NATIONAL HEALTH SERVICE

HC Deb 16 March 1944 vol 398 cc427-518

The Minister of Health (Mr. Willink)

I beg to move, That this House welcomes the intention of His Majesty's Government, declared in the White Paper presented to Parliament, to establish a comprehensive National Health Service. Just over a year ago, the Government declared their intention to establish a comprehensive and unified health service for the people, a service covering the people as a whole, a public, organised and regulated service for every man, woman and child. To-day, the Government seek the approval of Parliament for the broad principles running through the White Paper presented to Parliament four weeks ago, so that they may proceed with the next stage, the stage of closer detail, the stage of negotiations, and so to the preparation, with no undue delay, of legislative proposals.

I desire to commend these proposals, and my chief concern at this moment, when I know how many right hon. and hon. Members can make valuable contributions, is how to keep within reasonable limits what I have to say on proposals which are so wide in scope and so very conducive to digression. In the time I have, for I do not wish to be too long, I feel sure that I shall be right to concentrate upon principles and not upon any point of detail. The hon. Lady the Parliamentary Secretary to the Ministry, to whose help I owe so much in this connection, will be able, I hope, early upon next Sitting Day, to deal in greater detail with points that to-day's discussion shows to be of special interest; and my right hon. Friend the Secretary of State for Scotland, in winding up the Debate, will obviously be infinitely more competent than myself to deal with the specifically Scottish features of the scheme. And so, in this opening speech, the House would, I think, wish me to try to bring into clear focus the basic principles of the proposals that we ask the House to welcome. As I have referred to two of my colleagues I would wish, in the most public way possible, to refer to a third, my right hon. Friend the Chancellor of the Duchy of Lancaster, for without his labours it would have been quite impossible for me to put into final shape this scheme which I submitted to my colleagues in the Government, with the Secretary of State, little more than three months after my appointment.

Is it not right to think of a National Health Service as one of the main pillars upon which our post-war social structure will rest—education, health, housing, social insurance, and there will, of course, be others? Each of these pillars needs to be well fashioned and well founded, and then the structure will be good. This is the stage at which we are fashioning and founding. Education has already reached the stage of legislation, health has followed not too far behind, and it will not be long before social insurance reaches the same stage; and so, I think, we may truly say we see the whole structure steadily taking shape. Big as this scheme is, it is really to be regarded, I feel, as part of a bigger process still, the process of reshaping the background of individual life in this country. It is really a counter-process to all the destructiveness of war. I think it is true to say that we are discussing to-day a project which will be the biggest single advance ever made in this country in the sphere of public health. We have had other great public health landmarks in the past, but this dwarfs them all in its scope and conception. Bold though it is it is only right that it should be bold, for the health of the nation, the health of every citizen, young and old, is at the very root of national vigour and national enterprise, and this should be the scale, I venture to suggest, on which our discussions should be framed to-day and on the next Sitting Day. There will be time and opportunity for discussion of small details in the coming months and when the time comes for legislation.

What is our real object in this new National Health Service? The object, like the name of the service, is national. It is to fit the nation for its great responsibilities, to free its members, so far as it is humanly possible to free them, from the anxieties, the burdens and the pains of ill-health. This is no scheme for giving charity to individuals or State help to particular classes or groups. This scheme does not concern itself with poverty or wealth. It is a plan to raise national health to a higher plane and keep it there, and to use the nation's full resources to raise it ever higher. Nobody can guarantee health or get rid of sickness. What we can do is to improve the opportunity of health, and we can get rid, I have no doubt, of much of the wear-and-tear that goes with ill-health. We know the anxieties—the anxiety about paying bills, the anxiety about getting the best advice, an anxiety which is worse when we are considering our dependants than when we are considering ourselves. This scheme is an attempt to get rid of all that, to see what it is that the nation needs, to see that it is there and to see that advantage can be taken of it easily and readily.

In one or two places in the White Paper the word "free" occurs, and I should like to say a word about that, because it is not really an appropriate word. It is far less true in connection with this service than it is in the field of public education. A service of this kind has to be paid for—it cannot be free—and the real position is that the method by which our medical and health services will be paid for is going to be changed. Everyone will pay for a service for everyone and by three means—taxation, rates and the social insurance contribution. The only sense in which the word "free" is appropriate—and I do not really think it is appropriate at all—is that there will be no charge to those who use the service when they use it or because they use it.

The extent of the social insurance element in this scheme is not yet settled. That will appear in the Government's social insurance proposals, but it is not inconvenient, I think, to assume for the moment Sir William Beveridge's suggestion of a contribution of £40,000,000 out of the Social Insurance Fund towards the health services. Then, on a rough estimate, 27 per cent. of the cost of this service will be met on the contributory system, leaving about 36 per cent. for taxation and about 36 per cent. for the rates. Perhaps it would be convenient to compare these percentages with the percentages which obtained in our partial services in the last year before the war. In those services the contributory element amounted to no more than 20 per cent., the contribution from the Exchequer was far smaller than the 36 per cent. to which I have referred—it was a mere 6 per cent. —and the ratepayers' contribution was proportionately far higher, 74 per cent. This scheme is a novel blend of three systems, a novel blend of central organisation and expenditure, local government administration and expenditure, and a contributory system, and, woven into the whole a wide range of arrangements of a contractual kind for services by voluntary organisations of many sorts.

In the time at my disposal I do not think it is necessary or that it would be right to say much about our present services. We know what magnificent work has been done in many fields, and we know, too, the deficiencies. The present situation is set out very fully, and I hope conveniently, in the first Appendix to the White Paper, but, just summarising it, we know that there are local government units of half-a-dozen kinds, with different services put upon them at different times, with limited objects in view. We know that there are hospitals for general cases, chronic cases, acute cases, special cases, infectious cases, the mentally ill and the mentally deficient. There is a wide range of welfare services. There is the widest range of hospitals—voluntary hospitals, general, special, teaching and cottage hospitals. There are the public hospitals, which have made such great progress in recent years. But whatever be the wealth of good material, no one can say that it forms anything like an organic whole. There is in many places no inter-relation between the voluntary and municipal hospitals, no sufficient link between the general practitioners and the clinics, over-lapping, unnecessary competition. Perhaps the greatest deficiency of all is that our present services provide no personal doctor for the wives and dependants of insured persons. And there are real difficulties of access to the appropriate hospital for the particular case. There are new services which we need—dental services, ophthalmic services and others. What we have to do, I feel sure, is to see that this great new service evolves naturally out of what we have. We do not want any doctrinaire scheme; we want a natural evolution. We want a scheme that will work, and into which every one of the present elements can put their best.

The proposals in the White Paper, I think it is true to say, are built around certain principles which the Government believe to be fundamental. I would say that there are four main principles and, after stating these, I shall pass to a number of features in the plan which derive from these principles. The first principle, which I have already mentioned, is that of comprehensiveness. The whole range of health care must be made available to every person, starting with the family doctor and ranging through all kinds of clinic and domiciliary services to the consultant and the specialist—another service entirely absent at present in any organised form—and the hospital. I would emphasise again what I think is as yet hardly realised by the general public—the immense advantage of including wives and children and not merely the insured contributor.

Then, there is the second principle, the freedom of the individual. No one, patient or doctor, must be dragooned into any part of this service, or any form of treatment, unless they want to use it. We want it to be there for everybody, but not thrust upon anybody. There must be no compulsion of the doctors, or the nurses, or any others whose job it is to give the service. On the whole, professional people know their own professional job best, and should be left as free as possible to practise it in their own way. A certain amount of organisation is essential. The State is taking the the responsibility of providing the service and we must see that it is there, when and where it is needed, but we must do everything to see that organisation spells neither bureaucracy nor red tape.

The third principle, which runs clearly through the whole of this Paper, is the principle of democratic responsibility. We feel that the new public responsibility to see that the whole service is there and that it is good must rest, both centrally and locally, with the elected representatives of the people, that is, with Parliament and with Ministers directly responsible to Parliament, and with local government in the general sense in which we know it in this country.

Mr. George Griffiths (Hemsworth)

Democratically appointed?

Mr. Willink

We will come to that. The fourth main principle is that of professional and vocational guidance. The ultimate responsibility must be fully democratic, but the whole service must benefit throughout from the very best professional and expert advice and guidance that we can obtain. If this service is to achieve the best professional standards, it must enjoy and take note of the best professional counsels.

With those four principles in mind—and I hope the House will accept all four—I should like to turn to the actual organisation and point out a number of main features—perhaps six or seven—which the Government feel to be fundamental to their proposals. The first I would mention is that well-known principle, the free choice of doctor. There is no doubt that the personal and intimate relationship of doctor and patient is inherent in medical practice in this country. There are very few people who do not attach the greatest importance to being free to choose their own medical adviser and to change to another when they want to do so. Very few people want to be doctored by a service. They like being doctored by the doctor of their choice, and if people want this principle to remain, remain it must just so long as they want it.

Dr. Edith Summerskill (Fulham, West)

I should like to ask the Minister how he reconciles that statement with the fact that everybody who attends a hospital is doctored by the hospital service. Such people do not choose their doctor.

Mr. Willink

Of course, if you want to go to a hospital, that is a different matter entirely from choosing a personal doctor. Myself, I see very little likelihood of this attitude of mind in our fellow-countrymen, to which I have referred, coming to an end.

Secondly, there is, in the belief of the Government, no case for anything which could reasonably be called a regimentation of the medical profession. Some people believe in a salaried medical service; some people believe in the present basis of practice, under which a doctor, broadly speaking, is remunerated according to the number of patients whose care he undertakes; some people believe in practising in groups; some people believe in practising as separate individuals. These varying beliefs are not only found among the doctors; they are found among the patients; and so, in this matter, I would emphasise that, whatever rumour may say, the Government have no intention of seeking to establish a full salaried State medical service. We do believe that where doctors practise in public health centres, there must be a system of payment which does not involve competition between one another, and that is a proposal which is to be found in the Paper with regard to practice in health centres. But it would be a mistake to universalise one system at this stage. Let the service, we advise, be big enough to give scope to all these points of view. Let us try them all, side by side, the public will steadily find its own preferences.

This attitude of experiment is particularly true of the health centre idea. The White Paper contemplates experiments of many kinds which we are encouraged to suggest by the fact that health centres of many kinds have been suggested by the profession itself. Many in the profession believe that the best work of the general practitioner can be done in a health centre, specially designed and specially equipped, where the team of doctors would profit from the pooling of their experience, from up-to-date resources, and from the saving of their time by the provision of ancillary staff. Patients in an area where there were such health centres would choose their own doctor just as they do now. They would see him in his consulting room. He would have consulting hours and would visit his patients at home just as he does now. But there seem good grounds for suggesting that doctors practising in that way would have a considerable advantage—and their patients would have advantages, too—from the fact that the team could cover emergencies. They could deal with time off, holidays, and refresher courses more easily than they can now in solitary individual practice. The whole idea seems to us sensible and attractive and we want it to be tried out fully and fairly. The doctors and the people will want to see how it develops.

Thirdly, with regard to general practice, the Government do not believe that practice under private arrangements should be either prohibited or isolated. If people are to have the right to seek private advice where they want it—and it would be a strange proposal that people should not have that right—it follows that the doctors must be free to treat them. Nothing, in the view of the Government, could be more unfortunate than to divide the profession into two classes, those who practise publicly, and those who practise privately. What we want is to see the whole of the best of the profession engaged in this service, not to divide it into two camps. But there are one or two points which should be made in regard to that. We do feel that a doctor who has more private patients should have a smaller number of public patients, and the scheme provides for professional regulation of that balance. We think, too, that doctors in big practices will need young assistants and that there is a strong case for requiring all young doctors first entering on general practice, to serve an apprenticeship with an experienced general practitioner, especially in a publicly financed service where the patients have the right to rely on the doctor being an experienced practitioner.

The fourth point I would mention in this connection is in relation to a sentence which has, perhaps, as a sentence, caused more controversy than any other in the Paper. I was even asked a question about it when I visited the county of Suffolk a week or two ago. I have had only one discrepancy between the White Paper and the abridged version brought to my notice and considering all the difficulty of abridgement, that is not, I think, unsatisfactory. In the sentence dealing with the proposal that in certain cases the Central Medical Board ought to be able to require a young doctor to give his whole time to the public service, in the longer version the word "where" appears—"where this is required": in the shorter version the word is "when." The word should be "where" in each case, but, even after making that small correction, I think that the sentence might read more appropriately in slightly fuller form. The White Paper, on page 35, might say: The Board must also be able to require a young doctor entering the public service to give his full time to that service during the early years of his career in cases where the needs of the service require this. This sentence does not point the way to any direction of the kind to which we are accustomed during the war. All it is intended to mean is this—I give the following as an example. A young man thinks of Practising in Wakefield. He says, "I should like to enter into the public service in Wakefield." The Central Medical Board should in these circumstances be able to say, "Of course you can practice in Wakefield in private practice, but before we authorise you to take up public work in Wakefield we wish to tell you there is a great shortage of public service practitioners, and we feel that for five years you should give your whole time to that service and should not have any private patients." That is the meaning which that sentence was intended to have, and I am sorry if it was not quite clear.

On the general practitioner's side, we feel that the scheme proposed in this Paper will give him immensely greater opportunities. It is only a week or two since the Prime Minister described the attempt that we are going to make in connection with this service as war with disease as the enemy. That great man Sir William Osler once, in an address to medical students, described the family doctor as "The man behind the gun." That is how we regard him in connection with this service. We believe that in various fields he will be able to contribute far more in this service than before, and in particular we want to link his work far more closely with child welfare, maternity work, and all the different activities of the local clinic.

Here I would put in a word about the nursing profession. In a Paper of this kind it is natural to stress the doctor and the hospital, but I should like to say here that that does not mean that we underrate the vital part to be played by the nurse, the midwife, and all the medical auxiliaries, as they come to be called in war. The success or failure of this scheme will depend in large measure on the nurse, not only in hospital and clinic, but in the home, because the intention is to provide a real service of home nursing and ways and means must be worked out with the nursing profession itself. That is one of the next jobs to do. Here, too, we want to build on good existing foundations. I should like to pay a tribute in passing to the work being done to-day by the district nursing associations and the Queen's Institute of District Nurses. The nurse in this scheme will not be merely an executive. She will have a proper share in the whole machinery which is proposed for professional and expert consultation in running the scheme. The nursing profession will have its place, too, on the Central Health Services Council and on the local health services councils, and we intend that nurses shall find their place, too, on the expert inspectorate which we propose for the hospital service.

I pass from the general practitioner to the hospital. The voluntary hospitals of this country are a typical and successful product of this country's methods. A long history lies behind them. Many people believe in the voluntary hospital as an organisation and as a principle. Many, too, believe in the hospital service of local government, which, as I have already said, is going rapidly ahead and has a great future. But in building up this service we want everything good that is available; we want both types of hospital. The voluntary hospitals, I believe, are going to render valuable service in the new scheme. The proposal is that they should be paid—not as the paupers of old according to their needs, but like partners in relation to the service they give—by way of standard payments from joint authorities and by central payments representing social insurance contributions. We propose to take the voluntary hospitals by the hand; we do not propose to carry them and I cannot think that they would wish to be carried. For this very reason they will continue to need the support of those who want them to continue their work and to maintain their independence and autonomy. I would like to read one sentence from the White Paper: It is certainly not the wish of the Government to destroy or to diminish a system which is so well rooted in the good will of its supporters There is, I think, some misunderstanding as to the financial effect of our proposals upon the voluntary hospitals. That is not, in one particular, entirely unnatural or surprising, because in the Government's statement of October, 1941, is was contemplated that in the partnership which was to be built up the voluntary hospitals might well be largely served financially by the contributory schemes which have been so remarkable a development of recent years. After close consideration, the Government have come to the conclusion that to launch a major social insurance scheme which did not cover the contributors against perhaps the greatest normal contingency of life, prolonged illness involving residence in hospital, would be impossible. That being so, one of the two main objectives of the present contributory schemes must be affected. The contributor will no longer have that particular contingency to cover, and I feel certain that if that fundamental principle is accepted by the voluntary hospitals, they would be the last to suggest that contributory schemes should be maintained simply in order to continue the existing basis of their finances. Provision is made in the scheme for a change in this basis and I should like to give one or two figures. Taking the figures of the last normal pre-war year, 1938, so far as we can work them out from returns from about 80 per cent. of the hospitals, the payments received through contributory schemes and direct from patients through the almoner system would come to £5,300,000. The new Exchequer payment proposed to be made to the hospitals, worked out on the basis of 1938, would have given them in that year a payment of £6,500,000. There is a further factor. In 1938 the voluntary hospitals received for public services, almost entirely from local authorities, something like £900,000. That is in addition to the £5,300,000 to which I have referred. In substitution of this sum of £900,000, it is proposed that they shall receive from the joint authority, with whom they will be in contract, the service payment referred to on page 23 of the Paper, which will certainly be far larger than £900,000. In addition to these two provisions, there is a third factor. The Government, as is stated in the Paper, will most certainly be prepared to review the question of financial assistance in respect of teaching work at the teaching hospitals. The financial side is to that extent very fully provided for. If, as I believe, the voluntary scheme contributors were not merely paying an insurance premium but were paying to maintain a system in which they believed and to which they were attached, taking into account, too, the fact that there will surely be scope for the development of contributory schemes on other bases, and that there will be gifts, subscriptions and legacies which have for generations been given to the voluntary hospitals, I cannot believe that the anxiety which has been shown is really justified.

I pass to the fifth point, on which I have noted very little disagreement—the question of the rationalisation of our hospital services and the building up of hospital areas. The old conception of the local hospital is outworn. Specialisation increases, and special treatments mean special organisation. We must in this service plan a hospital system as a whole, ensuring that the people can get to the right hospital at their time of need. So we propose an area plan, worked out with local knowledge but submitted to my Department for confirmation. I pass from that plan because I have heard and seen very little criticism of it.

The next point I would mention is the consultant and specialist service. There is little in the Paper about this and there has been little discussion with representatives of the consultants and specialists, for we must on this, await the report of Sir William Goodenough's Committee. Two things only are clear to us at the moment. There will be need for considerably more consultants and specialists and there will also be a great need for an improvement in their distribution over the country.

Last of the main features of the plan is the local government structure. We have no doubt that the foundation of this scheme should be in local government. Much is said of the removal of functions from local authorities, but here is a new service which will add great new duties to local government. It represents an opportunity for an enormous advance in local responsibility, and I believe that the scheme is an immense opportunity for those who take a deep interest in the hospital and health services of their particular part of the country. I ought perhaps to say a word about a major feature of this part of the scheme. The hospital service areas will in almost every case be larger than existing counties or county boroughs. That, too, I have hardly heard criticised, and there is no doubt that many of those who have thought about it feel that most of the counties and county boroughs are too small to serve as a satisfactory hospital area. In those circumstances we believe that the joint board as the hospital authority, which will plan services for its area, in addition to the hospital service, is really the most reasonable system.

As I indicated at the beginning of my speech, this service is one about which any of us can talk at great length. I have pointed to the main principles which we hope will be accepted by the House so that we may go forward. We have set our hand to a great task, which calls for courage and which calls for patience and broad vision in many quarters. We ask for the support of the House, because we believe that the day when we bring this plan to fruition will be a day long to be remembered for good in the history of the British people.

Mr. Gallacher (Fife, West)

Before the Minister sits down may I ask him to arrange for something to be said about the remuneration of doctors and nurses who are going into the public service? It is very important to do so, if the scheme is to be a success.

Sir Joseph Lamb (Stone)

Would the Minister at the same time say whether the areas to be served by the joint committee will be the same for general hospitals and for special hospitals or whether the general hospitals have another scheme for collaboration with special hospitals in a larger area?

Mr. Willink

There will probably be two or three services in which there will be fewer centres in the country than the number of hospital areas. I think of cancer treatment and neuro-surgery, in which probably the centre will be linked with a university or teaching hospital. Apart from very specialised services of that kind, it is hoped that the areas will cover all hospital services.

Sir J. Lamb

Thank you.

Sir Ernest Graham-Little (London University)

I propose to try to represent the views of the medical profession, and I suppose that my selection to speak now has been determined for reasons which I shall give in a moment. I have been for 30 years on the honorary staff of a great London teaching hospital and for 20 years I have represented in this House the University that has, by far, the largest medical faculty of any university in the world. I very much wish that a more persuasive person than myself had been chosen, but I shall do my best to give the House some idea of the feelings of the medical profession in regard to these proposals.

I may say that, in January, 1941, when there was a prospect of planning for future medical service by the British Medical Association, I asked the Prime Minister not to let that question he decided by a private body, but to appoint a Royal Commission which would take evidence from all sections of the community concerned with health services. I submit that that would have been a very much more sensible course to take, and might have resulted, if it had been appointed three years ago, in the accumulation of much more positive evidence than we have now on how these services should be carried out. The Minister has made a statement in which he said that professional people "know their business best," but I think it is a fact that they have never been consulted in the preparation of this scheme. May I give some facts which support that contention? The Beveridge Report appeared in December, 1942. In March, 1943, the then Minister of Health invited some very prominent medical organisations, chiefly centred in London, to draw up some plans of their own. That body was called the Representative Committee of the Medical Profession. It was met by the Minister of Health in March, 1943, and the Committee were told in the very first session what had been decided. I have here the words reported as having been used.

Mr. Willink

I am sorry to interrupt the hon. Member but I think it should be stated that there is no doubt that all the talks that took place between my predecessor and his officials, on the one hand, and the representative body on the other, were expressly on a confidential basis.

Sir E. Graham-Little

That makes it much more difficult. Conversations did take place, and the result of them appeared in the Press. On 12th March of that year "The Times" said that the medical profession must recognise that a settlement of the future of medical practice had been reached. In September of that year, the chairman of one of the larger committees of the B.M.A. came to a specially convened meeting of the profession in London, and gave us information which he authorised me to put into a letter in "The Times." It was published in "The Times," and the statement ran: Negotiations must be based on the acceptance of the decision by the Cabinet, that a single unified health service, covering 100 per cent. of the population, would be instituted, and that local administration would be in the hands of local authorities and under the ultimate control of a Minister who would be responsible to Parliament. At the same meeting, as subsequently reported in the medical Press, the Minister off his own bat informed the Representative Committee that it was proposed to secure control of the medical profession, "in order to keep a firm hand on the issue of sertificates", and it was stressed in the Beveridge Report that strict certification would be necessary, in order to shorten the period of benefit on the scales contemplated. I submit that the proposals in the White Paper follow, essentially, the pattern of that "decision" of the Cabinet as announced. It was accepted as being the basis that would be followed in subsequent procedure. Therefore, I contend that these present proposals are essentially the same as those which have been before the profession and the public for at least a year.

What has happened during that year? In a recent answer to a question by myself the Prime Minister declared that the issue whether proposals are controversial would be best tested by Debate in the House of Commons. I am sorry that I have to contest the validity of that suggestion. Can a two days' Debate in the House of Commons, in the turmoil of political activity, when the Government are very strongly entrenched, with little opposition, and with the pressure that can be exercised by the Whips and all the other paraphernalia of Procedure, be regarded as a better index to public opinion than the free Press of this country, lay and medical? I think that contention would not be accepted in a free democracy. Therefore I hope the matter will go beyond a Debate in this House and that the question will be decided by a wider circle. May I put the matter from the angle of the medical profession? Surely it is impossible to work a scheme, if those who operate it are intensely resentful of the conditions imposed upon them.

Dr. Summerskill

The hon. Member claims that he represents the views of the medical profession. I belong to the medical profession, but I do not agree with his views. Would he substitute "a small section of the medical profession"?

Dr. Russell Thomas (Southampton)

The vast majority.

Sir E. Graham-Little

I would say that less than 10 per cent. of those who would be asked to work this scheme are in favour of it. Several quite notable events have taken place supporting this statement; I would ask the House to realise that the authentic voice of the medical profession is somewhat difficult to ascertain. The medical profession is divided, roughly, into three sections—general practitioners, consultants and those in the public service. The large majority of the profession are to be found in the general practitioner section. Figures have been given to me that suggest the proportion to be something between 60 per cent. and 70 per cent. Clearly, that section is much the most important in the operation of any scheme, and without their co-operation, any scheme that we could devise would be merely beating the air. If the present scheme cannot be operated, the Government are wasting the time of the country and of the House of Commons. Let me recall what has happened. On 16th May, 1943, there was a very big mass meeting, with an attendance of doctors of over 1,000.

Mr. Mathers (Linlithgow)

What proportion did that represent of those who were entitled to attend?

Dr. Summerskill

About one-seventieth.

Sir E. Graham-Little

A sufficient number attended to constitute a trend which we cannot mistake—

Mr. Mathers

The hon. Member seems to misunderstand me. I was asking, purely for information, what proportion this mass meeting represented of the medical profession for whom he is speaking? I am not versed in this. I do not know anyone concerned.

Sir E. Graham-Little

It has been estimated, and this is an official estimate, that there are 50,000 doctors who are actively engaged in practice. The total on the Register is 70,000 but many of them are not practising. About half of these general practitioners at the present time are serving in this country and half abroad. With half the profession engaged in war service of some kind, the other half are desperately overworked, and for them to have come along to this meeting, as they did, is a very remarkable thing. I submit it is a very significant trend, in the statistical sense of that word. That was in May, and throughout that year there were cities and large areas in the country which made their views known—Sheffield, Manchester, Birmingham, Worcester and a number of local divisions. Questionnaires were taken covering the practitioners in the area, that is, doctors actually practising and not on the shelf. These questionnaires seeking the opinion of those persons upon the proposals which were laid before the profession, showed a very remarkable result. Over 90 per cent.—the percentage ranged from 90 to 95—of the answers, representing a cross-section of the district, were against the proposals which involved lay control of the medical profession. The answers were especially against the control suggested by the Minister, that is by the local authority, which is to be especially strict in relation to general practitioners.

A little later that year the British Medical Association gave an opportunity to general practitioners to express their views on this particular suggestion of control. This opportunity was given through the Representative Body of the Association, which meets once a year. Those who are not familiar with the British Medical Association should know that decisions in the name of the Association are largely voiced by a council which corresponds roughly to a Cabinet, but the rank and file of the profession are represented much more effectively by what is know as the Representative Body. It is the resolutions of the Representative Body, which really indicate the reaction of the profession—resolutions reached often in spite of the extreme difficulty of making an agenda which was open and fair. In spite of the control exercised in restraining the exuberance of that meeting, the result of the meeting in September, 1943, was an explosive rejection of one of the principal items which is now proposed, that is the reduction of the profession to a salaried medical service. That is what this proposal must eventually come to. The voting was extraordinary—200 against 10—and the meeting consisted of seven-eighths of the whole of the Representative Body. Any more conclusive evidence of the opinion of the general practitioners' section could, I think, hardly be suggested. A still more recent questionnaire has been sent out to 30,000 medical practitioners in this country in active practice and the result has been 70 per cent. opposition to this control.

Mr. Willink

The hon. Member says "opposition to this control." What control?

Sir E. Graham-Little

To lay control by a central authority.

Dr. Summerskill

How is the vote of 200 doctors representative of 70,000?

Sir E. Graham-Little

These are chosen representatives of the members of the B.M.A. They are elected, and it is a very democratic election.

Mr. Alexander Walkden (Bristol, South)

Were they selected or elected?

Sir E. Graham-Little

Elected.

Dr. Summerskill

If the hon. Member says that this body is representative, why is this questionnaire sent to all doctors asking for their views, in order to show what is the view of the medical profession?

Sir E. Graham-Little

I think that is a sensible procedure. The House knows very little indeed about what is happening in the profession. Surely it is right, at any rate it is wise, to let the House know as far as possible the opinion which has been voiced outside?

Dr. Summerskill

I agree with that, but how can the hon. Member say that a decision has been arrived at, when the doctors are still being asked for their views?

Sir E. Graham-Little

I said that the decision which was taken at the meeting was a resolution passed by the meeting, a very definite resolution, and it was passed by that majority by a body representative of the members of that Association.

Dr. Morgan (Rochdale)

I am sorry to interrupt the hon. Member, but I happen to be a member of the Council of the British Medical Association, and while I realise that it has a very democratic constitution indeed, and does represent the profession, I want to say quite frankly that the hon. Member is misleading the House as to the actions that are being taken. I was at the meeting of the Representative Body, and I know how the vote was taken and the circumstances in which it was taken. It was representative of the profession, but this questionnaire deals with an entirely different matter—not policy or principles but details of the scheme. I was present at a meeting of the Council of the British Medical Association last week, at which the issue of this questionnaire was decided. It deals with details of the scheme, not questions of policy and principles.

Sir E. Graham-Little

I should like to take up that point. I have been informed authoritatively that the British Medical Association is proposing, at long last, to consult the members of the Association who are serving overseas. There was an announcement last night in one of the evening papers about five tons of paper being dispatched. That representated the document. It is a document of several pages with 28 different questions each with Sub-sections, and I think it will be exceedingly difficult for any serving officer to master that accumulation of questions with any sort of due consideration. With regard to the Council of the Association, I am glad that the hon. Member has raised that. In an answer I received a few weeks ago, I was informed that the Council of the Association since October, 1940, has delegated its duties for the most part to an executive committee, which is a very small body consisting of the higher officials of the British Medical Association. It has the least democratic origin I can imagine. I want to insist on the difference between the two voices in the British Medical Association, the voice of the Executive Committee and the voice of the bodies representing the rank and file.

I wish to deal with some of the points made by the Minister. He said at the beginning of his speech that 27 per cent. of the health services are to come from the Insurance Fund, that the Insurance Fund will furnish, roughly, a quarter of the expenditure on health services. The chairman of the National Municipal Councils Association, speaking about what would be put on the local authorities if these proposals came into force, told me that a rate of at least two shillings in the pound would be required to meet that expenditure, and that would have to be met by the local authority. He added that obviously he could not put upon his local ratepayers expenditure of that nature without having a very strong control of the personnel who were practising under that authority. Further contributions have to come from the taxpayer—£48,000,000–36 per cent.—from the taxpayer and £48,000,000–36 per cent.—from the ratepayer. So that what seems to me probable is that the insured person is being "sold a pup." He thinks he is to get something for nothing, or that he is to get a shilling for threepence—the slogan used to be ninepence for fourpence but we have gone a little better and it is now a "shilling for threepence." But most citizens of this country are either ratepayers or taxpayers, or both, and the individual expenditure that has to be faced will be much more considerable than the sum representated by the Insurance contribution. That, I think, has never been sufficiently explained.

I would like to say a word to the Minister about the health centres. I admit that that was a proposal which originated in the Interim Report of the Planning Commission of the British Medical Association. They are not quite so much in love with that idea now as they were then. In the last issue of the "British Medical Journal," for 11th March, there is a rather hesitating suggestion that the health centres have been devised really to put the medical practitioners into the service, and to make it a salaried service. But let us take it on its merits. The health centre is supposed to be an entirely new idea. It has very attractive features, as set out by the very competent salesmen who have been putting the idea over. But is it at all possible for there to be a free choice of doctors with the institution of the health centre?

I cannot myself see that possibility, and it has been questioned by more authoritative persons than myself, including a very prominent Socialist practitioner, in a recent book. He derides the desire of the average patient to choose his doctor or that he should have the same doctor throughout his illness. He would approve of the suggestion that the doctor in any town should have a beat, like the postman, the policeman, and the dustman, that one doctor should be assigned to all the houses in one area. That is an idea which is not, I think, welcomed either by the medical profession or by the private patients. The health centre idea is not a new one. We have had, for a very long time in this country an admirable series of cottage hospitals. They have been based on the idea of team work. The cottage hospital is staffed by a team of local practitioners. They meet and consult each other and that is valuable. But where is the infusion of specialist assistance to come from in the new Centre. The prospect of a number of specialists which is held out in connection with these centres is illusory. Yet it is one of the essential features of the scheme. I do not see the average health centre having the run of a number of specialists in anything like the profusion which is suggested here.

The Minister said that there would be no difficulty about keeping on private practice, that the public and private practice would go on side by side, and that those who did not want to do public work would be quite at liberty to decline to do so. But, as I understand the suggestion, which was repeated to-day, every new entrant into the profession would be required to serve an apprenticeship in the public service as a condition of being taken into this new universal service.

Mr. Willink

With exceptions.

Sir E. Graham-Little

I imagine that that would be a vanishing point. The Beveridge Report is much more frank, much more honest I would say, than some of the proposals we have had to-day; for it pointed out, quite definitely, in one of the paragraphs of that Report that the scope for private practice, with a universal service, must be so restricted as to be practically not worth while retaining. Can the Minister contend that the prospect of any worth while measure of private practice surviving is hopeful? I think not. I think it is quite impossible to suggest the contrary. I would like to deal, for a moment, with the question of control. It is expressly stated, in a very ominous sentence, that the control of the general practitioner would be much stricter than that of any oher section. One does not quite know the extent of this control but it is at any rate certain that the control of the general practitioner will be much more complete than it is at present, and than it will be of other sections. The Minister said that there will be no direction of the general practitioner to work by whatever body is set up to control these activities. A few weeks ago I was approached by one of my constituents, a young doctor who is medical officer to a hospital in Kent. He had an invitation to go to Dumfries, which is his home town, to take charge of a larger hospital there, with very much better remuneration. He applied for permission from the Minister of Health, and permission was refused, because, it was said, it would be very inconvenient to replace him at his present hospital. When asked by me on what authority he thus interfered with the liberty of a private medical practitioner in that way, the Minister quoted Defence Regulations. Is that the type of direction which is going to be perpetuated in future, merely a continuation of what is done under those Regulations now?

I want to say a word about the hospitals. There I am on my own ground, because I have been in intimate association with a great voluntary hospital, first as a student, and then as a teacher, and again as head of one of its departments, for over 40 years. What is the fate of the voluntary hospitals to be under the present proposals? The Minister said that every effort would be made to maintain them, but he went on to say that the contributory schemes would no longer continue. Let me tell hon. Members what that scheme means to the hospital. It means very much more than the payment of certain sums. I do not suppose that this House realises what the development of the voluntary hospitals system of medical treatment has meant in recent years. It has become a great co-operative system of medical service, widely appreciated by the public.

Some years ago Lord Iliffe, then Member for Coventry in this House, asked me to go to Coventry to give an address on voluntary hospitals. There were two hospitals in Coventry, one voluntary hospital and one municipal hospital. The meeting at the voluntary hospital attracted great interest; the whale place buzzed with excitement. The chairman of the hospital was the managing director of the largest motor firm in Coventry. The Mayor of Coventry was, I think, the chairman of the municipal hospital. He was in the audience, and Lord Iliffe—Mr. Iliffe as he then was—said, "Now, I think your hospital will have to be abolished long before mine." I mention that to show you what is behind these contributory schemes. [HON. MEMBERS: "What is behind them?"] The interest of those who take advantage of the service, and the interest of the hospitals themselves. Many Members of this House are members of hospital boards, and I feel sure they will know much more about the conditions of voluntary hospitals than about the conditions of practice. I hope for more support from the general body of Members on this point than on technical details of medical practice. I quite admit that much advance has been made with the public hospitals since the Local Government Act, 1929. But the voluntary hospital and the municipal hospital has been side by side for centuries and a very interesting account of the different developments of the two systems is given by Dr. Daley, the present chief medical officer to the London County Council. He points out that 400 years ago a divergence took place. One section became the voluntary hospitals, and the other became the poor law infirmaries, asylums for the sick. From the latter the public hospitals have sprung. As a rule the voluntary hospital is very much more popular with every section of the community than the municipal hospital. I will mention an example which has been told me concerning the father of the hon. Lady the Member for West Fulham (Dr. Summerskill).

Dr. Summerskill

As my father died very recently, I would be very much obliged if the hon. Member would not take his name as an illustration. Would he mind quoting somebody else?

Dr. Haden Guest (Islington, North)

May I urge, in the name of good taste and common decency, that this matter should not be pursued?

Mr. Mathers

What is the point of mentioning the name at all?

Sir E. Graham-Little

My point is that the most robust advocates of the public hospitals when it comes to a choice for themselves between voluntary and public hospitals, commonly choose the former. That is a point which I think is worth mentioning. Why is it that the voluntary hospital, on the whole, is more generally liked by patients? There are several reasons. One is that the staff of the voluntary hospital is very much larger than the staff of any public hospital; although the position of some of the largest L.C.C. hospitals compares with that of general hospitals in London, the proportion of staff to patients remains much larger at the voluntary hospital, the comparison being about 10 per cent. at the voluntary, 1 per cent. at the public hospital. The services of the honorary physicians and surgeons at a voluntary hospital are given without charge.

Dr. Morgan

They get it all right in other ways.

Sir E. Graham-Little

The hospital is not put to any expense to provide these physicians and surgeons.

Dr. Morgan

Yes, but they get paid in other ways.

Mr. Deputy-Speaker (Major Milner)

Will hon. Members kindly address their, observations to the Chair.

Sir E. Graham-Little

The services of highly skilled physicians and surgeons are very much in demand at these hospitals. The present Home Secretary, two years ago or less than that, said—that when he was leader of the London County Council—it was suggested that the L.C.C. should take over the voluntary hospitals in London, that he did not cotton on to the idea because it would have meant a rate of 1s. 6d. in the £, if the honorary staff were paid. The public have a very exaggerated idea of the "profits" of a consulting practice. Some spectacular figures of fortunes made in medicine appear in the papers from time to time, but they are earned chiefly by operating surgeons, forming a very small group, and they give people the idea that this is the rule. Now let me ask the Minister what provision is to be made for the body of consultants who will be required, and what plans he has to attract them to this scheme? It is a very arduous and difficult section of the profession to follow, but it is attractive to a small section of the profession precisely because it offers opportunities for medical research and advancement, and it also offers a certain measure of leisure and interesting work in a hospital where there is a centre of research. Why should these hospitals be centres of research? It is because there is a very large percentage of surgeons and physicians extremely interested in their work and able and willing to give far more time than would be possible if this were not the case. What will happen to this large body of consultants, and under what conditions are they going to work? We know that the general practitioners are going to be under the very definite and very strict rule of the Central Medical Board, and some of the conditions of employment I have already mentioned. I think the conditions will not be denied by the Minister. But what is going to happen with regard to consultants? I understand that there is a Motion to be moved in another place regretting that more attention has not been paid defining in the White Paper the conditions under which the consultant is called upon to work. I should like to pursue this trail but I think I must now sit down and I thank the House for the patience with which they have listened to me.

Dr. Haden Guest (Islington, North)

I am sure the House has listened with some surprise to certain of the statements of the hon. Member who has just spoken. I feel justified in saying that, speaking as a medical Member of Parliament, I may perhaps be allowed to speak in that capacity here. I do not claim to represent the whole of the medical profession, but I entirely deny my hon. Friend's claim to represent any large part of it. Let me say quite definitely; so that this can be taken down and if necessary checked, that the hon. Gentleman does not represent the views of the British Medical Association. I do not pretend to agree with them entirely, but the hon. Member does not represent them, and, in fact, I do not know any section of the profession for whom he can claim to speak with authority. I feel obliged to say that, because of the nature of some of his remarks, which I think have been very painful for anyone who belongs to the profession of medicine, as well as for others. The hon. Gentleman used some extraordinary phrases, from which we may get an insight to his psychology. He speaks of the health centres being in charge of a competent salesman who has to "put the idea over." I do not know whether that is intended to refer to the Minister of Health.

Sir E. Graham-Little

That is not what I said. I said the idea was in the hands of a competent salesman.

Dr. Guest

That commercial phraseology does not seem to be applicable to this subject.

Dr. Russell Thomas

It is very true.

Dr. Guest

The party has increased, I see, by two. The hon. Member asked, "Can there be free choice of doctors in a health centre?" Well, I do not think there is any doubt, in the main, that most medical persons, and members of the British Medical Association and others, would agree that there can be as free a choice at a health centre as there is else- where, but I must correct the hon. Member in one remark he made. He said that Socialists, meaning Members of the Socialist Medical Association, say that one doctor is as good as another, and he has some idea of a doctor being on a beat, like a policeman, or a dustman. Really, what that means I find it very difficult to understand, but I can assure the hon. Gentleman that it is not the opinion of the Socialist Medical Association.

Sir E. Graham-Little

This proposal was made by a Vice-President of the Socialist Medical Association.

Dr. Guest

The hon. Member also said that this scheme now to be brought forward by the Government was a desire to secure control of the medical profession in order to secure control of certification. In my most bitter moments of opposition to the Government, I have never thought that they had sunk as low as that, and I am perfectly convinced that the ideas now put forward in this White Paper are acceptable, in their main outlines, to a large proportion of the medical profession. They are a reasonable basis, which those of us who have different views as to how the medical profession, hospital services, public health services and everything that has to do with health services, should be organised can discuss. I believe the White Paper is a reasonable basis for discussion—

Dr. Russell Thomas

Of course, the hon. Member does.

Dr. Guest

If one indulges in the kind of criticisms in which the hon. Gentleman who has just spoken has been indulging, I do not think we shall get very far, because we must look forward, and I think it is pretty plain that the hon. Gentleman is engaged in constantly looking backward, and that is no way to get on. Let me take one example. It is not my business to defend the Ministry of Health, but I cannot refrain from taking up one statement about voluntary hospitals. The hon. Gentleman said they would be killed, or seriously prejudiced, if the contributory system of contributions ceased to exist. The Minister has clearly pointed out that, while in the last normal year, 1938, there was an amount of £5,300,000 received from contributions, the equivalent Exchequer payment to the voluntary hospitals under the scheme suggested in the White Paper would be in the nature of £6,500,000.

Mr. Craik Henderson (Leeds, North-East)

Will the hon. Member also admit that, according to the figures, between 1930 and the present time, there has been an increase in hospital costs of 50 per cent.?

Dr. Guest

The point of the Minister's figures was the comparison, and I hope we shall find the Minister just as reasonable when we came to consider things in the future. But the point is the comparison, which remains. I do not want to take up the point, except to indicate that it is quite unreasonable to suggest that that is going to destroy voluntary hospitals. The hon. Gentleman who has just spoken did not really begin to consider the main and very important problems of the health services of the future, because he was not looking at them in, if I may say so, a reasonable way and with a balanced mind. What we have really to consider is whether the proposals in the White Paper give the opportunity to Parliament and to the country to bring into existence a comprehensive health service which will be what so many doctors, belonging to all kinds of parties, have longed for. This is a service which shall place the great scientific knowledge of the medical profession and its auxiliaries at the service of the community fully and completely, without any question at all of money consideration.

That is what we want to do. We want to do that among the general practitioners. It is proposed in the White Paper that there shall be health centres, with groups of doctors working together, and also private practitioners. It is as certain as anything can be that of the thousands of doctors who will come back to this country after the war from the Services—where they have been paid salaries and employed in a service doing invaluable work, as they are doing at the moment—many will feel most drawn to the health centres and will be willing to work in the group practice. That is the kind of thing that they have been doing, on the field of battle and in regions close to the field of battle where the sick and wounded are attended, that and their work has made an enormous difference to our sick casualties and our casualties from wounds in the present war. Those lessons which have been learnt in war-time will be brought back and used for the benefit of the civil population. But there are many thousands of those doctors and some, perhaps, will desire to become private practitioners.

I would like to see this House take a decision that the duration of the commercial side of private practice should he definitely limited. I do not expect that you can transform overnight the very diverse and very numerous services and institutions in this country from their present basis, into a unified and comprehensive medical service of a complete kind. That you cannot do. The process is bound to take a period of years. The Government, in their White Paper, are proposing that private practice shall be allowed to go on side by side with the health services' practice, the man in private practice being remunerated on a capitation basis and the man at the health centre on a basis of salary. Perhaps the Minister who is to reply will let us know whether those private practices which are to be set up in the future—not those already set up —will be saleable practices or not. I think we would say on this side that, if they are to be saleable—I hope they will not—the period during which that commercial element in practice should continue should be limited as much as possible. I am not one of the younger doctors now, but I think I can speak for my younger colleagues in the medical profession when I say that the majority of the profession would like to see the commercial element quite out of it.

Sir Robert Tasker (Holborn)

Will the hon. Gentleman say whether he wants State control of all doctors and the elimination of private practice?

Dr. Guest

I want, ultimately, every doctor and every nursing service and hospital in the country to be a combination of service to the State and to the nation, with the retention of the principle of voluntary initiative in certain ways, which I will proceed to indicate. There are some new ideas possibly in some of these things other than mere Civil Service regimentation, and I have no hesitation in saying that.

I want to say something about the voluntary hospitals. I believe the voluntary hospitals, in which all doctors at the present time are educated, and for which all doctors have an affection, will be able to continue to exist, if they wish to do so, and they have before them, at this time, the greatest opportunity of service that they have ever had. May I remind the House—perhaps every one in the House does not know this—that during this war we have had a system inaugurated in London and in other parts of the country under which voluntary and municipal hospitals, and indeed, all kinds of hospitals, have been put into groups as an emergency medical service. The emergency medical service has meant the getting of all hospitals grouped together as constituting something like the kind of service that, on the general lines of organisation, we may get at the end of the war. In that grouping the voluntary hospitals have taken a most important part.

If the voluntary hospitals were foolish enough to say that they would stand out from this White Paper scheme of a unified hospital service in areas and in regions, and would have nothing to do with the State and with the local authority, then their power, influence and authority would dwindle away. But if Guy's Hospital, Bart's. Hospital and the London Hospital and other great hospitals in London, and the hospitals in Scotland, and the hospitals in Birmingham, and many of the great voluntary institutions in this country are wise they will say, "We will join this regional grouping of hospitals; we will give to that regional grouping everything that we have that is good to give in the way of scientific knowledge, our consultants, our apparatus, everything we have we will pool for the general improvement of the hospital system." In many parts of the country the hospital systems, apart from voluntary hospitals, are very bad. In London, since 1929, very great improvements have been made in the hospitals under public control and many of them are not only very good, but first-class and, in some respects, leading the way. The chief post-graduate research hospital in London is a London County Council institution, the Hospital in Ducane Road. There we have in vague outline an indication of how great a thing this future hospital service can be.

I have the privilege of working frequently with leaders of the main London teaching hospitals and I know the minds of some of them. I feel convinced that they will be willing to throw their weight, their authority and their tremendous capacity into this unified hospital system. Doctors and those associated with hospitals are concerned, of course, about a large number of the details of this plan. The hon. Member for London University (Sir E. Graham-Little) referred to certain documents of the British Medical Association but he did not, I am afraid, give a fair interpretation of the attitude of that association to the White Paper. I believe that a good many Members of the House have in their hands a copy of the document from the British Medical Association described as "The White Paper Analysis," and other Members can certainly get it, if they wish to do so. They will find there that the British Medical Association—for which I do not speak and with which, I wish to say again, I do not entirely agree—agrees to a very large extent with the White Paper, and that it is in matters of detail, though not only in matters of detail, that the British Medical Association disagrees.

There are some rather fundamental points, in the opinion of the Association, with which they disagree, but they are not the points to which attention was drawn by the hon. Member. If Members wish to acquaint themselves with what the British Medical Association really believes, they had better consult the papers to be obtained from the British Medical Association and not the report in HANSARD of the speech of the hon. Member.

I appeal to the House and to the whole medical profession in this country to put themselves, not behind every detail, but behind the spirit of these new proposals for a unified and comprehensive medical service. Those of us who are doctors, Heaven knows, have felt frustrated many a time in our work by the misery and poverty all around us, and by the fact that we have not had the tools with which to work and have not had the hospital facilities when we wanted them and have not been able to call in consultants. Here we have a scheme that provides a great future for every man and woman who enters the great profession to which I am very proud to belong. In this provision we have the organisation of the hospitals altogether into one service for the community as a whole; and in the hospitals also we want to see that no commercialism remains.

I am told that some hospitals are contemplating that they will continue their pay wards for patients, which means that you will have two standards of treatment in the hospitals—the treatment that you get when you pay in private wards or the standard of treatment you get when you go into the wards without payment. It is no good telling me as a doctor that there would be the same standard and the same kind of treatment. If one ward is being paid for and another ward is not, there will be differences of some kind; and even if there were not any differences, except perhaps in the quality of the mattresses and the cutlery and perhaps the quality of the food, we want to have no differences at all. There should be one standard of hospital treatment, and that standard the best treatment that we know how to produce. That could not happen at the present time.

I will not emulate the hon. Gentleman the Member for London University by speaking for a much longer time but I can say that, although many of us disagree on some of the points of this scheme, we realise that a completely new scheme of the kind of which some of us have dreamed, and which we would like to see in operation, cannot be brought into operation immediately. We see here in the scheme before us that the hospitals are being organised, that the medical profession is getting organised and all the other services will be organised in such a way as to enable the new structure to grow out of the old. If we put a time limit to the existence of the commercial factor in medicine as regards the purchase and sale of practices, and there is no question of pay wards in hospitals, or anything else which introduces a difference between one man and another according to how much one can afford to pay for medical attention or for nursing services —if we do that, then I am confident that, whatever else is put to the credit of this Government in the future, when historians look back they will see, in this period, a great development of the medical and health services of this country putting Great Britain in the forefront of the world in that respect.

Mr. Craik Henderson (Leeds, North-Fast)

The hon. Member for North Islington (Dr. Haden Guest) has, as usual, expressed his views with vigour and clarity, but I was slightly puzzled by his constant use of the word "commercial" in reference to his own profession. I thought the expression was ill-advised and unjustified. If he meant that the man of outstanding ability who had spent a long time in acquiring medical knowledge, and was prepared to devote long hours to his profession, might get better pay than the less efficient, less able, and less energetic doctor, I hope that that form of commercialism will continue. I prefer that type of commercial doctor to one who will be an office man working office hours, from 9.30 to 5.0 with a fixed salary which depends not at all upon his ability but merely on a question of seniority.

Dr. Guest

May I explain to my hon. Friend that I was referring very largely to the buying and selling of practices, and to the whole apparatus by which the rich can get better medical treatment at present than the poor.

Mr. Craik Henderson

I am glad to have the hon. Member's explanation. The proposals in the White Paper are very important indeed and I am sure we shall all want to approach them in the most objective way possible. This is, perhaps, the best example we can get of the House being given an opportunity to frame and assist the Government in carrying through far-reaching proposals. It has been said that democracy is government by discussion, and surely we can have no better example than an occasion such as this, when the House is given an opportunity to put forward individual views. I hope we shall do so with open minds, and I hope and believe that the Government will listen to what is said with an equally open mind, anxious to evolve the best system possible. I think, however, that there is some justification for a mild protest that there has not been a little longer time between the publication of the White Paper and the present, for the views of the medical profession, the voluntary hospitals, and the general public to be ascertained and made known. It seems to me, that with a large proportion of the medical profession fighting in Italy, in Burma, and all over the world, these men should have an opportunity of making their views known to hon. Members and this House. There is no doubt that the Government have had years to consider this matter, but voluntary hospitals and the medical profession are asked, in a few weeks, to apply their minds to these very far-reaching proposals.

In the White Paper there is one phrase which we on this side welcome. At the foot of page 8 it is stated: Organisation is needed to ensure that the service is there, that it is there for all, and that it is a good service; but organisation must be seen as the means, and never for one moment as the end. These are very wise words and I hope, though I am not quite convinced, that the White Paper has been compiled in conformity with these views. Nothing would be worse to my mind, when you get into this realm of endeavour and of research, of planning, and of intellect than to reduce everything to standardisation, uniformity and regimentation. If that is done, it certainly will not be to the advantage of medical research and medical advance. I think we all agree that much as has been done by organisation, vastly more has been done by the discoveries of individual men. This is a profession where science advances by the endeavours of the individual. I think there is no question that the discovery of chloroform, of antiseptic and aseptic treatments, the discovery of the new group of drugs of which "M and B" is the best known, and of penicillin have done more for the health of the community than all that organisation could possibly do. That does not mean for one moment that we should not, at the same time, endeavour to build up the very best possible organisation we can, but we should never forget that medical science will be advanced by the efforts of the individual and that, in the last resort, a good health service depends upon the skill of the individual. I do not think anyone would dispute that.

What are the essentials of a good health service? I think it is sometimes well to get away from merely looking at the machinery and to consider for a moment what are the essentials. Of course, one of the first must be to attract to the profession men of ability who are prepared to go out and work hard for the benefit of the patient and with a desire to advance knowledge.

Mr. A. Edwards (Middlesbrough, East)

The hon. Member asked a few moments ago for the highest rate of pay for the men who made the greatest efforts. He has just said that the men who have really made the greatest contribution are those who have made discoveries. Is he suggesting that these are the men who got the greatest amount of money?

Mr. G. Griffiths

What about Banting?

Mr. Craik Henderson

If my hon. Friend will allow me to reply, these people who have made great discoveries have got their reward in the thanks and in the esteem of the general public. I suggest to my hon. Friend that these discoveries could not have been made by a man in an office serving under someone else. They could only be made by the individual working by himself.

Dr. Russell Thomas

Whose soul is free.

Mr. Craik Henderson

Whose soul is free, and whose time is also free to work out a theory for himself.

Mr. Driberg (Maldon)

Has the hon. Member heard of the very remarkable results achieved by research scientists in the Soviet Union, where medicine is completely socialised?

Mr. Craik Henderson

I have heard of certain results achieved in the Soviet Union, but my hon. Friend makes a great mistake if he imagines that the Soviet Union regard people as equal. [HON. MEMBERS: "We did not say so."] That was their original idea, and they had to give it up early on. But I do not want to be drawn into a discussion of that kind. The point I am making is that if we are to get a really efficient medical service, we must attract to the profession the ablest men we can possibly get. There will be no dispute about that. However my hon. Friends on the other side may not agree when I go on to say that if the idea is that the State service is to be, as my hon. Friend the Member for North Islington has said, entirely a State-controlled service with private practice eliminated, that will turn away from the profession many men who otherwise would have entered it.

Dr. Guest

May I ask whether regular naval service and regular Army service turned away men from those Services?

Mr. Craik Henderson

That is not a fair comparison. I really must not be interrupted at every turn, though I am willing to give way a certain amount. The next important thing is that we must have the highest standard of teaching and training in the profession. That, again, is essential in order to build up the health service required. There must be every encouragement for research. One point with which I was rather disappointed in the White Paper has been cleared up by my right hon. and learned Friend, and I was very grateful to hear him say so. I was rather disappointed to find in the White Paper no reference to district nursing. If there was one I overlooked it. To-day, my right hon. and learned Friend paid a tribute to the district nursing, and promised that every effort would be made to extend home nursing. I believe that an enormous work has been done by the district nurses, who are quite insufficient in number, and that this side of the work must be vastly increased. It is not always possible or desirable for the working man or woman, when it is not a case of critical illness, to go off to hospital; there are the claims of the children, and so on, and they are unwilling to go. I am sure that nothing would do more for the health of the community than a great and well-planned development of home nursing. I was, therefore, relieved to hear the Minister say that he had that very much in mind.

Dr. Guest

As a salaried service?

Mr. G. Griffiths

The hon. Member wants it under private enterprise.

Mr. Craik Henderson

I really think my hon. Friend should refrain from being facetious. If the House cannot treat this matter seriously then it is a reflection on the House. I want to say a few words about the subject, in which I am, perhaps, most interested—

Mr. G. Griffiths

May I put this point? The hon. Member has been talking about the nursing association. I have been the chairman of a private nursing association for 25 years. We have discussed this question three or four times, and what we are perturbed about is the pennies and halfpennies we have been collecting. The White Paper states that it is hoped that the voluntary nursing association will accept salaries, and so forth. They hope that, but I want to say "Give us the money and let us pay the salary," What is the 'idea of the hon. Member on that?

Mr. Craik Henderson

I have finished with that special matter and the hon. Member will make his own speech. I do not care what the system is, provided it is an efficient one which will give the required service to the community. Now, with regard to the voluntary hospitals. I think the House is well aware of the services which the voluntary hospitals are rendering to the community. I believe the supply of beds, according to the last figures available, was approximately 100,000. Their income in the last year for which the figures are available was, I think, £17,000,000. The number of inpatients was about 1,400,000 and the number of out-patients over 6,000,000. Nobody would dispute that the voluntary hospitals, which are also the teaching hospitals in the majority of cases, are the keystone of the hospital system. Nobody who is reasonable would deny that, generally speaking, the voluntary hospitals are the most efficient and the most popular with the general public.

I want to talk quietly and persuasively about this matter. I do not want to get into controversy with hon. Members opposite, because I know that many of their constituents have the same view. Voluntary hospitals owe a great deal to the support they get from workers' committees and to working men and women on the committees. Nobody can pay too great a tribute to the personal interest which is taken in the voluntary hospitals and I am sure that no party in the House wants them to be prejudiced. They have rendered great services in the past and are capable of rendering still greater service in the future. This enormous system has been built up over the last 250 years. Before the 18th century I think there were only two hospitals—St. Bartholomew's and St. Thomas's. I have no idea of the value of all the hospitals in the voluntary system amounts to but it must be many millions — probably £l00,000,000 or £200,000,000, including their up-to-date equipment and appliances. Also, the voluntary hospitals have endowments amounting to a large sum of money. The White Paper admits that the voluntary hospital system is essential to this scheme in the immediate years.

How is it proposed to deal with the voluntary hospitals? The bodies which will be concerned are, principally, three in number. There will be the Ministry of Health and there will be a Central Health Committee, which is an important Committee, but on which the voluntary hospitals, presumably, will have comparatively small representation. Even those which are represented will not be nominated by the voluntary hospitals themselves but will be appointed by the Minister only after consultation. Surely, the great voluntary hospitals, bringing to the State this enormous advantage, by handing over assets worth hundreds of millions of pounds are entitled—

Mr. McNeil (Greenock)

Will the hon. Member explain what he means by, "handing over the assets to the State"?

Mr. Craik Henderson

I do not want to split hairs but it is directly stated in the White Paper that the joint authority shall have direct responsibility for all hospitals.

Mr. McNeil

Should they choose to come in.

Earl Winterton (Horsham and Worthing)

I am chairman of a hospital and I would like to point out to my hon. Friend that the White Paper does not mean that endowments of hospitals are to be handed over.

Mr. Craik Henderson

I am sorry if I have given a wrong impression. Of course, there is no question of them being handed over directly, but they are being put into the national scheme. The question is: Under what terms are they going into that scheme? I have read the White Paper two or three times with the greatest care. As I was saying, there would be a central authority under which voluntary hospitals will not have the right to nominate anyone; the Minister will appoint after consultation. That may be a small point, but it is important. Now we come to a very much more important point, the question of the joint authority which is entirely a body of public authorities. On page 17 of the White Paper it is stated: The new joint authority will, therefore, be charged to examine the general needs of the area from the point of view of the health service as a whole—not only in the hospital services for which it will itself be responsible but also in these more local services.

Dr. Morgan

That does not mean handing over.

Mr. Deputy-Speaker (Mr. Charles Williams)

If there are too many interruptions it will make the hon. Member's speech much longer.

Dr. Morgan

I have not interrupted very much.

Mr. Deputy-Speaker

It is not only a matter of one person interrupting; it is the number of interruptions that take time.

Mr. Craik Henderson

I would like to deal with the point of handing over. I do not mean handing over in a legal sense but in a sense which will be well understood. Under the scheme as a whole, you have a comprehensive health service, and into that all hospitals in the country must go. The few who want to stay outside might be turned into nursing homes, but the voluntary hospitals are going into the State scheme.

Mr. McNeil

I am sure they are, and on very generous terms.

Mr. Craik Henderson

What terms are to be offered? I have referred to the Central Health Council and now we come to the joint authority which is to be in control of the hospital services. The actual day-to-day management will be still left in the hands of the voluntary hospitals. What is this joint authority to be? It is to be the hospital owning body of the municipal hospitals. I do not think there can be any question that it is very unjust to ask the voluntary hospitals to come under such an authority and that all the power should be given to the body owning the alternative form of hospital service, where they have no direct representation on the hospital administration of the area—the joint authority—I suggest that is most unfair to the voluntary hospitals, and not to the advantage of the scheme as a whole.

I would like to make some constructive suggestions, some small but some probably more far-reaching. As regards the Central Health Council I think the Minister should agree that voluntary hospitals should have the right to nominate their own representatives to that body. It would be a great advantage, and would relieve the minds of those responsible for voluntary hospitals very much if there were set up a central hospital advisory committee which would consult with the Minister. This committee would contain representatives of the voluntary and State hospitals and it would be an advantage to bath to be in close association with the Minister and able to discuss problems with him at close quarters. I do not think there is any dispute between us on that point. It would do a great deal to relieve the anxiety of the Voluntary Hospitals' Association. I think there ought to be a district joint hospital committee or a local joint hospital committee for each area which, again, should contain representatives of the voluntary and State hospitals. That seems to be the only way in which you can have a partnership.

If these two system are to continue in friendly rivalry—as I hope they will—there should be a body in which they can meet to discuss common problems. If necessary there could be a neutral chairman. I am not sure how it is proposed that contributions should be made by the local authorities to the voluntary hospitals. It is not too clearly stated in the White Paper and personally—and in this I am speaking for no one but myself —I think there should be laid down clearly in the legislation which will be introduced the sum which must be paid by local authorities in respect of the number of beds in the voluntary hospitals in the particular areas. It should not be left to arrangements between various areas and various voluntary hospitals. I think that would be an unfortunate result which would lead to friction and would not give the voluntary hospitals a correct idea of what income they have to rely upon. It may be that it should be put into a special pool to be administered —that is a matter for discussion. I should like to see grants to voluntary hospitals administered very much in the way as the University Grants Committee deal with payments to a university. I think there ought to be something analagous to a University Grants Cornmitee—a Hospital Grants Committee. I hope the Minister will consider whether it is not possible to do something along that line.

I am sorry that some hon. Members above the Gangway have been led into controversy with me. I had no desire to do so. On this subject we are dealing with something of vital interest to the future and in the House of Commons we must be allowed to express our own individual views. If we do not do that, the House of Commons ceases to exist. I feel that this White Paper which is of extreme interest and which is, certainly, revolutionary in some respects will require—I am sure the Government never expected anything else—some modification particularly as far as voluntary hospitals are concerned. They are still the keystone of the hospital position. They have a great contribution to make in preserving the health of the community. They must be regarded as partners and should not be made subservient to other forms of hospital administration by being put under a Committee representative of these hospitals. I ask for modification of the White Paper in that respect and I am sure the Minister will give the matter his best attention.

Mr. Jewson (Great Yarmouth)

The hon. Member for North Islington (Dr. Guest) has said that the White Paper should be looked upon as a basis for discussion. With that I entirely agree. He modestly disclaimed the right to speak for any large section of the medical profession. I do not speak for them at all; I am afraid my family doctor would tell you that I have not qualified very well even to speak as a patient, but I think it is right that we should put our individual points of view and, if my individual points of view are too individual to suit hon. Members opposite, I hope they will be patient with me. I suppose everyone will agree that full medical treatment within the reach of all is a thing that we must do our very best to attain. I have not the slightest objection to levelling, provided it is levelling up and not levelling down. I hope we shall see, as a result of what comes out of the White Paper, a very great deal of levelling up and improvement in all the medical services that we at present have, great as some of them are. But, as the White Paper itself says, there is a certain danger or, as I should put it, there are certain dangers and I want to indicate a few that occur to me as I read it. My right hon. and learned Friend in opening the Debate said we are re-shaping the background of individual life, but we must be a little careful to avoid, in framing legislation on the basis of the White Paper, too much interference with individual life itself. I do not say that there is very great danger of that, but there is a danger, and that is one of the points that ought to be kept very much in the foreground. We must safeguard that self-reliance and freedom which are essential to the full development of the man and the citizen.

I think our aim has been very well expressed in the words of St. Paul about the fulness of stature of the perfect man. That is what we must aim at, and I think the White Paper is intended to show the way to secure at any rate some part of that. We must always remember that, important as the physical side of things is, and also what is medically called the mental side, that is not everything and, if we could create a nation of healthy robots, we should have done no good but only harm and should only have created a potential danger to mankind. One cannot read the White Paper without being reminded of "Erewhon" and wondering whether we are getting towards the idea of making illness into a sort of crime, with doctors as a medical Gestapo. I hope we shall avoid doing anything of that sort, but we may perhaps, possibly with advantage, adopt the Chinese system whereby doctors are paid while the patients are well but not while they are ill. Illness should be the exception and not the rule. I do not think the comparison with roads and water in the White Paper is right at all. Roads and water are external things and we are dealing with something which is very much a personal thing. We must, therefore, take care not to let that point of view get too far with us. We must maintain the right, and also the responsibility, to manage our own lives. Without that we cannot get the sort of citizens that we want.

I have always very great sympathy with the right reverend prelate who said he would prefer to see England free rather than England sober, and I think freedom comes even before the imposition of heatlh, if we are going to impose it on anyone. Therefore, within the framework of this system which we are trying to create, we must see that the individual has his freedom. I can see that that is a difficult matter to attain if you are going to create a service on the lines of the White Paper. I do not know whether it has been considered, whether it would be possible to adopt a system of medical coupons, which would allow people to obtain the medical service they want in their own way and according to their own desires. Possibly, with all the experience we have had in war-time, something of that sort might perhaps be a practical way of retaining the freedom of the individual to deal with his own matters.

I was very glad to hear what my right hon. and learned Friend said in regard to the description of the service as a free service. It occurs several times in the White Paper and every time I came to it I had to remind myself that it was very much of a misnomer. We are not providing a service free of charge, and I think we ought to make it quite clear, and keep it continually in mind, that it is not "something for nothing" that we are going to get. It is something for which we shall all have to pay, whether we want it or whether we do not. I am not complaining of that. Perhaps it is a good thing to add this very important item to our system of social insurance. Moreover, I think it is true that we shall have to pay more than we pay now, for the reason that we are going to pay through taxation, and that means we have to pay the man who collects the tax and distributes it as well as the doctors, to whom what is left of the taxes then goes. From that point of view it is a very expensive method of dealing with the matter; nevertheless, it may be well worth while if it gives us a healthy nation and does away with the enormous waste at present in industry and elsewhere caused through illness and loss of time. But we must keep it in front of our people that they are not getting something for nothing and that this is not a free service, and I am very sorry that those references occur in the White Paper. I am glad the Minister drew attention to this in his speech and I hope what he said will be widely noted.

I am hardly qualified to say much on the question of the medical profession. I have my own ideas, but there are many Members who are well qualified to speak at first hand on the subject. I should like to say, however, that I think our doctors, like our judges, should be entirely free from political control. I do not want the surgeon or physician to whom I am going to owe his appointment to the fact that he is a good Liberal. I hope we shall be safeguarded from that, which is a real danger, when we are bringing into being a comprehensive service like this. I hope the payment of salaries will not become universal. There is a type of mind which works very well on the basis of a salary, with a pension to follow in due course, but I do not think as a rule it is the creative type of mind, the mind to which we owe most of our medical advance, which has been so very noticeable in the last 100 years. I should like to take up the reference made by the hon. Member for North Islington to the way our soldier doctors are working on salary. Soldiers and sailors do not do their work, at any rate in war-time, just for their pay. Their work is done from entirely other motives and I do not think that was quite a fair thing to say.

I have been asked to raise the question of voluntary hospitals. In my part of the country we are extremely proud of our voluntary hospitals, and the people who are proud of them include very large numbers of working people. In Norfolk as a whole there are 150,000 contributors to the contributory scheme. In the village where I live I have seen this at work, and I know it is a very valuable piece of social work, gathering in these contributions and looking after them. Of course, it is done entirely on a voluntary basis, and the actual hospital to which they belong has 150,000 contributing members. It will be a very serious matter if we are going to destroy this particular piece of work though it may become necessary. What I want to suggest is this. I presume we are going to take from these contributors by taxation the money they are now contributing voluntarily. That will be inevitable if we bring this scheme into existence. Then, we are told, we are to give the money back to the hospitals and, therefore, the hospitals will be all right. Even so, that does not quite work. We are told that it does not destroy the voluntary hospital, and, in a sense, that is true. But shall we not he told that this money which we take from contributors by taxation and then give back to the hospitals becomes "public money" in the process of passing round, and, therefore, must be publicly controlled?

I had a report last week from a discussion group at a centre of the R.A.F. on this subject of the health proposals which said that we must have the voluntary hospitals maintained, and that it must be done in some way that will avoid causing them to fill up innumerable forms so as to justify the expenditure of public money. I thought that a very good point, and what I want to make sure of is that money which is taken by taxation instead of by voluntary contribution will not be used in such a way as to force these hospitals to come under a control they have not yet had, and I would suggest that the present members of the contributory scheme, or any others who desire, should have the right to earmark their taxation contributions, if they wish, for their own hospital's contributory scheme. If that were done the money would not become "public money." It would remain, as it is now, a contribution to the hospital and the contributors would then have their same share as they have now in governing their own hospital, and we should avoid destroying what I believe is a very valuable feature in our hospital life.

The right hon. and learned Gentleman referred to the great traditions of our hospitals, and I think that there is no one here, however strongly he may desire to put everything under public control, who wishes to see them disappear, but I am afraid the spirit of them might disappear if we were simply to hand over the voluntary hospitals to public control. Another thing which would disappear, of course, would be the men and women who at the present time are giving public service and who work on these hospital boards, but who are not suited, temperamentally, I suppose, or for some other reason, to what we commonly call political life. I think it would be an unfortunate thing if the only sort of public service open to anyone was service in some form or other in the political world. I wish the efforts of the right hon. and learned Gentleman every success and hope that after these discussions he will be able to frame legislation which will bring about this thing, which, as I said at the beginning, we all want—the very best medical service available to everyone in the country.

Mr. Alexander Walkden (Bristol, South)

I do not purpose making any attempt to follow at all seriously the somewhat mournful discussions we have listened to up till now. I think the House would probably like a change. I speak on behalf of my party, and once more, on behalf of the T.U.C. I have just had a letter from them asking me to welcome this White Paper wholeheartedly and to say that we will do our utmost to help the Minister to get the scheme carried through when he has it in the shape of a Bill. I am not worrying about the hon. Members who put down Amendments. They seem to be dissembling their love. They actually want to kick the Minister downstairs and I hope the House is not going to encourage them in any such effort.

I have been asked, and with great pleasure I do it, to congratulate the Minister on producing this wonderful White Paper which we regard as the basis for another great Bill. We have one great Bill before the House. It is getting on slowly, but steadily, and I want to congratulate the Minister and all his helpers on producing this scheme, not forgetting Sir William Beveridge who inspired us all to look forward to this type of legislation. I am also glad that the Minister himself, quite spontaneously, gave expressions of approval to a most important preliminary sentence in the White Paper. It is most significant, and I rejoice that he himself drew attention to it. It is at the bottom of page 10 and it says: The subject of health, in its broadest sense, involves not only medical service, but all those environmental factors, good housing, sanitation,"— May I say also good water supply— good conditions in schools and at work, good diet and nutrition, economic security, and so on, which create the conditions of health and prepare the ground for it. All of them must receive their proper place in the wider pattern of Government policy and in post-war reconstruction. The Minister himself spoke in the sense of those words and we do welcome his assurance that the Government intend to proceed with the whole plan of the great public service that is being evolved. The House is glad of that because it gives hon. Members some inspiring tasks to look forward to, not only at the moment but in the future life of this Parliament, and it relieves them of their thirst for doing some good work. Many of us are tired of hearing a lot of carping criticisms on minor matters without a chance of getting on constructively with something better. I am reminded of the great people in the free cities of antiquity. They kept their swords bright and ready. We are not sheathing our swords; we are going on with the war. They also had their trowels and they got on with the building of their cities, and defended them, and, at the same time, made progress with their national affairs. This House could do the same. We need not be restricted any longer.

The scheme is about complete and now due for enactment and all pleadings for delay and anything suggesting negative opinion about it are most untimely and unfortunate. The present public health service, is endowed with something like £60,000,000 a year. It is good as far as it goes, but it is only a patchwork arrangement and not good enough for present-day requirements. It represents all that has been done since the Public Health Act of 1848. We have done many things since then, but not anything like enough, and, at present, putting it on its best interpretation, only about half the population is provided for, as the Minister himself said, and, particularly, millions of women and children are entirely unprovided for. We must do something more if we are to be worthy of the great days in which we are living.

The new plan will be—indeed it has been—welcomed by all the people, and especially by the women of the country. We have to remember that the women are in the majority in the electorate, and their views matter very much. They have institutions for studying such questions as this, and they want to have this service established. It will be of enormous help to them, including the middle-class women. There are a lot of hard working middle-class women, wives of professional men and black-coated workers, of whom there are millions in the country, who have never sent for a doctor. Often they omit to send for a doctor when they ought to, and they drag on although they are seriously ill. They dare not send for a doctor because they know that when he has gone there will be a bill, and they know that their husbands are committed up to their eyes. They know that there are all sorts of accounts coming in regularly, especially if they work on the system of quarterly and monthly bills, and there is no margin. Therefore, women often sacrifice themselves for want of medical service.

One of the best sentences in this White Paper is that which says that this great service is to be free to all. It will be a fine thing for women to know that they will be free to call in a doctor for themselves and their children. I am one of a family of nine, and we had all the ailments to which children are prone, but mother rarely called in a doctor because she knew that his account would embarrass father, and she nursed them through all their illnesses herself. Bad results often follow on children's ailments through not calling in a doctor. All that will go under this scheme. The second feature of the scheme which women will most welcome is the home nursing service. Many a time in her life a woman would have loved someone to help her in time of trouble and sickness. I know that there are voluntary agencies which provide nurses, but everybody cannot subscribe to them and an honest woman will not send for a nurse from one of these agencies if she has not subscribed to it. Instead she will carry on and wear herself to skin and bone in consequence. The nursing service is one of the best features in the scheme from the home point of view.

I do not want to be critical, but I must draw attention to a strange omission from the scheme. I feel confident that the Minister will take note of it and give it a place. There is no mention whatever of any treatment arrangements for the rheumatoid class of diseases. These diseases are a very large and serious class, and they are very agonising. In the White Paper there is reference to special treatment for tuberculosis, cancer and a whole range of other diseases, but not a word about this class of disease. The figures about it from an industrial point of view, which will interest hon. Members opposite as it means loss of labour power, show that the loss is greater than from almost any other disease. I will quote from the "Post-graduate Medical Journal," an organ which is read by the younger men in the profession. There is an enlightening article beginning on page 4 entitled "Tuberculosis and rheumatic diseases," by Dr. Philip Elman, M.R.C.P., who has great qualifications for dealing with this subject. The most serious words in his article are: As far as disablement is concerned it has been reckoned that the rheumatoid diseases are responsible for ten times as much as pulmonary tuberculosis, and the loss of working days through such disablement amount in England to one-sixth of the total disability from illness. That is a serious statement. The author says later in regard to curative treatment: In point of fact, correctly handled and given therapeutic facilities comparable to those available for pulmonary tuberculosis, with similar after-care and vocational guidance and rehabilitation in all its phases in no group of diseases are results likely to be more successful, and they will certainly compare favourably with those of pulmonary tuberculosis. These agonising troubles are curable. I have had some trouble from this kind of disease, and I know that it can be cured by good treatment, remedial massage and exercises, which I myself practise every morning—37 varieties of them. This disease can be cured, especially if taken in hand when a person is young.

There is also no mention in the White Paper of convalescent home treatment. There are a large number of convalescent homes, many of which are organised and run by working men through the trade unions, which have acquired suitable houses once belonging to formerly wealthy people. Most of them provide facilities for men to recover after serious illness. After the doctor has done with you, you need two or three weeks to get your strength back. Convalescent homes are worth taking into consideration in this scheme, especially as there is hardly any provision for women in these homes. They need a fortnight away rather more than men when they have come through a long illness.

That brings me to the subject of voluntary hospitals. All of us have had communications of all kinds, some of them interesting and some of them very surprising. In view of what is stated in the White Paper I cannot understand what the apprehensions are founded on, especially after listening to the Minister's speech to-day. He showed that the voluntary hospitals are to have nearly £2,000,000 more revenue more easily under this scheme than they could get it by contributory collections. I should have thought they would have jumped for it, and so avoided all the miserable business associated with getting funds for the hospitals. For medical students to guy themselves up in comical attire and to rattle tin boxes and dance about on our railway stations is a very undignified way of raising money. If I were a governor of a hospital I would say to the Government, "Thank you; you can have our hospitals, and we will do all we can to help you to run them better than they have been run in the past." I do not know why anyone should take a different attitude in view of the proposals in the scheme. I know that there is a bit of consequence about being a hospital governor, but what does that matter? To have all this pomp and circumstance about being associated with a board of governors seems silly. This sort of thing is sheer snobbery and is one of the worst aspects of the voluntary hospital system.

The Minister made clear that the real service of hospitals can continue. Any one who desires it can find his or her place in continuing to help in public work. There is plenty of scope for public work in this country, the most gloriously democratic country in the world, from this House down to the smallest parish council. If anyone wants some public work he can have it. All our trade unions are open for them to do some service, and there are all sorts of other institutions. I do not know why anyone should mourn about the possibility—I do not think it is entirely a probability—of our hospitals coming under the care of the Minister instead of continuing as they now are, in this miserable state of poverty.

However, some of the communications are not quite so bad as I have indicated. I had one from an institution called the Children's Hospital, at Bristol. It finished up with these rather nice words: The Government has set its hand to a task which, in nature, is revolutionary, and which, as the White Paper concedes, can be accomplished only by a process of evolution, and with the utmost co-operation, understanding and good will of all the parties concerned. Those parties include the Central Government, the local government, the medical profession, the nursing professions, the voluntary hospitals and the British public. That is a good, acceptable statement. If the hospitals will work in that spirit I do not think we shall have much trouble, but if they pursue a different attitude I am afraid they will be getting themselves into the same unhappy state in public life as the voluntary schools. "The British public," referred to in the last sentece quoted by me, want this scheme very much, and they will not be hapy till they get it.

I would like to emphasise one or two other features about the hospitals. The Minister has made provision for their inspection in all departments, reaching down to the commissariat. That is quite a good thing. Some hospitals have been a little mysterious about what is going on. The working people have wondered rather how they are run, and do not feel altogether comfortable about them. Further, the Minister is providing for the preparation and circulation of annual reports. That is most helpful. I wish we had an annual report from the London Passenger Transport Board. This House might be able to see it and use it as a basis for discussion. Annual reports are very good things, because they sometimes make an undertaking careful, in case awkward questions arise during the consideration of the report.

We want to increase the ordinary person's confidence in the hospitals. In spite of all the particulars Which have been given to-day, there is, in the minds of thousands of working people, a suspicion that if they go into a hospital they will be experimented upon, and that the clever medical gentlemen who run them want to go on running them, so as to get patients who will give them a little more experience which they can use in the treatment of the rich. That is in the mind of the working people. The publication of a report would help to remove that suspicion and to develop confidence in the minds of the ordinary people.

Another point which I wish to commend, as an old trade unionist, is the stipulation that there should be proper rates of pay and conditions of employment for the nurses, midwives and the other members of the staff. I am glad that that is laid down on page 23. When I was on the General Council of the Trades Union Congress we had most pathetic complaints about the bad pay and awfully excessive hours of the nurses. There was thoroughly bad exploitation of very good girls in those hospitals and the girls came to us with tears in their eyes. They did not know what to do about it. They did not know how to form a union; they were afraid to form one. The fear was very real, and I was ashamed that such a mentality could exist in a British institution. I rejoice that the Minister has included that stipulation.

I would ask that there should be a sort of Whitley Council or appeal board. A large number of people are involved and there will be many more. There should be recognition of trade unions and there should be a body to consider cases of disciplinary action. This is the human side of the work. It is not a question only of duty or rates of pay, but of the human relationships inside the organisation. We have readied a perfect state of things in the railway world, wherein a man or woman charged with wrongful conduct has to be informed of the complaint. At the bottom of the form there is a query: "Do you wish to appeal against the charge? You can appeal to Mr. So-and-so, and, if you like, you can have a friend. Please say if you wish to be represented at the inquiry." It is Army practice. You can have a friend, who may be a trade union official.

We have got further; if the person concerned does not get satisfaction from interviewing the immediate superior, there is a right of appeal to the general manager, and a very responsible man on his behalf can hear the whole case. It is very often discovered that there has been wrong treatment or a wrong attitude of mind and that the person should not be punished. Or an arrangement can then be made to give him another chance. There will be these troubles in the hospitals. Indeed, there are indications on another page of the White Paper of personal troubles among the medical staff. Anyone who has read books like "The Citadel," by a great literary doctor, or "Dr. Bradley Remembers," one of the loveliest books I have ever read, by Francis Brett Young, knows the troubles of the young doctor vis-à-vis the old doctors, who are sometimes too pompous and important in their profession and impatient with the young men. It leads to difficult situations, and perhaps to injustice. There may be a damping down of a young man, and young doctors are very frightened and nervous about this sort of thing. If there could be an appeal court for the whole staff, I think there would be happier running—not that everyone would be going to the court, but that its very existence would make things better. We have an arbitration arrangement for the superannuation scheme in the railway world, and annuitants who are dissaisfied can go to arbitration. They never go, because the administrators are aware that they must give absolute justice, and in complaints about a border-line case the person concerned is given the benefit of the doubt. Therefore my suggestion would make for the happier running of the medical institution.

Now I come to the doctors themselves. I have been rather surprised and amazed to hear what was said about them to-day. I really thought better of them. I thought they were better informed. Their senior representative talked a good deal about democratic procedure, but I was amazed when he claimed as his chief point, which he made at great length, that 95 per cent. of the profession were absolutely against any lay control. That confirms what was stated to me by a doctor who came to see me. The doctors want to run this scheme exclusively. That is an extraordinary claim. One of my model industrial institutions is the London Passenger Transport Board. It is run by seven directors. Two of them are great professional transport railwaymen—Lord Ashfield and with him was the late Mr. Frank Pick—I am not sure who is with him now—and five representative men from the L.C.C., London borough councils and public bodies of that kind. It is under "civilian" control to the extent of five as against two. In our work as trade unionists from time to time the trouble crops up of having to dispel from workmen's minds the notion that they should have the industries for themselves, the mines for the miners, the railways for the railwaymen, the post office for the postal workers. That is called syndicalism. It is one of the most abominable principles in industrial life. We have to fight it and knock the nonsense out of people who cling to that notion. And yet we have a most eminent man claiming that there must be that principle in connection with this medical service. I trust I may be excused for speaking rather emphatically but it is something which we have been fighting against and I am sure that the Minister could not sustain that plea so far as the medical service is concerned.

Another object submitted to me—and I have had a lot of doctors to see me, and letters from them and so on—is that they are against any number of their profession giving full-time service. [An HON. MEMBER: "Hear, hear."] They do not say why. We may presently hear why. I cannot see any reason why, I cannot think of any reason why they should object to full-time service. The majority of people who are employed persons, are employed full-time. There is no disgrace in being employed persons. The judges on the bench are employed persons. So are His Majesty's Ministers—hon. and right hon. and learned everything else. I am amazed at this queer attitude of mind on the part of the doctors. All through the years, there have been fully-employed doctors in the public service. We have them in the Ministry of Health, we have them in the Home Office. There are medical officers of health under every county and borough council and they are doing very good work too. I have never known that they are considered less satisfactory members of their profession than the men who attend to us individually when we are ill in bed. I consider that they are as worthy of honour as the men who run the profession as private practitioners. Therefore, those who object must not expect us to entertain much regard for pleas of that kind.

Then comes the question of group practice. That has been deprecated to-day, but the young doctors I have seen and medical students who have been to see me—we have a medical college near where I live—welcome this idea of full time employment in health centres. "This is something fine," they say. "We can work together co-operatively. We shall escape the awful doom of being tied up, which a doctor suffers from all the year, by day and night, through being on call, with no one to send in his place. We can organise our work, get to know everybody and do all the better because we are working together." Then, having clerical and secretarial assistance in these centres will be a godsend. Instead of a doctor having to write out a report in his own hand he will have a typist to do it for him, and a secretary to look after his correspondence if that gets too abundant, and some of us know what that means. I can see that that will be a very great blessing.

Above all, the young doctors and those who aspire to become doctors feel that the Minister is giving them an escape from the awful problem they have to face when they have become qualified and are ready to practise. They have to buy their way in. There is no other way. Many of them, clever young men, have no money with which to buy their way in. As a result some borrow money but what then? The borrower has the loan round his neck for years and years, harassing his life, and preventing him from getting married —a most shameful thing. The first of the rights of man is to get married. Things like the situation I have mentioned deter a good man from getting married while he is young and enthusiastic. At an age when people are in love there is nothing more shameful than to be prevented from being married. Such a man will have his chance in group practice under the Minister's scheme. They will see that the salary is all right. The doctors have a strong enough trade union. But the young doctors welcome the Minister's scheme whatever the elderly gentlemen may say or think. I think the Minister can go ahead with it, feeling assured that he will have enough recruits when the scheme is launched.

They also welcome the scheme for superannuation. I think that is another very good thing that has evolved in the last hundred years. Think what superannuation means. I think Charles Lamb eulogised it once. When you are in a scheme, and know that if your health gives way, or when old age overtakes you, there will be reasonable provision for you for the rest of your life you are free minded. I am speaking of us poor men—you are all wealthy men on that side—and one is relieved in one's mind if one is sure of a pension. One can then enjoy civic life or professional life, or working life unworried by that awful carking care that one otherwise gets with advancing years. At 40 it is there; at 50 it is increasing, at 55 it is acute, at 6o you hear "It is time you went" and you say "I have not enough put by to keep me and my wife." That is the sort of thing that makes many people look so ill when they should be in the prime of life, enjoying the fruits of a life's labour. Superannuation is being provided here, and the young doctors welcome the prospect. They will all get fair play under local authorities. I would beg the doctors not to be afraid of certain words.

Dr. Summerskill

We are not.

Mr. Walkden

The hon. Lady is afraid of nothing. But words are being bandied about, very queer words—"regimentation," "bureaucracy." A lot of people frighten themselves with them. A bureau is only an office. The man in charge, is, in French, a bureaucrat. We should call him a clerk in charge in English. As for "regimentation," as applied to any civilian occupation it seems like "bureaucracy," only a bogy word. We are not going to be frightened by them. We get plenty of regimentation in industry, and I can assure hon. Members, as regards bureaucracy, that there is more of it in private railway companies than in the Civil Service.

Still we are not frightened of it. When necessary, we can fight it I am sure doctors can do so, too. I am afraid I have been a little severe, but I have tried to give a better picture to the House than has been given so far by the medical profession. I do not read "The Lancet" regularly—I believe something dreadful happens to you if you read it for 40 years —but "The Lancet" gave a very nice welcome to the White Paper when it came out. It said that the Government's scheme was bold, as well as reasonable, and it added: Much remains to be decided and defined, but, within the framework suggested, it would be possible soon to increase the value of medical knowledge to the public, to give most doctors more satisfaction in their work, and, in so doing, to prepare the way for a really fine service in years to come. On the whole, it is considered that the White Paper gives the doctors a square deal. It suggested that the new national service must set itself from the first to make more economic use of the doctors available. This, it is asserted, can only be achieved by the rapid development of health centres, which would do something to conserve the doctor's time and energy. You cannot have anything better than that from "The Lancet," which represents the profession much more truly than the speakers we have heard to-day. I am amazed at their being selected to speak for the profession. I was reminded of what the Minister of Education said the other day. Looking up, he saw certain people in the Gallery, and he said to them: Ye fearful saints, fresh courage take. The clouds ye so much dread Are big with mercy, and shall break In blessings on your head. That is what this scheme will do for the doctors, for the hospitals and for everybody else concerned. I come last to the objections made—not only by doctors, although they were made by one doctor here to-day—on the matter of expense. Small-minded people—some of them with big bank accounts—are saying that the country cannot afford these schemes. The answer is that the country cannot afford not to have them. We cannot afford to have sickness and illness and a feeble Population. Only a small proportion of our people live on the land: we are mainly an urban and industrial population; and the maintenance of health is no light matter. The country cannot afford ill-health and weakness in its people, just as it cannot afford to have an ignorant population. We must be strong, we must be well, and we must have our capacities well developed; we must be educated. We are a comparatively small nation, on a small island, but we have very great responsibilities; I do not know any country which has responsibilities comparable with ours; and we have illimitable possibilities. We have a great history, and I believe we have a very great future, even greater than our past. But we must be strong, we must be healthy, we must be intelligent, we must develop all our capacities, if we are to continue to be great.

Major Leighton (Oswestry)

The hon. Member for South Bristol (Mr. A. Walk-den) made a point which leads me to a question which I invite the Minister seriously to consider. He said that there was nothing in the White Paper dealing with the treatment of rheumatism. I want to ask the Minister whether he will go into the question of developing British spas. We all know that British spas are very much behind Continental spas. I went to a spa in Switzerland before the war, and when the war came, I had to look round to see what I could do. I found one in Wales. I asked my London doctor about it, and he said he had never heard of it; but he made inquiries, and said to me, "That will do you all right." So I went there. It is a very tiny place, and very primitive. There are a few sulphur baths, and there was no skilled doctor there to say what one should do. When I went abroad, the doctors examined sue very carefully, and prescribed exactly how long I should stay in the bath and how many baths I should have. At this place, I prescribed for myself. If we are to develop our health service, surely it is time we set about it; we have just as good health resorts here as there are on the Continent. In fact, the sulphur water at this place to which I went is as good as it is anywhere in the world. There are different sorts of wells, at Llanwrtyd Wells and at Llandrindod Wells, and there are brine baths. I found that there had been an association called the Association of British Health Resorts and Spas. I wrote to them, and I was answered by a firm of accountants, who said that the association was in liquidation. That association was started in 1931. It had some very eminent medical people on it, and for some years they evidently did good work; but when the war started they could not carry on. It might have been as well if the Minister of Health at the time had tried to keep such an association going.

The Minister may think it worth while now inquiring whether such an association could be restarted. After the war there will be a great demand for these places. Thousands of people who used to go abroad will probably not do so again, and there will be a chance for our British spas to come into their own. After the last war the Germans invited a lot of our specialists and leading doctors to inspect their spas. A large number accepted that invitation. From the time they left Victoria to the time they got back to Victoria they did not have to pay a penny, and they were entertained magnificently the whole time. They went to different spas in Germany, and were lectured and shown the various treatments, and I believe they were very good. What was the result of that? They recommended people to go to Germany, and, when they went to Germany, they were treated very well, and when they came back they were pro-German. I hope we are not going to have that again. If we have these health-giving waters in this country, would it not be as well to make use of them? I hope the Minister will seriously go into this. I had already written a letter to him on this subject, and he will probably find it in his office and be able to read all the details. I hope he will try to do something to help the British spas.

Mr. Graham White (Birkenhead, East)

I do not wish to follow the previous speaker in the somewhat specialised field on which he has spoken. I wish, as briefly as may be, to express, on behalf of my right hon. and hon. Friends, our general and cordial support for the proposals set out in the White Paper. Modesty perhaps ought to prevent me from saying that it does so happen that the main outlines of these proposals are very similar indeed to the proposals of the Liberal Committee on the National Health Service which re- ported some 18 months ago. [An HON. MEMBER: "Why condemn it like that?"] Be that as it may, the right hon. and learned Gentleman has set up a signpost on the road to health for all, and it will be our ambition in this matter, with such ability and knowledge as we can assemble, to help him to clear that road and keep it open. I do not know whether the right hon. Gentleman realises it—the point was brought to my mind by the hon. Member for South Bristol (Mr. A. Walkden)— but a very remarkable thing has been happening in this House yesterday and to-day, in which the Minister has played a leading part. Here we are, in the second half of the fifth year of a total world war—in contrast to the debilitated condition of the people of the Continent and the abominable tortures of mind and body that go on from day to day—in this House of Commons, giving two days, under the leadership of my right hon. Friend, to the consideration of housing and health.

We cannot be too grateful to all those who have made that state of affairs possible, and it has strict relevance to something else which my right hon. and learned Friend mentioned and to which I will shortly refer. No Minister of Health has ever had a greater opportunity for public service that he, and the whole House and the country will wish him well. He did say yesterday that he welcomes criticism. It is perhaps as well that he should, because he is most certain to get it. I do not want to criticise him to-day, but I want to refer to criticism generally, because it seems necessary that we should remember that there are dangers in criticism to-day. The danger is a real one. With the march of events now proceeding it is of the utmost importance that the Government should speak with the greatest authority possible, and any criticism which might lead people to suppose that we were divided in our purpose would, indeed, do the utmost mischief.

The delay in reaching decisions in various matters, and the delay in bringing to the House of Commons the proposals we are considering now, has produced a feeling in the minds of masses of people that the Government are not as serious in their attitude to peace as in the prosecution of the war. My right hon. and learned Friend the Minister without Portfolio told us some months ago that there would be a White Paper on the subject of social security as a whole, and I could not agree more than I do already with the Minister of Health that we must not consider these matters separately, but realise that they all hang together. Encouragement is given to us by the fact that the proposals of Sir William Beveridge are to be improved upon. My right hon. and learned Friend told us the other day that he was working on them now, and the Minister of Pensions said, in the very heartening and exhilarating atmosphere of a by-election, that the proposals of the Government would out-Beveridge anything that Sir William Beveridge had ever thought of. Robert Louis Stevenson, in one of his better-known works, wrote: "It is better to travel hopefully than to arrive." It is a statement which I do not think works out truthfully in practice, but the Beveridge proposals have been a very long time on the way, and we can only hope that, when their journey's end does come, they will be, in fact, better than was made out by the Government on earlier days.

I leave that, because I want to return to the point that all these things hang together. This is a part of the social security proposals. With regard to assumption A of the Beveridge proposals, we are still waiting for details of one of the most important arrangements, the scheme for full employment, because apart from the pronouncement in another place by the Minister of Reconstruction, we know nothing whatever about these proposals. They are in the hands of various Departments. The danger from this criticism is that the critics themselves should think that, if they have launched their criticism, they have accomplished something and their duty ends there. I am quite convinced that there is no short cut to prosperity, well-being or any other desirable state of affairs, simply through the method of adroit legislation in the House of Commons. My right hon. and learned Friend said in the course of his speech that we were engaged here in reshaping the background of the life of the people of this country. I venture to suggest, quite humbly, that we are doing something very much more than that. These events have much more than a mere domestic significance. We must, in these days, never close our minds to the kind of rôle we are to play in the world of the future. We know that our population will prevent us ever playing a decisive rôle as a military Power, even if we wished to do it. I yield to nobody in my intense belief in what we can accomplish in the field of industry, but my belief is that, if we are to be supreme in the postwar world, it must be in political and moral leadership.

It is my profound conviction that we can render no greater service to a shattered, devastated and bleeding Europe than to present to it, as an example, a living and working democracy, to which they can turn for help and for guidance. Therefore, I am entirely in agreement when it is said that all these things must be grouped together—health, education and housing—into one great scheme. I hope that someone on behalf of the Government will soon put a concrete scheme before the country, and that as a result we shall see the outward and visible sign of the attempt to rebuild Britain not only physically but morally as well.

The medical aspect of this scheme has our approval. The suggested central medical service has had a good reception. I imagine that there will be some criticism of it and I will proceed at once to make one criticism. It may be that it is an oversight or an omission, but perhaps my right hon. and learned Friend the Minister will give consideration to the point. The Central Council has the right to make representations on matters the Minister refers to it. It has the right to report to him on matters of urgent importance which ought to be reported to him. It is the duty of the Minister to present a report to Parliament annually. There is one thing lacking in the independence and utility of this Central Council. It ought to have the right to publish, on its own account, a report on matters on which it has tendered advice to the Minister and which advice has not been taken by him. That is the important thing.

We have to remember that we must keep all these things on the most democratic lines possible. That is the only criticism that I would make. I am now speaking of the administrative body. If that body were to be used, as conceivably it might be, to look after vested interests, either professionally or in any other way, it might become a close corporation and develop a Fascist tendency. It should be made clear at the outset that it has to be a public service. It will have very great power and we ought at some stage to consider whether there ought not to be a right of appeal from decisions of the Council to the Minister in certain circumstances.

There are two matters on which I still want to say a few words. It is only machinery that we are considering to-day and it is obvious that a great deal will depend on the capacity and the personnel of the new medical boards. I doubt whether the Minister has sufficient power of direction over these boards, as I understand them from the White Paper. Local government bodies vary in quality from place to place, and it will not be surprising if the quality of these boards does not vary a great deal from place to place, and the Minister ought to have some power to see that their functions are carried out. There is a great deal to be said for making the regions under these boards even bigger than suggested in the White Paper. The case for that really rests upon the hospital services. A bigger area is proposed for Scotland, and I am rather inclined to think that a proposal that is good enough for Scotland might, in this connection, perhaps be good enough for this country. It may be possible to raise more quickly the standard of outlying hospitals by relating them to the medical schools. That is an aspect of the matter which requires further consideration and discussion and we will deal with it on a future occasion.

I am sorry that opportunity has not been taken in connection with the Education Bill and with these proposals to try to deal with the administrative and departmental difficulties which would be involved in making the Minister of Health really Minister of Health for the whole country and giving him the control—I know I shall be at cross purposes with the Minister of Labour in this—of industrial health and also the school medical service. These are two matters which, while we are making these major changes, should be dealt with at once. Conversely I would take the opportunity on the Education Bill to hand over to the President of the Board of Education the control of the Home Office schools and also the Poor Law schools. These are matters which I merely mention in passing.

I now come to the last matter—the subject of finance. The estimates struck one at first sight as being on the moderate side when compared with the tentative estimate put forward by Sir William Beveridge. I guess that in the compilation of these estimates allowance is made for the shortage of consultants and practitioners and for various other matters. If the estimates had been based on an attempt to provide for a full service they would probably have been very much bigger. I want to draw attention to one particular object of the finances of this scheme. We have all been impressed—and some parts of the country have been very much alarmed—by the growing burdens being placed upon local authorities. The Education Bill already places very heavy burdens upon them in many cases. It proposes to place, over a period of years, an additional burden of £32,500,000, and if I understand the Bill, it proposes to add another £7,500,000.

This process cannot go on for ever. There have been many proposals for lightening the burden by pooling and by other arrangements. They have been considered and found wanting; at all events they have been rejected. I am not sure that there is not in these proposals a basis on which, without infringing our previous practice or our democratic ways of procedure, we could do something to relieve the rates. It arises through the arrangements made for the conduct of business by the joint boards. It has been the principle—and I think a proper principle—of Exchequer practice in this country that where the piper calls the tune control should follow. When a corporate body, local or otherwise, is solely financed by the Exchequer control should follow. No local authorities would wish to see their authority and control damaged, but here we are proposing to diminish the authority of local authorities over a very considerable field. I ask whether we could not bring about a great relief to local authorities, without infringing any of our former principles, by bringing our present procedure more into conformity with our principles and applying the cost of the proposal to the central Exchequer.

Captain Cobb (Preston)

When the hon. Member talks about relieving the rates he does not mean really relieving the ratepayer. How is he going to relieve the ratepayer if he asks him to pay higher taxes? It simply means taking the money out of a different pocket of the same pair of trousers.

Mr. White

I do not want to argue upon the comparative incidence of rates and taxes, but the point I was trying to make would be clearly understood, whether it is right or wrong, by any local authority and by the authorities of the Exchequer. That is the point which I mention and to which we shall return in due time. We congratulate the right hon. and learned Gentleman on his opportunity and on the work which he has done in presenting these proposals to the House. We are grateful, too, as he reminded us we ought to be, to my right hon. Friend the Chancellor of the Duchy of Lancaster for his work in helping to prepare the scheme and bringing it up to its present state. There are matters —and I have tried to mention some of the more important of them—with which we shall deal as the scheme goes forward, and in the meantime we wish the right hon. and learned Gentleman good luck and will do what we can to help the process.

Dr. Howitt (Reading)

The Minister must realise that the White Paper has had a good reception. As for myself, I welcome it, and I know that the great majority of the medical profession welcome it, and the people of the country, too. It is a well-written document and interesting, and, contrary to many White Papers, is very easy to read. That makes it a great deal more attractive than many White Papers with which we have had to deal. I am most anxious that any criticism I make shall be helpful criticism. This Debate has been given to us so that our criticisms may help the Minister to make the health services more successful, but I feel there is a wide feeling in the profession, and among the people, that the voluntary hospitals have had but a poor deal in the White Paper as it stands to-day. The Minister spoke very kindly of voluntary hospitals, and I am sure that he will do his best to see that they and the people who support them are more satisfied and more likely to support him in building up his service. We owe so much to the voluntary hospitals, not only for the work they have done in the past but also for what they are doing to-day, that I am sure the public, and the medical profession too, would deeply resent anything that took away the usefulness of these beloved institutions.

The White Paper undoubtedly shows that the contributory scheme is dead. I think we have to face that. It will be a major disappointment to a great many people who have been in the habit of working hard and continuously for years to make the contributory scheme a success, but I want them to feel that their voluntary hospitals are not going to be shut, and I want to ask the Minister if he will do something to make them feel that they are having a bigger work to do in the national scheme. After all, medical teaching all through the ages in this country has been undertaken by the voluntary hospitals, and the vast majority of the best research has been done by them. For that one owes them a very heavy debt. I know that not all voluntary hospitals are big teaching hospitals, but, taking the small voluntary hospitals up and down the country, they are on the whole very good, though some have their faults I have seen them and we all know them. We want to help those voluntary hospitals to be better rather than to abolish them, and we do want to keep up the initiative and the independent spirit for which our voluntary hospitals have been famed. If we do not do that it will a great set-back to research, a set-back to the wonderful feeling that has existed throughout all these years between the people and what they call "our hospitals." Therefore I ask that, in respect of the voluntary hospitals, the Minister will make the consultant services and the lay people working for the hospitals feel they are doing more in the reconstituted health service of this country.

Now I want to speak about the medical profession, the doctors themselves. I expect all hon. Members know, and certainly the Minister does, that a questionnaire has just been sent out to all members of the medical profession. It is a long questionnaire and has to go not only to people in this country but to others who are out with the Fighting Forces abroad and in the Colonies too. It is not expected that the answers will be received at headquarters until July, but I feel pretty sure that when they are received there will be strong representations that we do not want a great increase of the salaried services, that the vast majority do not want to become what might be called "Whitehalled" because, if they are, the valuable relationship between patient and doctor. which means so much to both of them, will be destroyed. If you do this, you will get, if you are not careful, far too many forms for the doctor to fill up. The average doctor to-day is frightened that he will have more forms to deal with and we do not want that because already we have too many. It reminds me of a case in my own constituency after there had been a bad blitz. The commandant of a first-aid post was very anxious about the patients, and an official came up to see how they were getting on. The question which was asked first was, "Did you get form MBC.44 properly filled up?" That question was asked long before any inquiry was made as to how many casualties there were, and what was their condition. We do not want that type of mind introduced too much into the medical profession. We do not want to be dragooned, and we have been assured by the Minister to-day that we are not to be. If he says so, I hope it is going to be so.

We have to realise that to-day we have a very great shortage of doctors, and to run this National Health Service satisfactorily there ought to be an increase of 5o per cent. of doctors. It takes a minimum of six years to make a doctor, and we must adapt this system a little bit slowly and make it attractive for the young people who go into it. I am afraid that the White Paper, as it stands to-day, When it is read by parents and young men and women, will not attract perhaps the best people into the profession. The majority of people going into the medical profession to-day are the sons and daughters of doctors. If you do not make a doctor's life attractive, if you do not allow him initiative and enterprise and a reward for hard and good work you will not attract into the profession the people you want to attract. That will be a very serious thing. Therefore, I ask the Minister to ensure that he will make the profession an attractive one for parents to send their children into, that he will leave ample scope for initiative, hard work and independence on the part of those going into the profession, so that they may feel they will be rewarded and will not be going into a dull profession in which they will rise inch by inch.

I want to refer to one or two details. As regards the Central Health Services Council I think it would be far more use- ful if the Minister asked representative bodies to elect their own representatives, instead of choosing individuals himself. In that way I think he would get a better Council. With regard to the Central Medical Board the Minister told us that he does not intend to dragoon young doctors into the health centres for five years or any such period. I hope that the Board will be able to use their powers of persuasion and not their powers of compulsion, because medical men do not like to be compelled to do things. They do much better work if they have some choice in the matter. With regard to the Local Health Services Councils I feel that the Minister can help the voluntary hospitals by having on them equal numbers from the voluntary hospitals and the local authorities. By so doing the Minister would get the advantage of the great knowledge of the representatives of the voluntary system and it would help to make the voluntary hospitals feel that they were pulling their weight more. In regard to health centres, I hope the Minister will not start by having an enormous number of them straight away. There must be an experimental stage. He knows little to-day about health centres, because there have been very few of them, and, therefore, I hope he will say that they must be tried out before they become universal. I would also urge upon him that there should be a few beds in these centres, as this will make them far more useful. In the White Paper there is no mention of such beds.

I am very keen that the Minister shall have the co-operation and support of the medical profession. I think it will make the scheme work much better if he has that support. The suggestions I have made are entirely with that abject in view. I hope he may help to make the medical profession and the voluntary hospitals feel that they are taking a more active and leading part in the work that lies ahead. I would like to make one more suggestion. I do not think—although I may be wrong—that the Minister has had much personal contact with these people, and I suggest that he has a round-table conference with three representatives of the voluntary hospitals, three of the Nuffield Trust and three of the British Medical Association. If he did this, I am sure that his persuasive powers would make a great deal of dif- ference to the outlook of the work that lies ahead. Finally, I wish to preserve the character and the reputation of the voluntary hospitals, and I would urge my right hon. and learned Friend to do all in his power to make the representatives of these hospitals, both doctors and laymen, feel that they are working with him, that they have an important job on hand and that the voluntary hospitals will be able to continue to do the same kind of work, in the same kind of way, as they have done hitherto. I want my right hon. and learned Friend to realise, most particularly, how urgent it is that he should make the medical profession so attractive that the right people will enter my profession. We do not want in it the average humdrum person; we require in it people who will have initiative and ambition.

Dr. Morgan (Rochdale)

I would like to pay my humble tribute to the White Paper. There has been a long period of incubation over it and I must say that I expected a certain abortion, if not a monstrosity. At last the infant has been produced; it is not a very healthy infant; it is rather emaciated, emasculated, but, such as it is, it is certainly a step in the right direction—although that I think is the wrong metaphor to use. However, if only half of what is in the White Paper comes to fruition we will have made a real land-mark in the health services of this country. A great many Members to-day have put up sore heads of their own and have knocked them down. The hon. Member for Reading (Dr. Howitt) forgot that the central idea of a health centre is health, and not disease. He asked for beds in these centres. The idea of a health centre is a separate centre entirely for health, health education, culture, knowledge, the prevention of disease and—

Dr. Russell Thomas

Red tape.

Dr. Morgan

It is blue tape in the hon. Member's case. On the other side is disease, which we have not been able to prevent, and having all the services at hand—general practitioners' service, with domiciliary facilities, laboratory department, statistical department, nursing facilities, secretarial assistance and dispensing facilities, and all that is necessary for a good opinion, with secondary opinions ready at hand—in that way to do the best that can be done for a patient, giving him that prime consideration which at present he does not get. There are benefits associated with this White Paper and the scheme. True, it is not a comprehensive national health service. It is a medical service, with the stress laid on the medical side at every stage of the White Paper. The nursing side, the side of the health workers from top to bottom is completely neglected. Conditions of service, environment, good teaching are all left absolutely alone. We are to have a Central Medical Board. Why not a central health board, to include not only the doctors in the service but a central board as the employing authority with all the institutional workers, health visitors, nurses and everyone in the hospitals combined under it? Surely they are entitled, as are doctors, to good negotiating machinery, good Whitley Councils for discussion of their working conditions.

That is one of the faults of the White Paper. Another, again on the medical side, is that it stresses the point of disease and medical services. Take the four divisions of medicine, Personal hygiene, Public health, Social Medicine and Industrial Health. Health education is still under an ad hoc body, with a selected personnel, with no representation of the workers, at all, nor medical inquiry referees. You select the men and you know the sort of report they are going to make before they make it. Anyone who knew the composition of the Rushcliffe Committee could have written their Report before it was presented, especially if he knew the Chairman. This is constantly going on. The hon. Member talks about representation of voluntary hospitals on any future Board. He has not reached the point when it comes to proper and adequate representation of the different grades of workers in the health services. In this comprehensive scheme the whole of that is left out.

Take the second section of health, which is not mentioned because it is not a health service, the question of public health. It is grossly neglected. Take the question of social medicine. There is only one school in the whole of Great Britain which has a lectureship in social medicine, and it is due to the generosity of a manufacturer—an excellent thing for him to do —and is in Oxford University. The whole question of social medicine, with the questions of good milk supply, prevention of disease, good food and nutrition, good housing, good recreational facilities, prevention of mental disability in its early stages—all this has been left out of the White Paper. There is medical education, an important subject which the laity in the House know very little about. I speak with diffidence and misgiving in the presence of one of my own professors, who, when I arrived a young student with £20 in my pocket to study medicine, first opened before me the great door of science and taught me to look into the vista of the foundations of medical education, the hon. Member for the Scottish Universities (Sir J. Graham Kerr), who in my young days was such an inspiration and help to me. I hope, in listening to me, he will think that I am keeping my proper biological balance. Biology is well done, but physics is not. It is not related to the later phases of medicine, nor is chemistry. As to the medical curriculum, social medicine is not taught.

Take another question of great importance to the workers—occupational mortality, the relationship between occupation and disease, the whole question of industrial medicine. In South Wales, the miners are asked to go down to the bowels of the earth with new mechanical appliances and they are being almost ravaged by silicosis. Asbestos workers are all being subjected to the risks of asbestosis. There is not one lecturer on industrial medicine in any medical school, or attached to any of our hospitals, in this pioneer industrial country, which has led the world in the production of goods. You will say there is no relation between industrial medicine and general health. There is. The miner who gets silicosis is liable to tuberculosis. He goes home under bad conditions and is a focus, a pivot of disease, not only to the people in his own household, but to the rest of the community. So that in the four sections of medicine, not a word is put down about a preventive policy. It is all left to be got up later by the Health Services Council, because the Central Medical Board is a purely executive body. None of them knows anything about industrial disease. The doctors have not been taught. There are very few experts on industrial disease in the country. It was left to the Trades Union Congress General Council to ask the General Medical Council, a body nearly 100 years old, unreformed, with 36 members, average age 72—it used to be 77—to put industrial disease on the curriculum so that students of the present day could have some knowledge of the relationship between industry and disease and health. All these things are of tremendous importance to the workers as workers. You cannot divide preventive from curative medicine. In the White Paper such an important subject as industrial health is scarcely mentioned. Sometimes it is the Ministry of Health, a body which should be wide awake, which is asleep. The right hon. and learned Gentleman made a speech yesterday which showed he had reached the Rip Van Willink stage.

Take the question, little known to this House and the public outside, about Rag Flock Acts. We have been asking for reform and amendment about this for years. A Departmental Committee was set up by the Ministry of Health to deal with the question of the filthy, dirty and insanitary fillings of beddings, upholstery, cushions and things of that kind. The whole thing is a perfect disgrace. New York has State laws about it, and what cannot be passed in certain American States can be sent over here. It is sheer rubbish, stuff they would not allow to be used in bedding over there. They send it over here in order that it should be put in our bedding and upholstery. It is put into the disintegrating machines and then used practically unwashed, the present standards being so low. I gave evidence before the Departmental Committee, in company with the trade unions concerned and the best employers. We produced samples and the dust was seen falling from them. The Report of that Committee has been written and the Ministry of Health has received deputations since. This Ministry, which has health administration in the hollow of its hands, say they cannot do anything about it because the chairman of the Committee, Lord Merthyr, has been away on military service for five years. No matter what sort of filthy filling is put into a mattress or a cushion, no charge can be made against those selling it even if it is sold under a guarantee. I only mention that in order to demonstrate that here is the Minister of Health telling us to reform our health services, while he himself, at the centre, is not doing something which he could easily do. He could easily get Lord Merthyr from mili- tary service for a month or two in order to sign this Report, which I know has been written, if it is not in the hands of the Government. For years nothing has been done in this matter and yet we have this body, the Ministry of Health, telling us that it is going to start devising schemes for our health.

The Minister of Health was described by one of my hon. Friends as the health centre, but it is not a fact that health matters are all centred in the Ministry. Factory legislation comes under the Ministry of Labour. The General Medical Council, which is its own master, deals with medical education. Medical research, a vitally important matter, is in the hands of a separate body under the Privy Council. It is in a Department of its own and it selects the subjects for research. It, too, is its own master. There is no inter-Departmental committee linking up medical education and research and all the various phases of the health problem. There is no inter-Department liaison or comprehensive health service as is mentioned in the Motion. Although I think this scheme is a great advance, I think I am right in asking the House to believe that a scheme for a medical service alone is not sufficient. The problem is one of general health.

A great deal has been said to-day about the voluntary and municipal hospitals. Those of us who have been trained and retrained in voluntary hospitals—and I took the trouble to take again the medical course 20 years after I qualified—have a great regard for voluntary hospitals. We were taught there and we know the excellent work that is done there. Voluntary hospital managements have no right to shelter behind the excellent umbrella of the brilliant medical and surgical work which is done there. We must be fair to the voluntary hospital system. We must realise that the system by which there is a specialist in charge of a case, who is responsible for the case and to whom the patient can look with confidence because of his special knowledge, does not exist in many cases in municipal hospitals. Many municipal hospitals have done wonders in the last decade and in a few years they will be of such influence and knowledge and such efficiency that they will rival the best voluntary hospitals, even those with teaching schools.

There is a lot of fuss made about grants to voluntary hospitals and the dual system of control. There is a dual system in education and if you contract out you are penalised, but in the dual system which is proposed for hospitals in the health service, if you contract out you will get extra payments. I have been asking for years for a uniform system for hospitals under which voluntary hospitals would come in a coordinated unified system with the municipal hospitals. Instead of that the Government propose to allow the dual system to continue, and those which contract out will have the whole of their costs paid. They will not only get £100 per bed used and contracted for but extra grants to cover additional costs, and grants for teaching schools. I want some of the teaching schools to see how much they will get. The grants will cover practically all their costs, but the taxpayer will be without representation or control on the board. The principle of no public money without representation or control has been surrendered as far as the voluntary hospitals are concerned. Under the contributory scheme the contributors subscribe anything from £6,000,000 to £10,000,000 a year. The British Hospitals Association, which represents the contributors, consists of 76 members. The total cost of voluntary hospitals, according to the last figures is £17,500,000, out of which £10,000,000 is subscribed by contributors. Yet of 76 members on the Board of the Association only six represent the contributors. The Government are now to take the place of the contributors, but they are to have no representatives.

This is a scheme which has been well compromised according to the demands of the profession. I have to see both sides. I am a member of the Council of the British Medical Association, but no word has come from me as to the arguments and policy of the Association. I also hear the arguments on the other side from the organised democratic movement, but again I have kept my mouth tight and have made no disclosures. I happen to have the opportunity of hearing both sides, and I know what is going on. I think I have seen the way out. I think we can have a very excellent service, and that the Minister's scheme is the start of it on the right lines, with adequate representation, good consultants and seeing that the thing is done properly. It does not matter if one institution has to give way. It does not matter if a municipal hospital has to give way to a voluntary hospital in one area and in another a voluntary hospital has to give way to a municipal hospital. The thing is to have hospitals and doctors properly distributed.

Take London. The big hospitals are badly sited and are in industrial areas. They have not followed the drift of population. Many suburban areas are denuded of real hospital facilities. In London itself, because it suits the consultants there are a number of hospitals. The consultants are well paid for their work, not in actual cash, but by their students, when they become doctors, sending their private patients to the consultants. [Interruption.] You cannot tell me how well they do or how well they do not, because I know. Many of them are friends of mine. To say that consultants on the staff of voluntary hospitals do not get paid, is trying to throw dust in the eyes of the intelligent public.

Dr. Russell Thomas

The hon. Member ought not to make statements of that kind without qualifying them. It is a fact that many consultants spend many years of their lives in hard work before they can build up a practice of that kind. Their school is a school of hardship, in which many hon. Members of this House would never want to take a course.

Dr. Morgan

That intervention seems to me perfectly jejune. Really, it is not worthy of an elementary schoolboy, much less a doctor. Of course, I agree that consultants work hard, and of course I know that theirs is a school of hardship. We have all had hardship. How does the hon. Member think that I became a consultant on industrial diseases? Does he think it fell upon me like manna out of Heaven.

Dr. Thomas

God forbid that I should be drawn into a discussion of the hon. Member.

Dr. Morgan

No, I should prefer to discuss myself, because I think I should stand a better chance.

Mr. Deputy-Speaker (Mr. Charles Williams)

I do not think we can have a discussion on either of the hon. Members.

Dr. Morgan

Let me come back to the subject of the voluntary hospitals. They are badly distributed and they are there for the convenience of the consultant. They were built originally for the convenience of the consultants. If things are changed, a consultant may find that in a municipal hospital he can do finer work with better equipment and instruments, instead of borrowing them, as he may have to do in the voluntary hospitals. Many of the consultants are hard workers. Many of them are my personal friends. If I were ill, I would not go to the medical superintendent of a municipal hospital. I regard him as an administrator. He has a specialised job in administering the hospital. The consultant specialises in his own job. I feel sure that, under any system, whether employed by municipal hospitals or voluntary hospitals, and whether he gets his money from doctor students, from the local authority or from the central authority or in any other way, he will be keen on his work and still do good work for the good of the community.

I have said sufficient to show that there are possibilities in this scheme. We may rest assured that the doctors are very anxious to give the public a very good service, but if, because of the lack of a preventive policy, the doctors are put to work under bad conditions, what can the doctor do? Suppose he is in a slum or overcrowded area, with a bad water supply and with all the flats or tenements streaming with parasites, and a patient comes to him in the initial stages of tuberculosis; what can he do? The present tuberculosis scheme is so badly designed that it does not deal with the chronic cases, which are already very resistant to tuberculosis. I ask the Minister to have some courage and imagination. Here we have the tuberculosis scheme in the hollow of our hand, to do good, and we miss the opportunity by leaving out the chronic case, which has shown that it can stand up to tubercle infection.

Doctors have a peculiar relationship with their patients. A plumber, an architect or a lawyer becomes qualified and can stop dead, and need do no more reading or study. In the medical profession we must go on studying. Doctors need study leave, because medicine is a changing science. Doctors must be given every opportunity to study the development of medicine, whether they want to become specialists or merely want a refresher course to keep them up-to-date. As a matter of fact, many doctors have been so busy that they have had no opportunity to study medicine for anything up to 15 years. The doctor should have such opportunities that he can become an efficient person and give efficient service.

My last point is about the Central Medical Board. Doctors are afraid, and truly afraid, of bureaucrats, especially medical bureaucrats. It may be a delusion on their part and an obsession, but when they look at the medical services that exist they have grounds for their misgivings. The Colonial Medical Service is one of the worst in the world. I represent the colonial doctors on the British Medical Association in certain parts of the world, and I can tell hon. Members that the Colonial Medical Service is a disgrace. Opportunities of medical and psychological research are allowed to slip by in our present Prison medical service, in which there has not been a man of international reputation for the last 30 years. There may be one or two exceptional men with a national reputation, but the opportunities are slipping by.

In all the services run by the Government there seems to be a blight to keep the doctors down and keep them from developing that initiative which they want to develop. The doctors therefore, and I think wrongly—because they are working under bad and difficult conditions—have the delusion that they do not like bureaucratic service. I am afraid of the directionary powers of the Central Medical Board. I want to know whether it is really intended that the Board should have power to distribute doctors from one place to another. In some places, such as Cathcart in Glasgow, we are told that the doctor proportion to patients is one in 700, while in Greenock it may be one in 3,000. The present distribution of doctors is bad. Is the Central Medical Board going to distribute not only the young doctor who has qualified perhaps after an apprenticeship in a health centre or otherwise, into a bad practice or a general one, when he is perhaps better fitted to be a specialist? Is he to be directed into a place or parish where he will have to work under social conditions which he does not like or hates? Is a doctor who has been 10 or 15 years in a certain place to be told that he must go and relieve a situation somewhere else, after his wife has made friends in the other place, and his children have all been going to school there?

I am putting these things to the Minister, not because I believe the scheme will be worked in that way—I think things will be done very much better—but because doctors have come to me very fearful and with great misgivings. They have asked me whether it is possible that they or their sons now being trained will be in situations where there is any possibility of this thing happening. When I tell them that there is no possibility, they do not believe me. They say: "You are biased in favour of this scheme." I want the Government to make a pronouncement that the directionary powers of the Central Medical Board will be used with discretion and discrimination in the endeavour to give the public a good service.

I can only say, finally, that I think the Central Health Services Council is a very good thing. I think the voluntary hospitals later on will accept the whole scheme and will come in and come into the plan for their areas. I think that joint authorities are very excellent except that the powers of the larger local authority must be closely watched, because the policy—health and otherwise—of many smaller authorities is sometimes very far advanced as compared with the larger authorities. That has happend in many cases. I wish the Ministry of Health—I hope the hon. Lady will not mind my saying this—would be a little more honest and just with certain localities. In Gateshead, for example, which I have visited recently, I saw an excellent hospital being constructed, a composite hospital, a most excellent building, very well done, but to my pain and regret I heard that the Ministry of Health had stepped in and would not allow the nurses' home to be built attached to the hospital, so that these nurses who have to work in that hospital will have for some time to be billeted outside.

The Parliamentary Secretary to the Ministry of Health (Miss Horsbrugh)

This has not to do-with the White Paper, but I visited Gateshead, and particularly this new hospital. Buildings are being put up. As the hon. Member knows, the shortage of materials and labour is extreme at this moment. What has been arranged is that the building of this new hospital should go on. That has not been stopped, but at the present moment there is not the labour or the materials for building a nurses' home as well. Therefore, the alternative will be to have a half or a portion of the hospital for hospital purposes and the other portion for the nurses, or some other arrangement will have to be made. The position is that at this moment of pressure a new hospital is being built, but we cannot find the material for the nurses' home until the time of pressure is over.

Dr. Morgan

I am very grateful for that information, but my information from people on the site there was—

Mr. Deputy-Speaker

This is a very wide Debate and I recognise the importance of the point, but I think it would be in the general interests of other speakers if we did not discuss this actual local detail.

Dr. Morgan

I agree with you, Mr. Deputy-Speaker, but this is typical, and I am mentioning it as an illustration of what the Ministry of Health can do. It is a health service and the Resolution deals with a comprehensive health service.

Mr. Deputy-Speaker

That is the point I made, but an illustration should not be made a subject for argument on both sides.

Dr. Morgan

I am sorry, but I can only look after my side. I was expressing my regret that even at this moment the Ministry of Health cannot make proper plans for the proper accommodation of a nurses' home attached to this hospital. It must be recognised that the nurse is important. Recruitment is down to the vanishing point. In certain voluntary hospitals tuition is not as good as in municipal hospitals. Where in voluntary hospitals only 5o to 52 per cent. pass, the figure for municipal hospitals is 80 to 89 per cent. I have bored the House overmuch. [HON. MEMBERS: "No."] But the House will forgive me. This is a subject on which I have practically spent my life, on which I have been addressing meetings in the country by request almost every week-end. I feel deeply on the subject. I think it is the right thing to point out the difficulties and the advantages of the scheme. I can only give the opinion that this little infant, if properly nurtured and fed as it should be, will grow into something of which we can all be proud.

Mr. Storey (Sunderland)

If I am critical of some of the proposals in the White Paper—and I shall endeavour to see that that criticism is constructive—it is not because I do not welcome the White Paper proposals as a whole. I do welcome them, and I should like to congratulate my right hon. and learned Friend and also his immediate predecessor, on the very sound basis they have provided for discussion, both in this House and elsewhere. I welcome the White Paper, because I regard it as a first step towards a National Health Service which will not only relieve and cure sickness, but will create the conditions in which good health is possible, and will spread the knowledge of how it may be achieved. If our National Health Service is to be really comprehensive, all its parts must be developed into a coordinated whole, and steps must be taken to see that we make the service attractive to the essential personnel, and that sufficient research is undertaken. The White Paper, perhaps of necessity, is mostly devoted to the treatment of disease and I think it right therefore to emphasise that we will make a mistake if, in our further negotiations, these other factors are not taken into full consideration.

I want now to consider the actual proposals for the hospital and consultant service, for it is idle to deny that both the administrative proposals and the financial proposals have caused great concern to the voluntary hospitals. If our hospital service of the future is to be built, as is the Government's declared intention, upon existing foundations, then it is right that we should seek to establish the right relations between the local authorities and the voluntary hospitals which my right hon. Friend the Member for Ross and Cromarty (Mr. M. MacDonald), in his too brief tenure of the Ministry of Health, was at such pains to emphasise as of the first importance. Neither in administration nor in finance do I consider the White Paper proposals create the right relations between the voluntary hospitals and the local authorities.

I will take administration first. The ideal area for the administration of a hospital and consultant service is one which is co-terminus with the ideal area for the co-ordination of an efficient service. Such an area must be one which can carry economically the most highly specialised forms of service, which would probably be concentrated upon a teaching hospital art the centre, as well as the more general services which would be dispersed through general and smaller hospitals, radiating out from the centre throughout the area. Such an area must have regard to the natural flow of hospital patients due to transport and geographical factors —.for instance there is a natural flow of patients from North Wales to Liverpool—and that area must also, if it is to carry these highly specialised forms of service economically, be of necessity a large one.

The White Paper is right, I think, when it says that the establishment of a local authority, directly responsible to the electorate for such an area, would be a major alteration in the structure of local government, which could not be undertaken without a general review and consequent legislation. Therefore, I think that the system of joint boards which is proposed—objectionable as joint boards are as a form of local government—is the practical approach at the present time. But if the local authority is unwilling to accept joint boards which are coterminous with the natural hospital area, or if it is felt that such an area is too large for efficient administration, I see no reason why the planning and co-ordination of our hospital and consultant service should not be done—indeed, I think it is essential that they should be done—for the natural area as a whole, so that we shall get not only co-operation and consultation between the voluntary hospitals and the local authorities, but between one local authority and another. Upon the constitution and the status of such a planning and coordinating body will depend whether we find those right relations between the local authorities and the voluntary hospitals, the necessity for which I have already stressed. As the statutory duty of securing an adequate hospital service is to be placed upon the joint boards, upon which the voluntary hospitals will have no representation, the voluntary hospitals must have adequate representation upon the planning and coordinating body, if they are to feel that that full partnership, which the Government has repeatedly foreshadowed, is to be real; and, that body, although excluded from power, must have influence and the means to make that influence felt.

I, therefore, urge upon the Government that, not only in Scotland but in England and Wales, we should have area hospital planning and co-ordination advisory committees which shall consist of equal numbers of representatives of the local authorities and the voluntary hospitals, with independent chairmen, and representatives of the medical, nursing, teaching, and other interests. I would go further, and suggest that not only should the joint boards be encouraged, as is proposed in Scotland, but that it should be incumbent upon the joint boards to consult the area planning committee before preparing their own schemes, and that the meetings of the planning committee should be open to, and their reports to the Minister and to the joint boards available to, the Press. If we had a body on such lines, we should have a body which could not be ignored except for very valid reasons, and we should go a long way towards getting that co-operation which would make the voluntary hospitals feel that they were partners in our health service.

I come now to the financial proposals in the White Paper. They also cause the voluntary hospitals considerable, and justifiable, concern, for, while the White Paper pays tribute to the way in which the voluntary hospitals have, to a degree so far unsurpassed, provided specialist and general hospital resources, which must for many years make their cooperation in a National Health Service a necessity, although the White Paper proposes to take over the contributory schemes which are the main, and growing, source of the voluntary hospitals' income, although it removes all incentive to voluntary subscriptions to the ordinary work of a voluntary hospital, by requiring all to subscribe to the National Health Service, yet it proposes a financial settlement which is based on the principle of paying substantially less than cost for the services rendered. When one studies the White Paper proposals, it is hard to refrain from the conclusion that those who framed them, deliberately framed the scheme, so that the voluntary hospitals could continue in business, only if they were prepared to provide a service at less than cost, so that, at no far distant date, it would be possible to acquire the voluntary hospitals, their buildings and equipment, at scrap prices, to build them into a full State service.

I cannot believe that this is the real intention of the Government. I prefer to believe that the proposals are based upon a complete misunderstanding of the essentials of the voluntary system. There are, I think, some grounds for this view in the White Paper's description of a voluntary hospital as in essence, an independent charitable organisation, deriving its money from voluntary subscriptions or donations or endowments of benevolent individuals or associations. That is a thoroughly antiquated idea. The modern voluntary hospital is, in essence, a paying hospital, where the very poor are treated free, but where a growing number of patients—even now a majority of patients—pay for their treatment, either when they receive it or by weekly contributions, either direct to the hospital or through a contributory scheme. The essence of a voluntary hospital is not its charitable funds, but its tradition, its experience, the facilities it offers for independent experiment, independent research, and individual teaching, and also the opportunities which it offers for voluntary public service. Here let me say that the remarks which fell from the hon. Member for South Bristol (Mr. A. Walkden) about voluntary workers and the jeers which he uttered were most unworthy, and were not the kind of thing we expect from one who has usually exhibited in this House a kindly and genial spirit. But, to go back to my argument, those things which I mentioned are what the Cave Commission had in mind when they wrote that the voluntary system was part of the heritage of our generation, and that it would be lamentable if, either by our apathy or by our folly, we suffered it to fall into ruin.

Is it possible to devise a financial structure under which the voluntary hospitals can maintain a large measure of independence, so that they may continue to make 'their particular contribution to a National Health Service, and yet be able to afford to carry on? I believe that it is. But we must first abandon this idea that when the State contracts with a private enterprise to render it a service, it can pay less than cost for that service. I think we can do that if we recognise that the voluntary hospital renders two forms of service to the community: one, the provision of general and specialist hospital treatment; the other, what is freedom, as the Hetherington Committee rightly pointed out, makes it well fitted to do, the trying out of new techniques, new equipment, new methods of treatment, which are at a stage which, although promising, have not reached the point where it would be right for a public authority to incur expenditure in introducing them. If the voluntary hospitals faithfully carry out their part in the National Health Service of providing medical and surgical treatment, they can reasonably expect to be paid the price for the job, without burdensome conditions, and with only liaison, and not dominating local authority representation, upon their governing bodies.

If the fair charge is paid for such a service, and the fair charge should include something towards the capital cost entailed, then the voluntary hospital will still be left to find the funds for its other service—independent, experimental work. To this, I think, they should devote the income from their invested funds, for it would not be right if this money was taken to reduce liabilities undertaken by the State, and they should also devote what money they are still able to raise in voluntary subscriptions. The latter, in my opinion—and I speak with a fairly long experience of voluntary hospital administration—would not be inconsiderable. Although few would continue to subscribe to pay the charges which would fall to be met out of taxes, out of rates and out of compulsory contributions, there will still be many who realising the value of the voluntary hospitals would be prepared to subscribe to maintain them. I will go further and say that if the many workmen who take an interest in their local voluntary hospital, and who will, in future, contribute compulsorily what previously they paid voluntarily, are still allowed, as I feel they should be, to take their part in the management of the local voluntary hospital, they will continue to subscribe to what they regard as their own hospital.

There are many other matters about the hospital and consultant services in the White Paper upon which I should have liked to comment, but I think they are mainly Committee points that can best be discussed when the negotiations have started with the interested parties. I will, therefore, pass on to one or two other points in the White Paper. The first is the Central Health Services Council. As with the area bodies that I have suggested, its value in giving confidence to the professional and experts bodies which will be represented thereon will depend on its status and influence and therefore I join with the hon. Member for Reading (Dr. Howitt) in urging upon the Minister that the constituent bodies should appoint their own representatives rather than that he should nominate them, and I think too that the Council should report, through the Minister, to Parliament, rather than the 'Minister report to Parliament on the work of the Council.

Just a word on health centres. I welcome the proposals, but I do regret that so much emphasis has been devoted to one particular type of health centre—the communal consulting room. I do not think it is the intention of the Minister that the experiment should be limited to this one type. Again, I join with my hon. Friend the Member for Reading in asking that we should have many types, and particularly that we should try the type in which beds are available to the general practitioner, and I would suggest that this type of centre might well be worked in connection with the smaller hospitals of the cottage type. Then, too, some of the health centres might combine general practitioner service with preventive and curative work of the maternity and child welfare type, which might well be carried on on a part-time basis by the general practitioners working at the centre, while others might link the general practitioner with the consultant and specialist services. The main consideration that we should recognise is that in the early stages health centres will be largely, in fact entirely experimental, and we should concentrate on getting as many and as varied experiments as we possibly can. Therefore I think that the local authorities should be encouraged to experiment with various types, and that the experiments should be coordinated, and the results weighed up centrally by the Ministry of Health.

In conclusion, I trust that all will approach this matter with a determination to build up a really effective health service. We shall only do that if, whether we are local authority, voluntary hospital or medical profession, we are prepared to put our best into a common pool and are not too stubborn on our own particular interests. In present circumstances, there will be no real progress without the co-operation of the voluntary hospitals and the medical profession. Therefore, the Government and the local authorities should go a long way to meet their views and give them that essential freedom which they believe is necessary if they are to give their best work to the community. On the other hand, the voluntary hospitals and the medical profession must be prepared to show a co-operative spirit. For instance, the voluntary hospitals, should, I think, welcome on their boards, representatives of local authorities and the medical profession should be prepared to join in devising ways in which we may have a 'better distribution of doctors throughout the country. Only if we practise this kind of give and take, will we get that good will, without which we shall not build up a truly national health service. Much progress in the past few years has been made in promoting a better understanding through the voluntary efforts of the Nuffield Provincial Hospitals Trust. They have done a remarkable piece of work in bringing together the local authorities and the voluntary hospitals and the medical profession, and these joint voluntary coordinating bodies have had considerable success in coordinating the work of the hospitals of their areas. If we all work to further that better understanding, I think we shall be able to build something of real value to the citizen and we shall go a long way towards lifting that dead weight of ill-health, which is such a cause of waste in our national economy.

Sir John Graham Kerr (Scottish Universities)

I find it very embarrassing to speak after the kindly and exaggerated remarks about the hon. Member for the Scottish Universities, and I ought in honesty to explain that it is a matter of distance lending enchantment to the view. I only wish I could take credit to myself for having inoculated the hon. Member who spoke earlier with some of the admirable ideas he expressed to-day with such eloquence, and I hope the right hon. and learned Gentleman will not be scared away from it, hut will realise that, among the eloquence, there are points of extraordinary value. I do not propose to criticise the White Paper as a whole, neither do I propose to criticise its details, because the moment you criticise in detail a complicated thing like that, you open the way for arguments for and against each detail and it is very difficult to arrive at the absolute truth. I will simply take some of the points that have already been made and help to drive them home with the weight of a little experience, and not try to make any new points. I would say about that experience that I have passed a pretty long professional life of 33 years as an active member of the medical faculty in one of the great medical schools of the country. I was also on the board of management and, what is perhaps more important, upon the medical committee of that board of one of the great voluntary hospitals of the country—that voluntary hospital of which it has been not unjustly said that it was the birth-place of modern surgery. I also happened to be a governor of the chief extra-mural medical school in Glasgow. These are the credentials on which I base the few remarks I have to make.

It is obvious that the success of a great scheme like what is foreshadowed by the White Paper must be due to the capacity of the personnel who have to carry it out. Perhaps the most important factor in that personnel are the doctors. Their quality as practitioners naturally rests, in great part, upon their training; not entirely, because of course a great deal depends upon innate ability. I happen to have examined many thousands of students, not merely of medicine but also of arts and science, not merely in Glasgow and Edinburgh but in a number of the chief universities of England. I am able to give this assurance, that the medical students as a body are students of a very high average ability and include a considerable number of really brilliant, promising persons. And it must be remembered that it is not merely the general average that makes success, it is the leadership by specially gifted individuals. We see that in the history of science; the great advances in science have been made not by organised science but by great individuals. Isaac Newton, Charles Darwin, J. J. Thomson—all of those were great individual leaders. So it has been also in the development in medical science in particular. Lister, that great man who took the chemical results established by Louis Pasteur in connection with the phenomena of putrefaction and fermentation. He had the vision to seize upon those results and to make use of them for fighting the microbes which attack man.

Dr. Morgan

What did Pasteur do?

Mr. G. Griffiths

What did Banting do?

Sir J. Graham Kerr

Then, again, it was no ordinary humdrum individual who hit upon that great idea the other day, the means by which the loathsome fungus that we see growing on various substances protects itself from the attacks of microbes by secreting a particular poison. That admirable man reflected that what would serve to protect the fungus, what nature had evolved for the protection of the fungus, might be diverted from that purpose to protect mankind; and to-day we have got penicillin.

It is very much the same thing when we are fighting those deadly microbes of disease as when we are fighting the great war which we are fighting now. Our success, no doubt, is conditioned by the ordinary men but, above all, it depends upon the great outstanding leaders—the Churchills, the Stalins, the Roosevelts. So it is with the war against hostile human beings as with the war against microbes of disease. We get these very highly qualified young men and young women entering and training for the medical profession. How are they trained? They are trained, again, by leaders, by people who, by experience, by innate ability, by success in the various departments of medical science, have achieved their great position in the medical and surgical world. These individuals are willing to play their part in teaching students. That is a very great thing, and the place in which they have done their clinical teaching up to now has been Mainly the ward and laboratory of the hospital. One of the most wonderful things in this country is that we have these voluntary hospitals which have their so-called honorary staff, the leaders in medical science. They are there, of course, as has been pointed out, because there are attractions of a material kind. The great specialist of one kind or another teaches in the ward of a voluntary hospital and there he establishes his connection with the prospective practitioners of the future who bring him in for consultation on operations.

Dr. Morgan

But in places like New Zealand the professors and the tutors in the medical schools teach not in voluntary hospitals but in hospitals belonging to the State and to the community, and the New Zealand students who come here as qualified men are just as well taught and do as excellent work in New Zealand as we do here.

Sir J. Graham Kerr

That is very interesting, but I happened to know it before. There is no doubt about the fact. The trouble is, what is the probability now for the future? On the whole, from my experience, I believe that the possibility of making a relatively large income, of attaining a great position in society, of attaining to dignity and recognition, these various things seem to me more likely to attract the brilliant young men into this particular profession than the no doubt safer course of mounting up slowly step by step in a safe, organised profession. It is only my own opinion, but I hold it pretty strongly, although I do not deny for a moment that in New Zealand, or in Glasgow, Edinburgh, or other centres of our own country, we might get that same thing happening. However, I feel there is a very great danger involved. I have said far too many words already, but may I just make an appeal to the Government to consider very carefully the enormous value of the voluntary hospital system, to see whether somehow or other they cannot devise a system which will carry it on in the great work it has been doing, without involving a real risk, as I am afraid is the case at present.

Mr. Douglas (Battersea, North)

May I, in the first place, add my congratulations to the Government on the preparation of this White Paper, which certainly marks a very great extension and advance in our medical services? It opens up problems of administration and finance and other things which are complex and involved and it also raises the question of relations between the State, the local authorities and the medical profession. However, I do not want to discuss these matters to-day; I want to consider for a moment what is the fundamental basis of these proposals. They are described as a National Health Service, but that description is a misnomer. The description should rather be a national disease service. The basis of these proposals is to extend to the whole population some, at least, of the facilities for the treatment of sickness which are at present available to a section of the population. That, I do not deny for a moment, is a thing of great importance and urgency, but I submit that it is very far from being sufficient. It touches only the fringe of the problem of public health.

The White Paper refers to long life, the lowered mortality rates and the decline in the incidence of the more serious diseases which has taken place in recent years. If a comparison be made with the conditions at the beginning of the last century, there is, undoubtedly, a vast contrast, but do not let us forget that if a comparison is made with a century or more ago it is made when the condition of public health in this country was at its very lowest ebb, when the population was living in most distressing and disgraceful conditions, and when urbanisation and industrialism had worked their worst upon public health. What we have to think about is not the improvement that has taken place since that time but the extent to which the population of the country is suffering from sub-acute disorders which lower vitality and ultimately lead to acute disease and sickness, and nothing is being done to deal with that.

Our public health statistics are all based upon mortality and upon the records of the treatment of active disease, but there is an indication in such research as that which was undertaken by the Pioneer Health Centre at Peckham. It is recorded in a very remarkable book published recently under the title "The Peckham Experiment." There you had a sociological examination of great importance, a cross section taken of the community, not of a particularly depressed part of it but a reasonably normal section of the London population. Taking a group of 500 families, about half women and half men, 21 per cent. both of the men and women were suffering from disease, that is to say, an active disease which was causing them discomfort which they recognised to be such. But of that 21 per cent. less than half were receiving medical treatment. There was a still more remarkable result of this inquiry. Of the men, only 16 per cent. were found to be without disorder of any kind, and of the women only 4 per cent. There were 63 per cent. of the men and 75 per cent. of the women who were suffering from disorder of some kind or other which was not causing them active discomfort, which they did not recognise as a disease, which in many cases, no doubt, nature, with its wonderful adaptability, by means of compensa- tory adjustments enabled the human being to go on living upon a lower basis of vitality, not feeling that he was actively ill.

There is nothing in the scheme of the White Paper which is actively directed towards dealing with the vast majority of the cases of disorder which are not recognised as illness, and which continue day after day or year after year and lay the foundation of permanent disease, which is tackled too late to enable a complete cure to be effected. The best that this scheme is likely to provide in its present form is care and advice for one portion only of those who need it if these figures are a typical example of the condition of public health. The step forward that is proposed is extremely valuable, but it is not sufficient. A radical change of outlook with regard to the whole problem is needed. Measures must be devised which will provide for the health examination of the people so that the incipient stages may be detected, as they can be, and the proper remedies taken if we are to avoid having the enormous mass of invalidity and sub-normal health from which the population is suffering. It is, I agree, not merely a question of medicine. It is a question of education in health problems, a question of housing, and a question of nutrition.

The whole of Western civilisation is a prey to the same conditions. The human organism has not been able to adapt itself to the conditions of so-called civilised life. Life is the result of an evolution which has taken place over vast periods of time, and the process of adaptation is not sufficient to enable men to live healthy lives under completely abnormal conditions. We have to look at the foundations of our system of living in order to see if it is adapted to the requirements of the human frame and stop fostering the idea that mankind can be twisted and warped to agree with an entirely artificial condition of life. Great legislative changes of the kind which are envisaged in the White Paper occur only at infrequent intervals, and I ask that consideration shall be given to this question of the positive attainment of health and genuine preventive measures to ensure that people do not become the subjects of treatment in order to remedy disease and disorder. That is the most important step which ought to be taken. If it could be taken it would reduce to an enormous extent the need for clinics, hospitals and the other means which have had to be devised in order to treat sickness. If sickness could be detected and dealt with at the earliest stages the need for a great deal of this vast, cumbersome and expensive mechanism would disappear. I ask the Minister to see that, in the framing of this scheme, it shall be laid upon such a basis as will enable the preventive work to be developed steadily and sensibly, without interfering with the immediate remedial work which is necessary in order to treat existing disease, with the object of reducing to its lowest possible extent the amount of disease which develops in the future.

Mr. Colegate (The Wrekin)

I will make probably the shortest speech in this Debate. I want to make only two points. I want, first, to congratulate the Minister and his predecessor most heartily on this scheme, and to express the hope that in the week-end speeches which Ministers deliver we might have one or two, not so much about the future, but about the schemes which are actively under consideration in this House. Such are this scheme and the education scheme, which reflect great credit on a Government which is so preoccupied with the burdens of the war. I want, second, to reinforce the appeal made to the Minister to consider carefully the two questions of the independence of doctors and the position of voluntary hospitals. I speak under pressure from two constituencies. My colleague, my hon. Friend the Member for Shrewsbury (Mr. A. Duckworth) is away from this country, and I have had to receive representations from the Shropshire and Mid-Wales branch of the British Medical Association and from many private doctors in a large part of Shropshire. I cannot believe that the number of people I have met, who are, if anything, above the average intelligence, should be so greatly disturbed about certain possibilities in this scheme if there were not some serious foundation for their apprehension.

There is great apprehension at any suggestion that the independent position of doctors should be replaced by a salaried service. The doctor is not only important from a scientific point of view, but he is also important from a political point of view. We are entitled to consider the political effects of any Measure brought before the House. One of the great drawbacks at the present time is the tendency for independent individuals to disappear, and one of the most satisfactory features is the fact that doctors as a whole are extraordinarily independent. They belong to all parties and they are in a position of being under no obligation to any municipal authority or Government Department. They are independent, and their views are of great value because of their independence. In regard to the voluntary hospital, that is another aspect of the matter, because the voluntary hospital is admittedly the leader in medical progress in this country. Without it, it would be impossible to contemplate the continuation of the progress which we have seen in the past two or three generations. I agree that there may be a time when that may come about, but it is being totally unrealistic not to face the fact that the State or municipal hospital to-day is not the field where the greatest progress is being made.

Mr. G. Griffiths

I want to contradict that.

Mr. Colegate

In that connection I suggest that further consideration be given to whether it is possible to preserve in some way the contributory scheme. The hon. Member for South Bristol (Mr. A. Walkden) made some reflections on that point which did not commend themselves to many Members of this House. The contributory scheme of the voluntary hospitals has had a wonderful effect on the people who are patties to it, because it has given them a pride in their local hospital and an interest in its progress which has been of enormous, not merely financial but moral, value to the people who are carrying on the hospitals and trying to improve them. We should preserve that spirit in some way or other. It should not be beyond the possibilities of my right hon. and learned Friend, when he meets the representatives of the voluntary hospitals, to secure that some part of that voluntary co-operation between the public using these hospitals and the authorities should remain. He would undoubtedly in that way remove part of the apprehensions which have been aroused by the scheme set forth in the White Paper.

In conclusion, I would say that the two criticisms I have made relate only to a small part of the scheme, and that the scheme as a whole is a first-rate effort of imagination and work on the part of the Department concerned. I am sure that when it is made known to the public it will receive as wide a support as any scheme of this kind could possibly be expected to receive.

Ordered: That the Debate he now adjourned"— [Captain McEwen.]

Debate to be resumed upon the next Sitting Day.

The Orders of the Day were read, and postponed.