measure would have a detrimental effect upon hospitals and maternity homes. I do not share that view. I do not think it will have any adverse effect, but, on the contrary, that there will be a need for more maternity homes than we have already in Scotland. There is a tendency in that direction at the moment. In my own district a new maternity home is being built, and if the local authority thought that this Measure was going to have a detrimental effect on that institution I am sure they would not welcome the Measure as they do. I think that a great deal more attention will be devoted to maternity homes as a result of this Measure, and that we shall find more hospital accommodation and more maternity homes than has been the case up to the present.

I rose only for the purpose of giving a general welcome to the Bill, and to express the hope that the Secretary of State will retain an open mind when we come to Committee and be prepared to consider the matters which have been raised by various hon. Members. This is a Measure which is going to increase the burden on local ratepayers. It is a strange thing that such a statement should come from this side of the House instead of the other. When measures of social reform have been discussed, the question as to the expense on local ratepayers has always been raised by hon. Members opposite. I am raising it now; with an object. For a considerable number of years I was a member of a county council, and during that time I saw Measure after Measure passed by this House calling upon local authorities to do this, that and the other thing, every one increasing the burden on local ratepayers. This House determined the changes that were made but forgot to give the necessary financial assistance required for carrying the Measures through. This is a Bill which will impose charges on local authorities, but I have no sympathy with that particular objection when the Measure is desirable and will confer benefits on the community. I have no objection to local rates being raised if the community is getting better service. At the same time, I hope the point raised by the right hon. Member for West Stirling will be kept in mind, and that proper financial arrangements will be made between the Government and local authorities which will encourage local authorities to go on with these schemes. I hope they will not be hindered merely because they are not able to stand up to the expenditure which the Bill will impose, but that the Government will look on this matter with a sympathetic eye and encourage local authorities to use the Measure to the fullest extent.

6.24 p.m.

Sir R. W. Smith

This Bill has been introduced mainly to deal with maternal mortality in Scotland which has been the subject of interest to Scotsmen and the Scottish Office for some time past. There are two ways of dealing with this question. The Government might have gone along the line of further institutional treatment, but instead are trying to provide better treatment in the home. I am glad they are proposing to deal with the problem in that way. I am not saying that institutional treatment is not good, but I think the Government are right in attacking the problem by trying to get better service in the home. Certainly, as far as the country generally is concerned institutional treatment is almost impossible, and if the Government had attempted to deal with it by extending institutional treatment there are large parts of the country which would not have been assisted at all. It is excellent that the main purpose of the Bill is to improve the standard of domiciliary midwifery in Scotland—a most excellent thing to do.

I should like to refer to one or two speeches which have been made by hon. Members opposite. The right hon. Member for West Stirling (Mr. Johnston) said that this was a Socialist Measure. I should like to ask him to look at the Bill more carefully; and how he reconciles the first words of Clause 2 with Socialism. I have understood Socialism always to mean the service being provided free at the expense of the State, but here the service to be provided is to be paid by the patient wherever that is possible. I do not know whether that is pure Socialism, but it is hardly the form of Socialism which we hear preached so much.

Mr. Mathers

The hon. Member seems to think that Socialism can be interpreted as pauperism. It cannot.

Sir R. W. Smith

Under the Bill it is most distinctly stated that the cost of the service shall be recovered where it is possible by the local authority from the woman who receives the treatment. The hon. Member for London University (Sir E. Graham-Little) has failed to read the Bill. He talked about lack of ante-natal treatment, but on page 1 we find that there is to be medical examination and treatment during pregnancy. The hon. Member seemed to think that the Bill did not do anything except to deal with postnatal cases and that nothing was done for the expectant mother at all. I agree with the hon. Member for Dunfermline (Mr. Watson). May I put this point? The hon. Member's suggestion was that the only form of treatment before birth was by means of increasing the supply of food. I think that a great deal could be done by directing the mother on questions of diet and seeing that she was spending her money on food which was of good quality. This is specially referred to in the report. It is not so much a question of the quantity of food, but its quality, and, therefore, women should have some guidance as to what they ought to eat.

I was rather surprised that the hon. Member for St. Rollox (Mr. Leonard) made a plea that more women doctors should be appointed because women preferred women to look after them rather than men. I do not know whether women prefer to be treated by women rather than by men in these cases. If it be the case it is rather strange. It is also extraordinary that, although we have several women Members of this House, there is not one present, so that at any rate they seem to think that the subject is better treated by men.

Mr. Leonard

The hon. Member is entirely wrong. I said that in past years there was a reluctance on the part of women to go to women doctors, but that that reluctance has now been placed on one side and they are more willing to call in women doctors.

Sir R. W. Smith

I think that on the whole women prefer to be treated by men doctors. As I have already said, I am delighted that this Bill has been brought in and that it attempts to deal with this question on the lines on which it does; but there are a very large number of small items in the Bill which will need to be dealt with in Committee, and I would like to refer to one or two of them. In connection with Clause 2, I would ask the Lord Advocate, in his reply, to tell the House whether the fees which are to be charged in accordance with a scale of fees approved by the Department will be uniform throughout the country. It seems to me that there would be great difficulty if they are not. Another point in the same Clause has reference to the question of whether a person not able to pay the fees should be charged such part of the cost of the service as he is in the opinion of the authority able to pay. I think that in many cases there would be a difference of opinion between the authority and the woman as to the amount that should be charged. Would it not be possible to have some disinterested body or tribunal which would be able to adjudicate? The Bill places upon the local authority the right to decide what the amount shall be, and the woman has no opportunity of appealing against it. I should be glad if the Government would give some thought to that point before the Bill reaches the Committee stage. The local authority is to be able to recover the fees from the husband or other person liable to maintain the woman, but I do not know whether, if a woman has an affiliation order against a man, that man would be considered as being liable to maintain her.

With regard to Sub-section (2) of the Clause, which deals with the payment of National Health Insurance benefit, it seems to me that the provision is unnecessary. If the local authority is to recover from the woman for whom they have provided services or from the husband or other person liable to maintain such woman, such fees as are appropriate, they would naturally be getting from her the money she was receiving in the way of benefit. In Sub-section (1) of Clause 1, which refers to applications, there is the following phrase: by whom, or on whose behalf application is made. If the woman makes application herself, naturally it is all right, but is there to be any limitation concerning who may make the application? I can conceive cases in which an outsider might decide to notify that a woman ought to have treatment, for which the woman would consequently be charged. It seems to me that the making of an application ought to be limited to her husband, or to some person having a special connection with her. In conclusion, let me say that I welcome this Bill, especially because it deals with the question of maternal mortality on the lines of improving the nursing services given to women in the rural areas.

6.37 p.m.

Mr. Buchanan

I do not propose to enter into the controversy as to who are Socialists, or who are good Socialists or bad Socialists, but the reference to the Secretary of State for Scotland having introduced a Socialist Measure reminded me of the 1929 General Election, when the Conservatives were badly beaten in the City of Glasgow. On that occasion I came out of the County Buildings rather elated by my own result, and one of my friends shouted out, when he heard the result for the Kelvingrove Division, "Thank God, there is one Socialist left in the City of Glasgow!" The subject of this Bill is an important one, and one that is causing great concern to the mass of people in Scotland. I do not intend to discuss the figures of maternal mortality, but I remember that some years ago I took part in a Debate in this House in which maternal mortality figures were given for England, and it was very striking to find that in some of the poor districts, where one would have expected the deathrate to be high, that was not the case, whereas in some of the districts that were better off, where one would have expected the death-rate to be low, it was extremely high.

While I do not seek to prove that this is a problem which affects the very poorest people, I would remind the Secretary of State for Scotland that, in dealing with this problem, the question of housing cannot be left out of consideration. It is of no use bringing a skilled midwife, trained in her work, into a house in which there are not decent facilities for her to do her work without undue interference from the rest of the family. If the midwife goes into a single apartment, where there are possibly two or three other children, she has no chance of doing her work properly. An hon. Member has referred to the question of the nourishment of the mother. I think no one can deny that apart from the actual nourishment of the mother, her mind has an influence on the child. If it is possible to relieve her mind of anxiety and worry at that time of her life, she is considerably helped. The terrible lack of security prior to childbirth is one of the things which often has a considerable effect on the mother. People who have a good income are to some extent relieved of that anxiety.

The provision of this Bill with which I wish mainly to deal is that which confers upon the local authority, through the Department, the power to make certain charges. I beg the Secretary of State to reconsider this matter. The primary object of this Bill is to save life, to bring about, if possible, a fall in the alarming deathrate. If that is brought about, the Bill succeeds; and anything that may prevent it from achieving that objective is wrong. I think the inclusion of these scales of fees will hamper the success of the Bill. In this House I am usually pleading for the poorest of the poor, but on this occasion I am pleading more for those who are on the verge of being poor. Very often the poorest people are chargeable on the Poor Law authority, and the Poor Law doctor has to attend them when they need a doctor. The doctor has a tremendous amount of work to do, and he is not paid by the patient for each visit.

The consequence is that, not only in childbirth but in all sorts of trouble, he sends the woman to an institution, and because she is in receipt of Poor Law relief, she is compelled to go. In this connection, I may tell the House that a person living in my neighbourhood in Glasgow died, and the doctor told me that if she had been very poor she would have been living, because she would, have been sent to an institution where the trouble would have been dealt with immediately. The very poor woman is usually sent to a first-class institution where the best medical skill is given to her. I speak of a City of which I know, and I am sure the hon. Member for St. Rollox (Mr. Leonard) will agree that the Poor Law hospital in Glasgow is staffed by the very best medical people. One of the reasons that the deathrate among the very poor is not so high is that they are sent to these institutions.

Mr. Guy

While agreeing with the hon. Member, is this fact not a very good illustration of the positive side of the means test, whereby the greater assistance is given in cases of greater need?

Mr. Buchanan

I will not bother to argue about that now. The facts are as I have stated them. Let me now take the case of the wife of a tradesman, with, say, three young children and her husband's income about £3 10s. a week. If she is going to have a child, her husband sends for a doctor. The doctor is usually a very human and decent man, and does not wish to run up an excessive bill. Therefore, he attends only when he is absolutely compelled to do so, and the result is that the woman drifts on. If fees are charged under this Bill the result will be that one of the considerations in the man's mind will be the question of fees and how they are to be paid. The infirmary in Glasgow is of world repute and is constantly saving human life. If the woman is very poor she is removed to a proper infirmary, and there is no charge of any kind. I would say to the Secretary of State that his first duty is to encourage, not merely the very poor, but struggling people like ordinary tradespeople, to take full advantage of the midwifery service and to get regular attendance, if need be, from the medical profession. There ought to be no charge falling on them.

No one can argue that such a thing would be abused. It is now the practice to extend these facilities to the very poor, and I cannot see why people who are just above the poverty line should not have the same facilities granted to them. As I say, I think one of the reasons why the death rate among the very poor, even though they are underfed and badly housed, is not so very high is because they are dealt with promptly in the way I have shown. On this question of fees I suggest that the right hon. Gentleman ought to recast his proposal. I see that local authorities are to have power to make charges according to a scale laid down by the Board of Health. What will happen under those scales? People will pay the charges if they can, but there will be constant wrangling which will do nobody much good. I want this Bill, as far as it is for social uplift, to be a success, but I think that the proposal as to fees ought to be reconsidered. Let this service be free and open to all. If an insured man is ill, he is sure of free medical attention and hospital treatment. The health insurance scheme does that for him. A man who is very poor will receive the same attention through the poor law authorities with no kind of charge or limitation. Why not extend the same facilities to the wife and child of the insured man in these cases?

If the Bill is to be the success which we all desire to see, the services of the midwife and the doctor should be regularly available to all without any question of charge at all. The one consideration should be the safety and well-being of the mother and the child. I am not now-going into any Committee points upon the question of National Health Insurance payments—I hope to be able to raise those matters in Committee. On general lines I would like to see the Bill applied to the greatest possible number of persons. I wish to popularise the use of the midwifery service. Whether we like it or not there remains among great masses of the Scottish people an objection to allowing these people into their houses. My own mother would never allow a midwife to come near her. I want to see the service extended, and I think the fees proposal is against its extension. I want people to get the services of the doctor and the midwife at the earliest possible moment, instead of waiting until the last moment and ringing up on the telephone perhaps at eleven o'clock at night when a birth is expected to take place at twelve. What chance has a medical man or anybody else in a case like that? Often the people concerned only run for the doctor then because fear drives them to do so. If there are no fees, people will be encouraged to make use of the service earlier Let there be no charitable basis in it at all. Let there be no tests in it at all. Let it be a free and open service and let the people make use of it as they go to the Victoria Infirmary or the Royal Infirmary to-day, rich and poor alike. Let us have no fees and no limitations, but let it be open to all to secure the best midwife and the best doctor available, and I have no doubt that much human life and suffering will be saved.

6.50 p.m.

Mr. G. A. Morrison

The Bill which we are discussing seems to me an excellent Measure. It is certainly a very necessary Measure, and I wish to congratulate the right hon. Gentleman the Secretary of State both on the Bill itself and on the reception it has had. I intervene only to support one point which was made by my hon. Friend and colleague in the representation of the Scottish Universities (Mr. G. Kerr). I refer to the anxiety and great concern which is felt by the universities, the medical schools and the teaching hospitals with regard to the possibility of any diminution in the facilities for domiciliary instruction in the case both of medical practitioners and mid wives. I would like to point out that the Amendment to Sub-section (8) of Clause 1 suggested by my hon. Friend is in line with the expressed opinion of a meeting of representatives of those teaching institutions held as recently as 30th October last. Like my hon. Friend, I have had a large number of letters on the point, and if the hon. and learned Gentleman who is going to reply on the Debate can even at this stage before the Bill goes to the Standing Committee give us a little more reassurance upon this point we shall be very glad.

6.52 p.m.

Mr. Pethick-Lawrence

The right hon. Gentleman must be pleased and satisfied with the reception which this Bill has had. Only a few days ago, in connection with another question, I complained of an attempt to put Scottish and English proposals into a single Measure. In this case we have the advantage of a separate Bill for Scotland which enables special Scottish views on this question to be dealt with in a special way, and I congratulate the Scottish Office on having secured that result. There is a great need for the proposed reform, a need which is even greater in Scotland than it is in England, if the published figures accurately represent the facts. I think there is little doubt that in the main, although some allowance must be made for different methods of computation, the information which we gather from the statistics is substantially correct. We have not merely to compare the Scottish position with the English position in this respect. We can with advantage compare the Scottish position with the position in the Scandinavian countries. As a result of improvements made in several of the Scandinavian countries, we find a maternal mortality rate there which is in the neighbourhood of half the corresponding rate in Scotland. It is clear, therefore, that the need for reform is great, and in so far as this Bill will help to bring about that reform, it has, I am sure, the best wishes of everybody in every part of the House. That has been reflected in the Debate, which has indicated approval of the general provisions of the Measure.

There are one or two questions which we shall wish to discuss in Committee, and we welcome the assurance of the right hon. Gentleman that these will receive careful and sympathetic attention where any ground can be shown for making a change in the present proposals. Perhaps the most important criticism this afternoon was that made by the hon. Member for the London University (Sir E. Graham-Little), who raised the question of ante-natal treatment. I do not think the hon. Member said what was attributed to him by the hon. Member for Central Aberdeen (Sir R. W. Smith), namely, that there was no provision in the Bill for ante-natal treatment. His point was rather that the provision for it did not bulk very largely in these proposals, and was liable to be obscured and overshadowed by the provisions for treatment at childbirth. There is in Sub-section (2) of Clause 1 provision for examination and treatment during pregnancy, and the whole matter depends upon the stress which is laid upon that part of the Bill and the arrangements made for carrying it out effectively. We have to-day compulsory notification of births, but, as far as I know, we have nothing corresponding to it in regard to pregnancy. Certainly, we have not compulsory notification of pregnancy. It is for the right hon. Gentleman to consider whether, without going as far as that, some steps might be taken, perhaps by circular, perhaps by some other means, to bring home to women the desirability and, indeed, the grave importance of notifying pregnancy in sufficient time to enable useful steps to be taken to assist at the birth when it occurs. Perhaps something will be said by the right hon. Gentleman later about the possibility of a step of that kind.

With regard to Clause 2, there has been a good deal of discussion on the question of the fees that are to be paid to reimburse a local authority for its expenditure. I listened with interest to the speech of the hon. Member for Gorbals (Mr. Buchanan), and although I often disagree with the hon. Member, I think there was a great deal in what he said this evening. I do not suppose it would be possible at this stage to make the complete change suggested by him, but I think we ought to examine Sub-section (1) of Clause 2 carefully in Committee with a view to ensuring that the best service is provided, and that any charges which are made will not be too heavy a burden on those who avail themselves of the service. We ought to do that, not only in order to prevent people being impoverished but also in order to prevent the charges deterring people from making use of the service. A number of authorities in Scotland have brought forward questions relating to Sub-section (2) of Clause 2, and these also will form the subject of discussion in Committee.

With regard to the question of compensation for midwives who are already practising, and some of whom perhaps have been trained in a different system from that which prevails to-day, I hope it will not be assumed that because a woman may be getting on in years she is necessarily incapable of acting efficiently as a midwife. Those of us who know the work of the district nurses who practise midwifery in the country, know the great success with which that work has been carried on, and it would be a grave injustice to those nurses and a considerable injury to this work in the countryside, if their services were dispensed with for any other than valid and adequate reasons. No doubt points arising on the question of the compensation which the Bill provides will be discussed in Committee with a view to seeing that no injustice is done to these women.

An hon. Member behind me pointed out that under Clause 6 there were a large number of exceptions to the main provision of the Clause. I hope the right hon. and learned Gentleman who will reply will give an explanation of all these exceptions. It may be that there is a good reason why certain treatment is not included, but the reason is not clear yet, and if there is not an adequate explanation the point will have to be carefully considered later. With the considerable measure of agreement that there is on all sides of the House with regard to this Bill, I do not propose to take up further time going over ground that has already been travelled.

7.1 p.m.

The Lord Advocate (Mr. T. M. Cooper)

My task in replying to this Debate is not the usual one of defending and justifying the Measure, but the simpler task of meeting criticism which has been helpful and constructive, and of endeavouring to furnish explanations to points which have been raised in good faith and with the aim of making this Bill a better instrument for the object which everyone is anxious to achieve. The hon. Member who has just spoken drew attention to the fact that we have here a separate Bill for Scotland. That is significant, for it throws into relief the fact that the problem of Scotland is in a real sense a separate problem. While the statistics of maternal mortality and morbidity require to be received with some caution because of the slightly different methods adopted in preparing them, they do justify the conclusion that Scotland stands lower in comparison with certain of the other countries than we Scotsmen would desire to see. In answer to the hon. Member for Central Edinburgh (Mr. Guy), I would say that the statistics are not compiled on a precisely comparable basis, and therefore a certain amount of reserve is required in comparing them. The problem is a separate problem also because of the habits and methods of the Scottish people who, as these reports have shown, have grown accustomed to the practice of utilising the services of the doctor much more than is the case South of the Border. Accordingly, it was not possible to adapt the English Bill to Scottish conditions, and therefore this Bill is necessary.

I would like to emphasise the limited objects which this Bill is designed to secure. The problem of maternal mortality and morbidity is capable of being attacked from several angles. There is that of institutional treatment, and also that which I might call, for short, of nutrition. The answer1 to some questions and criticisms by hon. Members is that this Bill is not concerned with institutional treatment because that is covered by other measures. That is not to say that my right hon. Friend and the Department of Health are blind to the necessity of pursuing the attack on the problem by means of institutional treatment; nor is it to say that they are blind to the advantages which could be secured from better nutrition for the pregnant woman and the nursing mother. The important point is that this Measure must be judged from the standpoint of the limited purpose with which alone it is concerned, that is, the provision of adequate domiciliary midwifery service for the woman. Many of the points that have been raised will inevitably arise again in Committee, and I do not wish to be regarded as wholly committed to any explanation or expression of view which I may give to-night, without having had the full opportunities for consultation with my right hon. Friend which may be available at a later stage.

The right hon. Member for West Stirling (Mr. Johnston) inquired with reference to Clause 1, Sub-section (9), whether it was contemplated that all the safeguards of the earlier Sub-sections would not be operative. According to my conception of the Bill no such result is intended, and if by improvement in draftsmanship that can be made clear, I shall apply my mind to the task. The proposal is that if under Sub-section (9) revised schemes are to be put into operation, the whole of the mechanism of the earlier part of the Clause shall again be brought into operation, and that, if necessary, there shall be again consultation with the voluntary organisations, or medical practitioners, or the other interests to which reference is made.

He and other hon. Members, notably the hon. Member for St. Rollox (Mr. Leonard), asked about the length of the lying-in period. The position is that the lying-in period is defined in the Bill as the period provided by any rule for the time being in force under Section 5 of the Midwives (Scotland) Act, the object being to secure a measure of elasticity so that when that Act provides for an extension of the lying-in period, that extension shall automatically be operative for the purposes of this Bill. At present the period is 10 days, but I am informed that consideration is being given to extending it to 14 days. If the authorities under the Midwives Act increase the lying-in period to 14 days, then that will become the period for this Bill.

With regard to the weighted formula for the finance of the Bill, I am not sure that it is possible or desirable to go fully into that question at this stage, but with reference to the special point raised by the right hon. Member for Caithness and Sutherland (Sir A. Sinclair), the whole purpose of introducing the weighted formula into the grant under this Bill was to secure that the sparsely populated Highland areas, and certain of the poorer districts in the West of Scotland, should receive a larger proportion than one-half of the money that is given, and that the rich areas such as that which has been instanced in the Debate should receive proportionately less. I am not dismayed when the right hon. Member for Stirling says that Edinburgh under the present formula would only get 27 per cent., because by comparison with other local authorities in Scotland Edinburgh cannot make the same case of need that many of them can make.

The weighted population and estimated population for the purposes of calculation mean the weighted population and the estimated population as determined at the date of the commencement of this Measure for the purpose of the apportionment of the general Exchequer contribution under the Act of 1929. If the new formula were substituted for the existing formula, certain alterations would be effected in the percentage, but not in the general principle that those who need most shall get most and those who need less shall get less, which seems to me a just method of distributing public money. A number of hon. Members inquired whether when compensating midwives it would not be possible to substitute a flat rate in place of the three years net earnings for the midwives who voluntarily relinquish their certificates and five years net earnings for those who are compelled to do so. In the English Midwives Bill the same problem arose, but the three years and five years were adopted there, and there seems to be a good deal of force in the argument that a higher measure of compensation should be paid to a person who was forced out of business than to one who is allowed to retire of their own volition and to claim public money for compensation.

The right hon. Member for Caithness and Sutherland was alarmed at an apparent discrepancy between the estimate of £120,000 per annum in the Memorandum to the Bill and the figures which he found in the report of the Committee on Scottish Health Services. These figures are on pages 286 and the following pages of that report. In order to make the matter as clear as possible, the comparison which falls to be made is not between £240,000 under the Bill and £310,000 in the Estimate in the Committee's report, but between £120,000 under this Bill and £310,000 in the report. So that I have a bigger gap to account for than the right hon. Gentleman assumed. It is accounted for in two ways. The £310,000 in the Scottish Health Services report includes a considerable sum for hospital expenditure which is not included in the Estimate under the Bill. The other factor which accounts for the difference is that the £120,000 under this Bill does not take into account the payments that would be made for the services rendered. The £310,000 covers a large amount for that purpose. I cannot pretend that these two elements account for the whole of the difference, but they account for the greater part. The remainder is to be attributed to the discrepancies which arise when two different people make estimates on bases which may be slightly different.

Another type of fear has been displayed by several hon. Members, notably the two hon. Members for the Scottish Universities. It related to the risk, which they justly apprehend, that the schemes under this Bill might operate to the detriment of the teaching of midwifery to the doctor and midwife. When the progenitor of this Bill was introduced last summer, no provision was made for these facilities. When the Bill now before the House was introduced this Session, it included provision in Clause 1 (8) for the maintenance of facilities for teaching midwifery. I may say without hesitation that if the language of that provision is inadequate to secure the requirements which those hon. Members have in mind, my right hon. Friend and I will be only too happy to examine any other formula which will achieve that object. Hon. Members in all parts will realise that in a very real sense the continued supply of competent trained midwives and doctors to carry on this work is an integral part of the scheme, and we must so adapt our scheme and our legislative and administrative arrangements as to enable that to be done.

A point was raised in regard to the Clause which imposes a penalty upon unqualified persons, who, for remuneration, attend as nurses on women in childbirth during 10 days immediately afterwards. The justification for the retention of the requirement of remuneration is to be found in the fact that it is hardly possible, consistently with the lawful habits of our people, to make it a criminal practice for, say, a mother or a grandmother to render assistance to one of her daughters. I am not one of those who want to see too many new crimes created. As to the question why we propose to except from the penalty various categories of persons who are set out in Clause 6 (1, b), the answer is that all those persons are in some recognised and responsible institution where medical assistance of a highly qualified character is readily available. All the difference in the world is to be found between a case of unqualified interference in a private house in circumstances where a great deal of mischief can be done, and unqualified assistance given in an institution under the supervision of qualified medical practitioners. Again, I am willing with an open mind to listen to any argument which may be directed to that point.

The hon. Member for St. Rollox (Mr. Leonard) referred to the refresher courses of instruction under Clause 7 with special reference to the question whether, if the courses involve expenditure to the local authorities, that expenditure would rank for grant. I have a little hesitation in answering that question without some consideration, but my prima facie view is that the courses might be brought within the schemes approved under Clause 1, in which case they would rank for grant. Perhaps the hon. Member will allow me to confer with him after a full examination of that matter.

The only other major topic which requires a word of examination is that which was raised with considerable fervour by the hon. Member for Gorbals (Mr. Buchanan), whether the provisions of the Clause dealing with fees for the services provided should stand in the Bill, or whether the services should be provided on a wholly gratuitous basis. The hon. Gentleman, and the hon. Member who followed him and to some extent adopted his arguments, will appreciate that the suggestion they are putting forward makes a substantial inroad on the scheme of the Bill. It involves a departure from the English Bill and from the financial scheme, and from the reports on the basis of which this Bill was framed, so that it is impossible to regard favourably such a suggestion, which cuts pretty deeply into the Bill so far as its financial provisions are concerned. The main consideration I would urge upon the House in that respect is that it is by no means too clear that the object which it is desired to secure, namely, that the services provided by this Bill should be fully taken advantage of, would be better secured by making all these services free. It is an undoubted fact that the contributory method of securing social service benefits has taken deep root in this country and is very much in consonance with the Scottish spirit. I do not know that it would be in any sense advantageous to make this service a purely gratuitous service—

Mr. Gallacher

Would the Lord Advocate not agree to make the contributions from those receiving maternity assistance voluntary and thus avoid the possibility of any of the poorer people suffering prosecutions.

The Lord Advocate

That is just what the Bill provides. Fees are recoverable if a person can pay them, but if the person cannot pay the fees are not recoverable.

Mr. Buchanan

They must pay if, in the opinion of the local authority, they are able to do so?

The Lord Advocate

That is so. The local authority determine the fees, which will probably not exceed the present fee paid for a midwife only. I think that hon. Members should consider a good deal before adopting the suggestion of the hon. Member for Gorbals that the advantage which he seeks to secure would necessarily be effected by making this provision gratuitous.

Mr. Pethick-Lawrence

There is one matter with which the Lord Advocate has not adequately dealt. That was the question raised originally by the hon. Member for London University (Sir E. Graham-Little), to which I drew attention also, namely, how far this Bill would enable ante-natal treatment not merely in the last few days before child-birth, but during pregnancy to be provided.

Sir R. W. Smith

May I ask the Lord Advocate whether I understood him to say that the question of compensation can be dealt with on the Committee stage upstairs?

The Lord Advocate

indicated assent.

Sir R. W. Smith

How will that be possible because, if an Amendment is moved to make the period five years for the person who retires voluntarily, it will impose an increased charge on the Exchequer?

The Lord Advocate

I am glad that the hon. Member for East Edinburgh has mentioned his point. The first of the four heads for which provision has to be made in the schemes of local authorities is medical examination and treatment during pregnancy as distinct from medical supervision during child-birth. Under that head it is certainly intended to include the type of thing that is dealt with in the report on Maternal Morbidity under the heading of pre-natal treatment. Therefore, I would say, in reply to the hon. Member and the hon. Member for London University (Sir E. Graham-Little) that there is no ground for any suspicion or fear that they may entertain that the whole weight of the endeavours of the central department and the local authorities will not be bent upon dealing with what, according to the reports which we have to guide us, is probably the most crucial period in the cure of maternal morbidity and the reduction of maternal mortality, namely the pre-natal period.

As regards the question of the hon. Member for Central Aberdeenshire (Sir R. W. Smith), the Financial Resolution which will subsequently come before the Committee will, of course, have a bearing upon what can be done upstairs and, therefore, it would not be correct to say that the question of "three years" and "five years" could necessarily be dealt with in Committee. That might depend upon the ingenuity with which the hon. Member was able to raise the point, but, broadly speaking, the question of three years or five years might impose a charge on the Exchequer, and if the Financial Resolution passes as it stands, difficulty might be found in bringing the matter up in Committee.

This Bill does not, and is not intended to, represent more than one aspect of the efforts of my right hon. Friend and the Department of Health to deal with this subject. Indeed, I think the wisest words that have been uttered with reference to this problem are contained in the Report about the Scottish Health Services to which a great deal of reference has been made, because on page 174 of that report they say, with reference to the problem: It is not by any single measure that success will be achieved, but by a series of measures making up a complete service. The service should be based on the doctor and midwife acting in concert, supplemented by consultants and adequate institutional facilities. The emphasis that is put on each will vary according to local circumstances, but in general the broad lines of policy can be laid down for the country as a whole. In this Bill we have endeavoured to preserve that measure of flexibility which will enable the needs of the different areas to be met by the methods most appropriate for them, but it is because the Bill lays down the general lines of policy along which I venture to think success can best be achieved that I commend it with confidence to the House.

Question put, and agreed to.

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