NATIONAL HEALTH INSURANCE (JUVENILE CONTRIBUTORS AND YOUNG PERSONS) BILL.

HC Deb 11 November 1937 vol 328 cc1950-96

Order for Second Reading read.

7.30 p.m.

Sir K. Wood

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

The object of this Bill, which concerns about 1,000,000 boys and girls, is to fill the gap which at present exists in the public provisions for their medical care and attention between the time of their leaving school and their coming under the provisions of the National Health Insurance Scheme by virtue of insurable employment after the age of 16. The House will agree that this is the vital and critical time when such care and attention are certainly needed, and this provision links up the school medical service with the service provided as medical benefit under National Health Insurance. The number of boys and girls who will immediately be affected by this provision is, as I have said, estimated at 1,000,000, but I should say that the number will fall with the raising of the school leaving age, and as a result of the fall in the birth rate during the past 15 years. But whatever the numbers may be, I hope that this proposal will be regarded as at important protection for this important section of the community, and will dc something to ensure their happiness and efficiency.

The medical service under the Bill will be of the same comprehensive character as that given to our existing insured population. It will be a full general practitioner service and will, of course, include the supply of all necessary medicines. The cost of providing the benefit is to be met, as in the case of the National Health Insurance Scheme, by means of a weekly contribution divided equally between the young worker and his employer, together with a fixed contribution from the Exchequer. The contribution will be at the rate of 4d. a week and, as in the main scheme, the proportion of the cost of benefit and administration payable by the State will be one-seventh in the case of boys and onefifth in the case of girls. Contributions will be paid in the usual manner by means of stamps on cards which will be issued and collected by the approved societies, while the services of the insurance committees will also be used for the provision of medical benefits in just the same way as for present insured persons. As under the main scheme, contributions will not be payable during periods of unemployment, or sickness or while the boy or girl is not available for work, as, for example, when they, as they may, return to school. I think that hon. Gentlemen opposite who are associated with the work of approved societies will agree with me that, as far as cash benefits for juveniles are concerned, there has been no substantial request for them and that they would necessitate the ordinary combined weekly contributions from boys and girls. If that were proposed, it would involve considerable inroads into their weekly earnings.

Provision is made for enabling the new entrants to become members of the approved societies, and this will have important consequences, as anyone who is concerned with the administration of National Health Insurance will know. This will enable them to obtain the full advantages of the main scheme when they become insured under that scheme on reaching the age of 16. It is antici-

pated, as I have good reason to know, that all but a very small percentage of these boys and girls will join the societies, and I believe that they have been fairly active already in that respect. For those who do not do so within the time allowed after taking up employment, it is provided that their contributions shall be paid into a special fund to be known as the Juvenile Deposit Contributors' Fund, out of which the cost of their medical benefit will be paid. The solvency of this fund will be guaranteed by the Reserve Suspense Fund of the main scheme. The title of the young people concerned to medical benefit, having been acquired when the boy or girl first takes up insurable employment after leaving school, continues until the age of 16½, or until the title to full insurance is acquired by reason of insurable employment after the age of i6, whichever happens first. I would add, because perhaps sometimes it is misunderstood, that the title of these young people to medical benefit will not be dependent upon the amount of their individual contributions.

An important provision of the Bill is that for linking up the insurance medical service with the school medical service— the right hon. Gentleman the Member for Wakefield (Mr. Greenwood) will appreciate this fact from his experience when he was in my position—by arrangements under which any insurance doctor who desires to refer to the school medical record of a young patient will he able to obtain confidentially such particulars and information as he requires for purposes in relation to the medical supervision that will be provided. I attach considerable importance to that provision.

The financial arrangements will be sufficient to cover the whole cost of medical benefits, including the administration expenses of the approved societies and insurance committees, and a small margin of contribution will be available, as I will explain later, and may be used for a matter in which I know the right hon. Gentleman the Member for North Cornwall (Sir F. Acland) is interested. It will be available to provide these young people with earlier dental treatment. The period with which we are dealing in respect of boys and girls of this age is one in which the ravages of dental decay may sometimes be rapid, and much can be done by preserving teeth and the replace- ment of some by dentures. Provision of this kind not only means much to the individual concerned, but also to the general health of the community. Much is being done to-day by public authorities in connection with their maternity and child welfare schemes and by the school medical services and the Dental Board, and this provision will undoubtedly assist them in their efforts, and perhaps will bring a greater realisation of the importance of dental health to the community. Under the Bill, young people will join societies at the age of about 14½ instead of 16, and under existing regulations they would become entitled to dental benefit at the age of about 17 instead of 18½.

I confess that I would like to see this gap in the provision of dental treatment for our young people completely filled, but I am afraid that it will not be possible as long as dental benefit is not included among the statutory benefits of National Health Insurance. But under this Measure it will be possible to make a good step forward towards filling the gap. I heard it said in the debate on my former Bill that I introduced Bills that did not go far enough, and the retort I would make is that it is better to introduce Bills and make some provision than to have no Bill at all. The gap, by reason of the earlier date for joining approved societies, will be shortened from 4½ years on the average to about three years. The hon. Gentleman who is chairman of the Dental Board will be glad to know also that I am considering the possibility of going a step further still by amending the Regulations so as to give title one year earlier for this class of member.

Sir Francis Acland

Will that provision come in a Clause?

Sir K. Wood

I shall be able to do it under my Regulations.

Sir F. Acland

In the Regulations under the powers of the Bill?

Sir K. Wood

Certainly. The result of this would be that there would ordinarily he an interval of less than two years between leaving school and acquiring a title to dental benefit under National Health Insurance.

Mr. Logan

Would the regulation apply to those affected by the present Bill or to all?

Sir K. Wood

No, it will apply to young people under this provision. I am considering whether this can be done, and I have invited the views of the approved societies on the proposal. Some further discussion will be necessary before I can arrive at a final decision. Medical benefit will be given immediately a boy or girl becomes a juvenile contributor, and will continue whether or not they remain continuously employed. There is also this further point, which I think will be of value to them, namely, the period of juvenile membership of an approved society will also be counted towards the qualifying period for treatment, additional benefits, such as dental and ophthalmic benefits, when the juvenile contributor becomes an ordinary insured person. It will be of considerable value to the contributor. The rate of payment to doctors for their attendance upon these young people has recently been considered by an independent Court of Inquiry, in conjunction with the wider question of the doctor's capitation fee, who made an award that the rate should remain at the present figure of 9s. a year for each person on a doctor's list, and that this rate should apply also to the new juvenile contributors.

I will be as modest about this Measure as I was about the last, and I present the Bill to the House as another health Measure, which will remove a deficiency in our health services, and I am sure that it will be welcomed in all parts of the House, at any rate as another step forward. When the provision in this Bill has been made and approved by the House, as I feel sure it will be, we can then legitimately claim that the great body of industrial workers and other wage earners of the country are provided with medical care and attention from the cradle to the grave. Such provision begins with the maternity and child welfare work of the local authorities, covering the years up to the age of beginning to attend school. It is continued under the school medical service, and when this Bill becomes law it will be followed without any break by the insurance medical service to which the worker is entitled not only during his working life but after he receives his old age pension at 65, until his death. This Measure gives to the younger section of the community not only many immediate benefits but, as all associated with approved societies know, further opportunities of participating in the considerable benefits of the national health insurance scheme. It will also bring the day much nearer when I hope it will be possible to do very much more. For all these reasons, I present the Bill to the House and commend it to my colleagues for their hearty endorsement and approval.

Mr. G. Griffiths

The right hon. Gentleman has said that benefits are provided from the cradle to the grave, but that will not apply to those who have been State insured persons who become voluntary contributors, when they are 65.

Sir K. Wood

I think so, but I will have that matter further examined.

7.47 p.m.

Mr. Greenwood

I rise for the second time to-day to say again that the Bill introduced by the right hon. Gentleman has much cry but little wool. The right hon. Gentleman is an adept in introducing a small Bill which looks good on the surface but is little in fact. I think that is true of this Bill. I have said many times that it was very desirable that we should close the gap between the school-leaving age and entry into national health insurance. It is part of the policy of my party to ensure that there shall be continuous supervision of the health of the person, as the right hon. Gentleman has said, from the cradle to the grave. It is unfortunate as we develop our school medical service and then bring the young people into industrial life that during two years of the adolescent life of the boy or girl there is no kind of collective supervision over them. The right hon. Gentleman has done something not to abolish but to shorten that gap. I want it to be completely abolished, and the Bill goes some little way in that direction.

The Bill gives the young worker in industry medical benefit. It enables the worker of 16 who normally would be beginning to pay his stamps to enjoy benefits earlier than he otherwise would have done. I admit that there is something to be said for the Bill, small though it may be, because it does that, but I would suggest to the right hon. Gentleman that the Bill should be noncontributory from the point of view of the juveniles who are brought under it, and that cash benefits should also be pay- able between the ages of 14 and 16. It is not customary for the children of the well-to-do to go to work at the age of 14. When the children of insured persons go to work at the earliest possible opportunity it is because of family need.

Sir F. Fremantle

What about going into the Navy?

Mr. Greenwood

I leave that to the hon. Gentleman. That does not appear to be in the Bill. The vast majority of working-class children enter industry because they must. If the hon. Member likes to bring in the Navy, he may do so, but the fact remains that the vast majority of children do not go into the Navy but into industrial life, because the parents need such earnings as can be brought into the family at the end of the week. Juvenile labour is shamefully exploited in this country. Nobody is likely to deny that, yet the right hon. Gentleman is suggesting that these children, driven into the labour market by family need, are to contribute a sum which is not a matter which Members of this House would consider to be much, namely, 2d. per week. It would have been a little more generous on the part of the right hon. Gentleman if, instead of compelling the young person to pay his 2d. and the employer 2d., he had put the whole 4d. on to the employer. He knows perfectly well that there is a precedent in the National Health Insurance Acts for that procedure. There is a provision whereby employers pay the whole of the contribution in respect of low-wage earners. No one will contend that juvenile workers just having left school will receive high wages. It would have been an indication of the right hon. Gentleman's sincerity if he had provided, as in the case of other low-wage earners, that the contributions should be paid by the employers, who are so willing to exploit juvenile labour and after a year or two leave them derelict on the labour market. A trifle of 2d. per week is not a large contribution to be expected from the employer. These young people between 14 and i6 would not be at work if the family could afford to do without what they can earn.

That brings me to my second point. The right hon. Gentleman has made great play with the fact that he is giving medical benefits. I am glad that he is doing that. The fact that these children are at work is an indication that there is need of new financial resources in the family, but when the juvenile between 14 and 16 is out of work and his meagre wages have gone, there is need for a cash benefit if he be sick. I do not believe that the provision that is made in the National Health Insurance Act for cash benefits is adequate, and to deny the young worker who is now being compulsorily brought into insurance the right to a cash benefit to aid his family when he happens to be ill seems to me to be very short-sighted on the part of the right hon. Gentleman. I have spoken on more than one occasion against the Unemployment Insurance Acts, and especially since the establishment of the Unemployment Assistance Board, but, niggardly though the provision may be under the Unemployment Insurance Acts, young people between 14 and 16, who are asked to provide 2d. per week as their contribution, get a cash benefit. They get that cash benefit, it is true, if the father is out of work, but there is this recognition that if the juvenile is out of work there is a cash benefit. I should have thought that having introduced this Measure the right hon. Gentleman might have been guided by the Unemployment Insurance Acts.

What he is giving to these young persons by way of medical benefits is negligible. He is drawing from them and their employers £800,000 per year. He is rather boastful about the fact that it will cost him £120,000 in the first year, but he referred with greater pride to the fact that that amount will fall to about £90,000 a year during the next five years. If we wish to bridge the gap during the period of adolescence it must be with something a little more generous than that provided by the right hon. Gentleman. He has admitted that this Bill does not close the gap but only shortens it. We have spent in this country on maternity benefit, maternity and child welfare services and our school medical services scores of millions of pounds, and we have established a system of National Health Insurance, imperfect in its way, but still a system that has been a great boon to masses of people, and yet there is this hiatus of two years with regard to these young people. The right hon. Gentleman might have been a little bolder—as he might have been in the Bill for blind persons' pensions—and have provided a continuous health service from the cradle to the grave. I am sorry he has not done that.

I repeat what I said on the previous Bill. We shall not vote against the right hon. Gentleman. The Bill, for what it is worth, we accept. Like the previous Bill, it is impossible for us to amend it in the way we should like, because the right hon. Gentleman has drawn the Title so carefully that we can do very little with it. We shall accept the Second Reading, and if we can devise ways and means of improving it in Committee we shall do so, although the right hon. Gentleman has the whip hand there. If I have to say it for the second time, I should like to have seen the right hon. Gentleman a little more vigorous than his stature.

8.1 p.m.

Sir F. Acland

Hon. Members, I suppose, will deal with this Bill after their nature. For my part I welcome it. I say as specifically as I can that the Minister is not insincere—that is rather a strong adjective—because the Bill does not go further. It does not do everything, but it does something which is of extraordinary value. The right hon. Gentleman intimated that he has extensions in mind, and on certain very important matters an extension by regulation. That seems to me to be important for the young people who are now coming out of school in my county, of 14 and 15 years of age, who may perhaps come into my gardens. They are becoming very much more intelligent and keen and interested in everything in the future coming out of senior schools instead of the unreorganised parish school. I say that young fellows and girls of that kind will not feel there is any stigma upon them by being asked to pay their twopence alongside my two-pence. I think they will feel rather more pleased to be paying their share than if it was all found by me or by the State. My experience is that boys and girls of this age very rightly pay the larger part of their wages to their parents for their food and keep, but they are left with far more pocket money to spend than ever before. They will feel when this twopence is being deducted almost grownup, at any rate, in the matter of statutory benefits to which they are entitled, that they are young citizens. I believe they will be prouder in paying this two- pence than they would be if it was all provided by somebody else. At any rate, I know the people in my county, and I do not quarrel with hon. Members above the Gangway when they say that their acquaintances feel a tremendous grievance in being called upon to pay this twopence, when they are asked to be contributory citizens instead of eleemosynary citizens in these matters.

I was glad to hear the Minister say that the very serious gap, particularly as regards dental treatment, is to be reduced from the difference between 2½ years from i6 years of age to 2½ years from 14 plus, whatever the time a boy or girl is going to get employment. The right hon. Gentleman was in the right way when he hoped that it would be possible to shorten the gap still more in the matter of dental benefit by regulation, and I am sure the Minister means to do a thing when he says so. I hope he will have all the success in the world in the negotiations with the approved societies on the matter. As Chairman of the Dental Board of the United Kingdom I say that the gap in the dental treatment is a very serious one indeed. We have nothing like the number of school dental officers there should be, and it is no encouragement to local authorities to provide an adequate supply of school dental officers if we are certain that after a boy or girl has been launched from school there is going to be a period of 4½ years before any public body will be able to come along and help them to have their teeth looked after. That is not encouraging, and it is a serious gap, particularly when you are dealing with adolescents who are passing through changes in their development every six months, and who are often poisoned by bad teeth. Scientists are now discovering that a good deal of ill-health is due to bad teeth, and when a person is suffering from ill-health they are told to have all their teeth out. They have them out, but it does not quite effect a cure. Although it prevents more poison passing into the blood stream, yet there has been a good deal of poison passing all the time from the bad teeth, and you cannot eradicate all the effects of this poison in that way. Therefore, any movement towards closing this gap we welcome with both hands.

It has always been a favourite theory of mine, knowing that the dental benefits were only voluntary, that when approved societies could see an improvement in health of their members from having dental treatment, they would be the first to try to make it not only a compulsory thing like ordinary health benefit, but would be inclined to make it begin as soon as it possibly could. At present they have not much chance of realising that. When it can only begin at 18½ years of age there is not a very great deal of health improvement by getting things right at that stage or later, but the earlier it can start I am certain the more approved societies will realise that teeth health underlies a great deal of other health, and if they can get their members to be right dentally and kept right dentally, they will soon see that a member who is dentally sound is less likely to be ill during the rest of his life than one who is dentally deficient.

Mr. Cove

It may be due to bad nutrition.

Sir F. Acland

I am quite ready to debate the question of nutrition at the proper moment, but I do not see that I am called to deal with it on this Bill. It is not those who are insufficiently fed but those who are unwisely fed whose teeth go wrong. It is in those families where there is always a sweet bit of cake or a biscuit on the table that the teeth go wrong. In those families where there is no such thing, where the food is of a different character, the chances are much better.

Mr. G. Griffiths

You are wide of the mark this time.

Sir F. Acland

I am sorry, but it is my business to know. I agree that bad nutrition of the mother has perfectly disastrous effects on the dentition of the child, from which it cannot recover except by constant care and attention. I welcome the Bill not as closing the gap, but as shortening the gap. I do not find fault because this contribution has come from a short person. I do not find fault because we do not do everything at once. I suggest that it ought to be apparent to approved societies that the shorter you can make the gap the more value the Bill is going to be. If you can give dental treatment early, and therefore secure a larger measure of health and less claims on their funds arising from bad health the better for the approved societies. That is the suggestion which I confidently make. We know many grown-ups who say that they enjoy bad health—and they appear as if they did. You have only to look in their mouths to know that if their teeth had been put right early they would be in perfect health and would enjoy life instead of enjoying bad health. As an instalment, a thoroughly useful instalment, I am glad the Bill has been brought in.

8.1:4 p.m.

Sir Henry Morris-Jones

It is so many years since I spoke in the House that I am almost tempted to ask hon. Members for their indulgence as I did on an occasion many years ago. This is the second instalment of a series of Bills which the Minister of Health is introducing this Session, and may I take this opportunity of congratulating him upon being so very successful, the most successful of all Ministers, in dealing with the Treasury in regard to Bills of a social character? I am sure that the sympathy of all hon. Members went to the right hon. Gentleman the Member for Wakefield (Mr. Greenwood), who was Minister of Health in the Labour administration. The right hon. Gentleman must have found it extremely difficult to say anything against this Bill, and in circumstances of great difficulty, I think he did very well. The fact is that the National Government are introducing so much social legislation that, if they go on in this way for many years, there will be very little left in the future for hon. and right hon. Gentlemen opposite to do. The Government seem to be doing this in a quiet, insidious way, and before many years have passed the whole gamut of the social sphere will have been captured by them, as it were, and there will not be a great deal left for a Labour administration to do.

I think this is a particularly useful little Bill. It brings in a class of person at an age when it is most important that they should have their health looked after, and I have no doubt that it brings them in at a time when very many children, especially in the poorer classes, arc prevented on many occasions from consulting the medical opinion to which they are entitled and which they ought to get in the same way as the children of the rich. As a doctor who once had a very busy practice, which I have given up for some time now, I feel sure that very many honest, poor, working-class people in this country deliberately refrain from getting medical attention for their children at those ages because they cannot afford to pay for it. That happens at the very time when the utmost care, precaution, and preventive medicine are necessary. From that point of view I am very sorry that there is no provision in the Bill dealing with dental and optical benefits. I understand that this could be dealt with by regulation at a later stage, but I think it is rather a weakness in the Bill, as it stands, that that provision does not commence from the beginning. The years between 14 and 16 are very important for young people of both sexes. It is at that time that they leave school, where they have been accustomed to a certain amount of regulation and preventive examination of teeth and eyes, and they will rather miss the regularity of inspections to which they have been accustomed. I trust that it may be possible for the Minister yet to incorporate a more thorough provision for that inspection.

A feature of the Bill which, I think, is very good, is that the medical attendant is to be allowed to have the school medical record of the child. That will certainly be a great help to him and will, as it were, give him another eye. No doubt those records are confidential, but I hope that a complete medical record of the child's life up to the time that he or she leaves school will be allowed, in order that the medical attendant may have the opportunity of combining his experience with the experience gained by the school medical officer.

I am told that the panel practitioners in this country are a little disappointed at their remuneration under this Bill. The sum is to be 9s. per head per insured person, a figure which is certainly not extravagant. If it be remembered that the 9s. per head is the figure that has been adopted for some years for medical attention to adults, no one, I think, will say that 9s. is excessive, and some may say that it is not reasonable, for looking after children who require far more attention, probably a more thorough inspection, and more frequent visiting, and who are far more important people, as a class of life, to the community than those people who are at later ages. Additional to that is the fact that under this scheme the medical practitioner will have to keep very careful records. The extent of clerical work which medical practitioners have to do in connection with their work is hardly realised. A very substantial proportion of time which they ought to give to prevention and cure has to be given to clerical work.

This is a good Bill. I foresee a time, before this Government or a similar National Government leaves office, when the whole life of a person from childhood to adulthood will be covered. Let me say candidly that I am rather sorry about that. I am rather an individualist, I belong to the old school, and I believe in personal contact between each person and the medical man. But I am afraid I am behind the times. The whole tendency of the State is to embrace people in its arms, or tentacles, from the cradle to the grave. According to all the tendencies, it has to be done even by a Conservative administration, for this is largely, in its elements, a Conservative administration. If the Government go on at the rate at which they are going now, I am very much afraid that hon. and right hon. Members opposite will have very little to do when they come into office.

8.23 p.m.

Mr. Logan

I wish to make a few observations on this Bill. I listened with interest to the Minister enunciating his policy in regard to the gap, but I am unable to understand the optimism of those who think that dental benefit is to be brought in by regulations. Anybody who has knowledge of National Health Insurance must be aware of the fact that the valuation of the approved societies is based on the solvency of the societies and this particular class of insurance introduces a relatively unknown population, which must be brought under the Act at 16 years of age. It is nonsensical to speak of boys or girls being able to get dental benefits earlier than at 14½ or 16½. They will get them if they are fortunate enough to be in an approved society which is solvent, but when the majority of approved societies throughout the country is not solvent, optimism must go and disillusionment must come to every parent. I understand the gilding of a pill in order to make it acceptable to a child, but when we are getting, as we are to-day, a present from the National Government, it is well to understand what it is that we are getting. Let us not have a false perspective placed before the country. The National Health Insurance Act is complex enough without making it more complicated, and the simpler we can make it to the simple people outside, and to the simple Members of the National Government, the better it will be for everybody concerned. I have to be careful not to make too many eulogies on this Bill, because the last time I eulogised the Government it was all over the hoardings at the elections in the Scotland Division and the Exchange Division of Liverpool. Therefore I must be careful that I do not give too much praise to the Minister on this occasion.

The Bill is said to be for the purpose of bridging the gap which now exists after the school-leaving age. I take it that at the end of the school term in which a child reaches the age of 14, if that child gets the necessary permission, he will be able to go into the industrial field, and then he will become not an insured person but a juvenile contributor. I notice that the term "juvenile contributor" is printed in the Memorandum in inverted commas. It carries a special meaning. It does not carry with it the full qualification of an insured person. The boy or girl does not reach the status of an insured person until later when he or she has entered the real scheme. The Bill, which I hope will become an Act, is, we are told, to give certain benefits, but I am at a loss to understand what is meant by these words: The Bill accordingly provides that any boy or girl who after reaching school-leaving age but before the age of 16 becomes employed within the meaning of the National Health Insurance Act shall immediately become entitled as a 'juvenile contributor' to medical benefit, etc.". What is the meaning of the word "employed" in this connection? Under the amending Act of 1924, which is the present National Health Insurance Act, employment carries with it certain obligations. In this Bill the obligations of employment are not dealt with. If a boy aged, say, 14 years and three months is employed, he can become a member of an approved society, and if he afterwards falls out of work then, for the purpose of this Measure, he is insured and insurable until the age of 16½.That, to my mind, involves preferential treatment. He is to receive medical benefit, and I am not objecting to that. But the qualification in regard to the waiting period will entitle these young people to additional benefits when they get into an approved society. That means that the person having once joined, can, at the end of the waiting period, qualify and have benefit in respect of the two years waiting period, an advantage which is not given to those who join the approved society at the age of 16. That appears to be a discrepancy, and I wish to know by what system of actuarial calculation it is possible to say that a person who will contribute 2d. per week for this period is entitled to get these additional benefits.

I submit, however, that the term "additional benefit" is a misnomer, and that there are no additional benefits which can be given unless the parents of the children concerned take jolly good care at the commencement to see that the children get into societies which are already paying such additional benefits. If this House is the sounding-board of the nation, I hope my advice given here will reach all fathers and mothers when I tell them not to rush their children into any society at all, merely for the sake of getting them into a society, but to see that their children join good societies until the State undertakes the duty which every right-thinking man hopes it will undertake and assumes responsibility for the whole system of national insurance. I get my livelihood from insurance, but I think the system on which we are working to-day is the wrong system in the interests of the nation. It ought to be taken out of the hands of the societies altogether. The inequality of benefits in different parts of the country is a curse, and we shall never be able to get the full benefit of all the health services until the State takes over the whole system as regards both adults and juveniles.

What is to happen under this Bill if the young person falls out of employment? I hope the Parliamentary Secretary will deal with that important matter, because it is a matter with which I have to deal when I am making up accounts and preparing audits and going through all the rest of the insurance paraphernalia which is necessary in order that we should know where we stand. I give every benefit in my society that can be given under the Act. We are giving them out week after week, but there are many societies which are not giving them, for the simple reason that casual labour and non-continuous employment make them impossible. The conditions of employment in casual occupations like those of dockers and seamen make it impossible for such societies to give any of these benefits, an they will not be able to give them for the next 50 years under existing conditions. But those are the benefits which are set out in this Bill to be given to these boys and girls in the course of a couple of years. Boys or girls who go into casual occupations will never get any of those benefits under present arrangements.

How, then, is it proposed to give young people the additional benefits which are considered so essential for their health? Everybody knows that every child, with proper attention, can be made an asset to the nation, and that no boy or girl can be of much use in any occupation unless he or she has plenty of vitality. Children require special attention, and dental and optical examinations and treatment will prove very expensive. It is very important that children entering on the industrial field should have their teeth, sight and hearing properly looked after at the commencement. Unless they are put right at once in those respects they have little chance afterwards. But that does not appear to be provided for in the Bill, and it is not provided for in the National Health Insurance Act because under that Act, with all the millions at their disposal, the societies are not able to give benefits such as are pourtrayed here. I do not want any illusion to be created about this Measure. I do not want it to be thought that we are now going to give optical and other treatment to these juveniles, because we are not going to do anything of the kind.

Suppose a boy or a girl falls out of employment. Under the 1924 Act no one can be a member of an approved society unless he or she is employed, and it naturally follows that no matter what arrangements you are making under this Bill to carry along a child up to 16½ years of age, if he is not employed, he cannot become insured under National Health Insurance. It is quite possible that a boy or girl will not be working at 16½ years of age and yet will be qualified under this Bill to receive all the benefits of medical attendance up to 16½. How is the old Act of 1924 to be amended so that an unemployed person can be taken on and continued under National Health Insurance although unemployed, which is contradictory to the Act itself? I should like to know if that problem can be answered. I want to know, Can we take into National Health Insurance any boy or girl at 16 who is not employed? If the favour is going to be given to the boy or girl who comes in unemployed under this Bill, then it will be logical to take in the unemployed person under the National Health Insurance Act, and that is a proposition that will not bear examination, because that Act is based on an actuarial standard, and no actuarial standard would stand the unemployed being allowed to get any benefits under the National Health Insurance Act, which is on a contributory basis.

Turning to another matter, I have no objection to the remuneration of the medical body. If there was ever a body of people in the world that deserved remuneration for the great work that they do, not only in private life, but in hospitals, of which I have seen a lot, that body is the medical profession, and I do not begrudge the fact that under this Bill, according to my computation, they are receiving a sum of about £450,000 at least, if 1,000,000 is the true number of people that w ill come under the Bill. But is there not another point? The medical man certainly takes an account and puts it down, and sometimes it would be better if he wrote more legibly. I think most doctors must have been versed in Greek hieroglyphics, because their writing is abominable, and they do not seem to be able to understand how to write. When you get a doctor's note, you can get it made up to any prescription, because it may mean almost anything.

The Minister has been very subtle tonight in his statements. He has a wonderfully benign manner of expressing things, and he is very suave in dealing with things. He mentioned about doctors, but he did not mention anything about the administration or about the society that has got to administer the Act. There are many who are engaged and getting their livelihood in societies—clerks and such like—and while we want to give benefits to some, I would like to know, in regard to the staffs engaged in many of these societies, what the amount for administration will be. By regulations, I am told, you are going to deal with dental benefit. Would it not be better if, without talking of regulations, we were able to know what the man on the job is to get for carrying out the work of National Health Insurance?

There is another important point, which I hope the Minister will be able to understand, because it is a subtle point. I do not wish to be in any way insulting, but the point is very deep. I want to know whether this Bill means that a person must pay 26 weeks' contributions after 16 years of age to qualify for cash benefit. The important point to be borne in mind is that this Bill is giving only medical benefit, but the essential point in regard to the home will be, When shall we be entitled to receive cash benefit? Under the 1924 Act, after 26 weeks' contributions are paid, then at a reduced rate the boy or girl is able to get cash benefit along with other benefits, but under this Bill there is no indication of how long he or she must be in before getting cash benefit. If you are unemployed, you cannot get cash benefit, and I want to know whether there are going to be franks, during the period of unemployment, to link you up. I want to know whether, when a boy is unemployed, although he is now registered under this Bill as a member, there will be registration at an Employment Exchange. Will the franks for registration be brought along as they are brought along to-day, or can there be a gap without any registration whatever? I want to know how that link is to be made up, not only that societies may know that a boy is looking for work, but also to see that a boy will not lose the benefits under the Act, and that, from the point of view of continuity, that relationship from 14½ to 16½ years of age will entitle him, by proper registration at some responsible place, to get the full benefits to which he is entitled.

It must be understood that unless there is going to be a proper linking up, the benefits can be lost to a boy. Seeing that you are going to give him the advantage, in regard to additional benefit, of at least two years in the waiting period— because the earlier the age of joining enables him to qualify about two years earlier—I say that, just as an adult has to register at an Employment Exchange, so should a boy who is unemployed, if he is to get the full value of those two years, have a link with the society and the Employment Exchange so that he may get the additional benefit. I should think you have got about as far as you could possibly go, considering the proposition placed before the country, in regard to dental benefits. I hope the Minister will make plain to the nation that they cannot get these benefits unless the child is in a society that has funds at its disposal; otherwise the parents, if they go into the back-alley societies, can never get any benefit whatever out of them, and the sooner that is made known to everybody the better.

There is one other matter which I should like the Minister to take into consideration. You have made, in regard to the school-leaving age, a proposition that a boy or girl can go from school to employment and get the benefit of those two years. I want to see that extended. I want to see the best benefit under the Bill given to every boy and girl. I do not want the funds of the societies to be built up, for they should be devoted to the purpose for which they were contributed, namely, for the benefit of the health of those who join. That being so. I would like to know how it is proposed to deal with the boy or girl who does not leave school so early. The Bill gives two years additional benefit to the boy or girl who leaves school and rushes out to employment. It there to be any franking for those who remain two years at school? Will you not give the benefit to the child of 16 who goes into the field of life after leaving the secondary school, while you give the poor breadwinner who had to leave school a chance of getting qualifications earlier? Many parents sacrifice themselves and do without the extra two years earnings of the child in order that the child may have a better chance at a secondary school. What provision is being made in the Bill to see that the new qualifying period is given to such a child? The children of the nation, whether they are poor industrial workers who go out to work early, or whether they are kept by their parents at school in the hope than: they will have a better chance in life, are worthy of consideration at our hands.

8.48 p.m.

Mr. Denman

The hon. Member who last addressed the House has put to the Minister a series of searching questions, and we shall await with interest the answers to them. He made one point specially which, I hope, will receive wide publicity, that is, the importance of children joining the best societies if they are to obtain the full benefits of this Bill. Clearly the additional benefits will be paid by only a relatively small number of approved societies. I am one of those who regard the dental benefit as of the greatest importance for the children of this age. I rejoiced to hear the Minister state that he is able to do a little better than the Bill announces it will be able to do, and shorten the gap by one year. According to the Memorandum to the Bill, the gap was shortened but very little. In shortening it further the Minister has undoubtedly met a real need. Like other hon. Members on all sides of the House, I look forward to the time when the gap will be completely abolished.

We all welcome the Bill as a distinct step forward, for it means that a part of the gap in our medical services is being filled. Every time we have a Bill to fill one of these gaps it emphasises the gaps that remain. Even after this Bill becomes an Act, what a medley our medical services for child welfare will be! We begin with the inadequate and fragmentary service for children before they enter school. We then go on with a completely different set of doctors while the children are at school. It is true that they are inspected at intervals, and that they receive a certain amount of treatment, but to maintain that the school medical service provides an adequate medical treatment for childhood is an impossible idea. Then they come under panel doctors, and will probably be examined by factory doctors. Throughout this process the children are objects of interest to a different set of doctors at each stage. Medical opinion is practically unanimous that the most effective medical supervision is that of the family doctor. He knows the child from the early years upwards, knows the particular family idiosyncracies and the weaknesses to which every child is liable, of which a new doctor will know nothing.

Instead of having a family doctor responsible for the health of the breadwinner, his wife and children, we have this extraordinary medley of medical supervision from the earliest years until the child is well embarked on life. It is outside the scope of the Bill to deal with that big problem, but the fact that we are remedying a little bit of the trouble throws into relief the amount of ground that has still to be covered. I look forward to the time when my right hon. Friend or his successor will be able to tackle this problem of the treatment of child health from the earliest years as a big question, and will give us a service that will ensure us a far better standard of health, the absence of a C.3 population, and a childhood physically fit and able to enter upon the tasks of manhood and womanhood in a far more satisfactory manner than hitherto.

8.53 p.m.

Viscountess Astor

I want to congratulate the Minister on many things that he has done. Naturally this Bill is a step in advance but what I think should be the first consideration of this House is a survey of a problem which has alarmed every responsible person in it. It is no good the Minister bringing in these patchwork Bills. They are better than nothing, but what we want, and what the nation will demand soon, is to know what we are going to do about the fact that 50 per cent. of our recruits are turned down for ill-health and 16 per cent. of our children in elementary schools are physically deficient. Nothing adequate is being done about it, although we are spending an enormous sum on medicine. When an hon. Member asks what we are doing about the school medical services, I would point out that we are spending £4,500,000 on them, including the special schools. We spend £3,700,000 a year on tuberculosis, £836,000 on venereal disease, over £2,000,000 for special schools, £9.000,000 on the insane and £7,000,000 on mental defectives. Those are colossal figures, and we are not really getting better in the way we should do.

I am getting weary of saying, when everybody talks about getting fit, that we should get to the bottom of it and see how we can prevent ill-health instead of adopting this bottle system of curing people. The Minister of Health, in a very able speech, has deplored that we are becoming a bottle-minded nation. He said that in the last 12 years the cost of prescriptions had increased from £1,750,000 to £2,250,000. He was quite right in saying that we are a bottle-minded nation, but will not this Measure just mean more bottles? I shall not say a word against the medical profession. because I think some of the most splendid men in the country belong to it—and some of the worst scallywags; there are some of the best arid the worst —but I do not believe in looking to medical men for health. We go to medical men in cases of ill-health. If hon. Members want to see good health let them consult the people who have beaten the doctors at their own game; let them go to the Margaret Macmillan Centre in Deptford and see what she has done.

It is madness for us to go on as we are. There is a terrific problem before us. We have a falling birth rate. Ministers talk about the tragedy of the falling birth rate. Well, the Government cannot do anything about that. There are 599.000 children born in this country each year. Of those, 25,000 are born dead, and 57,700 die before they are two years old. Why do not we get to work to see whether we cannot save those 57,000 children, who were presumably born fairly healthy but died before they were two years old? We should see also whether we cannot do something about that 16 per cent. of our children who, when they enter the elementary schools, are found to have physical defects which many of them had not got at the time of their birth.

I would remind the Minister that we have a chance under this Prime Minister, because he is a man who does understand these things. He understands local government; nobody in the world has done more for health than he has with his Poor Law reform. He has a great record behind him. I wish he would go to the country and say, "We have got to stop patching up." The last thing we did was to patch up recruits who were in a low state physically. It was found that if they were fed well and looked after they would soon be all right. With our nursery schools we have shown the improvement we can make in children when they have proper food, proper sleep and good environment. I remember a child whose legs were so very much bent as a result of rickets that the doctors wanted to break the legs and send the child to an orthopaedic hospital. We said, "Give it to us for one year." We had the child one year, and now that child's legs are straight—much straighter than the legs of many hon. Members of this House.

Mr. Logan

You could not stop the Prime Minister having gout.

Viscountess Astor

He did not get it when he was two years old. This problem of the children really does alarm me. If we look after the children from the age of two to five we can cure them of rickets, which are the root of a great many other diseases, and we can make them half an inch taller than other children and 5 lb. heavier. It is amazing what we could do—but we are not doing it. We are getting research. Almost every time I look in a newspaper I see that somebody is "researching" about health. Why do they not use common sense? We are becoming medically-minded and medically-ridden. I would not mind if the medical men gave us health, but they do not. This Measure means more bottles. While we ought to welcome this Bill, I want the House to say that we must face up to this problem of ill-health and physical unfitness. Other countries are doing it, and doing it with a vengeance. We cannot do it in the way they do it, and I do not believe we can do everything all at once—I am not in a hurry about it. If this Bill passes there will be £500,000 more a year—

Mr. Bernays

£130,000.

Viscountess Astor: If

you gave me that £130,000 a year, and part of the £4,500,000 you are spending on medical benefits [An HON. MEMBER: "You would go on holiday!"] No, I should not go on holiday. This is nothing to laugh about. I can be as cheeky as you like when I want to be, but I want to deal with this matter seriously. We have a falling birth rate and 57,000 children dying before they are two years of age, and we go on patching things up in this way. We must have a system of prevention instead of having to remedy so many ills. We heard the other day of the enormous increase in mental disease cases. It is terrific.

Mr. Duncan

In London this year there has been a decrease.

Mr. Deputy-Speaker (Sir Dennis Herbert)

Now that other hon. Members seem to be joining in this discussion, I must ask the Noble Lady to look at the title of the Bill.

Viscountess Astor

As it is a Measure dealing with health, I thought it was a good time to talk about health.

Mr. Deputy-Speaker

I am afraid the Noble Lady must do so with some reference to the proposals which are contained in the Bill.

Viscountess Astor

I was aware that I was going a little outside the scope of the Bill, but I thought it was such a wonderful chance to get in a little propaganda about good health, and to remind the Minister that although we welcome this Measure as being better than nothing it is still going to leave us a bottle-ridden nation. I am hoping that sooner or later the Minister will tackle the subject—indeed, the Government as a whole ought to tackle it, because it concerns not only the Ministry of Health but the Board of Education and other Departments. There ought to be some coordination between the Departments, and they ought to face up to this terrific question. As I have said, 50 per cent. of our recruits are turned down on account of ill-health, and i6 per cent. of those who go to our schools to get education are not in a fit condition to learn. I am sorry that I have been out of order, but I feel very strongly on this subject, and this was a great chance. There are other questions, but other questions will wait, and the children cannot wait. If once we let them get past the time when we can deal with their small diseases they will be ruined for life.

9.3 P.m.

Dr. Haden Guest

The Minister has told us that the Bill will bring in a million young people of 14 to 15 years of age. That is a very small number in comparison with the total of those who are dependent upon insured persons and who, under a Bill which would recommend itself more to this side of the House, could also be brought in. The hon. Member for the Scotland Division (Mr. Logan) riddled the Bill with some very good shots, pointing out some very large gaps in the drafting of it, and I think the Minister will find some difficulty in replying to him. The speeches of the hon. Member for Central Leeds (Mr. Denman) and the Noble Lady the Member for the Sutton Division of Plymouth (Viscountess Astor) have also subjected the Bill to very severe criticism. Like the Noble Lady, we on this side welcome the Bill for what it is worth, but I think that the Minister trumpeted too much about it, claimed too much for it. He made out that it was a good deal better than it is. If he had confined himself to saying that it is a small Measure of administrative and practical importance it would have been a fairer statement. To claim that it is an important advance is far removed from the facts, especially regarding the number of persons to be treated.

No doubt the Minister has the facts at his disposal. Estimated on the calculations of the 1926 Royal Commission on National Health Insurance with regard to the number of dependants, there are now approximately 18,168,780 dependants of the 35,000,000 insured persons. That means, if this method of treatment and medical provision is to be continued, that that very large number of people ought to be brought within the scope of National Health Insurance. That would prevent the gaps and deficiencies which will defeat the Minister's aims. As my hon. Friend the Member for the Scotland Division said, young people brought into insurance under this scheme will not receive dental benefit. There are very few approved societies who can give it. If the Minister can invent some way of giving them dental benefit no one will be better pleased than ourselves, but how will he do it? It is no good to promise dental benefit to persons in two years' time, because these young people want it when they are entering into employment.

I have some figures of the proportion of people who need dental treatment when they leave school, taken from the Report of the borough of Cambridge, relating to 1934. No doubt the figures are about the same at the present time. In that year, 784 children between 13 and 14 years of age were examined and were found to have a total of 2,929 permanent carious teeth. That is a fair proportion of the large number of carious teeth in the mouths of children at the school-leaving age. If you apply that proportion to the total of 1,000,000 who, the Minister said, would be brought into insurance under the scheme you have a large figure of the number of carious teeth which will require treatment. If they are not treated in the years between 14 and 16—the Minister said there would be a delay of two years —there will be permanent damage to their health. There is not the slightest doubt about that, because one of the most important things for young people of that age is that their teeth should be kept in proper order to prevent all kinds of septic conditions arising and to enable their digestion to function properly. Good teeth are one of the conditions of health. The Minister knows the enormous benefit which has accrued to children since school medical and dental services were instituted. They have produced almost a revolution.

To reinforce my opinion I will quote the Royal Commission on National Health Insurance of 1926, which said: The general effect of this evidence is to emphasise the value to health of timely continued and effective dental treatment. The need for making the benefit generally available on uniform lines and the adequacy of the number of qualified dentists to deal with the whole insured population. Then they go on to say: The evidence leaves no doubt in our minds that any system of public medical service cannot be regarded as complete until it includes the provision of adequate dental treatment in generally available form. That report was made with regard to adults. The argument is TO times more forcible with regard to children and young persons. I am sure that the Minister will agree with me.

You, therefore, have an apparently irrefutable case for the provision of dental treatment for young persons. How will it be done? I should be very glad, speaking personally, to support any reasonable method of doing it, although I would very much rather that the Minister took his courage in both hands and provided a national health system to take in all the dependants of insured persons. It would be an excellent national economy which would provide medical superintendence of children by a doctor who knew them for a long period of their lives, and it would really begin to approximate to what the Minister somewhat grandiloquently said about this very small scheme—to caring for the insured population from the cradle to the grave. If he had made a little more provision for their dental treatment there might have been more to be said for it.

If the Minister cannot do more than provide some kind of what the Noble Lady the Member for the Sutton Division called a bottle method of treatment, it is not much to come to the House about. If this is to be regarded as a first step in the extension of insurance treatment to the dependants—although technically, of course, these young persons would not be dependants—it might be an advance to be seriously welcomed; but in its present form it is not a very big thing. I hope that the Minister in his reply will be able to outline some method by which dental treatment can be given. I think I am justified in saying that I am speaking not only for myself but for every medical Member of the House. I think every medical man is agreed on this matter.

9.13 p.m.

Mr. Duncan

I have some hesitation in intervening in a Debate after so many doctors and insurance experts have been speaking. I am a simple layman trying to take a layman's interest in the matter. I thought it was a little ungracious of the right hon. Gentleman the Member for Wakefield (Mr. Greenwood) and the hon. Member for North Islington (Dr. Guest) to belittle this Measure so much. The Minister did not blazon it forth as a major Measure. He was particularly modest— I thought he was too modest—in introducing it. It will benefit in some way or another 1,000,000 boys and girls in this country at a time when the benefit is most needed, and that is not nothing. The right hon. Gentleman the Member for Wakefield seemed to criticise the Minister for not including cash benefits, but I think the Minister was quite right. Cash benefits would make the contributions very much heavier. The general view of parents would be that they would rather their sons and daughters paid only 2d. per week and got medical benefit rather than a very much bigger contribution to get more benefit and cash benefits as well.

With regard to the question of dental benefit, I listened with great care to what was said by the hon. Member for the Scotland Division of Liverpool (Mr. Logan), and, as far as I can understand, he seemed to have spotted one or two weaknesses in the Bill. As I understand it, if a boy or girl leaves school at the age of 14 or later, becomes employed, and is employed until the age of i6 plus and for some time after, he or she gets all the additional benefits of the Bill, including ophthalmic and dental benefit; but they do not become entitled to any of the benefits of the Bill if they leave school and do not become employed. The benefits do not start until the young person becomes employed, if I read the memorandum to the Bill aright. Again, if the young person falls out of employment before reaching the age of 16½, having been employed after leaving school, then he or she is continuously insured for medical benefit until the age of 16½ anyhow; but if they are out of work at the age of 16½, they have to start all over again when employment is obtained after the age of 16½. There are no running benefits after the age of 16½ as regards cash benefits, medical benefits or additional benefits, and none of the special measures taken for the highest class, namely, those who have been continuously employed, will inure to the boy or girl who gets out of employment.

Mr. Logan

My point was that, although the lad, after being employed, is entitled to benefit up to the age of 16½, if he falls out of work at 15½ and is out of work for one year, he is still qualified for medical benefit, while riot being an insured person. He is getting preferential treatment. Whether the benefit is medical benefit or not is immaterial; you can get no benefit unless you are an insured worker under the Act. I was dealing with the gap, and asking how the Minister was going to bridge it.

Mr. Duncan

I also was going to ask the Minister to explain exactly what happens to the boy if he falls out of work—how he gets back into insurance and into the scale of benefits after the age of 16 plus, and if and when he becomes eligible for additional benefits.

Mr. Logan

I was wondering whether the machinery of the Employment Exchanges was going to be the connecting link for registration.

Mr. Duncan

I must thank the hon. Member for helping me on this technical question. With regard to dental benefit itself, the Financial Memorandum says: Provision will be made for this purpose by regulations under the principal Act. I should like to ask the Minister whether he could have these regulations published in draft form before we consider the Bill in Committee, so that we shall begin to understand it a little better than I, at any rate, can at the present moment on this rather technical point. In spite of these technical difficulties, I heartily welcome the Bill. It deals with medical benefit for boys and girls at a very critical age, when they are growing up and when there has been a gap for so long in medical benefit when medical benefit is really needed. I hope that the Bill will receive a Second Reading without a Division, so that the parents of the country will be given a clear indication that the House of Commons is doing its best to help their children.

9.21 p.m.

Mr. Leslie

We on this side welcome the Bill as an instalment, but only an instalment, of justice far too long delayed. I think it should have been introduced at the same time as young persons were included under the Unemployment Insurance Act. The Minister tells us that the object of the Bill is to fill the gap between school and the age of 16, but really it does not fill the gap, because while at school a child is under the watchful eye of the medical officer and entitled to both dental and optical treatment, but this Bill provides neither. I happen to speak for an occupation that employs nearly a quarter of a million young persons between the ages of 14 and 15. The exact number of young persons between the ages of 14 and 15 employed in the distributive trades is 242,730. Why are they employed at this early age? Undoubtedly it is because of the need for additional income in the family. Poverty is the main cause of children being sent into the distributive trades at the age of 14. They are taken from school, where they are engaged for 28 hours a week, and are dumped into occupations where the hours are very long. That imposes a big strain on them, and the result is that their health becomes impaired. Van boys and errand boys are subject to the inclemency of the weather, and the sickness rate among them is very high. I want the Minister also to bear in mind the fact that employers are not all generous in paying wages to juveniles during sickness, so that the family is deprived of the boy's wage at a most critical time, namely, a time of sickness. The hon. Member for North Kensington (Mr. Duncan) said he thought it was right to exclude payment during that period, but we certainly think otherwise. The Bill fails to make provision for the payment of benefit during sickness, and I think that that is a very serious omission. I

have already mentioned dental and optical treatment, which are not to be given until the age of 17.

The hon. Member for the Scotland Division of Liverpool (Mr. Logan) mentioned that a large number of approved societies are unable to give additional benefits. Fortunately, I represent one that does, because it has a reserve of something like £750,000. But boys coming, for instance, from miners' homes are certainly at a disadvantage if they want to join an approved society, because they will not be able to get these additional benefits. If they had been at school instead of being dumped into industrial occupations, they would have had both dental and optical treatment, and, as previous speakers have mentioned, defective teeth are a wellknown cause of incapacity. Surely, therefore, dental treatment ought to be provided.

Then, in view of the fact that the payment of the 4d. contribution under the Bill is to be divided between the employer and the employé, I would ask, why are these young people employed at that early age? They are employed because they are cheap, and, that being so, we think that the employers ought to pay the full amount, and that amount should be such as to make possible sickness benefit provision. The Government can be very free in granting huge subsidies to many cases less deserving than this. The Government has been boosting the "Keep Fit Campaign." Why not start by keeping the children fit? One slogan which I observed the other day, and I think it is a very good slogan, is "All the wise exercise." May I suggest to the Government that if they are wise they will exercise wisdom in being a little more generous in the provisions of this Bill. I think the Bill should provide, in addition to the medical benefit, payment of dental and optical treatment during sickness, the whole of the contribution to be paid by the employer and the Government's State contribution increased. Unless these provisions are made it will be far short of what we desire.

9.27 p.m.

Sir Ernest Graham-Little

I want to stress some points which, I think, make this Bill a very valuable effort. The ages at which it will become operative are between 14 and 16. Those are the ages when physical development occurs and nervous troubles become important, and it is at that period that persons really require far more watching than at any other periods in the life of a human being. It is high time to fill that gap because of the work which has been done in the last decade dealing with the psychology of the adolescent. It is quite new work. The Regius Professor of Physic at Oxford, a very famous nerve specialist, has recently said some things about the incidence of nervous diseases in this country. He said the amount of nervous disease was strikingly large, and many of those nervous disorders are begun in this very critical period. This age is very little understood, and its importance is becoming more and more widely recognised. There are many diseases and affections which are peculiarly liable to begin at this period. The adolescent is often put to physical exercises for which his frame is not fitted. One of the fears which I have personally of the physical recreation movement is that in many of these cases mischief may be done because it is quite obvious you ought to know of what the physical framework is capable before you put it to any physical strain.

Let me give a concrete instance. A very skilled medical friend of mine practising in the country had a boy sent from Eton, a boy of very good family and of very fine promise. To his astonishment the boy had a very large heart. The first: examination revealed it. The father said to him, "I have brought him down here. I know you well, and I know that you are an excellent practitioner. I have not been able to get any proper attention paid to him at school." That boy had been forced to do many quite improper things in playing games much more vigorous that he was capable of, and by my friend's order he was kept on his back for a whole year before he could recover the proper size of heart that had been affected by that exercise. This kind of attention will prevent, I think, many terrible things like that happening.

I think that another very important phase of this question is the optical benefit; many cases of disease and disability of the eyes seem to arise in this period. Far too little attention to-day is paid to the condition of children's eyes. The conditions of homework are of prime importance at 14. It is that kind of attention which I hope will be provided by this Measure. I am very glad that it is a contributory Bill. I think a contributory Bill will be far more successful with an independent people like ours. As a first effort I think it should receive nothing but encouragement. I do hope that there will be absolutely no opposition to this very valuable Bill.

9.32 p.m.

Mr. G. Griffiths

This is the second Bill that the Minister has introduced to-night. They are both little Bills. While they have not been opposed, it has been emphasised that there are defects in them. I think the Minister admitted on the last Bill that he could not come down to the age of 18 because of the Financial Resolution. I was hoping that he would, but I must not talk about that too long for I shall be out of order. What I do want to say is that I belong to a society. I have been in it for a good many years. It is a practical one, in the West Riding, and all the members of that society are miners. The miners carry a tremendously big incidence of sickness owing to the conditions under which they work. The society has only been able to pay sickness benefit and disablement benefit, and only the minimum amount. Never have they paid anything above 15s. and when members have drawn 26 weeks it has never paid anything beyond 7s. 6d. We have got a lot of boys between the ages of 14 and r6. When the Education Bill comes into operation in 1939, it is likely that any kind of employment in a pit by a boy who is the son of a miner will be beneficial employment, and he will go into the pit. When it comes to the boy going into a society—the hon. Member for the Scotland Division of Liverpool (Mr. Logan) sent it out to all the world—he must go into this kind of society or he will not get benefit. I do not blame him. That is the defect in this Bill. Dental treatment and the inspection of the eyes should have been merged into the Bill.

The chief defect is that this is not a State medical service. I disagree entirely from the hon. Member for London University (Sir E. Graham-Little). This is the occasion on which the Minister of Health could have done one of the greatest things in Great Britain; he could have started a State medical service for everybody who requires it. Yon have a State medical service for every T.B. case in this country if they want it. During last year, 100,000 were inspected for T.B., and there were 64,000 notified, and every one of those could have inspection and treatment free. It is estimated that it costs at least 7£3 per week for each of these T.B. cases. I do not desire to continue on that point, but I will put one other point. The Noble Lady, who has gone out now, stated that we expended last year £436,000 on venereal disease. If people contract this painful disease— largely on their own account; it is no good blinking the fact—the Government say, "Come to the clinic, and we will pay every penny of the cost." There are two points. Now I will come to a third. There are 250,000 people in this country suffering from diabetes. When they are certified as suffering from diabetes, and the doctor says that they are to take insulin, the Government say that they are to buy their own, no matter what their financial position is. Is that fair? And it is one of the most costly drugs, especially for working men and women. I have asked the Minister repeatedly, why cannot State-insured persons' relatives have insulin free? They would live if they had it, but a lot of them do not have it and they die, because they cannot pay for it. A State medical service would take in those people. It is true that the Minister or the Parliamentary Secretary will reply to me that they can get it. The Minister nods his head.

I have raised the question of one of my own constituents, a woman, who has to pay 14s. or 15s. a week for insulin, and could not get it from the public assistance committee because the man was getting £3 5s. a week, working seven shifts a week. Because there are only himself and his wife, she cannot get insulin free, yet, over and above the cost of the insulin, she has to have a different diet from his. If there was a State medical service granted to diabetics, the same as there is to T.B. and venereal disease cases, there would be something to be said for a Bill similar to this. I put my plea in here that this is only a small affair. There is nobody in the country who can make little things look big better than the Minister of Health. He brings a Bill here to the Box and says, "This is a great thing, there must be no opposition; it means the life of so-and-so." It means, I agree, medical benefits, but when the Minister tells us at the Box, "I am managing now from the cradle to the grave," I say that he is leaving out 250,000 people who are going to the grave. I appeal to him to do better than this. I ask him before he leaves that office to bring forward a State medical service, so that everybody will have a fair crack of the whip.

9.41 p.m.

Mr.

Westwood: Every speaker, on either side of the House, has welcomed this Measure, but almost every speaker has claimed that it is an exceedingly short step to cover an extremely wide gap in services that we must provide if we are to make the health services truly national. I suggest also that the step we are taking to-night is long overdue. Twenty-five years ago the National Health Insurance Act was introduced. It has taken 25 years to introduce an amending Measure that will provide for medical services, through a family practitioner, to those between 14 and 16 years of age. We complain that whilst this Measure provides for a very limited medical service, the Minister knows that he was painting the lily when he seriously suggested that the additional benefits would go to the 1,000,000 persons, or to 50 per cent. of those 1,000,000, who are being brought within the scope of national insurace. He also knows that it is not always the best-administered approved society that can provide the best benefits. He knows from his own experience that many societies can pick and choose, within certain limits, so far as their memberships are concerned. Whereas there are some societies whose members can pay 50 contributions out of the 52 in the year, there are other societies restricted to heavy industries, whose contributions are restricted to an average of 45 weeks or less in the year. Therefore, it is difficult for those societies to provide the additional benefits which the Minister suggests will be available for the 1,000,000 new entrants into national insurance.

We also complain that no provision is made for sickness benefit. It is a serious thing in the household of a working family if a boy starts to work at 14 or 15 years of age and then his earnings, through sickness, cease to go into the home. It is a hardship to have no financial provision to provide the extra food and nourishment which is required, apart from medicine, for restoring that boy or girl back to health and strength again. Therefore, one of our objections to the Bill is that while it provides only for some forms of medical benefit—not for all—it does not provide for any form of financial assistance in case of sickness. Much has been made of the fact that it is a contributory Measure, and the hon. Member for the University of London (Sir E. Graham-Little) and the right hon. Member for North Cornwall (Sir F. Acland) made special reference to the fact that they were proud that this was a contributory Measure. I hope to convince them that they are on wrong lines before I finish dealing with this particular problem. The Bill is altogether too niggardly and inadequate in dealing with the problem with which we are faced, setting up a truly national health service. The Minister said that he is going to bring within the scope of this Measure 1,000,000 boys and girls, but it will leave out all the boys and girls, despite his reference to the school medical service between 5 and 15 years of age, in so far as the provision of the service of a family practitioner is concerned.

We have been told that it links up the school medical service with benefit under the National Health Insurance Acts. It does nothing of the kind. It only links up a section of the youths and the children, and does not link up the school medical service with National Health Insurance. Again, I submit that I am proving my case that the Minister, in introducing the Bill, was painting the lily, and painting it with a vengeance. The Minister said that there is no substantial claim for juvenile financial benefit. Why? Working-class organisations have had far too limited a time to consider the proposals in the Bill. There has not been adequate time allowed for consideration by the trade union movement or the friendly society movement. I have known Bills introduced before which, after discussion, were withdrawn, and in a new Session obviously improved Bills were introduced. But there has not been adequate time to discuss the full provisions of the present Bill. The friendly society and the working-class movements generally would have welcomed financial provision for sickness benefit being made in the Bill which we are discussing. It would have been a better Bill if there had been provision made for statutory benefit, including treatment for visual defects and dental treatment, which have been dealt with by almost every speaker.

My hon. Friend the Member for the Scotland Division of Liverpool (Mr. Logan) raised one or two very important points, which, I trust, will be dealt with by the Parliamentary Secretary when he replies on the Debate. The Minister leaves the child that is attending school out of the provision for family medical attendance in the case of sickness, while providing for the child who has left school at 14 years of age, entered industry and ultimately become unemployed. Surely there can be no justification for that. Working-class parents must make great sacrifices if their children are to receive a secondary education from 14 to 17 years of age. In case of illness they are compelled to pay the fees of the medical man who is called in. That would not be quite so bad, if they always had the finances available with which to pay those fees. What actually happens is that the child is oftentimes sacrificed and the doctor is called in too late to give the aid, which, if it had been given earlier, might have saved unnecessary suffering. The very great weakness in the Bill is that provision is not being made for the family doctor for all children over 14 years of age.

I have already dealt with the point made as to joining up with the best societies. Until the treatment of visual and dental defects is made a statutory benefit under the National Insurance Acts, you will never be able adequately, efficiently and effectively to deal with the problems of ill-health as they affect particularly that section of our population between 14 and 16 years of age, a point that was very ably and eloquently made by one of the representatives of the English Universities. The Consultative Council on Medical and Allied Services of the Scottish Board of Health, in a report published in 1920, stated: We regard it as of primary importance that the organisation of the health service of the nation should be based upon the family as the normal unit, and on the family doctor as the normal medical attendant and guardian. The Minister, in producing his Bill, does not propose to take the family as the unit but merely to take those who are working, and, in refusing to do the obvious, the Government leave unprovided, with vital and disastrous consequences to health and happiness, the remaining units in the family. This truth was emphasised by Dr. Burgess, the Medical Officer of Health for Dundee, in the evidence he submitted to the Departmental Committee on Scottish Health Services, on which I had the honour to serve and try at least to make some useful recommendations to the Government, with a view to improving the health services of Scotland. On page 157, paragraph 478, of the report, we find that Dr. Burgess stated: One of the most important criticisms of the organisation as it exists at present is that advice and treatment are not immediately accessible to every individual unless the payment of medical fees is a matter of little or no moment. This fact has been brought home to me on numerous occasions when visting in the district for purposes of housing. During the winter months particularly, one finds in numerous dwelling-houses children who are obviously ill and in need of medical attention. No doctor is in attendance, and the reason, admitted or obvious, is always connected with finance. Why at this time of day, if we are desperately anxious to improve the health of the nation, should the lack of finances be the guiding principle in a home as to whether they can call upon the best medical knowledge available within the district. It is a crime against the children when they have to be sacrificed because of the poverty of the parents in a land that is wealthy and has sufficient scientific knowledge at least to reduce to the very minimum the unnecessary suffering that occurs in our midst at the present time.

To-day we are creating a problem by not dealing with the existing problem as it ought to be dealt with. We are also creating a problem associated with our hospitals. Let me quote from the Committee's report: Apart from housing conditions, inability to provide medical treatment at home, for financial reasons creates a considerable demand on hospital accommodation. This cause of pressure on the hospitals is most apparent in large industrial centres. Yet we have a niggardly Bill of this kind merely to provide medical attention for children between 14 and 16, instead of the Government having the courage to bring in a Bill which would provide medical attendance for all and enable us to deal with this problem in the way we could deal with it if the Government had only the courage to face up to the problem. They have a glorious opportunity of co-ordinating, but not in a niggardly Bill of this kind, the medical services in the interests of the health of the people, but they bring in this puny Measure at a time when, to quote again the report: Every member of the community should have access to the service of a medical practitioner, with medical attention at home normally to be provided through the family doctor. Nevertheless, the right hon. Gentleman introduces a Bill to continue the contributory system, which has been advocated to-night by the hon. Member for London University and the right hon. Member for North Cornwall (Sir F. Acland), which has outworn its usefulness and ought to give way to a more progressive method of dealing with this problem. Let me again quote from the report, because we on these benches object to the contributory system as far as this Bill is concerned. There might have been an argument for the contributory system in the Bill if the Government had been providing financial benefits, but for those who have been brought within the scope of the Bill they are providing only medical benefit. Another section of the report says: The chief argument for maintaining the contributory system is that it is now in operation, yielding a considerable contribution towards the financing of the scheme of medical benefit. On the venerable maxim (of doubtful validity) that 'an old tax is no tax' it may be thought unwise to sacrifice the substantial sum which is at present being borne without too obvious discontent. Mingled with this are arguments—to which it is unnecessary to attach undue weight—that the contributory system is a bracing influence "— that is the argument used by the hon. Member for London University— in maintaining a spirit of sturdy independence. I wonder the House did not smile when that statement was made. I wonder that they did not doubly smile when the right hon. Member for North Cornwall suggested that it might make boys feel like men if they had to pay 2d. per week contribution in connection with National Health Insurance. The report proceeds; It is unnecessary to discuss how far forebodings of demoralisation consequent on the extension of State activity have been justified in the result. it is sufficient to note that in the particular field with which we are concerned, the whole burden of the evidence placed before us points, over the period of the extension of health services, to an increased sense of personal pride and responsibility, exemplified, to take but one instance, in the greater parental care exercised over the health and cleanliness of the children. We believe that parental responsibility is developed not superseded by civic organisation. Later, that section of the report says: The insurance principle becomes continuously less appropriate as the field covered is widened. It has pre-eminent merits as a device for raising money for purposes that are sectional; but when the whole, or substantially the whole, of the population are potential beneficiaries, the retention of the insurance system means the retention of a considerable amount of machinery to achieve an end that might be compassed more simply. We say that the more simple method would have been for the Government to have introduced a non-contributory scheme, not merely for the juveniles under discussion, but for the whole population. I hope the hon. Member for London University will not think that I am suggesting a full-time State service, but an extension of the existing panel system, free choice of doctor, the payment for purposes to meet the legitimate demands of those doctors being provided by the State, while the money sought for in the way of national contributions could be used effectively to improve old age pensions or to extend the financial benefits of families who to-day are insured —reforms which must be faced sooner or later by this House. Finally the minority report of the committee said: We do not think that anyone would advocate the establishment or continuance of the contributory system at the present stage of development if we had a clean slate in the matter. It is a legacy from the past. On the other hand, we do not doubt that the arguments for cutting ourselves free from this legacy will operate with increased force in the future, and the abandonment of the contributory system. so far as concerns the medical side of insurance, will be found to be an ineluctable stage in the development of our health services. I admit that that was the minority report, signed by seven members of the committee; but the Government had the courage to accept the minority report in its application to the maternity services. was the principles contained in the minority report on maternity services—I had the honour of being one of the minority of four who signed that report— that was accepted by the Government in the Bill which they introduced to deal with the maternity services. If it was good for the Government to accept the minority report in its application to maternity services, it is equally good, when the minority in this case has reached seven instead of four, to accept that minority report in its application to medical services. It is equally true to say that the majority report stated that it was only a question of time until some Government would be compelled to face up to a non-contributory scheme for dealing with medical services in the interests of the general community.

Whilst accepting the Measure before us, although we believe it to be niggardly and altogether inadequate for dealing with the problem, we shall put no obstacles in the way here or in Committee, but shall do our best to improve it. As a party we shall go forward with our agitation inside and outside the House for a health service that will be worthy of the scientific knowledge that is available for the people of this country, and the provision of a health service, under a Government that has the courage to deal with it, which will make our people more healthy and more fit than they are at the present time.

10.5 p.m.

Mr. Bernays

The hon. Member for Stirling and Falkirk (Mr. Westwood) has quoted copiously from the report of the Committee on Scottish Health Services and has made great play on the question of employed children so far as health services are concerned. On page 278 of that report I see in paragraph 771 this recommendation: The needs of employed children between 14 and 16 will be met by the Government's proposal to reduce the age of entry into National Health Insurance to school-leaving age. When the Government are carrying out that recommendation I think it is a little churlish to describe the Bill as niggardly and puny. On this occasion I have only one opposition to deal with, as the right hon. Member for North Cornwall (Sir F. Acland), on behalf of the Liberal party, has given the Bill his enthusiastic support. I will try to answer the questions which have been put to me. I take the first question by the hon. Member for the Scotland Division (Mr. Logan). Apparently the hon. Member once said some nice things about the National Government and it appeared on posters. The hon. Member suggested that my right hon. Friend had something to do with it. At any rate, it shows what value my right hon. Friend attaches to the opinions of the hon. Member, who speaks with expert knowledge on these questions. He will not expect me after a few weeks study of these questions to rival his knowledge. He asked, what about the boy who stays at school? And another hon. Member suggested that he would have no medical treatment. That, of course, is not the case. A boy or girl who stays at school after 14 remains under the school medical service, but he cannot count the extra year at school as part of the waiting period for dental benefit.

Mr. Logan

As long as the parents sacrifice for the extra period in school, is it not possible to incorporate that extra year and give additional benefit under the Bill?

Mr. Bernays

We have gone carefully into this matter and I am afraid that I cannot give any promise upon that matter.

Mr. Westwood

Is it seriously suggested that the school medical service provides for medical attendance on the child? Is it not the fact that they merely refer the child to the family doctor and that there is no provision for school medical inspection or for treatment or services by a medical practitioner?

Mr. Bernays

We are not altering the present practice in this respect. The next question which the hon. Member put was: when does a boy receive cash benefits? He will receive them when he has paid 26 contributions after the age of 16. The 4d. contribution for juveniles contains no provision for the cost of a cash benefit. The hon. Member also asked me whether juveniles would have to prove unemployment. The answer is "No;" they will not have to prove unemployment by franks on their cards. This only applies after the age of 16. A juvenile gets his medical benefit up to 16½ years of age in all cases. He asked further: what is the position of a boy or girl who reaches the age of 16½ without getting any employment after the age of 16? It is true that if a boy or girl reaches 16½ years of age without getting any employment after the age of 16 he falls out of insurance and has to start again when he subsequently obtains employment. I have made some inquiries into this and am informed that such cases are, in fact, very rare.

Mr. Logan

Will any amendment of the Act be required, because the 1924 Act lays it down definitely that no one can be a member of a society unless employed?

Mr. Bernays

I will look into that matter. I have indicated what the position is under the Bill. I turn now to the speech made by the Noble Lady the Member for the Sutton Division of Plymouth (Viscountess Astor) who has left the House. Her speech was out of order and, therefore, if I attempted any reply I might get out of order, too.

Mr. G. Griffiths

If a boy drops out of employment before 16 does he lose his medical benefits also?

Mr. Bernays

No, but in any case I am told that the cases of unemployment between the ages of 14 and 16 are very small. The hon. Member for the Sutton Division referred to the importance of prevention rather than cure. I can assure her that we are alive to the importance of that consideration, and that is one of the reasons why we are introducing these Measures. The hon. Member for North Kensington (Mr. J. A. Duncan) asked whether the draft regulations would be issued before the Bill was passed. That is not possible, but my right hon. Friend will on this occasion, as on all other occasions, consult the approved societies.

I come now to the question of dental benefits. The right hon. Gentleman the Member for Wakefield (Mr. Greenwood) made great play on the fact that there is a hiatus of two years. That is true, but it is better than a hiatus of 4½ years. Hon. and right hon. Gentlemen opposite say that both these Bills have fallen short, but at any rate the Opposition fell short even of the two Bills that we have introduced. With regard to the question put by the hon. Member for the Scotland Division of Liverpool as to how the dental benefits will be paid, the answer is that the juveniles will get dental benefits, when they become fully insured, out of the funds of the approved societies which they join, irrespective of the number of individual contributions. I understood the hon. Member to say that the majority of these approved societies have not surpluses sufficient for dental benefits.

Mr. Logan

I did not say the majority had not, but many of them.

Mr. Bernays

As I was surprised when the hon. Member made that point, I made some inquiries, and I discovered that the figures are as follow: 5,434 units out of a total of 6,125 do, in fact, provide dental benefits, that is to say, 80 per cent, of the approved societies or branches of approved societies in the country.

Mr. Logan

Those figures need to be qualified by the statement that they do not pay total benefit, but reduced benefit only. I was referring to the total cost.

Mr. Bernays

I come now to the speech of the hon. Member for Hemsworth (Mr. G. Griffiths), whose argument may be summed up by the statement that he wants to have a complete pooling of existing surpluses. That, of course, would be entirely inconsistent with the retention of the approved society system. That system was deliberately adopted in 1912. I think it has justified itself by bringing in many self-governing bodies, and that on the whole their work has given general satisfaction. As this late hour I do not think I can be expected to defend the whole approved society system, but I will say that it has stood the test of time and that no Government has thought fit to change it. The hon. Member also raised the question of insulin, and on that point my answer is that if a doctor says that insulin is necessary, the dependants of insured persons can get the insulin free, provided their income is not above £250 a year.

Mr. G. Griffiths

When does that provision come into operation? I have known of applications of people whose income has not been anything near £250 which have been refused.

Mr. Bernays

If the hon. Member will send me all the details of those cases, I will look into them.

Mr. Griffiths

I thank the hon. Gentleman. I will let him have them.

Mr. Bernays

Other hon. Members have asked why cash benefits are not to be given. The hon. Member for Stirling and Falkirk answered my right hon. Friend's statement that we had not had evidence of any real demand for them by saying that the Bill had not been considered long enough for such a demand to be made. I would point out that the Bill was presented on 29th June, and I think very much more time has been given to consideration of it than is given to the majority of Bills. There are objections both on principle and from the point of view of practical difficulties in providing cash benefits. The ordinary weekly contributions for full health and pensions insurance—1s. 8d. for a man and is. 2d. for a woman, shared by employer and worker—would represent, in our view, a very heavy charge against the average weekly wages paid to juveniles when they first take up employment. Moreover, health insurance benefits at the adult rate would be so high in proportion to the normal wage rates in the case of juveniles that they would obviously tend to encourage claims for benefit. In those circumstances it would almost pay to be ill, which would be completely contrary to the principle on which our national health insurance system is based.

Mr. Westwood

Could not that point be met—since you are amending the National Health Insurance Act—by laying it down as a condition that not more than half or two-thirds of the wages should be paid in the way of financial benefit?

Mr. Bernays

That raises a different point altogether.

Mr. Westwood

It is facing the problem.

Mr. Bernays

You would have to meet these objections by the provision of specially reduced rates of contributions and benefits, which would involve administrative difficulties of a very complex kind for the approved societies, and the financial and actuarial structure of the health insurance scheme would need to be reviewed, since the basis of that scheme rests on the assumption that insurance begins at 16. Surely the real need in all this is continuity of medical supervision and that is what we are providing under this Bill. Then the right hon. Gentleman the Member for Wakefield asked: Why have any contributions at all? That point was driven home by the hon. Member for Stirling and Falkirk. It is argued that juveniles cannot afford even so small a sum as 2d. out of their meagre earnings, and should not therefore be asked to pay anything. If they do not pay, who is going to pay? There are only two parties who can pay—the State and the employers. For the State to shoulder the whole burden would cost £800,000 which is a very big sum. As regards the employers, apart from the argument that such a proposal would destroy the whole principle of contributory insurance, if the employers were asked to pay it would lay a very substantial burden upon industry. As I say, in any case it would cut across the principle of national health insurance.

There is the further point that if it were proposed that it should be an entirely free service the question would arise by whom should it be administered. It would clearly not be for the approved societies, and it would be a matter for consideration whether it should not come as a post-school medical service, which could only be provided at very great cost. In conclusion, I deny the contention of the Opposition that this is a small Bill. It deals with 1,000,000 people, and it will do much to improve the health of the nation. The years between 14 and 16 are among the most critical years in the life of a boy or girl. To bring these boys and girls within the scope of national insurance is no mean reform. When the Bill becomes law and these boys and girls receive these new medical benefits, they will, I believe, have cause to bless this Parliament for they will find that with increased health will come increased happiness.

Mr. Logan

Will the hon. Gentleman answer the administrative query as to the amount which is to be allowed? It is, we are told, to be by regulation. Can he say what the amount will be?

Mr. Bernays

I could not give any indication now. It is under discussion between my right hon. Friend and the approved societies.

10.25 p.m.

Mr. Godfrey Nicholson

It is difficult to embark on a discussion at this hour, but I feel called upon to protest against some of the unhelpful criticisms of the Opposition. They seemed to imply that this was a niggardly Bill, a puny Measure, but it affects a whole million people, and I am sure that it needs no further words of mine to show that the Opposition have taken up a mistaken attitude.

Bill committed to a Committee of the Whole House for Tuesday next.— [Captain Margesson.]