HC Deb 21 October 1941 vol 374 cc1653-703

Motion made, and Question proposed, "That this House do now adjourn."— [Mr. James Stuart.]

Dr. Howitt (Reading)

I am very glad to have the opportunity of speaking in this very important Debate to-day. At a time when the nation is using every ounce of energy in its efforts to achieve victory, no more important subject could arise for discussion than the health of the people. Indeed, if we do not make certain of keeping up our very high standard of health in this country, it will be impossible for us to gain victory over the enemy as quickly as we should. Important as it is, I do not propose to-day to speak on the health of the Services. I will confine my remarks entirely to the health of the civil population, and will deal with the subject under two headings, one, the health of the people during the war, and the other, the health of the people after the war.

During the war, as I think everybody will agree, the health of our people has been surprisingly good. At the beginning of the war we had many fears of what might happen to the health of the people. First, we feared that there would be an enormous number of bombing casualties; we made great preparations for such cases, and many of the beds which we put aside for this purpose have remained unused. Yet everyone will agree that we must prepare for such an eventuality and must remain prepared for it. Then we feared that the health of our workers would suffer severely as a result of working during black-out hours. I am glad to say that this fear, too, has been unfounded, and that the health of our workers has been good. We were also warned that, owing to bombing, we would have a tremendous number of cases of nervous breakdown, but the authorities in this country have been amazed at how few cases of neurosis have occurred among the civil population as a result of bombing. I feel very strongly that this is largely due to the wonderful spirit of our people. If they are asked to face anything, they face it gladly, and there is no question of breaking down or of the development among them of the various forms of neurosis. Lastly, we feared the danger of "Teat epidemics arising from the use of air-raid shelters, but again this has not materialised, and I think our very sincere thanks are due to the Ministry of Health for the wonderful way in which they have improved the shelters in this country. Our thanks are also due to Lord Horder and his willing workers for the improvements which they have been able to carry out in shelters.

Still, we must be prepared to face all these possibilities. I would warn the House that we must be prepared above all" to face the possibility of epidemics. There is no doubt that epidemics do come in wars, and none of us will ever forget the terrible flu scourge which ran through this country in 1918. I hope that will not happen again, but we should be very remiss if we did not make full preparation for such a catastrophe overtaking us. We have feared and we still fear invasion in this country. In the same way we have feared and still fear the possibility of epidemics and we should be foolish indeed if we did not do everything in our power to ward off invasion should it happen and to deal with epidemics should they come upon us. We must hold on firmly to all those preparations.

When we are speaking of the good health which has been enjoyed by our people during the war, it is a good moment to look at some of the causes of this good health. First, I would mention the enormous improvement which has been made in the last 20 years in our public health services. There is no doubt that our people during recent years have learned a good deal about the simple, elementary rules of health. I assure hon. Members that if they went into the out-patients' department of a London hospital to-day, they would find it a very different place from what it used to be when I was a student. The dirt and squalor of the people 30 years ago were terrible, whereas to-day you can go into the out-patients' department of a hospital in any big city to-day and find that there is a very different story to tell. I am glad to think that the students to-day do not get nearly bitten to death as they used to be in the old days. Another cause of good health among the people is the great improvement which has, undoubtedly, taken place in housing since the last war. I am not saying that housing conditions in this country are perfect, but they have improved enormously, and good housing is the foundation of good health.

We have been very fortunate in that all through the war we have had an excellent supply of food and a great variety of food. For this we owe a great debt of gratitude to our Navy. We are also indebted to the Ministry of Food, although we often find fault with them, for the excellent way in which they have managed the distribution and storage of the food of the country. There has, then, been an enormous increase in milk for children, and this has certainly had a marvellous effect upon the health of the children. I only wish it were possible to do what Lord Dawson wants us to do, and for all of us to be able to drink quantities of milk. At any rate, we are agreed that children should come first in being able to get extra milk. In recent times communal feeding in British Restaurants throughout the country his had a very good effect upon the health of the people. Both food and cleanliness are very important in maintaining the nation's health. Some of us have had the opportunity of going to the country and seeing the conditions, month by month and year by year, of the evacuated children whom we meet there. It brings joy to the heart of anybody who can see them to realise how vastly these children have improved, both physically and mentally, during the war. This will give us a field for much thought and much planning after the war. This lesson which the war has taught us must be remembered in our consideration after the war of how best to produce a high standard of health among our children.

There is one thing that disturbs me. There is no doubt that at the beginning of the war we made a very great mistake in evacuating so many cases of tuberculosis from the sanatoria back to their homes. I believe our fear of this has perhaps given some of us an exaggerated idea of the amount of harm that has been done, but let us acknowledge that it was a very great mistake. I believe that steps have already been taken to get these people back to sanatoria, but there is another danger that we have to face, and it is the danger of the contacts in the homes to which these infectious tuberculosis cases have returned. Many years ago I took a small part in one of the first careful investigations of contacts of tuberculosis in London. I know what a very big work is involved and how much tact is needed to persuade the people to go to the hospital and be examined, but it is of the utmost importance that all people who have come into contact with infectious cases from sanatoria should be carefully examined. I hope that the Minister, in his reply, will be able to give us an encouraging report on these cases and tell us that the work of examining the contact cases has been started. There is a field for great work by the health services of the country in getting the contact cases together, examining them carefully, and making sure that tubercle does not spread again. The work on tuberculosis in this country has been magnificent during the last 30 years, and we cannot allow the position to slip back to where it was before that work was done. I am sure we shall not do so, but I urge the importance of having these cases examined.

With regard to the health of the people after the war, it is of the utmost importance that there should be thinking and planning now. In this country we do not do things well in a hurry, and we do not want the end of the war to find us unprepared as to how best to assure the good health of the people. I was very pleased with the statement made by the Minister of Health on 9th October with regard to the hospital policy of the Government after the war. I consider that that statement will become a historical landmark in the foundation of a great medical service in this country. The day after the statement was made, I went to Oxford to attend a meeting of the Nuffield Provincial Hospitals Trust. The Nuffield Trust has already done an enormous amount of research work throughout the country to find out exactly what our hospital services are like. I can assure the House that those meetings are extraordinarily invigorating. Round the committee table one finds the representatives of local government, municipal hospitals and voluntary hospitals, all working eagerly together with the object of doing their utmost to combine the best in each of their departments, so that there may be a better service after the war. At that meeting, the excellent chairman of the Trust, Mr. Goodenough, welcomed for all of us the statement that had been made by the Minister of Health of the previous day. I think he was very right when he said: It is a short statement of enormous importance, and I want to impress upon you all that the important part of it is in that one word ' partnership '. The secret of success after the war in the hospital service will be to get a proper partnership between all the workers, municipal and voluntary, so that we can share and pool all that is best, and make a fine service. In this House we have had grievous political differences and fought severely on many subjects, but to-day having sunk all bitterness and strife between parties, we are united in our determination to fight against our enemies, the Nazis. I ask everybody who is interested in the public health service to adopt the same attitude now and after the war with regard to that service. Let us sink all differences and work together so that we can have a first-class service. We want to have a service in which it is possible for everybody in the land to have quick attention, the patient going to the general practitioner, and the general practitioner being able to obtain special help locally. Although years ago, when this sort of regional plan was brought forward by Lord Dawson, it seemed a dream, to-day, it seems as if that dream will come true. We are coins to have the finest service this country has ever known, and indeed the finest health service ever known in the world, but only if all workers are willing to sink their differences and work heartily together to that end. A great example has been set in the work which the Nuffield Trust has already done. The Nuffield Trust has been doing research work in the provinces, and we were informed by the Minister on 9th October that his Department are making a similar survey in the London district. I look forward to great things coming from the combination of these two.

I hope also that after the war there will be a great increase in the number of nursery schools, which have proved their worth to the health of the children. The work done by the noble Lady the Member for the Sutton Division of Plymouth (Viscountess Astor) has been very well rewarded. She has seen perhaps more than any of us the good that has come from the hard work she has done, and I know that we could never have started the excellent nursery school which we have to-day in Reading if it had not been for her constant help month by month. Wherever these schools have been started, they have been a great success, and I hope that after the war their number will be very greatly multiplied.

Another very important side of the hospital services is the work done by the hospital almoners. There may be some Members of the House who do not realise fully what a hospital almoner is. I assure them that a properly trained hospital almoner holds quite a different position in the hospital from anyone else on the staff. These women are chosen very carefully, and they go for two years to the School of Economics or some similar training place, where they obtain a diploma. After that they have four months in the office of the Charity Organisation Society, and finally they have 11 months in a hospital almoner's office. Those 11 months are spent partly in London and partly in the provinces. These people are very carefully educated for the work that lies in front of them. There is no one except the trained hospital almoner who knows what can be done with a case, who knows what the voluntary services are and who can join together all these places, without any overlapping, which can help the patient.

The almoner acts, as it were, as a liaison officer between the hospital and the home, and this is enormously important. Suppose someone, say a breadwinner, is suddenly taken seriously ill and removed to a hospital. It makes an enormous difference to the patient to know exactly what is happening at the home, to know that the children are being properly cared for, fed and clothed, and sent to school, and that is what the almoner can do. She stops an enormous amount of waste. What is the good of a doctor saying to a patient, "You want rest and extra milk and a great deal of care taken of you"? To many people that is quite impossible. But when you have a proper almoner's service the wife will be interviewed by the almoner before she leaves the hospital, and the almoner will arrange for carrying out the treatment which the doctor knows to be right. If you do not have that service, the woman goes away hopeless. She knows that she cannot follow the directions. Through the good working of the hospital almoner's service you save an enormous amount of suffering and an enormous amount of waste in hospital administration. I hope this service, which has increased so greatly during the last few years, will go on increasing. I should like to thank the Ministry of Health for their appreciation of the work that the almoners do and for their support of them in every way in all the hospitals throughout the land. It is not everyone who knows about the work of almoners, but the Ministry is fully alive to its importance.

I should like to say something about post-war policy in regard to housing. There is much to be done in better housing. This is the only thing in which the enemy has helped us, by clearing away a lot of the worst dwellings. I hope there will be very careful planning as to how best to build up. I should wish the authorities to remember the importance of keeping up the individuality of the home unit. There are people who like living in flats, and there are people who hate it. There are people who like to live in maisonettes and people who like to own their own little houses. Do not let us have monotony in our planning. Let us give the possibility of people having some choice as to what their homes should be. There is a book published by the Bournville Trust called "When we build again. "They have conducted a very interesting research into building. Their remarks are very sane, and their proposals are very sane, too. I am sure that anyone who has not seen this book would be well advised to study it. It is simple and straightforward and of extraordinary interest. I know that the Ministry of Works and Buildings have all this in mind, but there is a great deal besides the matter of building itself to be thought about, and I hope the Ministry of Health will see that the ideas of their advisers on health and on the unity of the home are observed.

I believe this is a very important thing for the health of the people. I hope that after the war we shall sink all differences of opinion and unite in that partnership that was advised by the Minister. Let us have a partnership free of all bitterness. Let us pool all that is best in the systems that we have had in the past, so that we may have a service of health which will stop an enormous amount of suffering and enable patients to be treated quickly in their own localities instead of having to wait for weeks until the disease has made further progress and it is too late really to cure. I ask all interested in the subject to sink all bitterness and narrow mindedness and to unite together with the Ministry of Health, and indeed with the Nuffield Trust, in order to be quite certain that after the war we have a health service such as we have never known before.

Mr. Messer (Tottenham, South)

We have listened to a very comforting speech. If we could all feel as the hon. Member feels, there would be no need for this Debate. But I want to suggest that the time at our disposal to-day is completely insufficient, and I hope I shall get support from all quarters of the House in asking that we shall have a fall-dress Debate. This question is of such wide dimensions and its ramifications extend in such a way as will not permit of any one speaker covering the whole ground or every Member who is interested putting his special point of view. You cannot separate the hospital service from the general medical service of the country. I agree that you can for the purposes of rough debate divide the question up into two parts—war-time action and post-war planning. War-time difficulties must not be an excuse for inaction but a reason for action.

One aspect of the matter which calls for immediate action is in regard to tuberculosis. During the last war the mortality figures from this cause rose, and we find the same phenomenon during this war. In the first two years of the last war the figures went up by 3,000. In the first two years of this war they had gone up by 2,000. I know that figures can be dealt with so as to give the most satisfactory or the least important implications and that standing by themselves they do not mean anything, but a 2,000 increase after we have had 20 years of intensive work on tuberculosis is a different thing. Another significant figure is that which is related to age-groups. The death-rate for women in the age-group 15–24 was 109 per. 100,000 in 1914. It had risen to 158 in 1918. The important thing is not so much the total number involved as the section cf the community which is affected. In that age-group of 15–24 we have the flower of England's womanhood, the mothers who are to be, and a section of the community which we can least afford to spare. In a test recently taken in two areas there were 21 new cases in the age-group 11–20 in the first quarter of 1939. In the first quarter of 1940 there were 28 new cases. The mortality figure is not the only one of importance. The figure of new cases is important, for there can be a block of deaths at an age when they can be expected so that the mortality figures do not bear the same relation to the incidence of the disease as the figures of new cases in the younger groups. In the 11–20 group the new cases again went up in the first quarter of 1941 to 35. In the age-group 21–30 the number of new cases in the first quarter of 1939 was 34. In the first quarter of 1940 they had gone up to 52, and in the first quarter of 1941 to 65.

That means that there is a progressive increase, not a fluctuation, and that the falling curve up to 1935 has not continued, but has made a sharp rise. I cannot be comforted, as my hon. Friend was, with the idea that seemed to be in his mind that so much had been done and that everything was right in the best of all possible worlds. I am not satisfied that everything is being done, especially in this question. Have we sufficient sanatorium or hospital accommodation? We were told, in answer to a question, that there was a waiting list of 1,700 people who need treatment and cannot get it. We have therefore 1,700 innocent "fifth columnists" who ought to be in a sanatorium or hospital bed and who are a danger to the community for while they are waiting, there is the possibility of other people getting that dread disease. What is of equal importance, the longer a T.B. case waits for positive treatment the less chance there is of an improvement in his condition. The Minister may tell me that we simply have not the accommodation, that local authorities have been empowered to provide it, and that if they have not done so, it is not the Minister's fault.

Looking round the country where can we find beds? I would do with big mansions and houses what has been done with the manhood of the country—I would conscript them. I know that it is possible for compulsory powers to be invoked to get them, but those of us who have had anything to do with that sort of thing know that it is not an easy matter. For instance, in Saffron Walden there was need for finding a school. The education authorities approached the Army with a view to releasing a big house which they occupied, and the Army agreed to go. Somehow, a private individual got hold of the key and moved in, and it was impossible to get him out. I approached the Minister about it. That was a house which could have accommodated others than a private individual. Looking round for other accommodation, we discovered a big house in the same district in which there lived one lady. The house had 16 rooms, and I suggest that they could have been turned into a T.B. sanatorium or hospital. I read in the Press on Saturday of a house of 91 rooms, including 55 bedrooms, 10 bathrooms, 26 other rooms, garages and stabling, and because a tenant could not be found for it the assessment committee agreed to reduce the rates. So that the rate goes down and the death-rate goes up.

The Minister was good enough to answer a Question which I addressed to him last week with regard to percentages, and I mention it to press the point about age-groups. He said that the percentage increase for the whole population of England and Wales in 1939 was 9[...]7. The highest rate was 15 per cent., which was among women between 14 and 25. In the first quarter of 1941 there was a reduction of 7 per cent. We ought to discover some system under which immediately there is a suspected case of tuberculosis it should at once be handled. The difficulty is that a T.B. case is not necessarily one when; the man or woman feels downright ill. The patient feels ill enough to see a doctor, and the normal course when a general practitioner examines the patient is, if he suspects T.B., to send him to the T.B. officer, clinic or tuberculosis dispensary. If, after undergoing tests, examinations and observations it is found to be a case for a sanatorium, the patient will be put on the wafting list. If he remains on the waiting list long, the fear of that dread disease begins to deepen, and he is more and more reluctant to go away because he will have to leave his wife and family, who will, in all probability, have to go on public assistance because the panel benefit will not be enough to keep him and his family. We ought to encourage every one suspected of T.B. to have treatment as speedily as possible and to remain under treatment as long as possible. I do not wish to differentiate among diseases, but a special case can be made out for T.B. Then, it is not enough to send a T.B. case to a sanatorium. You erect fine buildings, furnish them with the most up-to-date equipment and there build up the wasted patient until he looks fitter than ever with the flush of health on his cheeks—and then you send him back to the slums which gave him the scourge, send him back to widen, possibly, the field of danger because of the danger of contact.

I shall not be able to spend too much time on the subject of tuberculosis, because those who are in contact with health questions see so much that there are other cases of priority in their minds. There are the vexed questions of maternal mortality, infant mortality, rehabilitation and fracture clinics, and one Debate is really not long enough in which to deal with all these problems. The tuberculosis problem can be divided into three parts. There is the initial stage, where it may be decided that the case is one for remedial treatment and should go to a hospital or sanatorium, or that it can remain under treatment in a tuberculosis clinic. Here I would ask the Minister whether he is satisfied that scheme-making authorities are really doing all they might in the provision of clinics for chest complaints, and whether they are equipped with X-rays and there is provision for screening and all the other things which are so necessary in an up-to-date clinic. As to the cases which require sanatorium or hospital treatment, I would urge the necessity of taking all T.B. cases out of our general hospitals and putting them either in special T.B. wards or in special T.B. hospitals or sanatoria.

After-care is the third aspect of the problem. The Ministry of Health has given county councils power to deal with it, and if I may respond to the hon. Member who asked for some recognition of the work already done by the Ministry of Health let me say that when I have attended with deputations at the Ministry of Health the Ministry have never discouraged anything that would lead to an extension of efficiency in after-care, and, indeed, have urged the desirability of extending after-care provisions. When I have pointed out that some of the sufferers are existing on public assistance and cannot get all that a T.B. patient requires in the way of food, or that the husband has to sleep in the same room as his wife and children, the Ministry of Health have said "Treat him differently; treat the sufferer as outside the Poor Law." I wish to see tuberculosis sufferers outside the Poor Law. We have taken the blind outside the Poor Law, saying that blind people are poor because they are blind, that their poverty is not transitory but permanent:, and they ought to be recognised as forming a special category. Cannot we do that with sufferers from tuberculosis? Not only should we take the patient outside the Poor Law but the dependants of the patient also. Then we shall not be in a position where a man who is a sufferer from tuberculosis is being dealt with in one way whilst his wife and children depend on public assistance. After-care is very important. If we could get the figures of readmissions, showing the number of people who have to return to sanatoria after they have been discharged, we should get an enormous number.

The Papworth scheme is a very interesting one. At Papworth there is a colony of tuberculous people. They are in the country, not in a London slum, and live an ordinary life in ordinary houses. The workshops in which they work are adjacent to their homes. It is in a beautiful part of that country', on the road from Royston to Huntingdon, and if any hon. Member wants an interesting afternoon I would advise him to go there.

The Minister of Health (Mr. Ernest Brown)

I have been there more than once.

Mr. Messer

In the workshops there the men are not working competitively. They are expected to work according to the measure of their strength, not always doing a full day's work. The products of those workshops could not possibly meet the competition of the open market and they ought not to be expected to do so. I wonder, sometimes, whether people realise the importance of doing work for other reasons than earning money.

Mr. Gallacher (Fife, West)

Not the Members on the other side.

Mr. Messer

I know of some very hard workers among my political opponents. In matters of health no party considerations are raised. We can all meet on the common ground of humanity. If in these discussions we leave aside the point of view of the voluntary hospital, or the municipal hospital, or the general medical practitioner, or the specialist who wants to maintain his preserves—if we will forget all those and look at the patient I think we shall be doing as much as can be expected of us.

Mr. Gallacher

Is the hon. Member not aware that it was only because Members on the other side wanted to save the population in order to get more profits out of them that they interested themselves in the health of the people? They look for profits.

Mr. E. Brown

No, no.

Mr. Gallacher

Yes, it is so.

Mr. Messer

I would not mind taking up the challenge, but it would take a longer time to deal with it than I can now give. I think I should be able to show easily that sociological evolution is very much like biological evolution.

Mr. Gallacher

It is very different.

Mr. Messer

As one system decays, another grows. Every system bears within itself the germs of its own destruction. Out of the most rotten conditions, the prettiest flower can bloom. I still hold that this question must not be one of particular interests, professional interests or even of political interests. I want to see those who have been deprived of the means of prolonging their lives get those means. I want to see a reduction in the sum total of human suffering. I want to get. if possible, a more humane treatment of those who are dependent upon us for what we can do, because they are deprived of the ability of doing it for themselves. While we shall fight as fiercely as ever on all political questions, I hope that this question will be treated as above politics. I urge that when the Minister gets the result of the inquiry by the Medical Research Council he should turn his attention to those aspects of the question that will present themselves as a result of to-day's Debate, and should take such steps as are possible to deal with the matter as speedily as can be.

I have not touched upon the question of maternity, but next to tuberculosis maternity is perhaps the most important. I regret that there is not sufficient accom- modation in hospitals for all women who would like to be provided for there. Week after week I am confronted with questions of who shall go into the maternity hospital. The doctor in charge of a case will represent it as being of such surgical difficulty that it must have priority, or the lady almoner says that a case is unsuitable for confinement in the home. Then there is the case which needs to come into the hospital because of inability to pay the doctor and the midwifery fees outside. The Government have gone a long way in the midwifery service. Something has been done, but whether it is as much as we desire is another question. It is no use blinding ourselves to the progress that has been made, but to the extent that there is a woman outside a hospital who should be inside, we have failed. To the extent that a woman is discharged at the end of nine days to go back to the workshop, factory or home, we have failed. Maternity in the hospital is not just a question of more efficient medical treatment or more efficient nursing; a woman away from her home is away from a great deal of anxiety. She is free for that period to devote herself to the task of bringing into the world a new life. Every woman has the right of bringing that new life into the world with the least pain and suffering and with the greatest assurance that the child shall inherit the right to life. The number of children born is not the most important factor, but rather the number of children who survive.

The Minister made a statement on postwar planning, and it was heartily welcomed by the hon. Member who has just spoken, but that statement did not give me complete satisfaction. There is a possibility that when the Minister amplifies the statement we shall have a better idea of what is in his mind. He said either too much or too little. He aroused grave misgivings in the minds of some people by what he said. What he left unsaid gave ground for graver doubts. He seemed to suggest that responsibility would be placed upon the municipal authorities for some measure of co-operation with the voluntary hospitals. He did not say who the municipal authorities will be, and whether he will retain the county councils or not. I hope the idea will not be an ad hoc body like the Metropolitan Asylums Board. As a basis, it would appear that we shall take the Emergency Medical Service. This service has not been an unmixed blessing. If I had been privileged to say anything in the drafting of the plans for that service, I certainly should not have left out of account the vast experience of the medical officers of local authorities. Take the London region. Here are nine sectors, six of them North of the Thames and three South of the Thames. The spearhead of those sectors is a distinguished medical man who was drawn from a voluntary hospital, but his task is not medical; it is administrative. If there is anybody who has had no experience—I say this with all respect—of co-ordination of hospital services, it is the medical men attached to the voluntary hospitals.

The suggestion has been made that we have in this country a voluntary hospital system and a municipal hospital system, but we have nothing of the sort. There is no voluntary hospital system, and equally there is no municipal hospital system. Each voluntary hospital is a law unto itself and acts quite independently. There is a vast amount of overlapping. Departments in one voluntary hospital are duplicated at the next voluntary hospital, and the hospitals are usually situated without any regard to population. There may be vast areas where there is no possibility of hospital treatment. There are not two systems but two types of hospital—the voluntary type and the municipal type. I agree that the time has arrived when they should be replanned, but rather more comprehensively than was outlined in the Minister's speech.3 I think we need to deal with this matter somewhat on the lines of education. There is the Board of Education, and there are standardised salaries throughout the whole of the country—less salaries for women than for men, but you will not get that in the medical service. Believe me, any attempt to make the women doctors treat a person for less than the men doctors would certainly not meet with any sort of support. I would like to know why it is that the municipal hospitals were left out of any office in the Emergency Medical Service. Why was it that at the head of each sector a representative of the voluntary hospitals was appointed? I considered the Emergency Medical Service as having two objects. One was to enable the London hospitals to evacuate, because they were in a dangerous spot, and the other was to provide beds for casualties. Perhaps that was the main reason. But there seems to be no earthly reason why this new Emergency Service should have had all its posts filled by representatives of the voluntary hospitals.

As one of my hon. Friends remarked in a supplementary question last week, voluntary hospitals in the modern world are an anachronism. [An HON. MEMBER: "No."] A person who will not recognise an anachronism when he sees it is getting to the stage when he is an anachronism himself. The truth is that the voluntary hospitals did meet a need in the past. Where would the health services have been without them? Do not let us, in our criticism, fail to recognise that the doctors and staffs of the voluntary hospitals have done a great work in the past. But it is in the past. They have grown up, and the time has arrived when what was done by indiscriminate charity should be done by the community for the community. The Emergency Medical Service was intended, therefore, to permit the evacuation of the London hospitals, to provide means for treating casualties and, possibly, to preserve the voluntary hospitals from extinction. For it is very doubtful whether the voluntary hospitals could continue to function except under this E.M.S. scheme. Under the E.M.S. scheme every bed in our voluntary hospitals is paid for 100 per cent., while every bed in a municipal hospital receives 60 per cent. I do not complain about that, because, after all, the local authority is a public authority and has a measure of responsibility, while those who are in control of a voluntary hospital are not a public authority. There is a wide difference. We owe a very great debt to the voluntary hospitals, but the time has arrived when they themselves should recognise that in the interests of progress and of an efficient medical service they must be brought into a comprehensive scheme. It could be on the lines of our educational system. The truth is that the voluntary hospitals cannot continue.

Now I want to refer to something which the Minister said and which did more than arouse grave misgivings. It aroused my suspicion when he said that special arrangements will be made for financing the teaching hospitals. Why? Not a word was said about the possibility of the municipal hospitals becoming teaching hospitals. What are we doing about that? I do not want to be selfish, but I rarely speak in this House and then only on questions which interest me deeply and about which I feel keenly, and here is this statement that special arrangements will be made for financing the teaching and specialised hospitals. Does that mean that when the new plan comes into operation the teaching and specialised hospital will get all the acute cases, all the operation cases and all those other cases which are so valuable from the standpoint of the student, and that the municipal hospitals will be left with the chronics, with the tuberculous, infectious, senile and mental cases? Is that all the work which the municipal hospitals will do? If so, you are going back to the bad old days of the Poor Law infirmary, and it will be bitterly contested.

I would not give a penny piece to a teaching hospital except on certain conditions. I would say to the great teaching hospitals, "You can have public funds, providing the public can benefit—that is, everybody shall have an equal opportunity of becoming an officer." They must drop their snobbishness. It is out of date, it is Victorian, but it does exist. I know a case of a young lady who went through her first year as a probationer, then through her second year, and was going through her third year when she was told she could not continue. She was alarmed, because this amounted to shutting the door in the face of her professional life. She sought the advice of her parents who had an interview with the matron. Nothing could be done; she would have to give it up. Why? Because of bad character? No. Inefficiency? No, because she has subsequently taken her certificate and is now a State registered nurse. The reason was that her father was a carpenter. That cannot go on. She was not able to continue her training because her father was a carpenter. Years ago, a carpenter founded a new religion, and 2,000 years afterwards a carpenter's daughter was prevented from putting that religion into practical application. I know that one swallow does not make a summer—

Dr. Morgan (Rochdale)

I know hundreds of them.

Mr. Messer

—but let me now turn to the medical profession. Only a short while ago I received the usual form from a certain medical school asking me for a reference on behalf of a student.

Sir Joseph Lamb (Stone)

Before my hon. Friend goes on, will he tell me if the girl he mentioned, for whom we all have sympathy, appealed to the committee? I cannot conceive that such a thing could have been allowed.

Dr. Morgan

I could tell of a case in which a nurse, who was the daughter of a trade-union official, was sacked from a well-known children's hospital.

Mr. Messer

A challenge has been made, and I think it should be met. What is required is the name of the hospital and the name of the person concerned.

Sir J. Lamb

I did not ask for that. I asked if the individual had appealed to the committee.

Mr. Messer

I cannot regard my hon. Friend's Question as being anything but a challenge as to the truth of my statement. Very well. The hospital was King's College Hospital, and the name of the girl was Kent, the daughter of the present Mayor of Tottenham. Those are the facts. I must satisfy the House that I am not speaking without some basis for what I say. I did not want to give the name of the hospital or the name of the girl. I received a form recently asking me to give a reference in respect to a student. The first question was "Educational attainments"—quite sensible and quite a right question. The second was "Character," which was quite a good question. I do not think that anyone of bad character should have entry into such an honourable profession. The third question was "Social standing of parents." If the father had been a navvy, I would have said "Gentleman" had his character justified it. He happened to be a doctor. That is snobbishness. The same door through which the rich man goes should be open to the poor man.

Sir Francis Fremantle (St. Albans)

So it is.

Dr. Morgan


Mr. Messer

If it is, then clearly there is no reason why any alteration should be made. If it is, why did not this girl continue to work as a nurse? Suppose I had said that this man was the son of a convict. Would he have got into the hospital? No, he would have had to suffer for his father; not for his father doing wrong but for being found out. The majority of teaching hospitals refuse to accept women students. Why? If we are to have a proper system of health services, the treatment of the sick is one thing, and the method of education of those who are to treat them is another. If we believe, as we say we do, in democracy, do not let it be mere lip-service. Let us build up a democratic system wherein the value of the individual will find its expression for the qualities he possesses, irrespective of his antecedents. I apologise for taking up the time I have occupied and hope to have a further opportunity of speaking on other questions in another Debate on health.

Sir Francis Fremantle

I am sure we have been much interested and moved by the speeches of both the opener and the last speaker in this Debate. I think we have particular regard for the splendid work which the hon. Member for South Tottenham (Mr. Messer) has done in connection with the Middlesex County hospitals and those elsewhere. I wish to point out one or two points in which he is grossly mistaken in his appreciation of the work of voluntary hospitals. I bring in another aspect because I was a county medical officer of health for 16 years, and I had to see to the building-up of a service of voluntary hospitals or municipal hospitals which were then quite apart from the other health services although obviously there were the beginnings of a municipal hospital system under the Poor Law and Public Health Act. There was a patent and obvious need. Therefore I maintain that the line we have to take, the line in which I have been engaged in my professional work, is, What are the needs of the nation, and how can we make the best use of the facilities and equipment available at the present time? As the hon. Member for South Tottenham said, let us all concur on behalf, not of any section and, I would add, not on behalf of any ideology, but simply in the interests of humanity. So I want to deal with the question more particularly of the voluntary hospitals and their position in this scheme.

The hon. Member for South Tottenham has spoken of the voluntary hospital as an anachronism. I am not certain what he means by that. This House is an anachronism, in a way. It is not designed for the purposes for which it is now used, whether before the war or during the war. Yet it is extremely useful. So, in the same way, arc a very large number of our services. It has recently been said by the President of the Board of Education in another connection that we have the great benefit of tradition and a modern spirit, and that in a world in which the State has come to stay it must be our endeavour to secure an enduring place for private enterprise. Here you have the resources of the State being brought in more and more and being developed in the public interest, and at the same time we have to secure that we shall still make the most of private initiative. The first thing that has to be remembered in introducing the State into these matters is that it is a comparatively new departure for the State and a new idea of the State to take over the social services and social care of the people. It is a very useful, and a very right and proper development, but it is new. It is true that the Poor Law was introduced to take the place of the monasteries in Queen Elizabeth's day. But the interests of humanity in the social services were largely left to private initiative outside the State. Now we realise that the State, in addition to governing, protecting and judging, can also be made responsible for those services but no law has been passed to make it responsible. That is why the State services may be found to be deficient in various ways. They require development in order to fill the need. They do not always fill every need as they are at the present time.

You have to take the services developed by private initiative and see to what extent the State can supplement and help them and perhaps, eventually, to some extent, displace them. But the time has not come for that. Meanwhile you must have co-operation between the two. There are those who would wish to sweep away the voluntary hospitals and bring them entirely into a State service. That is not the way in which we have developed in this country, and I do not think it is the way in which sound development would take place. We are fortunate in having an old tradition and a modern spirit. Old tradition is useless without the modern spirit, but the modern spirit is useless unless it makes use of old tradition. Old traditions are the roots from which the State services sprang and will develop. You do not cut the branches off a tree and expect the branches, the boughs and the flowers to develop future trees. You make the most of the tree which is growing. You go in for root pruning to improve the tree, and it is out of such a tree that you get the most in the long run when you cut it down for timber. It is the same with these hospital services. A wonderful service has been developed, with extraordinary inequalities and extraordinary deficiencies undoubtedly, but with extraordinarily good results.

It must be recognised that a municipal system, like any other system, has its defects as well as its advantages. Taken broad and long, it is run by people elected by local electors. What is the value of local elections when very often only 30 per cent, go to the poll? What is the real advantage if the management is elected on any qualification except that of their capacity for the work? It is not often that you find people like the hon. Member for South Tottenham who will take up the work so keenly. Yet because people have been elected they are to run this whole institution. Contrast that with the voluntary hospitals, supported and run only by people who are interested in them, people who come to them because of their interest. It is like the voluntary system in the Army rather than compulsion: it is like the system that we have through the whole of British life, of using voluntary interest rather than putting people in by some system of so-called representative government. That policy has its disadvantages undoubtedly. There are many voluntary hospitals which have outworn their day and the managements of which also have outworn their day. That is why co-operation between the State service and the voluntary service is so useful. I believe that, while the voluntary system is valuable, you must have some kind of interference by the State in the management of the voluntary hospitals. That, I take it, is one of the matters to be considered in the survey to be made by the Minister of Health. But I am perfectly certain that if you take away the voluntary management and the voluntary support of those hospitals you will take away a large part of the special quality of the voluntary hospital system.

I think all who work in hospitals will agree that voluntary running of the hospitals, taking it by and large, results in greater freedom, greater initiative, and greater elasticity. We can all find many exceptions to that or to any other rule. No doubt there are certain municipalities, especially the London County Council, and, I am sure, the Middlesex County Council, which have developed their hospital services in the direction of greater freedom. But it is very difficult for the officials of the hospitals, even for the medical officials, and still more for the managements, to undertake the large experiments that are possible in a voluntary hospital. In a voluntary hospital the doctors and staff work in close collaboration, and the doctors have a very large amount of freedom and are supported by the governors. I admit that sometimes there is not sufficient check on the doctors, and that they have too much power, without proper control by the governing body, but, taken as a whole, the system is good, because the doctor feels that he has a free hand to do what he and the governors think right for the patient. In a municipal institution there is always the chance of the doctor and his management being hauled up before the council; they are responsible to the electors in a way which is not the case with voluntary hospitals.

Mr. Messer

As the hon. Member knows, a voluntary hospital generally is run by a lay officer, the secretary, working with a committee or a board of governors, and each member of the medical staff is an independent medical man. The voluntary hospitals have usually a medical committee. Does the hon. Member agree that if there was a lay administrator in a municipal hospital, with a medical committee, but still retaining the resident medical officers, you would have a better system, than exists now in the voluntary hospitals?

Sir F. Fremantle

I do not admit that straight away. It might be the case. You might have a very efficient organisation, almost as efficient as at my old hospital, Guy's, where there was a medical superintendent who was one of the greatest brains of this century, Sir E. Cooper Perry. You could get that efficient arrangement under either system. You may get inequalities under either system. It is not a matter to generalise over. The hon. Member generalised, and I do not wish to do so.

There is another large feature, perhaps the main point of the Minister's statement last week on the future policy of the Government. That is the question of the greater grouping of hospitals in the system of collaboration that is to be the future basis. The Minister referred to the necessity of having larger authorities than those which in many cases are now responsible for the health of the people. That is a very large question. I was glad to see it suggested that the time has come to concentrate these powers in the major authorities, the county and county borough councils. I think the Minister suggested the necessity for an even wider area than that of the county and county borough councils. Last Saturday I was privileged to take part in one of our quarterly conferences in the Eastern area with the regional commissioner at Cambridge. I raised the point as to whether he thought the future was tending in the direction of regionalisation. He recognised that you do not want to duplicate systems of authority and get another system introduced between those that already exist and the Departments of State. I called to mind that our own Prime Minister, in his less responsible days, about 15 years ago, outlined the possibility of provincialisation of local government, if not of all government, in this country, in areas such as the provinces of Wessex and Essex. He suggested seven different areas. That has been brought to the fore again recently by the necessities of the war—and even before the war—by what was being done in that direction by the Departments of State, especially the Ministry of Health. But it seems that the right solution unofficially suggested itself at Cambridge on Saturday and that there would always be the need for this regional view of things, and, therefore, for some kind of regional commissioner or advisory council. That would appear to be the way in which it would develop in the future. It would have to be more than a casual voluntary organisation and would have to have very definite powers, duties and responsibilities, and be in a position to give advice to the authorities concerned.

This sort of thing is of enormous importance in the hospital question. The division of local government between county and county boroughs does not help in hospital work. The hospitals of the big towns depend very largely upon the surrounding county, and to an increasing extent for convalescent homes and sanatoria, and I hope that as a result of the war we shall be able to do all that I have wanted to be done from the first, and that, instead of the big hospitals of London rebuilding in London, they will keep only casualty and reception stations and one or two special departments that are necessary, and an administrative office, and will shift the patients out to the country. They could still put up large hoardings calling attention to their existence and appealing for support. When King's College Hospital moved to the suburbs it moved entirely and went out of the sight of a large public. When we are dealing with the question of regionalisation, we have to see that the old geographical boundaries are made much narrower. We want to retain the hospital administration of the separate counties and county boroughs, but we want a wider field included in regionalisation. This sort of thing would have to be brought in after the war under a rearrangement of the system of local government.

At present it is clear that you have to use the additional facilities under the Board of Education and other facilities that are given in connection with whatever hospital is being used. We have to get some system whereby you combine the municipal hospitals and the voluntary hospitals; surely that is possible. I suggest that the analogy of the education system is extremely useful in considering this problem. The hon. Member for South Tottenham alluded to it. Compulsory education was brought in something like 70 years ago, and the non-provided schools were allowed to remain. They still remain, although, by degrees, they are passing out. The preparatory schools and the endowed public schocls and the universities go on and will still go on, largely because of their detachment and independence, and they will still go on with State help and grants of various kinds. That is why I believe that the voluntary system will continue and be a permanent part of our hospital system.

I agree with the hon. Member for South Tottenham that it is part of the health administration, and therefore I would like to see the hospitals, whether voluntary or municipal, become collective centres of all the services required for health. I would like to see the medical officer of health have his offices there. We ought not to have small clinics scattered about; they all ought to be in parts of the same building. The hospital ought to be the centre of research and of private practice and preventive medicine. Our nursing services have been a great development of the voluntary hospital system, and nurses are now being used very largely in municipal services. There has been a differentiation between the nursing of nurses in hospitals and the nursing of nurses outside. The work of district nurses is immensely important even to the treatment of individual patients in hospitals, both in attending to them in the early stages of illness before they go to hospital and when they come out of hospital and require to be looked after. Hitherto there has been a separate growth of the district nursing association and the hospital association. I want them to be combined into one service, and I hope that that will be one of the many results of the great improvement which has been foreshadowed by the Minister. It has been said by somebody that it is premature to start planning now, but it is not premature to think out and make your survey now. It is said that if the first button of a man's coat be wrongly buttoned, then the whole will be wrong. Let us see that the first button is buttoned right and start on sound lines. We should be able to look forward to the next stage without embarrassment and with confidence when the main controversies of the past are settled.

Dr. Edith Summerskill (Fulham, West)

The hon. Gentleman the Member for St. Albans (Sir F. Fremantle) devoted most of his speech to upholding the voluntary hospital system.

Sir F. Fremantle

As part of the whole.

Dr. Summerskill

I intend to devote most of my speech to condemning the present system root and branch. It may be that the hon. Member for St. Albans represents a generation different from mine, but I can assure the House that what I am about to say is the view held not only by a small group of doctors to- day but by all doctors who think in terms only of the welfare of the patient.

Sir F. Fremantle

Oh, no, that certainly is not the case.

Dr. Summerskill

Will the hon. Member for St. Albans during the next 10 minutes remember that I did not interrupt him, because I have a feeling that he may be provoked more than once by the time I sit down? I wish that the Minister of Health were present just now, because in planning the health services of the future he must realise that he will have to have the courage to face up to the diehards who seek to retain the voluntary hospital system. It has been queried whether a voluntary hospital is an anachronism or not. The voluntary system dates back to the days when the State disclaimed all responsibility for the sick who were dependent on the charity of the wealthy. Those who support this system have used ad nauseam the words "tradition" and "prestige." They have reminded the House that the tradition of the voluntary hospital is so important that the whole system should be retained for that alone. But I want to remind the House that most voluntary hospitals in the country to-day are small institutions, modern in type, which have no more pretentions to tradition or prestige than the municipal hospitals in the same town.

We are told that voluntary hospitals have always been supported by charity and that there is something ennobling and line for a hospital to depend on charity. In olden times, perhaps, when some generous, warm-hearted individual came forward and gave many thousands of pounds, we might say that this was a generous and ennobling deed, but I ask the hon. Member for St. Albans—let us be honest—Is there anything ennobling in our large teaching hospitals sending out nurses and students to make clowns of themselves in the streets? Is it ennobling for the secretaries of our large teaching hospitals to have to sit and think how to make money out of bridge parties, dances, concerts and other things in order to get more money from the public? Is it ennobling for our large teaching hospitals to deface the facade of a hospital with advertisements for proprietary foods and beer in order to raise money for the hospital? I suggest that this is not a dignified form of charity. Surely, it is an undignified form of begging, and we are wrong to support a system which relies upon financing one of the most important services of the country in this matter.

I suggest that these hospitals, because they have insufficient funds, are economising at the expense of their patients. It has been suggested that there are other features which are to be found in our voluntary hospitals, but I have noticed that other speakers often slur over these other features. Again I would ask the hon. Member for St. Albans whether there is anything fine in asking sometimes as many as 100 seriously sick people to sit in an out-patients' department waiting their turn for attention? Is there anything fine in asking men and women who are seriously ill to wait for five or six weeks, or even two months, before they can be admitted into voluntary hospitals?

Mr. Lipson (Cheltenham)

Does that ever happen with regard to municipal hospitals?

Dr. Summerskill

The hon. Member is misinformed. A municipal hospital is under a statutory obligation to admit any patient immediately.

Mr. Lipson

If all the beds are full, how can they?

Dr. Summerskill

A municipal hospital does not always have its beds full. Very often it is a much bigger place than the voluntary hospital, but if a case which has to be admitted does come along, and there is no room, very often the hospital contacts the voluntary hospitals asking for the case to be admitted. I wish Members who come to an important Debate of this kind and dare to interject would make themselves better informed.

Now to come to another point. I feel that the time has come when we should discuss this matter in a practical manner and not deal with it in these vague phrases. My hon. Friend the Member for South Tottenham (Mr. Messer) mentioned the question of education. I believe there are something like 17 teach ing hospitals in London, of which 10—my numbers may not be quite right—refuse to admit women. I suggest that every teaching hospital, governed as it is by a handful of medical men who are, let us say, a little out of touch—I do not want to say they are out of date—

Sir Ernest Graham-Little (University of London)

I have been for 50 years in close touch with a voluntary teaching hospital of the best type, as student, teacher and member of the honorary staff. It is not run by a handful of medical men, but by an able and important board of management, of which not more than a third as a rule represent the medical staff.

Dr. Summerskill

I am, of course, quite aware of these things, but the Minister has indicated that he is shortly to make grants to voluntary hospitals for the purposes of education, and my point is that women should not be excluded. Then there is the question of honorary staff, which I am sure will offend many people when I mention it. We have been told time and again that these men give their services without hope of reward. Well, Sir Dennis —

Mr. Deputy-Speaker(Sir Dennis Herbert)

The hon. Lady must remember that one of the traditions of this House is that the occupant of this Chair must not be addressed by name.

Dr. Summerskill

I beg your pardon, Mr. Deputy-Speaker. We must face up to this question. I agree that if the public were convinced that the staff of the voluntary hospitals gave their services without hope of reward, that in itself would be a strong case, perhaps, for upholding the hospitals, because they would feel that these men were serving the public, but the fact is that the best way of creating a remunerative private practice for any man is to be appointed to the staff of a voluntary hospital. That is why there is such competition to get on to the staffs of voluntary hospitals. This outworn system must be replaced; it is time it was replaced by a State-aided system. If the Minister of Health hopes to evade making this decision by giving his blessing to an unnatural union between municipal and voluntary hospitals, I feel that he will be doomed to disappointment, because cut of a union of this kind there can come nothing but disharmony.

I want now to deal with another person who plays a very large part in the medical services of this country—the general practitioner. A good deal of emphasis has been laid on the hospitals, but we cannot, of course, maintain an adequate health service without having the general practitioners. The general practitioner in the country is visually a very hard-worked and over-worked man or woman, who usually has scarcely any time to have any post-graduate studies. They are, I believe, the only workers who are expected to do a consecutive day and night shift cheerfully. If we are to have an ideal health service, we must also arrange it so that the workers in it are given not only adequate pay but limited hours and, in this particular field, an opportunity to have post-graduate study. I hope also that the time will come when no general practitioner without a higher surgical qualification is allowed to operate in some of our small cottage and voluntary hospitals. It is an appalling thing that the ignorant public, particularly in some of our provincial towns, are operated on— very often major operations—by doctors who have not a higher surgical qualification.

With regard to the other very important section, the patients, I want to remind the Minister that, at the present time, every worker who has an income up to £420 a year has some form of medical service. If he has over £420 a year, it very often happens that he has a struggle to pay his doctor and is very often exploited by inferior nursing homes. The wealthy, of course, can have the best treatment available in the country. But there is another section of which I want to remind the Minister again, because it is a very important section. All those who work in the home, unless they are paid, have no opportunity to-day of availing themselves of any insurance scheme. I want to ask the Minister a question. We have heard a good deal about tuberculosis during the last two or three weeks, since the House heard that tuberculosis has increased, and I feel we shall hear a good deal more about it, because it is a reflection of the whole administration of the health services of this country that tuberculosis should have increased. I want to ask the Minister whether, in view of the fact that tuberculosis has increased among women, particularly women between 15 and 30, he thinks it is only a coincidence that large numbers of those women have no opportunity of availing themselves of any health service? I think the Minister should remember that in tuberculosis one of the most important parts of the diagnosis and treatment is to see the patient in its early stages. The people among whom there is an increase of tuberculosis are chiefly just those people who would wait perhaps weeks or months before going to get advice, because they are unable to avail themselves of the health services. I want the right hon. Gentleman to remember, when he is thinking of plans—I feel that he is thinking along these lines, and that after the war we shall see some tremendous developments —that we shall never reduce diseases, particularly the incidence of those diseases which should be diagnosed in the very first instance, unless everybody is given the opportunity of going to a doctor irrespective of the patient's income.

In conclusion, I realise that the Minister of Health has a tremendously difficult time in front of him. I appreciate that, perhaps, services which have been recognised as part of our social life and have been run along certain lines are cherished by many people, but I think the Minister has to take very strong action and to be very bold. I would like to see not only the voluntary hospitals taken over by the State, but the profit motive eliminated from the treatment of disease, and every man, woman and child in this country have an opportunity of availing themselves of State medical services.

Captain Elliston (Blackburn)

We have so few opportunities of discussing health matters in the House that it is a great disappointment that the length of this Debate is being curtailed in order to deal with other matters. I shall be bound to omit reference to a number of matters which I would have liked to have brought to the notice of the Minister, but we are told that there will be a further opportunity in the near future, perhaps, of raising these questions. I propose now to confine myself to the subject of the Government's policy in relation to voluntary and municipal hospitals. Of the four hon. Members who have spoken in the Debate, three are members of the medical profession. It may be useful if, as a lay member of a local health authority, I state how this matter appears in the eyes of those who are responsible for local health administration.

I want at once to thank the Minister for the statement which he made with regard to the Government's policy. To my mind, his promise of a comprehensive hospitals system providing every form of medical and surgical treatment for every person in need of it in every part of the country represents an outstanding advance in the development of our health services. Such a scheme will bring the full benefit of medical progress not only to those who already use the hospitals, but to the many thousands of blackcoated workers, tradespeople, or struggling professional men, who, at the present time, can ill afford the great expense of modern treatment. In the old days, we relied upon the family doctor for everything. He never thought of asking for a second opinion until his patient was beyond hope, and when he did call a consultant from London or a neighbouring country town, it was only to emphasise the social and financial position of the patient. To-day, with the tremendous expansion of medical science, specialists have grown up in every branch of practice. They have been said to know more and more about less and less.

To-day, if one goes to a distinguished consultant for an opinion, he may perhaps want half a dozen reports before he will give even a diagnosis. He may want one's teeth examined; he may want one's eyes examined; he may want a report from a pathologist; he may want X-rays; he may want one to be in a nursing home for observation for a fortnight or more. All that, which is the natural outcome of the growth of medical science, has made treatment so expensive that it is no longer possible for ordinary people of small means to afford it. Full treatment, in fact, has ceased to be available for anybody but the very poor, who get the benefit of free services, or the very rich, in spite of the great generosity of the medical profession in moderating their fees according to the means of the patient. In a middle-class family, however, a surgical operation may represent a major financial calamity and may cripple the family for years to come. So it comes about that you will find people to-day who ought to undergo a course of treatment but who fear to consult a doctor because they dread an operation they cannot afford.

This question of the hospitals is so urgent that it can no longer be postponed. In addition to the increasing cost of medical attention, we are faced by the great crisis created by the war. It has been estimated that up to the end of last June the damage done to hospitals exceeds £20,000,000. As on the occasion of the last war, therefore, it will be necessary for the hospitals to come to the Government for assistance in rebuilding and reconstruction. That being so, the Minister has taken very timely action in having preliminary consultations with bodies representative of the voluntary and municipal hospitals to ascertain what steps can best be taken to repair the damage inflicted upon them. He has now appointed a survey committee to assess the needs of London and provincial centres in the replacement of hospitals. He has already available the expert advice of the representative bodies and also much information collected by the Nuffield Trust. Those appointed to conduct this survey will have some enormously difficult problems to consider. They will have to consider the relative incidence of conditions requiring treatment in various population units. For instance, it is obvious that the hospital needs of Eastbourne and Wigan are very different. There must be inquiry as to the best size of hospitals for different purposes. We want advice regarding the transfer of bombed hospitals from noisy, crowded areas to more suitable sites. There is also the question of increased provision of private wards for paying patients.

A very thorough survey will be essential if anything like intelligent understanding of the problems is to be reached. Those entrusted with it must be persons with open minds and wide experience, with no axes to grind for any vested interests or established systems. Their function must be a complete review of all types of existing provision for general and special hospitals, fever hospitals, and maternity homes. Having completed the survey, they have to suggest how replanning can be done, what must be ruthlessly scrapped, what institutions may be amalgamated, which can be modified, and which must be extended. They have also to suggest means of supplying very special services, such as radium and deep X-ray therapy, perhaps for combinations of regions. It may be hoped they will go further and consider the conditions of service that will ensure the first-class staffing of these regional hospitals, for there is no just reason why patients in Cornwall or Westmorland should have less skilful treatment than patients in London. There should be no difficulty about this. For generations past we have seen, in Harley Street and in the consulting quarters of Liverpool, Manchester and other big cities, a constellation of medical talent unequalled in any other country in the world, but for every man who makes good in Harley Street or in these other centres, there are half-a-dozen perhaps equally good men who have not the opportunity or the means to dig themselves in, and achieve positions in the great hospitals. First-class men of that type are available, and they can be distributed to these regional hospitals all over the country, so that they can be staffed with men of the first rank who will make a great contribution towards the advancement of medicine.

I have no doubt at all that those responsible for this survey will recognise all the good that there is in the voluntary system, which has served us so well in the past, but the time has come when flag days, carnivals and even contributory schemes are unable adequately to support the great expense of these institutions without further help from the State. Those who recognise most fully that the municipal extension of hospitals is necessary should not detract in any way from the tremendous contribution that the voluntary hospitals have made, not only to the health and safety of the people, but in providing education for the doctors. The municipal hospitals date only from the Local Government Act, 1929, but in that short period you have had ill-equipped Poor Law infirmaries in London, Liverpool, Manchester, Bradford, Birmingham, in the counties of Middlesex and Surrey, and in other areas converted into first-class hospitals which compare favourably with some of our best voluntary institutions. That has been a great achievement in a relatively short period, and, if those hospitals are given a fair chance, I believe they can take their place side by side with voluntary institutions, and medical men of distinction will be proud to be associated with them. They should be entitled to a fair share of clinical material. They should not be regarded as mere homes for chronics or incurables. When the waiting lists in the voluntary hospitals have been abolished, the municipal hospitals will be in a position to contribute a greater share to the teaching of medicine, and they should be great places for refresher courses where general medical practitioners can keep in touch with the latest developments in medicine in a way they have never yet had an opportunity of doing.

The Minister's decision that the responsibility of securing adequate hospitals must evolve on the local authorities is, I suggest from my own experience, a wise one. I have been connected with local authorities, and I have watched other local authorities in this connection, and I am convinced that they can be trusted to discharge this duty of hospital supervision with vision, judgment and singleness of purpose. The local authorities are proud of the voluntary hospitals in their areas. In the Lancashire towns the local voluntary hospital is an institution in which a town takes the greatest pride. The people who administer the local health services are also members of the governing bodies of those hospitals, and to suggest that we have anything to fear from them in the management of the hospitals is to raise an alarm which is unjustifiable. Above all, they will see, what I think is important, that there is a proper linking up between the domiciliary and public health services and the hospital services. That will be a great achievement.

The Minister has done well also to decide that patients should make payment for the treatment they receive, either by assessment or through a contributory scheme. Free treatment for the poor will always be available, but others will hesitate to accept charity and will gladly pay. When the statement about hospitals was made in the House by the Minister last week, I met a friend who is always critical of politicians and asked him what he thought of it. He replied, "It seems to me that the Minister is trying to make the best of both worlds." After thinking that over I decided that it was precisely the Minister's purpose. He is trying to make the best of the world of the municipal hospitals and of the world of voluntary hospitals, and I believe that the House will wish him success in this great undertaking. Certain it is that he could earn no greater fame than to be remembered by posterity as the man who made complete hospital services available for every man, woman and child in every class of the community who was in need of them.

Professor A. V. Hill (Cambridge University)

There is no time for a discussion of details, and I should like, therefore, to refer to certain matters of principle which I feel we should keep in mind in dealing with this important and complicated question. I cordially agree with the hon. and gallant Member for Blackburn (Captain Elliston) in deprecating hostility between the voluntary hospitals and the State hospitals or between the upholders of these two systems. With a good many of the points brought forward by the hon. Member for West Fulham (Dr. Summerskill) I also agree, but I would dissent from the undue depreciation which she has of the working of the voluntary system. Nobody, at any rate, nobody who knows me, would suppose that I am an upholder of the privileges of the medical profession or of all the arrangements which have grown up in our health services. I realise fully that drastic changes are necessary and that new measures will be required, but it seems to me a pity not to recognise the great good that exists in the present arrangements and the great achievements of medicine and the public health services in this country in the past. One thing which is characteristic of British hospitals—I can speak for one which I know rather intimately—is the high standard of humanity towards the patients. There is no question that the patients in our hospitals are grateful and appreciate what is done for them. That is not the case in all countries. In the State hospitals of Germany—I do not think this depends only on the German character, but it depends also oh their system—patients can be treated simply as experimental animals, and it is recorded of one well-known German physician that he asserted that such and such experiment must be made even if it costs 100 peasants. That attitude is not adopted in our hospitals.

The inherent humanity of our system is a thing we must insist on preserving, and we must try to get the good we can from the existing system and graft on to it the good in other systems. The principle of our Government organisation is that of close co-operation between the good citizen and the organisation of the State. On the one side we have laisser faire or independence. On the other side we have bureaucracy. Neither by itself will work, and we have in all our systems to try and obtain the optimum of the best possible combination or compromise between the two conditions. So also it should be in medicine. We have a long-established voluntary system which has grown up gradually—and there is usually something good in anything that has grown. We have also the newer public health services which are developing much more rapidly. The reason the voluntary hospitals developed first is that the sick man makes an obvious and natural appeal to human emotion. The prevention of sickness and ill-health does not appeal so naturally to emotion; it appeals more to the intellect. In such matters we have to find the proper compromise, the optimum condition between emotion on the one side and reason on the other. Medicine and public health have two sides—one the treatment of disease or the forestalling of disease as an entity, and the other the treatment of the patient or the social and human side. Here again we must have a compromise and an optimum condition between the two.

The social aspect of disease or of the public health services depends upon such agencies as the hospital almoner, of whom the hon. Member for Reading (Dr. Howitt) rightly spoke so warmly. The proper optimum depends upon a proper combination of the scientific treatment of disease on the one side and the humane treatment of the patient as a social being on the other. There is no doubt that in our choice of the compromise between the different factors which affect a matter so complicated as public health we are at present very far from the optimum and from the best compromise. For example, there is no doubt that disease and imperfect physical development leading to disease, and failure to realise fully the capacity of the individual, are largely due to imperfect nutrition. That is on the social side.

There is no doubt that the imperfect development of the human individual is in many cases due to lack of physical education, and I very greatly welcome the efforts that are being made by the Board of Education in introducing a system of physical education into schools and into big industrial undertakings, by which these imperfections may be made good. For reasons which have no relation to health, such a movement may be thwarted by pacifists or others who see in physical education a means of militarising the country. Such nonsense should be put out of our minds in dealing with matters of public health. We should not play politics when matters of such great public urgency are involved.

In another matter, preventive immunisation, we are very far from the optimum. There is no question that diphtheria could be wiped out completely in this country if we would take the matter in hand with sufficient firmness and boldness. The efforts made in this direction are checked by two sections of opinion, one the antivivisectionists and the others those who talk of the freedom of the individual and object to compulsion. Few people object to compulsory education, but compulsory immunisation is regarded as something different, and an average of 5,000 beds are continuously occupied with diphtheria cases which could be altogether abolished if we would take the trouble to do it. A compromise has to be secured between the different factors involved, between the scientific, the humanitarian, the social, the nutritional, the educational and the financial. We cannot expect to reach the millenium in any one of these directions. We have to try to hit off the best compromise between the different factors involved. It is essential, if good results are to be obtained, that individual parties in the compromise should not play politics but should work together for the public good and recognise that in such a complicated matter compromise is really necessary.

On scientific grounds I personally should like to go a very long way in the direction of prevention through public health services, physical education and the like. Others, more moved by humanitarian considerations, would naturally tend to go further in the direction of preserving the sick and the old. Others would be more concerned with the interests and prestige and the healthy state of the medical profession. Others would be more concerned with the desire to assert the power of the State over the individual, and with introducing their own particular ideal organisation or their own particular ideology into what was done. Others, too, would be more concerned with preserving the individual and the independence of our present system. A compromise must be worked out between these differing views. There is something to be said for all of them and the compromise needs to be worked out not by medical people alone but by those interested in the different aspects of the problem. Laymen, medicals, the nursing services, and the social services, all are involved.

In the end it is clear that we must have a universal medical service at some time. Whether it will depend on a State medical service in the sense that the Navy is a State service, or upon an insurance system, is a matter which there is no time to discuss on an occasion like this, and no doubt many of us would have no definite opinion, but that a universal public health service is necessary both for preventive work and for the treatment of individuals there is no doubt. That it should be based on the family idea many of us are convinced, and the experiment which has been made at the Peckham health centre is one which we should like to see developed in the future.

We must not rush in and try to build up a system without careful thought and experiment. It is an experimental subject, and if we rush in too quickly we shall get the same difficulties and scandals as we find in large departments which have been suddenly created to deal with war emergencies. Nor, on the other hand, must we go too slowly, because human lives and human happiness are involved. A number of our younger medical people are very socially-minded. There is no doubt about that. Those who are in contact with them—and I have several in my own family—know how socially-minded they are. They are not yet spoiled by prosperity, perhaps, and I do not know whether they will be spoiled or whether they are capable of being spoiled. A little while ago I was told by a student at St. Bartholomew's Hospital of an attempt to get up a debate on a State medical service. He said it had been found impossible to arrange for the debate. I was somewhat astonished, because I thought there must be somebody there who would be prepared to support the institution of a State medical service, and I told him so. He replied that I had completely misunderstood what he meant. The position was that there was nobody who would take up the opposite point of view. In a few years they may think differently. They are idealists at the present time; they will gain experience later which may make them modify their views. There is no doubt that we have the basis of a very socially-minded medical profession, and I myself am very much inclined to let these young people develop in their own way.

If we let things develop, I believe there is every chance of obtaining the kind of medical arrangement that many of us look forward to. I regret it when temptation is put in the way of a man to neglect his public duty because of private profit. That temptation is put in the way of any man who has both panel patients and a private practice of his own. With that temptation before him it is very difficult for any man to avoid unconsciously slipping over into making what he can from his private practice, to the disadvantage of his panel patients. I am told that a State service may be inefficient, and that it would be impossible for a full-time State medical service to be sufficiently elastic to allow a man to be privately employed by the patient who had called him in. I cannot really believe that a State service is necessarily inefficient. Nobody says that the Royal Navy is inefficient. There were days when the Royal Navy lived- upon piracy; now it lives upon fixed incomes. Some may perhaps regard the medical profession as living by piracy, but even if some members of it came to be State servants, as the officers in the Royal Navy are, I cannot believe that their morals would depreciate or that they would show a lower standard of humanity or decency or science.

I would deprecate any attempt to lay down beforehand how far we should go in any direction. Speaking as an experimental scientist, I say that the important thing in medicine is to experiment. Take the systems, let them develop side by side, find out what is good, find out what is bad and discard it, and in that way progress as animals have progressed, and as our social system has progressed—by evolution. I welcome the proposal of the Minister for strengthening our hospital service. I believe it is a step in the direction of gradual development which we all welcome, but we shall have to go a good deal further, and there is a great deal more to be done, before we can see the end of this business. I have satisfied myself that, for the time being, the Minister is proposing the right thing. I hope that we may all go forward, in this matter of improving our public health services, in the spirit of friendly compromise with one another, not failing to realise the urgency which exists, but being willing, at the same time, to see the good in the different factors and in the different systems of medicine, not seeking to get a perfect system and so failing to get a system that will really work.

Major Haden Guest (Islington, North)

Like many other Members, I regret that we have such a short time for our Debate. I believe that the Minister agrees with me. I am glad that we have had powerful support from the other side of the House for what the hon. Member who has just spoken called first a universal medical service and subsequently called a State medical service. I do not want to concentrate the few minutes at my disposal upon the discussion of this hospital question, because, although the question is important, it is certainly not urgent at the present time. It is not the most urgent question which could be brought before this House. There are very urgent health questions that ought to be brought before this House on a future occasion, and I hope that we shall have an opportunity of doing so.

Tuberculosis has been mentioned several times, and I want to refer to it again for a special reason. There has been a considerable increase in tuberculosis in this country during the last year. The summary report of the Department of Health for Scotland says that the figures for the first half-year relating to tuberculosis were provisional, but that the incidence was still high, over 4,300 cases having been notified in the first six months. Deaths were also more numerous. In 1940 the death-rate from tuberculosis in Scotland was 82 per 100,000, the highest figure since 1932. It happens that in the "British Medical Journal" for 27th September there was a very interesting article by Drs. Laidlaw and Macfarlane, analysing the incidence of pulmonary tuberculosis in Glasgow, and indicating what, in their opinion, was the reason for the considerable rise in the number of cases. I shall not recite the figures which they gave, but I would like to direct the attention of hon. Members to the conclusions to which these two doctors came.

These doctors very carefully analysed all the cases from 1939 to 1940. Their conclusion was that the cause of the increase in the number of cases of tuberculosis was a combination of long hours, overtime, strain, and ill-spent leisure. I would draw the attention of the House to the fact that that is not what we should have expected in the ordinary way to cause the increase in tuberculosis. Tuberculosis is a poverty disease. It comes out of the slums, and it depends upon malnutrition. In the case of the rise in the incidence of tuberculosis in Glasgow —I think it is occurring all over the country where industrial conditions prevail—these officers drew attention to causes which arise out of the strain of war-time production. Had I the time, I could add many quotations giving the scientific authority for the point of view which I am putting forward. I say emphatically to the Minister that we are not using our great public health organisation at the present time to avoid increase in that kind of disease.

In every county council in the United Kingdom, and in a multitude of other local authorities, we have very highly qualified and competent medical officers of health who are performing very important public duties, and who still have time and energy to perform other duties. Just as a factory producing the necessities of peace-time can be switched over to war-time production, so this very important organisation of medical officers of health can be switched over in wartime to the supervision, control and direction of all the conditions of life of people who are employed in industry, in order to avoid the bad results of which this rise in tuberculosis is an example—I am afraid only one example. I believe that what I suggest can be done comparatively easily, that it is urgent, and that it should be done.

May I remind the House that the chief functions of medical officers in the Army are not to treat the diseases of soldiers, pick-up casualties on the field, bandage them and send them from the front line to some aid post, and from there to a hospital where some other section of the Army Medical Service will treat their injuries; it is not those curative, medical or surgical functions which are the most important, but those of keeping the Army fighting fit. These functions are carried out by supervising all the details of life, ranging from clothing, billets and camping accommodation to hours of work, hours of sleep and morale. Those functions make the medical officer indispensable in any well-run unit, and make it possible for a unit to be at its fittest— to be, in fact, fighting fit. We realise the immense importance of those functions for the Army, but it is very remarkable that, while, in public speeches. Ministers and others constantly stress the urgent importance of greater production, how very much larger the industrial army now is and how it is working long hours under black-out and all kinds of conditions which impose a very great strain, we have not yet placed supervision of the hygiene and welfare—in the broadest use of the word—of factory workers on a satisfactory footing

I cannot give the number of medical officers who are in charge, whole-time or part-time, of the factories, not because I do not know them, but because the figures were given to me confidentially—no doubt the Minister of Health knows what they are—but I can tell the House that the total number of medical officers who are engaged in the supervision of men engaged on production in this country is insignificant compared with the number in any of the Forces, and it is really a waste of power, ability, capacity and organisation, which is ready and waiting to be used, that it is not employed in this way.

That is all that I shall deal with to-day, although I had a good many other things to say. Perhaps on some future occasion there may be other opportunities for dealing with other matters, such, for instance, as the question, which has not been raised in the House, of the medical organisation which will be required at the end of this war when the epidemics to which one of my hon. Friends has referred are threatening. May I say that at the present moment the greatest epidemic of typhus fever known in European history is raging in Spain? I have that on excellent authority. There is typhus fever in Russia, and there are epidemics of malaria and other illnesses in other parts of the world. There is not the slightest doubt that at the end of this war we shall have the greatest world public health problem to face that we have ever had. It is, I venture to think, much more urgent than the precise relations between voluntary and municipal hospitals that we should have, after the war, an organisation capable of dealing with that problem. We should have that organisation right now and I hope our American friends will co-operate in it. The Rockefeller Foundation is already working in Spain, and I hope they will be willing to come into an organisation of that kind.

I see, however, that I am being led away. I will not allow myself to be led into the paths of interesting speculation about the control of medical man-power. That is a matter which we must leave for another occasion, but I hope that the Minister in his reply will give us some hope that the potential public health and medical resources of the country will be turned to deal with this very important question of the hygienic supervision of those who are working in the nation's productive effort, in order that we may keep them fighting fit for the work of production.

The Minister of Health (Mr. Ernest Brown)

I am sure the House will agree that this has been one of the most interesting Debates we have had for a long time about this vital subject. I am sure also that hon. Members in all parts of the House would wish that the Debate had been longer, but, as the House will gather from the statement made by the Lord President of the Council at Question Time, the usual channels have been busy, and I have no doubt that we shall have an opportunity in the not too distant future to have a Debate on this vital question of the health of the nation, which is a much bigger thing than either doctors, hospitals or a score of other things.

Of course, my hon. Friend the Member for Reading (Dr. Howitt) pointed out, in the excellent speech with which he opened the Debate, that one of the things we have to take into account in our measurements of all our problems, both present and future, is the extraordinary variety of disturbances the nation has to face in wartime. Another of my hon. Friends was a little optimistic about the extra burdens which I or anybody else can cast on medical officers of health at this moment, because one of the outstanding features of the war has been the extraordinary variety of new duties which medical officers of health have had to shoulder and have shouldered—and which have meant for them many far from routine operations. When dealing with facts and figures, I have, as the House already knows, done my best to produce such statistics as will give us a general guide, and in a few weeks' time I hope to have a shortened report in which I shall incorporate such available statistics over the whole field as will give the House a fair and reasonable guide as to the trend of public health, because I think it is vital that we should have an understanding not merely of the things we have to do now but of the things we shall have to do in the future.

When one considers, first of all, the extraordinary changes in population which have taken place in the last two years, and that millions of people are now living in another environment, one can see the pressure which has been put in the reception areas upon public services—in some cases already before the war too small for their duties. When one considers the abnormal life people lead in the periods of heavy raids, the life that is going on in the shelters of our land, and the plans that had to be made for casualties on a scale which happily at the moment has not yet been reached, but which may be, it will be quite clear to the House and to the country as a whole that our normal standards of measurement by statistics must always be viewed against that background. I have only said this to show two or three of the outstanding divergences between peace-time experience and war-time experience in the health field.

My hon. Friend the Member for Reading put the matter in perspective when he said that, considering the disturbances already referred to, the health of the nation had been surprisingly good. Of course, that is so. Personally, I think it is bad, psychologically, to be always talking of epidemics, except in so far as that discussion may lead to preventive action. I think our psychology last winter was a little awry in that we were expecting every morning something which did not happen. So far as I am concerned, that will not be the case next winter. What we want to do is to make as widespread as we can the services which make for the health of the nation, and side by side with that to spread more widely than ever a simple, elementary knowledge of the things to be done in the home and else-where which help to keep people fighting fit.

While I am on that topic, may I point out to the House that a great deal has been done and is being done in that field; and in a sentence or two I would like to pay my own tribute to the admirable work done, in liaison with the Ministry and other bodies, by the Central Council for Health Education. If hon. Members have not seen the whole series of pamphlets and leaflets that have been produced, I would draw their attention to them, and also the attention of the general public. They deal with problems which are very difficult, and there is one which I am surprised to see has not been mentioned to-day, a problem not merely of disease but of dirt too. It is not without significance that the second of the hints published by the Central Council for Health Education is entitled "Scabies and Impetigo." I can tell the House, although it has not been mentioned to-day, that it has given not only me but every medical officer of health in every area concerned not only furiously to think but furiously to act. In reception areas we are having to provide scores of new sick bays in order that that particular ailment may be dealt with properly and effectively. More than that, we shall have to go nearer the root of the matter, and a little later on I hope to make an Order, under a Regulation which has now come into force, which will give the medical officer of health more power in regard to inspection than he has had up to date.

Then there are pamphlets on measles, on influenza, the war against lice, and on saving children from diphtheria. There is one with the title of "Bugs." All these leaflets are virile and simple; the subjects include some not ordinarily talked about, and I understand that one or two of them are even too vigorous for some of our popular Press. These are among pamphlets which have been produced in order that the nation may know, not in general terms, but in specific, definite terms about these matters. My hon. Friend the Member for South Tottenham (Mr. Messer) will be interested in "Health in the Shelter," "Health for A.R.P. Workers," and "Health Hints About Sleep." I only mention these to show the House that we are taking not merely an abstract view of our health problems but are doing our best to get down to positive and preventive action, not merely in the field of medicine and hospital treatment, but in the sphere of education. I regard this health effort as a magnificent opportunity for spreading knowledge about health. We shall do our best to see that this process of education is intensified and made even more effective.

With regard to the general position, there has been a good deal of talk about epidemics, but I thought that there were one or two other general tests about which the House might like to have the latest, information. In normal times we do not merely take statistics for certain diseases, but the general death-rate, the infantile mortality rate and the maternal mortality rate as important indices. The general death-rate in 1940 was 14.3, including air-raid deaths of civilians. That figure is also not comparable with those of recent previous years, because deaths of non-civilians have been excluded since the outbreak of war. The figure for 1939 was 12.1, and in 1940 it was 14.3, excluding the deaths of non-civilians.

The 1939 figures relating to diseases for England and Wales require to be taken with a little caution, because I have no doubt that in the great movements of population that took place notification was a little slower than previously, or than this year. When general conclusions are based on the figures for 1939, those figures should be taken with that caution. The infantile mortality rate was 56 per 1,000 births in 1940, six per 1,000 above the low record of 1939, but lower than the rate for any year previous to 1938. The maternal mortality rate per 1,000 declined to a new low record of 2.61 as compared with 2.82 in 1939. I have no doubt that a good deal of that has to do with the wartime maternity hostels which we have set up in the reception areas, and it is a source of gratification to me and to all concerned to see how, every week, these mothers from London are taking more and more advantage of the opportunities given them by this new service. In our wartime maternity homes alone nearly 30,000 new babies have been born in this period of the war. It is a source of gratification to the House to know that the maternal mortality rate in war-time is at a new low level.

It is true that the condition of public health generally remains satisfactory. One or two figures may interest the House. In the early part of 1940 there was an appreciable increase in cerebrospinal fever, and a recurrence to a less marked extent in the early part of this year. The incidence fell from 1,380 in February to 420 in September, and the mortality rate of this disease has been reduced in the last few years to one-third of the previous figure. Measles, which has been prevalent in the past 18 months, has almost completely disappeared at present, the figure of new cases for September being 2,768 as against 29,804 in September of last year, and 62,737 cases at the peak in February of this year. Scarlet fever and diphtheria have never been high, and the incidence is less than in the corresponding month of last year, and approximately the same as in 1939.

Several Members have rightly called attention to the increase in tuberculosis. I was interested in the way in which the hon. and gallant Member for North Islington (Major Haden Guest) fixed his attention on the Glasgow figures. I am happy to say that our experience in England and Wales has not been quite the same. The facts are that in 1913 the death-rate from pulmonary tuberculosis per million was 958, in 1918 1,165, while in 1939 the rate had been reduced to 476. A point brought out by the hon. Member for South Tottenham was that in the county of Middlesex in 1940 the figure had increased by approximately 10 per cent. The figures he gave the House for between 11 years and 20 years is not information which is borne out over the whole field. When the House has the figures for the first quarter of January of this year, it will find a reduction of seven per cent. as compared with the first quarter of 1940. I hope to have these figures out within a fortnight and those for the second quarter as soon after as may be.

With regard to young females between 15 and 25, in 1913 the rate was 1,020, which by 1918 had gone up to 1,580. Owing to the increase of services and the attention given, it was down by 1939 to 762 in that group. Members have called attention to the 1940 figures compared with the 1930 figures, rising to 881 in that group per million. The first quarter of 1941 shows a slight decline of about four per cent. in that group. These figures illustrate the progressive improvement in general social measures as well as in particular health services, and especially the improvement in housing between the wars. While I am Minister of Health I shall always regard housing as a vital health service, the foundation of the health services. The sooner we get to the point when we can resume our progress, the better for the health of the nation.

Directly we saw these figures I instituted an inquiry by my own people, with the Medical Research Council, and asked for an interim report on the causes of the rise. I hope to get the interim report as quickly as may be, to inform all the authorities concerned, and, of course, on the appropriate occasion, to let the House know the view of those who make the inquiry as to the cause of the rise. I could not go into great detail in the time I have, but I could not agree too much with my hon. Friend in what he said about hours and overstrain. I think that all who followed the most interesting series of reports on industrial fatigue in war-time, instituted in 1917, came long ago to the conclusion that you cannot, over any long period, equate production with hours. The ideal for the nation is to have such a state of strength and health and skill that you get the maximum production in the normal working day, not the abnormal hour. My right hon. Friend the Minister of Labour has his eye very much on this particular side of the industrial problem.

With regard to tuberculosis services, it was necessary to make the preparations we did for the casualties which have not yet arisen. We should have been lacking in our duty if we had not had ready the services for the wounded and the sick which came to us in the course of the war, whether they were Army or civilian casualties, or the casualties of war industry. In doing that, we had to limit somewhat the number of beds. I have that matter under attention, and beds have been released. I propose to do my very best to meet the need for beds. Here we are up against the problem not merely of beds, but of nurses, too. We are giving urgent attention 1o that. As hon. Members know, the treatment and nursing of infectious diseases is a very special problem. The hon. Member for South Tottenham need not fear that there will be any undue congestion there. Of course, the duty of the local authorities to carry out their tuberculosis schemes, covering clinics and health visitors as well as sanatoria, has been continuous.

Sir J. Lamb

There is a shortage not only of nurses, but of domestic staff in institutions.

Mr. Brown

I am well aware of that. The problem of domestic staff exists not merely in regard to T.B., but in all our hospitals. My hon. Friend has already written me about a hospital in his area in which he is interested and he knows from his connection with the local authorities' associations how wide the problem is. I am sure that the authorities responsible for carrying out the duty imposed upon them by Parliament in this vital field will not merely continue to intensify their efforts to deal with contacts. I do not believe that they are not fully aware of the urgency of that problem.

The Debate has naturally turned a good deal away from the general health problem to the statement that I made recently. I would like, not in protest against what my hon. Friend the Member for South Tottenham said, but in support of it, to refer to the fact which he pointed out that in the emergency hospitals scheme the London Group Sector Officer was from a voluntary hospital. That is true, but I must add, in fairness to those who devised this organisation, that each officer has two deputies, one for the voluntary hospitals in the Sector and one for the municipal hospitals. Similarly, in each Sector there is a voluntary and a municipal Lay Sector Officer, and also a voluntary and a municipal matron. This duality is also in force at headquarters. At the Ministry of Health, under the Director of Emergency Medical Services concerned with the London Region, there is a deputy drawn from the municipal side and one drawn from the voluntary side.

The House in this Debate has shown quite clearly that it understood that we were dealing with principles, and getting the machinery right for working out the details. Indeed, I made that clear when I answered supplementary Questions on the statement that I made. The Debate has been very interesting to me, because it has brought out that, while Members had their own views about this matter, the presentation of this problem to the country has meant a very wide acceptance of the line of approach—whatever views Members may have in terms of ideology and, of course, there are Members who always desire to shatter things and to re- mould them nearer to the heart's desire, and there are, alas, few Members who have the chance of doing that. My hon. and gallant Friend the Member for Blackburn (Captain Elliston) said that we were making the best of both worlds. Why should we not? If there were three or four worlds, we should make the best of all of them.

It has been a good thing to have this Debate. People who would like to abolish voluntary hospitals have expressed their view. On the other hand, there has been a gratifying indication that the House understands that we can have confidence in the democratic representatives who will come into the discussions and make these schemes, after a survey, to look after democratic interests. It seems to me part of my political lot to get people around a table when they have never met before. In 1932 I got the miners and the mineowners around the table together, and I seem to have been getting people together around a table ever since. I deliberately used the word "partnership" to describe the intended relationship between the voluntary and municipal hospitals. It is not a new arrangement. Financial arrangements between them have been common since 1875, by which voluntary hospitals provide services under contractual arrangements with a council. It has been within the power of a council to make contributions, not on a contractual basis, since 1915.

I have taken heart from the Debate today to believe that, on the whole, whatever Members themselves may think theoretically and ideally, they realise what was previously stated in the moving speech of the hon. Member for Cambridge University (Professor Hill), having regard to facts, history, traditions and people's loyalty to institutions they have known for a long time. I would say to the hon. Member for Rochdale (Dr. Morgan) that there are many towns where the local hospitals, whether municipal on the one hand, or voluntary on the other, or both, as in many cases, have not the monopoly of affection of any party but the affection of the citizens as a whole and have very strong popular local feeling behind them. These facts must be faced. The preliminary discussions have led to this statement, and all I would say now is, Let the good work go on, so that in the end it really does mean what we mean to have—an effective hospital service of every kind for every citizen in the country.

I am sure that Members of the House who read with very great interest that remarkable book of Mr. Seebohm Rowntree's "Progress and Poverty," containing an extraordinarily detailed examination of social conditions in York compared with 30 years ago will take courage and heart, for it shows two things: First, that all the efforts that we have made in this country, men of all sorts and conditions and of all parties, to build up enormously effective medical and health services have been well rewarded by the progressive improvement in the standard of health and length of life of the nation, while, on the other hand, it reminds us of how much more there remains to be done in the days that lie ahead of us. As far as I and my administration are concerned, I can assure the House that I shall take the guidance of my hon. Friend the Member for St. Albans (Sir F. Fremantle) and other hon. Members who have spoken in this Debate, and shall not cease to look for opportunities in war to find an additional service which may continue when the war is won and we can carry on the great improvements which were in progress when it began.