Order read for resuming Adjourned Debate on Question [16th March]:
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."—[Mr. Willink.]
§ Question again proposed.
§ The Parliamentary Secretary to the Ministry of Health (Miss Horsbrugh)
I listened to every speech made in this House yesterday, with the exception of one, and I have been able to employ some of the intervening hours, since the Debate was adjourned, in looking through my notes, and in studying the speeches in the OFFICIAL REPORT. I think it is true to say that in every speech which I heard, a welcome was expressed for the scheme the outline of which we find in the White Paper. The one exception was the speech which I did not hear, and in which I think the welcome was in muffled tones. So far as I can gather, many of the criticisms in that speech were not against the White Paper which has been published, but against what was thought, or feared, might be in the White Paper, on which various organs of the medical Press expressed, some months ago, their fears and their suggestions to the Ministry.
My right hon. and learned Friend feels much encouraged by this support which he received from all the Members who took part in the Debate yesterday. That encouragement, I think, is also shared by those who, for many years past, have been working on this scheme, and who have wanted a comprehensive health scheme and a really good hospital service for the people of this country. I think there is common agreement that what we want is a good health service. We want it available for all, and we must set up machinery for accomplishing this aim. I notice that one or two Members thought the Debate rather too early after the publication of the White Paper. The Debate was fixed for this time in order that Members of the House might be the first to express their opinion on the main outline, and in order that the Minister might have a chance of filling in some of the gaps and explaining some of the points 536 contained in the White Paper, After the Debate it will be possible to go on to the next stage, of full discussion, with all those who will, we hope, take part in working this scheme and making it a success.
I will deal as shortly as I can—because I know many Members wish to speak— with the main points which were raised in the Debate yesterday. The first is the machinery by which we hope to build up a good health service, and to make it available to all. A good many questions were asked about the various committees and boards, the central and local health service councils, who should sit on those councils, and how they should be appointed. I suggest that, if we get agreement for the main scheme, we must then look into details, and take advice from all those who are willing and anxious to give us advice, and from all those who are taking part in the health and hospital services. The actual questions which have been asked about the Central Health Council and the National Health Service, I do not think we should settle in detail. We should get the principles settled, and then fill in the details of planning and execution. The first of these principles is that those concerned should have the best technical, professional and vocational advice. The second is that the machinery set up for this purpose should not be such as to rob the scheme of proper democratic control at the centre, through the Health Ministers, responsible to Parliament, and at the circumference by the local authorities responsible to the electorate. The Government believe that their proposals observe these principles. They do not want too much complexity—some people believe that there is rather much complexity already in the scheme—but they will be ready to consider any suggestions made by Members or those whom they are going to consult, who have been dealing with such services.
Another point which was raised by my hon. Friends the Member for Sunderland (Mr. Storey) and the Member for East Birkenhead (Mr. Graham White) was the size of regions. The hon. Member for East Birkenhead said that he was rather attracted by the Scottish scheme of having not only joint boards, but regional schemes as well, and the hon. Member for Sunderland said that he wondered whether the areas of the joint boards 537 would be large enough to give a proper service. He also was rather attracted by the idea of the larger area. The proposal for Scotland with its five big hospital regions as consultative regional councils, is different; and one reason is that in Scotland the actual administrative area, under the joint authorities, for hospital purposes, will have resources so much smaller than those of England and Wales, that they will be much less self-contained units, and will need much more co-ordination. I have been looking into the question of the size of various areas in Scotland, and in England and Wales. Taking the population of all five regions in Scotland together, I find that it does not amount to as much as the population of Lancashire and its county boroughs. I give that as an example, to bring out the point that, even with the regional scheme in Scotland, the regions together are not as large as some County areas in England.
§ Miss Horsbrugh
Because it is more scattered it is necessary to divide Scotland into areas which will have smaller populations than those in England. The hon. Member for Sunderland suggested that it would be better in England to divide the country up into larger areas, as in Scotland; but the areas of the joint boards in England will have larger populations than the corresponding areas in Scotland. Therefore, it will be possible for them to give a service such as would not be possible in the smaller joint board areas in Scotland. But, as my right hon. and learned Friend said yesterday, arrangements will be made in England for certain highly-specialised services, such as cancer and neuro-surgery, and others, to be dealt with in wider areas, by arrangement between the different area boards, so that there will be grouping of areas, rather than single areas, for certain specific services.
Several hon. Members, particularly the hon. Member for Reading (Dr. Howitt), referred to the supply of doctors. The hon. Member for Reading said that here was a service that he welcomed; but should we have the personnel to work it? What was being done about the supply and training of the necessary number of teachers? We have looked into that. Let me take, first, the general practitioners. The number of general practitioners works out at present, 538 apart from war conditions, to about one to every 2,000 of the population—that is, taking an average. As we all know, they are not evenly distributed; that is one of the difficulties. Consultants and specialists in this country, to work this service, are far too few—that is a fact which we have to face. Recruitment has been promising; between 1937 and 1941 it increased, so that the average per year was 1,900. Of course, each year some doctors retire, some die, and some of those trained here go outside Great Britain, to the Colonies and other parts of the world.
During war-time admissions to the medical schools have been at the rate of 2,300 a year. In the discussion on the Education Bill there was some reference to the shortage of teachers. The shortage is far worse in the teaching profession than in the medical profession, because, during the war years we have been recruiting and training doctors. These doctors during the war are working as doctors and gaining experience. Many of them are serving as doctors with the Services. It is not as if we had to begin after the war with a gap, as we may have to do in the case of teachers. Of course, the hospital services at present are inadequate, and specialists and consultants are too few, and we want more doctors. It was because of that, that a committee was set up under Sir William Goodenough which was asked to inquire into the organisation of medical schools, particularly in regard to facilities for clinical teaching and research, and to make recommendations. I think there is no doubt that one of the difficulties with which we shall be faced is that of finding the increased number of doctors.
I noted that, when dealing with doctors, the hon. Member for East Birkenhead in discussing the Central Medical Board which we suggest was not quite sure whether he liked it or not. I can assure him that we are agreed that doctors must have full protection, but I would remind the hon. Member that the Minister will be responsible for that Board, and the Minister is responsible to Parliament. I think if that is remembered, it will take away this fear that something is going to be done on that subject which will not give protection to the doctors. As I am speaking of doctors, although I do not want to weary the House, I should like once more to deal with what has been called direction for 539 doctors, as I am told that, alter the explanation given by my right hon. Friend yesterday, hon. Members in some quarters thought the policy had been changed. If those who are interested in this point would really study the White Paper, I think they would see that the policy was not changed. There was never any direction for doctors. There was one mistake between the two Papers, to which the Minister referred, the word "where" being used in one place, and "when" in another. The Minister yesterday, I thought, clarified the situation, but I was asked one or two questions, and so perhaps I may make it even clearer.
What is suggested by some people is that the young doctor is going to be directed. May I say, quite categorically, that no doctor is going to be directed? The doctor can set up a private practice anywhere he likes. There is no control whatever of private practice. The doctor can, as will be seen in the White Paper—because I would remind hon. Members that the one thing that cannot be said of this scheme is that there is regimentation, but what can be said about it is that there are alternatives available to both the patient and the doctor of the future, each of whom can choose—the doctor can, as I say, if accepted, do full-time public practice. He can do part-time public practice and part-time private practice, the number of patients for public practice being rather less if he takes private practice. But there may be some areas—and here is where the difficulty has come in—where there is a shortage of doctors undertaking what we call public practice. It is stated in the White Paper, that if there was such an area—my right hon. and learned Friend gave the example of Wakefield, and perhaps I might continue with Wakefield to-day—if there was a shortage of doctors for instance in Wakefield, and a young doctor wanted to apply to go to Wakefield to do part-time public practice and part-time private practice, it is possible that he may be told "We are short of doctors in Wakefield; therefore, we must ask you to do full-time public practice. If you do not want to do full-time public practice, or full-time private practice, there are many other places in England and Wales where there are openings for doctors who want to do part-time private and part-time public practice." In particular areas, where 540 there was a shortage, the young man might be told that, in that particular area, he could not do the part-time scheme, but that there were many other opportunities in the country, and he could choose one of them. I cannot see that that is, in any way, direction. I think that, perhaps, some people have not quite understood the wording of the White Paper, and I hope I have now made it as clear as it is possible, by human words, to make it.
On the subject of health centres, several hon. Members have asked if there is only to be one type—simply a communal surgery. They have asked if there are to be no health centres where there are beds. What we want is that health centre experiments should be made, and I think it is common sense that, if you are making experiments, you should make them in different sorts and kinds. We certainly want experiments made in different types of health centres. The whole scheme is only a beginning, and we have to see how it grows, what works well and what the people like. I can assure hon. Members that there is no fear that there will be only one type. We want them to experiment with what they consider to be the best type.
§ Dr. Russell Thomas (Southampton)
Is it not a fact that, in the ultimate resort, the Minister, under the White Paper, can establish health centres anywhere if he considers it in the public interest; and does not this mean that, in the course of time, every doctor will be a State salaried official, and is not that the end of medical freedom, the first occupation to be controlled, and the first stone in the building of the New Fascism?
§ Miss Horsbrugh
We have already spoken of the freedom of the doctor. He can do part-time and full-time work. He can practise by himself, or in a group, or in a health centra.
§ Miss Horsbrugh
Yes, he can retire, or he can leave the country and go to the Colonies or Dominions and see what their schemes are. He is perfectly free. There are many possibilities.
§ Miss Horsbrugh
Now, I want to get back to the health centre. We want experiments with health centres and we want to see different types of health centres. It is a new scheme, and we want to see how it works and how the patients, who are the people for whom the scheme is being devised, like the idea. Do let us keep that in our minds. We want to see the patients liking the scheme of the health centre; we must find how the centres can give good service and, in the years ahead, many experiments will be tried. It may be that we shall make many mistakes, but it is our hope as I am sure hon. Members will agree that, in the course of years, we shall find the scheme that is the best. Personally, I think we shall have many alternative schemes. On the subject of beds for health centres, our idea was that, in some cases, it might be a good thing to have a health centre attached to a cottage hospital, where there are beds and where treatment can be given.
I now come to the subject of hospitals. The Debate yesterday turned more on hospitals than on anything else. I think that one of the most important things in' the scheme is the family doctor—the fact that, in every home, an adviser will be available to discuss all points of health, and assist the individual to get advice and proper treatment, if he has found either that there is something wrong or else perhaps that there is a danger which might later produce a breakdown in health. A great deal of the discussion has however turned on hospitals. I was glad that the hon. Member for North Islington (Dr. Haden Guest) mentioned the emergency medical service, because that was the first attempt in this country to get a hospital service, and not only a large number of hospitals of both sorts,, municipal and voluntary. The scheme, I would emphasise, was begun in order to give a hospital service. I remember when I first went to the Ministry of Health, more than four and a half years ago, the work done by the first Minister under whom I served. I have now served under four Ministers and I can look back to the part each Minister has contributed to the building up of what we hope this service is going to be. The right hon. and gallant Gentleman the Member for Kelvingrove (Lieut.-Colonel Elliot) did a tremendous work in the building up of the emergency medical 542 service scheme and I think I can say, looking back, that it has proved its worth. He has enabled us to bring the hospitals, both municipal and voluntary, into a common service to provide the right treatment for the particular disability of the injured or ill person. We have our common inter-hospital transport, and specialists at the different hospitals. The first time the scheme was tried to the full was after Dunkirk, and I know what an inestimable benefit it was then to the man with a head injury to be taken into a hospital where there was the particular specialist who could deal with his injury; there were other specialists to deal with other types of cases in other hospitals. That scheme has bound together the whole of the hospitals who are providing the service required by the small class of people who can be looked after under the scheme. But, all the time each hospital has kept its identity. As we go on, we are finding the good points, and also the difficulties that have to be overcome.
I was glad that my hon. Friend the Member for Sunderland referred to the part played by my next Minister the right hon. Gentleman the Member for Ross and Cromarty (Mr. M. MacDonald). At that time we had conferences on the hospital services every week at the Ministry. We were dealing with those services long before the Committee was set up, over which Sir William Beveridge presided. Then came my right hon. Friend the Chancellor of the Duchy of Lancaster who put in two years of hard spade work. The hospital surveys were made; we saw the possibilities and got down,, not perhaps to exploring avenues and turning stones, but, I would rather say, to hacking into jungles and to a good deal of quarrying.
§ Miss Horsbrugh
It was left to the present Minister to deal with the coordination of all the information we had obtained and to bring to this House the outline of this scheme which has had a vast amount of discussion and inquiry But, it is indeed, as yet, the outline of a scheme and we wish to have further discussion upon it. As I have said, in our emergency medical service scheme, both municipal and voluntary hospitals took part and there was no question of confining it to one or other but of includ- 543 ing all the hospitals of the country. That is what we want to do under the new scheme. It is not a case, as I heard some hon. Members say yesterday, of bringing in the voluntary hospitals. The whole scheme is founded on the hospitals of this country whatever they are, whether municipal or voluntary. It is on that basis that this scheme is founded; it has to take into account the individual hospitals and to see how they can best give their services to the people of this country.
We had a good many questions yesterday on the subject of finance. I think that perhaps the position has not been clearly understood. The hon. Member for North-East Leeds (Mr. Craik Henderson) talked about handing over hospitals, and also asked who arranged the payments for services rendered. I think that if he had studied page 23 of the White Paper he would have found it clearly explained there. There is a direct grant of a certain sum per bed, but all who are interested in hospital work will agree that it would be no use at all, if you are building up a service, simply to give a fiat-rate amount to every hospital, on the bed scheme. In addition to the flat rate per bed for hospitals there is payment for services, which vary from those provided by the first-class general hospital to those provided by the small cottage hospital. Different services are given, and certainly, the expenditure is very different. We all agree that very expensive equipment is required and that there are very heavy charges on the big hospitals which are doing the first-class surgery work and a great deal of other important work, which means a large outlay both for equipment and upkeep.
§ Mr. Gallacher (Fife, West)
The hon. Lady said that all hospitals were to be taken into consideration. Does this include such institutions as nature hospitals, which are outside the recognition of the British Medical Association? There are many such hospitals in the country doing good work.
§ Miss Horsbrugh
It takes in all who are registered, whether general practitioners or otherwise, but it still leaves people free either to practise as they wish outside the scheme, or for patients to go to anybody for certain types of treatment which are not provided inside the scheme. This 544 scheme deals with the registered medical practitioners and the hospitals are naturally those, which we know to-day, under the registered medical practitioners. People are able to use other schemes if they wish, and to obtain treatment—there is no control of that—as they are doing under various schemes, which some people believe are better schemes. Coming back to the point of finance, apart from the direct grant from the Exchequer, on the flat rate basis, there is the payment for services rendered. On page 23, the White Paper says:Whether the sum will be calculated in terms of beds or occupied beds, or otherwise, is for the moment immaterial. In order to avoid a large number of individual bargains, and the risk of competitive bargaining leading to undesirable results, it will be convenient for standard payments, in respect of different kinds of hospital service which involve different levels of expense, to be settled centrally. These payments will be made by the joint authorities and will fall on local rates, assisted by Exchequer grant.Therefore, there will be standard payments. I think that the hon. Member for North-East Leeds did not realise that the tariff is to be settled, not locally but centrally. Therefore, the hospital will get a direct grant from the Exchequer on the flat rate, and payment for services rendered on a tariff arranged centrally. As my right hon. and learned Friend pointed out yesterday, particular regard will need to be given, in connection with the area plan, to the position of hospitals used for clinical teaching and training of medical students. Attention was also drawn to the fact that the voluntary hospitals had been drawing large sums, and a great deal of their support, from contributory schemes. It was pointed out that this might mean the end of contributory schemes. I would suggest a better way of putting it would be to say that, the hospitals having arranged this contributory scheme policy, and such a scheme having been a success, we are now making the contributory scheme universal and compulsory. What they started, is now to be carried on. We have had contributory schemes and many other social schemes, but the very thing that they have started, and have found to be a success, is now being made universal and compulsory.
Some people suggested that it should not be compulsory but should be paid to the individual hospital. It is quite clear and was clear in our discussions at the 545 time of the Beveridge Report, that we all wish, if possible, not to put a few pence to this and a few pence to the other, and give another stamp to someone else, but to unify that contribution through the Exchequer and then have that money disbursed to the various authorities or institutions that have to use it. So, as my right hon. and learned Friend pointed out yesterday, with the direct grant from the Exchequer alone, the money coming from the contributory schemes will be more than reimbursed. I notice, when I look up some of the funds that the voluntary hospitals draw, that one column is in respect of gifts from grateful patients. We all know of the man, or woman, who goes to one of our great voluntary hospitals, who receives care, attention and sympathy, whose confidence is gripped at a time of great difficulty by those who, whether nurses or doctors, are looking after the patient. It is very natural that these gifts should be made. They show the appreciation felt by people for what has been done for them. Personally, I cannot feel that because of a new scheme in the White Paper, we should chalk off at once, anything in that column. People will still be grateful, and I know the service given in these hospitals will still be appreciated.
Mr. McNeil (Greenock)
Yesterday when the Minister was dealing with contributory associations, he used an odd phrase. He said there would be an area in which the contributory associations would still function. Would the hon. Lady care to amplify that statement?
§ Miss Horsbrugh
I think my right hon. and learned Friend in using the word "area," did not mean it geographically.
§ Miss Horsbrugh
But I can imagine that as has always been the case in our history, people will want to pay into contributory schemes for one thing or another, and there may still be things for which they can pay. It is quite possible.
§ Miss Horsbrugh
That remains for both sides to decide. After all, a contributory scheme is voluntary, and no one can be pressed to pay into any contributory scheme. Such schemes are a success only 546 because people want to pay that money, but I do not think anybody could say that any hospital running a scheme into which people were willing to pay, would say, "No, I cannot take your money," and it is quite possible that there will be further things for which people will wish to pay.
§ Dr. Haden Guest (Islington, North)
But such things would include private wards for which people pay extra fees. That is a matter not only of confidence but of policy. What is the policy of the Government?
§ Miss Horsbrugh
If the hon. Member will look at the White Paper he will see it is quite clear that the hospitals, if they wish, can have paying beds. If we give good treatment in our hospitals, if we try to make the people comfortable, and feed them well, and look after them well, surely that is the main point. They will receive that not by a payment at the time of treatment, but by paying their contribution, and by what comes from rates and taxes towards this scheme.
§ Mr. Cyril Lloyd (Dudley)
I understand the hon. Lady is now expressing the view of the Government, and that she is definitely hostile to voluntary efforts in support of the hospitals. [HON. MEMBERS: "No."] She is taking pride, in fact, that the scheme eliminates this voluntary contribution scheme and substitutes a compulsory one.
§ Miss Horsbrugh
I think the hon. Gentleman should allow me to continue. Those who know me will know that in the last 4½ years I have been in the large majority of hospitals, and that I am intensely keen that the voluntary hospital should continue as an independent unit. I believe we are helping it to do so.
§ Miss Horsbrugh
I am coming to that. I have given one instance of a voluntary scheme, the gift scheme, which is not a contributory scheme, the figures of which have been given before by my right hon. and learned Friend. After all, the voluntary hospitals, with their great history and traditions, who are receiving support from the public, were there long before there was any contributory scheme, and I believe they will go on doing that work, and we hope to assist them financially. If 547 the hon. Member will study the income of voluntary hospitals, which we have gone into very carefully, he will find that it is not derived entirely from the contributory scheme. There is the money which will be paid universally and compulsorily, and there is the direct grant from the Exchequer, but there are other funds which the hospitals get, and I believe will still get. They will get funds from individuals. Even I, who contribute in a very small way, will still contribute in order to keep that independence, that initiative, and to keep the control of the hospital in the hands of those particular people.
That is why people will contribute as they have done in the past—not merely in order to provide free accommodation for themselves if they are ill, but because they are in favour of this particular type of hospital. It was their hospital; they were interested in it, they helped its work, and contributions, donations and gifts were given for that purpose, not simply with an idea of keeping free accommodation for themselves. I want them to continue, and the Government wants to see the different types of hospitals working out by experiment and initiative the great processes we hope will be discovered for the treatment of injuries in the future. I regard the work of the voluntary hospital as private enterprise without profit. Some hon. Members opposite have sometimes said, "Ah, but private enterprise is simply based on profit." I believe a great many people in this country want private enterprise in the voluntary hospitals to continue, and it is private enterprise without profit. Those who have organised it have given great service and, I hope, will continue to give that service. They have done great public work, and I would say to the hon. Member for South Bristol (Mr. A. Walkden) that some people might have thought from his remarks yesterday, that the only persons doing public work, or giving service to the community, are those who have been elected to a local council. There are in this country to-day, any number of people who are giving first-class public service to the community. They are not elected, they are not able to give their whole time to any particular local authority, but they may have an interest in one aspect of social service, such as the hospitals. They have given great work in the past, and I believe they will give an equal interest and work in the future.
548 Some hon. Members spoke of the University Grants Committee and asked if the scheme could not be more on the lines of that committee. I wish they would develop that point more, because I cannot quite see in what way they think such a scheme is preferable to what we are putting forward. It is quite clear that we must have further discussions on the details of how the payment is to be made to the voluntary hospitals, and we might well include a pooling scheme if it is desirable. That, as hon. Members know, has already been referred to in the White Paper. Voluntary hospitals, we hope, will enter into a free contract based on reasonable conditions—and I do not think anyone has criticised the conditions in the Report—.but there will toe no interference with their autonomy, status, or identity, as long as they continue this service.
§ Mr. Messer (Tottenham, South)
Is this not the first instance of a State grant being made without any representation?
§ Miss Horsbrugh
No, there are many grants at the present time. There are the university grants, grants which are being paid to voluntary hospitals for increases of salaries of nurses, and there are grants being paid now for emergency medical services. But conditions are imposed with the grant. There will be inspection, and various conditions will be laid down, as stated in the White Paper. The grant is given on condition that certain proposals are accepted and that the right service is rendered.
The hon. Lady has emphasised the autonomy and independence of the voluntary hospitals who are asked to come into a scheme. In what way will they co-operate with other hospitals in the region?
§ Miss Horsbrugh
I think the words "coming into the scheme" have led to a good many misunderstandings. Voluntary and municipal hospitals are being asked to join in a service to give treatment to people who require it. These hospitals will contract to give treatment under certain conditions. The local authority which is responsible for the municipal hospital will be able to decide the policy of their hospital and how it has to be run, while the board of governors of the voluntary hospital will be able to decide how their hospital is to be run. 549 But there will be Government inspection of both, to see that the proper standard is maintained and that reports and accounts are rendered. Having given service for which they have contracted, the hospitals will receive certain payments.
I want to clear up this matter. The hon. Lady is, no doubt, familiar with the arrangements at present existing between voluntary and public hospitals under the emergency medical service. The hospitals co-operate; there is no question of individual hospitals having separate policies. They play ball with each other; they work with each other as one team. Is that to be continued or is it merely a question of a hospital undertaking certain responsibility and getting individual payments? What the hon. Lady has said rather frightens me. Is it to be a co-operative scheme? [HON. MEMBERS: "Speech."] Of course, it is a speech.
§ Miss Horsbrugh
I am sorry the hon. Member for North Islington (Dr. Guest) looks on me as a big bad wolf to-day. I was trying to develop the matter as a whole, but it is rather difficult when one is so frequently interrupted, I know the emergency medical services scheme well and I know that patients are accepted under contract, both by the municipal and voluntary hospitals. I know that they are working together happily in the great majority of areas and I see no reason why they should begin to quarrel now. In laying down a scheme, one must try to get clear what hospitals are contracting for a service and what the payments will be. As the hon. Gentleman realises, in each area there will be a plan, and a certain number of hospital beds will be required. Some will be required for dealing with certain specialist injuries and diseases and other beds will be needed for other specialist care. The plan is made by the joint board of the area, in consultation with the local advisory committee. When the plan has been made, it will be for a voluntary hospital, contracting with the local authority, to carry out that plan. There will be a plan for the area as to the hospital accommodation in the area. All types of hospitals will be taken into that 550 plan, and each will contract to do particular work for which it will receive payment in addition to flat-rate payment.
This is an important point. The hon. Lady said, "If the voluntary hospitals continue to do the service they already carry out." I accept that to mean that where an area plan is made, the voluntary hospital, if asked to undertake new work, would have to do it?
§ Miss Horsbrugh
No, what I meant is, "Give accommodation to the injured and sick" I am sorry if I did not make myself clear. There is nothing to force a voluntary hospital to go into a plan or to prevent it from giving service as such hospitals have done for a long time —in other words remaining as a hospital, treating people—and agreeing to the conditions laid down, and taking its share in the plan. It all comes into the plan laid down by the joint board. The board consults the local advisory committee and then the hospital will be asked to make a contract which it can refuse or accept. If it accepts it gets a flat-rate payment from the Exchequer and payment for services rendered.
§ Mr. James Griffiths (Llanelly)
Let me put a concrete case. Suppose there is a board for South Wales in an area in which there are both voluntary and public hospitals. Suppose the board works out a plan, which involves the use of all the hospitals in the area. Would one voluntary hospital be permitted to contract out?
§ Miss Horsbrugh
It need not come in. If there are not enough hospital beds in the area, the joint board must help to supply enough beds if necessary, by a new hospital, to meet the requirements of the plan.
§ Miss Horsbrugh
I think they will be pleased to come in. Capital expenditure is not referred to in the White Paper. Of course, there must be capital expenditure and the only reason why it is not referred to is that no discussion has yet taken place on the subject. It is obvious that that must be arranged. My hon. Friend the Member for East Birkenhead (Mr. Graham White) said that the scheme might put too heavy a burden on the 551 rates. Well, there is the flat-rate contribution and the Exchequer grant of 50 per cent, of the additional expenditure. But, just in the same way as voluntary hospitals are left to make up a gap, so local authorities, if they are really to have control and local interest and initiative, would also have to make up the remainder from the rates. Otherwise you will get a State service of hospitals all controlled from the centre, with an appalling uniformity and lack of local interest. Local authorities have made a tremendous push forward with their hospitals. There are municipal hospitals to-day which are second to none. There are some not so good, but a start has been made, a standard has been set, and what we want to see is that those that are not so good are able to come up to the standard and improve as we go along.
The hon. Member for South Bristol referred to the treatment of rheumatism and to convalescent treatment. We agree that rheumatism is one of our biggest failures, because we have not found a solution of the problem. There has to be a great deal more research, we do not know enough about it, but under this scheme we hope we shall get ahead in dealing with it. My right hon. and learned Friend is already asking his Medical Advisory Committee to look into the subject, to see what further research can be made and how we can co-ordinate what discoveries are already known. As to convalescent treatment, and what is now called rehabilitation, such treatment will certainly be included. As to the reason why those points are not found in the White Paper, if we had included everything, the White Paper Would have been very long, and probably quite unreadable. Our anxiety was to give an outline of the scheme, leaving the details to be discussed later We wanted the House of Commons to say, if they approved of the outline, if they thought the setting up of a health scheme as put forward in the White Paper, was good, "Go ahead with your discussions, get down to details, consider the various points which have been brought up in the Debate, and will be brought up in other discussions, and see how we can get the best service." I was glad to hear several Members say they thought the White Paper was a readable document and well-written, because those who had the job 552 of drafting it took endless trouble to get the information that was required, and without taking up too many pages, to present it in a form which, in these days, when so many papers have to be read, could be easily read. I know that the praise given to it is very much appreciated.
The hon. Members for the Scottish Universities (Sir J. Graham Kerr) and Reading (Dr. Howitt) asked whether this service would attract the best brains in the country; would young men and women feel that it was a service worth going into?; should we still get the type of people like the great leaders of the past, who had made discoveries, and worked hard and long, to find out the best treatment for a particular disease or the origin of the disease? I believe they will have far greater opportunities. I have been told over and over again, and we all know of doctors who have been almost in despair because patients come to them with illnesses already far advanced and who, if they had only been able to see the patient when the disease was beginning, would have remedied it speedily. As I go about the hospitals, and go into wards where there are cases of chronic illness and incurables, I have said to myself, "If only we could get a better health service, that number of chronic and uncurable people would be greatly diminished." They will get that opportunity.
Some things were said yesterday about the commercial view of doctors. Of course, there are good and bad, but I think a great deal has been done by many doctors without payment because they thought the individual could not pay. It has been due to their keenness to help the individual, to cure and to heal. They will find that in the new scheme they are not to be hampered by inability to pay. Schemes for research, training and teaching will give the very best possible opportunities. We shall be able to co-ordinate much of the information. There will be a great many more chances. We are going to give them the tools and I believe they will do the work better. Several Members have said the Minister has a great opportunity. He has. So have the people of the" country as a whole. If we can get the co-operation of all who will be asked to help in working the service, and that of the citizens of the country as a whole to 553 make use of the service—because we may need more education to get them to do that—I believe we shall be starting a scheme from which future generations will benefit perhaps more than any of us can realise now. I hope that, when they get it, they will sometimes look back to the year 1944 when, in the midst of a time of destruction, a time of increase of suffering, of wounds and maiming and crippling, we in this House launched a scheme to allay suffering, to get people made well and, in the middle of destruction, to do something constructive for the people of the country.
§ Mr. Arthur Greenwood (Wakefield)
The hon. Lady has had rather a difficult duty to discharge in a short space of time, and she has discharged it with greater good humour than I should have been able to show, in the face of so many interruptions. I should like to thank the right hon. and learned Gentleman and the Parliamentary Secretary for the free publicity that they have given to my constituency. I should also, at the first opportunity, like to enter my protest against the description of me by the hon. Member for Frome (Mrs. Tate) two days ago, as the "Minister for Wakefield." I am not the Minister for Wakefield, nor the Vicar of Wakefield. There is, most happily, a rather better atmosphere in the House to-day and yesterday than on Wednesday, and I think we ought to be congratulated upon that change. This is an example of team work—and I am not accusing anyone of playing off-side on this occasion, as I had to do on Wednesday. An enormous amount of work, time and labour must have been put into the scheme now before us. It has been going on a long time. It is three years since the Chancellor of the Duchy and I began preliminary discussions on many aspects of the problem dealt with in the White Paper, and we have now what is the first comprehensive approach to a National Health Service. We are presenting an extraordinary advance on the situation that obtains to-day, and it would be mean-spirited not to admit the grand conception of the scheme. We have in the last 40 or 50 years made substantial progress in the development of our health services, especially during this century. At the beginning of this century it was true to say that the field was really held by the voluntary hospitals, the poor law infirmaries and private practitioners. 554 We now have municipal hospitals, maternity centres, child welfare centres, school meals, medical inspection and treatment of school children, and a broad system, though not satisfactory, of National Health Insurance. We have in the clumsy way we adopt in this country stumbled on from one experiment to another.
Now we have a scheme that does, at any rate, carry us a very considerable way. There are points, of course, which my hon. Friend said were not referred to or emphasised in the White Paper, which are of considerable importance. The Parliamentary Secretary seems fairly optimistic with regard to the supply of medical men, and I hope her view is a right one. My own view is that the young men in the medical profession now on war service will feel a new pride in their profession when this scheme gets going. It may be an encouragement to other people to come in. We shall need proportionately more members of the medical profession in the future. It ought now to be possible for every medical practitioner to have a decent holiday every summer and, say, every three years to have a refresher re-training course of three months—a scheme with the development of which I had something to do when I was Minister of Health. If we are to give proper conditions and leisure to the medical profession, which is often now unfortunately too overworked, and if we are to give them the opportunity, with all the new developments of medical science, to become familiar with new methods of treatment, we shall require a bigger personnel in the profession. That must always be borne in mind. That being so, we are faced in addition with an extension of the provision for medical teaching. I do not believe, in view of the numbers of the profession which will be required and the responsibility which will be cast upon them under this scheme, that the existing teaching hospitals will be adequate.
I hope that when the scheme is worked out there will be a section of it dealing with the co-ordination and development of medical research in all its many aspects. That, no doubt, is not a subject which could be amplified in the White Paper, but one feels that there must be coordination and a greater development of medical research than in the past. 555 Rheumatism has been mentioned as one case in point, but one could give thousands of cases where there is need for far more intensive research and on a larger scale than has been the case in the past. One rather gathers from the White Paper that there may be some delay in this. I would hope that the provision of both dental and optical treatment will be proceeded with as quickly as possible. There may be difficulty with regard to personnel and so on, but, speaking as one with very defective eyesight, and observing the large number of people who suffer in the same way, I think that the development of optical treatment from childhood onwards would be a distinct human advantage to a large number of people. The same, of course, is true of dental treatment. We could save ourselves a good deal of medical treatment subsequently if we had an effective system of dental treatment as widely dispersed as ordinary medical treatment.
I would like to see a little more prominent place, when the details are worked out, given to the question of mental treatment. Mental treatment seems always to have been the Cinderella of the health service. I know it is intended that it should be part of the scheme, but I hope there will be no delay in the matter because we are very much behind and very old-fashioned. When I abolished the term "lunatic asylum" by Act of Parliament, I did it for a psychological reason. There is nothing disgraceful, nothing that can be shown up against one, if one happens to suffer from mental disease. It is not a crime, it is an illness, and there is many a man who has suffered from mental disease who is better than men who have suffered from gout at the other extremity. One feels that mental treatment has rather been neglected. It is a terrible thing to go round a mental hospital. One sees the most tragic sights and one feels that it is a human problem and ought to be put well in the forefront.
It is clear from the criticisms that have been made in the House there are certain fears with regard to voluntary hospitals. Some sections of the medical profession appear also to be very anxious about their future. We cannot stay still in this matter. We had to obtain a full national health service sooner or later, and this scheme has proceeded by the method 556 described by hon. and right hon. Friends yesterday as a process of natural evolution. One cannot expect in these days the voluntary hospitals to play quite the part that they did when they were the only hospital agencies in the country. Nor can we expect them in these days of extraordinarily expensive equipment and of higher standards of treatment, with all the added charges, to be in all cases able to enjoy quite the same amount of independence as in the past, because of increasing financial difficulties. There is nothing more disgraceful than to see flag-days for voluntary hospitals. Therefore, their position does alter. It does not necessarily mean that in an organised coordinated scheme they are not still able to exercise a certain amount of initiative. As my hon. Friend said, the voluntary hospitals could stay out but would not. If they were to attempt to stand out it would be an act showing very little public spirit. If this scheme is to work at all it can only work effectively on a basis of good will.
As regards the future of the medical profession, they and the lawyers are shining examples of 100 per cent, trade unionism—an absolutely closed shop and a model for my industrial friends. The medical profession, quite rightly, takes a pride in its profession, and, quite rightly, would dislike excessive interference, but it is nevertheless true that a very large number of doctors are under a good deal of enforced discipline during wartime in one or other of the Fighting Services, whether as combatants or as non-combatants, and a little healthy self-discipline would, perhaps, be all to the good. They cannot evade their responsibilities under the scheme. After all, this profession is a servant of the people, it exists for the public good, and therefore, in my humble submission, the doctors cannot be the final factor in determining the future of this scheme, nor, indeed, can the voluntary hospitals. Health is the very basis of our national life. All God's creatures are morally entitled to what science and skill can do to prevent disease, ill-health, disability, unnecessary suffering and premature death, and I should have thought that, on consideration, both the voluntary hospitals and the medical profession would agree that the Government have tried to do a good job with a minimum of upset to the nerves of the medical profession and the boards of voluntary hospitals.
557 Let me say a word or two with regard to the Amendment which was placed on the Order Paper. It is a most comprehensive Amendment, so comprehensive as to cover almost the whole of the Government's responsibilities in the post-war situation. It refers to full employment, better housing and nutrition, and that is a fair dose to put into an Amendment, but it is undoubtedly true, and Sir William Beveridge made it clear, that we could not get an effective scheme of social security unless we did tackle the problem of mass unemployment, developed a National Health Service and. established children's allowances. This scheme is a contribution to one aspect of the matter, and it is not fair criticism of the Government to say in an Amendment that it is regretted that there are no proposals in the White Paper for dealing with full employment. Of course that does draw attention to the fact that the National Health Service does not stand alone. A good deal does depend upon a proper standard of nutrition among our people, it does depend on abolishing, as far as we can, material poverty from the homes of the people, because, as Sir William Beveridge pointed out, the need for children's allowances arises from poverty in homes where families are large. That leads to the question of housing, which we discussed with some little heat two days ago. With adequate housing the strain on the medical profession would decrease enormously. I have no doubt the amount of rheumatism would diminish if there were clean, dry, healthy homes, and that applies to a good many other diseases.
My hon. Friends and I accept the scheme as a very substantial instalment of a bold public health service. It is, to us, in the nature of a compromise. To some hon. Members it is a bitter pill to swallow, but we regard it as a great contribution towards the kind of plan which we, in the fullness of time, would like to see established in this country. I express to my right hon. and learned Friend, who will be engaged in somewhat difficult negotations—because doctors can be disputatious as I know to my cost—the hope that the Government will not falter or weaken in those negotiations. When the Bill comes before the House, and I trust that it will not be too late in appearing, I hope that it will not be subjected to a process of erosion by those who do not 558 like every aspect of it. I should hope that the medical profession, on consideration, will see that this does not endanger their future, but ennobles it; and I hope the voluntary hospitals will realise that it gives them a wider sphere of activities than they have enjoyed in the past. If that be the spirit, then my hon. Friends on this side of the House will make their contribution to putting the Bill upon the Statute Book. But I am bound to give this warning, as I did with regard to the Education Bill. If this White Paper is to be whittled away in the House we shall resist every attempt to weaken it. That I must say. I have paid as generous a tribute as I think anybody could pay to the White Paper, and I mean it, and I believe in it heartily and I hope the House of Commons will treat this as a great opportunity to do much for the masses of our people.
§ Mr. Speaker
It may be for the convenience of hon. Members if I tell them now that I propose, in about an hour and a half's time, to switch the Debate over to the Scottish Members. I would, therefore, point out to hon. Members that if we have speeches of the length of some of the speeches yesterday very few Members will get a chance of taking part in the Debate, and perhaps they will be ready to curtail their speeches somewhat.
§ Sir Arnold Gridley (Stockport)
I gathered, Mr. Speaker, that you had decided not to call the Amendment standing on the Order Paper in the name of my hon. Friends and myself, and therefore I was a little astonished to hear it referred to by the right hon. Gentleman the Member for Wakefield (Mr. Greenwood). I realise that you will consider it to be my duty to keep as far as possible from that Amendment, and I will endeavour to do so. Like other speakers I welcome wholeheartedly the White Paper proposals outlining the Government's plan for bringing in a National Health Service, but there is a good deal left out of that White Paper. I made a list, which I do not propose to read in response to your request that we should be as brief as possible, of n items, and they include a number of most important matters that will have to be discussed by the Minister with the various interests who will need to be brought into consultation. We shall not be able to give really full consideration to the whole 559 scheme until further important details have been filled in. No one will be so foolish as to deny the great importance of having as an objective the creation of an A.1 standard for our people. If is uneconomic to have workmen who are constantly absent from work owing to ill health, and the sickly wife and mother in the home is uneconomic. To have puny and ailing children likely to grow up into weak parents, producing weakly offspring, is not in the national interest. There must, therefore, be general agreement that it is our duty to provide the best possible National Health Service which it is within the capacity of all to pay for. As the Minister properly pointed out yesterday, it is a misnomer to call this a free-for-all service. It is not a free service; every one of us will have to pay his contribution towards the cost.
A criticism which I have heard generally expressed outside is that we in this House so constantly put the carts before the horses in our legislative proposals. The criticism of these proposals is not against them as proposals for dealing with a. problem which we have to tackle, but that we are not giving that proper attention to the root causes which make so large a part of our population C.3 instead of A.1. The right hon. Member for Wakefield referred to the root causes of the present unsatisfactory state of the national health, and I shall not develop them, but there is no question that the present state of affairs is largely due to the fact that during the last 20 years we suffered so much from underemployment and therefore from lack of proper nutrition for so large a proportion of our working people and their children. The evacuation of our children to the country revealed that many of them had been quite improperly fed in the past and found it most difficult to accustom themselves to the right type of food which they are now getting in the country. What chance have children born and brought tip in such circumstances and in unhealthy housing conditions of coming into this world as A.1 grade or of achieving an A.1 status as time goes on? Sound health depends upon the children having a really good start in life, and this means, first, that the breadwinner, that is the father and husband, must be reasonably secure of 560 employment at good wages, so that he can feed and house his family properly— when we have provided the so urgently-needed housing.
While following your request to be brief, Mr. Speaker, I would say a word or two about voluntary hospitals and voluntary contributory schemes. I was genuinely sorry for the Parliamentary Secretary when she was rowing her Ministry of Health boat in such troubled waters a few moments ago in trying to explain how the voluntary hospitals and the contributory schemes might have some hope of continuing. In my view the White Paper proposals, while paying lip service to the voluntary hospitals and their contributory schemes, sound the death knell of the voluntary hospitals as we have known them. We run the gravest risk of losing the value of work which has been of inestimable benefit to this nation for hundreds of years. If we all have to contribute the same number of shillings per week for the social security services, part of which money is to be earmarked as a hospital contribution, few people will see the necessity of continuing their payments under voluntary contribution schemes.
The White Paper envisages, quite rightly and inevitably, that the system by which patients when they had had hospital treatment contributed towards the cost of that treatment what they could afford to pay will disappear. Already, people who, in their wills, had left legacies to hospitals, and others who intended to do so, are asking whether, in the circumstances, they should not revise their wills, or abandon their intention to leave important sums to hospitals, because if the hospitals are to come under the State there would be no necessity for that kind of philanthropic action in the future. There are three sources of revenue on which voluntary hospitals have hitherto depended, namely, the voluntary contributory scheme, the system by which treated patients contributed as much as they could afford to pay and gifts from those better able to afford large sums. From these sources the hospitals were enjoying a revenue of no less than £18,500,000 a year. Therefore, I ask, how can the voluntary hospitals be expected to survive unless some way can be found to rescue them? The White Paper proposals certainly do not provide such a way.
561 I would say emphatically to my right hon. and learned Friend the Minister that if the Govt, seek to frame a Bill, based on their White Paper proposals, it will not be acceptable to a great mass of the people of this country, unless the continuance of the voluntary hospital system is, somehow, assured. I hope when the Bill comes forward, we shall see some concrete plan which will save such a. valuable and long-established British institution and part of our national life. May I remind the House of what the Home Secretary said on this point when he intervened on the memorable third day of the Debate on the Beveridge Report? In regard to the proposed hospital services the right hon. Gentleman said this:This is a country in which it is well to understand that there will always be a lot of voluntary effort of one sort and another— voluntary effort, voluntary social service, voluntary public service. If it dies in this country, British democracy is dead. That is not to say that voluntary hospitals ought necessarily to be preserved. They could all be taken over by the municipality. I nearly had the offer to take them over in London, but I found they were doing good work and that for me to take them over, would cost the ratepayers a is. 6d. county rate. Being a good financier I said that could be post poned. But is a voluntary hospital necessarily wrong? There are voluntary hospitals in mining communities to which the miners often attach the utmost value even to the point? that in one case they did not appropriate the Poor Law hospital under the Public Health Act, because they did not want to injure the voluntary hospital they had been running. Therefore, it is not necessarily a crime if voluntary hospitals—Here the right hon. Gentleman apparently was in disagreement with his friends because there was interruption. He went on to say:The Government thought it right that they should intimate that they did not propose to destroy the institution of voluntary hospitals, and I can assure the House that if the Government declared that it was going to destroy them, then indeed some controversy would develop over this matter."—[OFFICIAL REPORT, 18th February, 1943; col. 2040, Vol. 386.]I ask the House and I ask the Minister and his Parliamentary Secretary, and those who advise him in his Department, to give attention to what the Home Secretary said on that occasion. It profoundly impressed the House. To sum up, I would say this. We should certainly seek to provide the best national health service which the nation requires. It will, as has been said already in this Debate, take 562 some years to bring any plan to full fruition, because doctors and dentists will not be available in adequate numbers to meet the demand for their services. Therefore, let us proceed on wise and prudent lines, and in the intervening period, deal with the root causes of ill-health, namely, unemployment, bad housing and malnutrition. In my judgment, it is in that way that we can best hope to raise the great majority of our people to an A.1 status, and therefore lessen the need for costly provision of curative treatment. I would end by quoting four lines from Dryden:Better to hunt in fields for health un-bought,Than fee the doctor for a nauseous draught.The wise, for cure, on exercise depend; God never made His work for man to mend.
§ Mr. Messer (Tottenham, South)
I want to follow your very good advice, Mr. Speaker, and say what I have to say in as few words as possible, though I cannot, in my heart, condemn those who have made long speeches because the White Paper provides the material for long speeches. I shall have to leave out a great deal of what I had prepared, in the hope that, when the Bill is produced, there will be opportunity to repair the omissions. I cannot follow the hon. Member who has just spoken. As I read the White Paper, the voluntary hospitals are going to be saved. A life-belt has been thrown to them. They were in the process of going out of existence. The truth is they are not any longer voluntary hospitals. The White Paper mentions two systems, the voluntary hospital system and the municipal hospital system, but in this country there has not been any voluntary hospital system. Voluntary hospitals have not been following a system. They have been a series of separate units, unco-ordinated, working separate from any thing, and anybody else. Neither have the municipal hospitals been working on a system. In some parts of the country you will find municipal hospitals of as high a standard as can be found. But in other parts of the country, public hospitals are the last word in a despairing effort to dodge one's obligations.
It is these things which make necessary the proposals in the White Paper. The first consideration must be the health of the people, not the interests, either of those mandarins of the parish pump or 563 those very often self-appointed governors of voluntary hospitals. The White Paper has attempted to do a very clever piece of work. The Government met representatives of various interests, and discussed the problems with them, and the White Paper has gone a long way towards meeting the claims of certain interests. I notice that the hon. Member for London University (Sir E. Graham-Little), in the early part of this discussion, said that public announcements had been made by the medical profession, although those consultations ought to have been quite confidential.
§ Sir Ernest Graham-Little (London University)
I did not say that. What I said, as the hon. Member will see in the OFFICIAL REPORT, was that the public Press published a very explicit description of what was proposed.
§ Mr. Messer
That only means that doctors who were being consulted must have divulged what was happening. The Government also met the representatives of local authorities, and they did not divulge anything. I think the Government did quite right to meet the separate interests, and get, as far as possible, their observations on how this plan would work out. No one, I think, will say he is completely satisfied with the White Paper. We live in an imperfect world, and with what measure of ability we possess in the country we have to move towards our objective, and in the process we have to compromise.
There axe, however, things in the White Paper which make all minor points fade into insignificance. In the first place, anybody who needs it will be able to get a bed in hospital without any question of ability to pay being raised. That is most important. There has been nothing so humiliating as the inquisition which a patient has had to endure in the past. "How much do you earn? How much rent do you pay? To what trade union do you belong? To how many sick clubs do you contribute?" Then there is an assessment of the patient's contribution towards his maintenance while in hospital. That happens both in municipal and voluntary hospitals. I wonder if anybody can understand the state of mind of such a patient, who realises that, while he is in hospital, money has to be found for his maintenance. It causes a desire to get 564 out as speedily as possible, because he cannot afford to go on paying, and that is not helpful towards recovery. We have been told that we must not be misled into thinking that we are not paying. Of course we are paying, but paying by the right method of equal distribution of liability, for the health of the nation. Is not that the right way to do it? Is it not right that those who enjoy good health should contribute to the restoration of those not so fortunate? I think that one thing alone makes the White Paper worth while.
Then there is in the White Paper provision for a measure of co-ordination. I am not sure that I like the type of administration proposed. I do not like ad hoc bodies. I remember that all who were interested in the development of local government thought it a good thing when such bodies as the Metropolitan Asylums Board and the London School Board were abolished. Joint boards are not the best way, and I think the Government must, sooner or later, undertake a reorganisation of the machinery of local government. We have started in education where there is to be a different type of service. Now, we are dealing with health and there is a danger that we may get a series of unilateral local government units, unconnected with each other, which would be bad. Although the White Paper calls this a comprehensive health service, in point of fact it is not. It is, in reality, an extension of the medical service. I regard health as divided, broadly, into three parts: the preventive and environmental health service; the curative and remedial service, which is that of the White Paper; and what one may term the restorative and rehabilitation service. They should be connected, but the White Paper does not connect them. What is to happen with the joint committees of the county councils? They will be divorced from the housing authorities. Where these joint boards include county borough councils, that will not be so, but the county councils are not housing authorities. We are to give these joint boards responsibility for building tuberculosis sanatoria, but not the power to build a house. I cannot afford the time now to read a letter which I have received from the medical officer of health of a county council, but perhaps I may be permitted to quote from it. It includes a letter from somebody else to him, com- 565 plaining of the condition of a house. The letter stated that the condition of the house was so damp that the paper peeled from the wall. It went on:One of my daughters had pneumonia, which turned to T.B., and she died at 19. I have seven in family. It is impossible to leave my youngest girls, twins, age 12, at home, because the house is infested with rats.The medical officer of health of the county council had to write back and say:I regret very much that I cannot help you, as we are not a housing authority.You cannot, logically, separate housing from health. The environmental services —sanitation, drainage, water and such things—come into the sphere of health. I would prefer to see a comprehensive health service, in the sense of having a body that would deal with every aspect of it. The White Paper leaves out of account services rendered by the present health authorities. Possibly we shall get a change in the course of time in our system of local government which will come nearer to the ideal.
As I read the White Paper, I see in my mind a very big addition to the number of patients who will come for treatment. They will be able to get treatment without the necessity of putting their hands into their pockets immediately for it. They wanted it before, but they could never afford it. The panel system dealt with only one member of a family, or at any rate with the members of the family who were employed. It did not deal with the wives, or with the children under working age. Large numbers of people may need hospital treatment who have not taken advantage of whatever facilities there were, as they would be called upon to pay for it. That means that there will be a big accession to the number of patients—not because there will be more disease. There will be more people getting treatment, and possibly they will have a longer stay in hospital. One of the results of the bed shortage at the present time is that large numbers of people are discharged from hospital long before they ought to be, especially a few types of surgical case. I go so far as to say that I welcome wholeheartedly the system of health services, and of what is called in. London the polyclinic, which is a health centre or multilateral clinic to which people can go to find out whether they are ill. That is a very valuable thing. If the case is a minor one, the people 566 can be treated, but if it is a case that needs care in a hospital the case can be sent to the appropriate hospital within the area of the plan. That is all to the good. Because we shall have that big addition to the number of patients, we shall want a big addition to the number of doctors. I am sorry that Sir William Goodenough's Committee could not have reported in time for the report to be embodied in the White Paper. It deals with the medical schools and the teaching hospitals.
I have long held the view that a great deal of very good work could be done if some of our municipal hospitals were medical teaching schools. The truth is that there is a wider variety of clinical material in a municipal hospital than in many voluntary hospitals. The voluntary hospitals have done good work, and I want to praise them for it. They are the foundation upon which our hospitals have been built, and our municipal hospitals owe a great deal to the work that has been done by them. The voluntary hospitals are not anxious to take chronic cases. They are not anxious to take T.B. or carcinomatous cases, but in municipal hospitals, where there are these cases, there is excellent clinical material for the training of students. I heard the hon. Lady say that there was a shortage of teachers, but she did not say what sort of teacher, whether lecturer, undergraduate or post-graduate. The emergency medical hospital service which has been running has shown the advantage which can be gained by using the municipal hospitals. The London Hospital was evacuated, and part of their students went to a hospital known as Chase Farm. After a time, the London Hospital came back to London. The students wrote a letter expressing their regret that they were no longer able to take advantage of the excellent teaching opportunities at the hospital, where the medical superintendent had a high standard and high qualifications and was quite competent to teach the students. There is a bottleneck in this connection, and I hope that when we get the Goodenough committee's report we shall see in it recommedations for the use of the municipal hospitals for training. Let nobody get it into his head that you cannot get as good a service from a municipal hospital as from a voluntary hospital. Both largely depend upon the type of people who manage things. There 567 are 30 county councils in this country who have not taken full advantage of their powers under the 1929 Act. There are 30 county borough councils in the same position. Obviously, the people on those authorities have not been doing the job that they ought to have done. That sort of position justifies this White Paper.
I have always hated the term "State medical service." I have never wanted this very personal service to be run from Whitehall. I have always felt that the rigidity, the lack of elasticity and of variation that was bound to result from a service of that description, would be against the best interests of the patient. I want to speak, therefore, about the administrative machine. It is quite right that the State should come into it. For the first time, the State has recognised its responsibility to the extent of coming in financially. Education has received State grants in the past, but health never. The local health authority gets nothing for the work it does for the State. It has to work entirely out of public funds. I hope that the question of finance will engage the attention of the Minister. We are to have as the basis of finance for this service, a grant from the State. We are to have a grant from the Insurance Fund, and the balance is to be made up from rates. I would like to know what is to decide the size of the grant from the State. It must not be per capita and it must not be according to bed capacity. It must take into consideration the different rateable values, per head of the population. For example, in Lancashire there will be 5,000,000 people. The Lancashire County Council will be responsible for 2,000,000 and 16 county boroughs will be responsible for the other 3,000,000. Those county boroughs can raise more rates than the county council.
I know that in the county the rates will be spread over a wider area, but look at some of the areas that will have to be grouped. The Lancashire County Council, with a population of 2,000,000, can raise £40,000 by a 1d. rate. Middlesex County Council, with a population of 2,000,000, can raise £82,000 by a 1d. rate. Clearly, Middlesex can give better service because it gets more money per head of the population. That fact will have to be taken into consideration. Take East Anglia. When we group East Anglia, we shall find 568 that we have a lot of small populated poor districts, ranging from the Isle of Ely and the Soke of Peterborough, to Huntingdon —if that is to be included in East Anglia. Rutland, I imagine, would be included with Leicester. There will be a grouping of areas, all of which are capable of raising only a small amount of money per head of the population by a 1d. rate. The State grant will have to take into consideration some method whereby every member of the community, in all parts of the country, will be entitled to equality of service, and it must not press too hardly on the finances of the local authority.
I promised not to speak at great length. I must apologise for the time I have already taken up. There is one other point in the White Paper to which I desire to make reference. I hope that after it has been given a trial, reasons will be found for changing it. I refer to the dual system that is likely to operate in the health centres. We are to have a full-time salaried service for the doctors who can come in, and a part-time salaried service for those, who, if they desire to do so, can also have private patients. I believe that to be wholly bad. It will be far better for the general practitioner who; does not want to come into the scheme to stop out of it. I would not refuse him the right of following up his patients who come into the hospital. That might be arranged, but I look with misgiving on the possibility of having two doctors in a health centre, one who has a private practice, working next to one who has no private practice, with the opportunities that there may be for the selection of patients by the doctor. A lot of nonsense is being talked by critics of this White Paper about the patient's choice of doctor. How far does that extend? When once a workman gets on the register of a panel doctor, he finds it very difficult to change, and he has not chosen that doctor; he has automatically gone to him because he happened to live near the doctor's practice. In the villages what choice of doctor is there? Very often there is only one doctor to a large number of villages.
I apologise again for having spoken so long. But, I did desire to deal with that point of choice of doctor because I have seen so many patients come to a municipal hospital where it has not been a matter of wanting to choose a doctor 569 but of getting the best doctor for their particular type of case. I am not sure that in such a case it is always a good thing to choose one's doctor. One does not know what is wrong, or the best man to deal with it. This very personal service, this profession cannot be compared with any other profession, because of the type of work concerned. The doctor's intimate relationship with the patients and the confidence that is necessary, take it right outside the possibilities of comparison with any other profession. Realising all that, the White Paper does give a free choice of doctor, and to the extent that that can be made, I would not quarrel with it, but I want to make the point that it is not as important as is assumed in many quarters.
There is just one other point I wish to make. It is not usual for laymen, and especially laymen doing local administrative work, to welcome the idea of giving technicians, experts and professional people, freedom of action. I mention that because I want to say how glad I am that, in the White Paper, the Minister proposes to set up a National Medical Committee. I have seen laymen appoint doctors, and laymen are inclined to appoint doctors because of the colour of their eyes, and their appearance, or even the glib tongues they may possess. I welcome the idea of that medical committee sending down a short list when appointments need to be made, so that from that short list the best appointment can be made. I welcome the joint consultative committee. I welcome the inspectorate. It is a strange thing that in the case of a poor law institution, with people lying in bed in the chronic wards, the Minister of Health sends down an inspector, but in the case of a municipal hospital, one never sees an inspector, no matter what standard of work is done. I am glad that the Minister is to see that there will be an inspectorate of the major health authority. That is all to the good. I welcome the White Paper. I hope we shall see a Bill introduced based on it and I hope we shall bring within the reach of every man and woman the right which God gave them, and which man has no right to take away—the right to live.
§ Sir Henry Morris-Jones (Denbigh)
I quite agree with the hon. Gentleman who 570 has just spoken that it is very difficult to make a short speech on this White Paper. Although I know that he has great knowledge of this subject, he did not quite resist the temptation, if I may be allowed to say so, of enlarging on it rather more than the time of the House would allow. I hope I shall fall in with your request, Mr. Speaker, in view of the very short time left to Members in this House. I think this White Paper is the ablest State Paper I have ever read, as a Paper. Its author is a complete master of his subject. One hears sometimes that civil servants do not possess any soul. Whoever wrote this Paper, has a great soul. He seemed to have been enthused, as he developed the theme, in the course of the White Paper, until even the elaborate details of this scheme fell into a very clear and happy picture, a co-ordinated whole. In fact, the author of this White Paper builds a very fine architectural edifice—on paper. But we have to realise that the material with which he is dealing are the lives of the people of this country, 47,000,000 people, with their individual minds and bodies, individual perspectives and idiosyncrasies. From that point of view, no proposals embodied in any White Paper, can expect to be a complete success if it is intended to marshal the whole nation into any scheme, which the nation itself, as such, does not want.
The present Minister is, naturally, responsible for the White Paper, but I am quite sure that it shows, to some extent, the hand of his predecessor, the Chancellor of the Duchy of Lancaster. It was he who was sent out to prospect the land. It was he who sailed into the mine-field originally, and I think it speaks very well, not only for my right hon. Friend's persistence and agility, but also for his sagacity and ability, that he caused as few detonations and explosions as he did when he was dealing with such an explosive subject. I wish to submit to the House that this is the greatest social scheme ever attempted in this country. It dwarfs by a long way the National Health Insurance scheme of 1912. No other country at the present time has attempted a scheme of this character, except Russia. My right hon. and learned Friend said that it is going to place in front of the nation a health service on a communal basis. Even our gas and electricity we pay for; we have 571 to, pay for our water supply in this country, in many cases according to the amount of water we use. Some of the roads of this country are not altogether free. But my right hon. and learned Friend is to provide for the people of this country, free doctoring for everybody, not only for those who need it, but also for those who do not want it. My right hon. and learned Friend is in this scheme replacing what has been a personal service in this nation, by a State national service. That is what it comes to. It will not immediately be a State national service, but it will be a State national service at one very short remove.
The Leader of the Labour Party rather let the cat out of the bag when he said to-day that we must have a State service sooner or later. I rather cavilled at the remark of my right hon. Friend when he went on to say that the doctors of this country cannot be factors in holding up this scheme. Would he say the same thing to the miners? I say that the medical profession of this country are more vitally affected by this scheme, by the proposals in this White Paper, than the miners have been in any Bill that has ever been before this House.
§ Sir H. Morris-Jones
My right hon. Friend the Member of the Labour Party is an ex-Minister of Health and has dealt with doctors himself. That was not the way my right hon. Friend the Chancellor of the Duchy dealt with them. He dealt with them, with perspicacity and tact.
Although I welcome the White Paper in many respects, the enthusiasm we see for the scheme on the Labour Benches is not likely to commend it to those of us on this side of the House who are individualistic, and who are believers in freedom and private initiative. I would advise hon. Members not to continue to display the enthusiasm they have shown already. I would have preferred it if the scheme had been confined to those who need it but I do not quarrel with the far more ambitious scheme of my right hon. and learned Friend in this extremely ably written White Paper, provided that he adheres, inexorably and without faltering, to those principles enunciated on page 47 572 —the four freedoms mentioned in the White Paper. What are they? The first is the freedom of people to come in or not—to come in as they wish, not only for the people of this country, but also for the medical profession of this country.
§ Sir H. Morris Jones
The second freedom is absolute free choice, for every patient in this country, of the doctor he or she wants, incidentally not ruling out a choice for the medical man. It has always been there, and I trust it will remain. The third freedom is professional, that is to say the right of a medical man or woman to diagnose, prescribe and treat in his or her own sphere, without any interference from any lay individual. The last freedom mentioned on page 47 is that the family doctor basis should be retained. If these freedoms are not maintained, this scheme will break down, because this country is the most individualistic country in the world. If the scheme is a success, there will have been a complete abolition, practically, of private practice in this country. If we find private practice flourishing in this country five years after the scheme has been introduced, it means that the scheme is a failure, and that it would have been better for it never to have been introduced.
I want to refer to Wales, where the conditions will be very difficult under this scheme. I notice that in the White Paper there is no mention of the Welsh Board of Health. I do not know whether that is due to complete satisfaction with the work of the Board, or complete ignorance of what it is doing—at any rate, no great intention is shown of patting the Board on the back. Wales is a separate country; it is a principality; it is a nation. In South Wales the position will be fairly easy; there is a medical school in Cardiff. North Wales is an entirely different portion of the principality. It has no town with more than 25,000 population, as in Colwyn Bay, and no very large hospitals. It may be that North Wales will have to be amalgamated with Lancashire or Cheshire. That will go against the true national feeling of Wales. I hope that my right hon. and learned Friend will pay very special attention to the position in North Wales. The voluntary hospitals have already been mentioned, and I trust that my right hon. and learned Friend will consider them. They, after all, are 573 the fundamental institutions on which this country has depended. For generations the medical profession has been educated at these hospitals. Every doctor who has made any discovery in the realms of science has been brought up in the freedom which is the basis of these hospitals. I trust that an adequate financial arrangement will be made for them.
There is an element of compulsion in the White Paper. I do not like it. The hon. Lady the Parliamentary Secretary, in her introductory speech, tried to get away from it, but under these proposals a medical man, practising in an industrial centre, whose wife is an invalid, and who wants to change to a seaside resort, will not be able to do it if the authorities object. He is completely in the hands of the Central Medical Board in London, and if they do not allow him to go he will have to stay where he is. There is the additional element of compulsion that young doctors who qualify must go into the health centres. They must serve for a period as assistants. The hon. Lady—although I greatly admire her and the very fine work she has done for the Ministry—was not very happy when she said to-day that, in the event of doctors being dissatisfied, there are always the Colonies for them to go to. I trust that the scheme will not be of such a character as to drive many of our doctors to go to the Colonies.
§ Sir H. Morris-Jones
I quite agree, but I do not want any Minister to get up and say, as a recommendation for this scheme, that there is always a way of getting out by going to the Colonies. The other day, Mr. Nash, whom we all esteem for his work in New Zealand, addressing the Labour Party, said that he hoped that this country would have a salaried State medical service.
§ Sir H. Morris-Jones
I am quoting from a report in "The Times." I might remind the House that the New Zealand doctors have totally and resolutely declined a salaried State-service.
§ Mr. G. Griffiths
Will the hon. Member quote him fully, now that he has half-quoted him? The doctors in New Zealand have not totally declined; there are doctors there working such a scheme. That was the statement which was made by Mr Nash himself. I will tell the hon. Member that now, although it was a secret meeting.
§ Sir H. Morris-Jones
I read the report, and I have quoted it quite accurately. I am not going to adumbrate further this question, save to say that what the doctors of New Zealand have declined, the doctors of this country are not likely to adopt. As I said before, this White Paper is beautifully written, and there are great ideals under it.
§ Sir H. Morris-Jones
We admire the conception of it. It all depends upon the administration of it, whether it becomes a success or not. I want to commend those parts in it which are idealistic, namely, the fight against disease in this country, and the great fight, after Germany is beaten, to postpone death in this country for every individual for as long as we can. I only want to warn my right hon. and learned Friend the Minister of Health that great as this conception is, idealistic as it is, much as we admire it, we must watch right through all the stages of negotiation, and right through the passage of the Bill —I trust that it will not be introduced until consultation has taken place with the men in the Services who are affected by it —and after the Bill becomes an Act, to see that the freedom and liberty which we have cherished in this country shall not be thrown away.
§ Mr. Silkin (Camberwell, Peckham)
I want to say a few words, particularly in reply to my hon. Friend the Member for Denbigh (Sir H. Morris-Jones). He seems to feel that this scheme is to be condemned because it has been received enthusiastically from this side of the House. While we accept the principle of comprehensiveness with enthusiasm, there is a great deal in the White Paper that we do not accept with enthusiasm. I hope that the Minister will appreciate that we recognise that this White Paper is a compromise, an honest attempt to reconcile strongly-conflicting points of view, and that it cannot please all sides.
575 I am not at all happy about the position of the private practitioner. It seems quite unfair, even to the practitioner, to expect him, on the one hand, to be a public servant, and, at the same time, to receive private patients. No man can be half-slave and half-free; and that is to be the position of the private practitioner. What is the bait to be offered to an individual to become a private patient, instead of a patient under the national system? The private doctor is going to be in a great difficulty, because he has to offer to the private patient some extra inducement to be a private patient. I find it difficult to understand what other inducement there can be than the offer of better service, and such an offer would be in complete conflict with the White Paper, which clearly says that the service is not to be any worse because the patient is a national patient. Then, we are very much opposed to the buying and selling of practices. We think there is something abhorrent in buying and selling lists of patients en bloc. The White Paper does not abolish this principle, except in cases where a doctor decides to enter a health centre, or where it is decided that there are too many doctors in an area. I should like to have the point clarified as to whether when a doctor goes into the system and receives a large addition of patients, as of course he will, that addition will become an asset which will be saleable. As I read the White Paper, the moment the principle has come into operation and there is an addition to the number of patients on the doctor's list, he acquires a right to sell, and the State has made him a present of a considerable sum of money. If that is the case, what compensation is the State going to get for making the doctor a present of so large an addition to the value of the practice? If it is not the case, how are you going to distinguish between the value of the practice before the scheme came into operation and the value, which will accrue by reason of the additional patients?
Something has been said about regimentation. I for myself do not understand what is behind the allegation that this scheme will regiment the doctors. I should have thought that the doctor would have been quite free under this system to treat his patients as he thought fit. There is not the slightest suggestion 576 of any interference. The State, which is to be responsible for a large part of the remuneration of the doctor, has a right to insist that the doctor shall be efficient and continues to be efficient, but, subject to that, there is no right, on the part of the State, to interfere with the actual relationship of doctor and patient; and such a thing is not suggested.
One word about voluntary hospitals, I recognise that a change is proposed in the relationship of the voluntary hospital to the municipal hospital, and that, if the voluntary hospital wants to come in, it will then become part of the national system. But I feel that, if the State is to provide a large part of the finances of the voluntary hospitals, then it has some right to take a part in their administration. I think that is inevitable. I agree with those who feel that the voluntary hospitals ought to be autonomous, but if the State provides a large part of the money, I think their autonomy must go, to a certain extent. I think they ought to have freedom in the general policy and management of the hospitals, but I think they must be subject to a certain amount of public control, and I feel that the voluntary hospitals will have to face that fact. Something has been said about the shortage of beds that will arise. I should like to suggest to the Ministry that there are a great many patients in the hospitals to-day occupying a few beds who ought not to be doing so, and who could be removed to convalescent hospitals, or other places. There are the chronic sick, who ought not to be occupying in large numbers the beds that are very much wanted in acute hospitals, and I feel that, if a re-arrangement could take place to find further facilities for convalescence, it would be possible to release a great number of beds, urgently required for acute cases.
On the question of consultant and specialist services, I understand that this is the subject of consideration by the Goodenough Committee, because a shortage of consultants and specialists is expected. I hope they will lay down some standard for consultants and specialists. At present, anybody, more or less, can call himself a consultant or specialist if he can find enough money to put up a brass plate in Harley Street or Wimpole Street and get a few patients. I think a standard ought to be definitely 577 laid down, so that we shall know what is a specialist and what is not.
My hon. Friend the Parliamentary Secretary stated earlier on that this White Paper was by no means intended to be comprehensive of all the services that will be provided. I should like to mention one of which the hon. Lady might not have thought, but which should form part of a comprehensive medical service, and that is chiropody, which has become a rather specialised form of treatment. Latterly, various chiropodist professional organisations have grown up and they confine themselves to the treatment of the feet. There has been a growing consciousness of the importance of the treatment of the feet. I think that is in danger of being lost sight of. Very large numbers of people are getting foot treatment, and, as the Minister knows, it has been found necessary, in the Army especially, to train people for giving foot treatment. I hope that, when the time comes to develop a comprehensive medical service, the question of foot treatment will not be overlooked. Like other speakers, I welcome this comprehensive medical service wholeheartedly, although there is a great deal in it I should like to improve. I am prepared to accept it as a compromise, but if there is any attempt to whittle it down, we, on this side of the House, will press just as hard for improvement.
§ Flight-Lieutenant Raikes (Essex, South-East)
The hon. Member for Peckham (Mr. Silkin) raised one point, the implications of which I do not think he realised. He objected to a person having both a public and a private practice. Does the hon. Member realise what the alternative would be? Either you have to abolish private practice altogether, which, if you did it forcibly, would undoubtedly be totalitarian, or else you would have to debar the public from making use of the services of any doctor, however eminent, who was, in point of fact, taking some part in private practice at all. I think the only effect would be that the public would be bound to suffer, in any event.
I may be a little more critical of the White Paper than some speakers. I admired the hon. Lady's clear and able discourse. I think it was a very fine Parliamentary performance, but I must, first, deal with one or two matters in regard to private practice to which she 578 referred. She pointed out that, so far a a person who was taking up a purely private practice was concerned, he or she could go to an area whether, from the public point of view, it is an over-doctored area or not, but anybody who proposed to take up public service, could be directed away from entering into certain areas, if those areas were over-doctored. I believe the White Paper has approached that matter from the wrong angle. What you want to do is to make the places that are unattractive, more attractive to the keen doctor, rather than to bring in an amount of regimentation, which would not affect very many people. Nobody but a man of considerable private means or a prize donkey would be likely to choose to go into an over-doctored area and compete for public patients, who, after all, are not the best-paid part of the profession. If you did it the other way, you might make it more attractive to young men to take public appointments in the more difficult areas. I do not believe that the public would suffer in the slightest, and the fact would remain that persons could go to certain over-doctored areas, if they wanted to do so.
One other point in regard to private practices. It does seem to me that this White Paper might have been rather less complicated and might have really served the purpose, which is a comprehensive service for the community, quite conveniently, if, instead of making a limited scheme, the Government had, in point of fact, extended the comprehensive medical service to dependants of all insured persons rather than going right up to the top Income-Tax level. I believe there are a certain number of cases, perhaps among the richer classes of people, who while perfectly contented with the doctor whom they will now have free through their general contributions to the fund will continue to pay a further sum of money, not because the doctor is really doing any more for them, but because, after all, they had always paid him reasonably in the past. Dr. Jones is going to have his guinea just the same. I think doctors will be in the position of, in a sense, taking tips from their private patients. That is what it amounts to and it may, in certain instances, affect the dignity of the medical profession.
I should like to say a few words about the voluntary hospitals. I will tell the House quite frankly my difficulty. I think 579 you have to differentiate very clearly between the three types of voluntary hospital. There are the teaching voluntary hospital, providing a very great service, and for which I understand special arrangements are to be made; the big voluntary hospitals, which engage in experiment and specialisation and serve a purpose which cannot be served by the ordinary municipal hospitals; and the large number of smaller voluntary hospitals, many of which have not a very considerable number of beds. The big voluntary hospital will be faced with very great difficulties indeed, unless, for its ordinary type of service, it receives the fair cost, and not less than the fair cost, from the State. What I mean is this. You will, in the voluntary hospitals, still get a certain amount of money from charitable bequests and benefactions, but that money will, and should go, for the purpose of increased experiments and specialisation, the provision of special X-rays and so on, over and above the ordinary service for which you sent people to hospital. That money will also be needed in regard to capital expenditure on hospital buildings. It is all very well for the hon. Lady to talk of the grateful people who contribute because they once had a fair and pleasant time, so far as it can be had, in a voluntary hospital, and of people who contribute, although they never go inside, because they realise how good these hospitals are. Once you have this increased grant from the State, and once the ordinary person feels that the State is paying for the hospital, these benefactions will gradually go. I cannot see anything that will replace them to anything like the extent to which they apply at the present time.
In dealing with the cost of voluntary hospitals, on a comparison with 1938 figures, the Government are not quite fair. In these days, with taxation very much higher than it was before the war, you are going to find it more difficult, even to get the large sums which are obtained by general appeal for some new building which the hospital requires, than it was in the days before the war. That is due to economic change, and not to the virtue, or lack of virtue of those who normally subscribe. The smaller voluntary hospitals, or a great many of them, could be taken over by the joint authori- 580 ties, and run as municipal hospitals. A great many of them have no particular specialisation or experimental school, and a good many will die out, but, where a joint authority goes to a hospital, desiring not to take the whole hospital over, and asks or demands the allocation of a certain number of beds in that hospital, I think it should be definitely laid down that those beds are paid for at cost price, and not at less than cost price.
That is the main point that arises from whatever criticism I have of the White Paper in regard to the voluntary hospitals. The assumption is that, if you give rather less than cost price, the voluntary hospitals will, nevertheless, be able to rely on a very considerable amount of outside money. The big general hospitals will, when they make their big appeals, get money, but not a hospital which is not well off and whose chief sources of income have very largely dried up. I would rather that they were taken over now, than that they should gradually dwindle until they are forced to go out without income at all.
While I think that the White Paper has very considerable opportunities, if it is worked with flexibility and imagination, we have to watch this. If we make private practice too difficult, we are going to bring into the medical profession, if there is no real chance of outside practice, men with a mediocre mind and men with the Civil Servce mind, men who are searching for "safety first," rather than for enterprise and advancement. I heard the right hon. Gentleman the Leader of the Opposition say that the young men in the Services would be looking to this scheme as raising their hopes for entering a medical profession which would be a much better profession than it had been. If the whole thing is to be publicly controlled, hon. Members will get a very big shock if they suppose that men who have been in the Services and under Government control for four or five years, are, when they come out of the Services, going to jump into complete Government control for the rest of their lives. This is one of the few prophecies in which I have some confidence. If private practice is given a fair opportunity; if voluntary hospitals are treated on their merits; if there is discrimination between the various types of hospitals, and if always when it comes to like service the authority pays a like price, 581 I believe that the White Paper may be the beginning of something better, as far as the health services of this country are concerned. I believe it will play some small part in improving the health of the nation and that the labour which the right hon. and learned Gentleman and other Members of the Government, have spent upon it will not have been in vain.
§ Dr. Edith Summerskill (Fulham, West)
I feel very grateful for being called in view of the fact that time is very limited. The hon. and gallant Gentleman the Member for South-East Essex (Flight-Lieut. Raikes) will forgive me if I do not follow him, but I must refer to one point in his speech. He said that if we had a State medical service we should encourage men of mediocre minds. Some of the finest doctors in the country, men and women, of the highest principle, are in the salaried medical services, the medical officers of health of the country, who approach the question of health from the preventive angle—which is the right approach—and not simply from the curative angle.
§ Flight-Lieutenant Raikes
I do not object to that, but I will not interrupt further as time is limited.
§ Dr. Summerskill
I do not want the House to think that we, on this side, welcome this scheme without any qualifications whatever. Obviously, this is a Coalition compromise, and, while I welcome it, as a member of the Socialist Medical Association, which has always advocated a salaried medical service, I criticise it, not as my medical colleagues have criticised it, because it is taking freedom from the doctors, but because, in my opinion, the White Paper puts the interests of the doctors before the interests of the patients. My criticism is that it is planned primarily to cure disease, rather than to prevent it, and I am a little afraid that we are in danger of making the nation medicine-conscious rather than health-minded.
The general practitioner service has been mentioned. It is a very important service, because 70 per cent, of the doctors in this country are general practitioners. On paper, I agree, this service looks very attractive, but whether it is practicable, or even workable, is questionable. As it stands it will, undoubtedly, accentuate instead of removing social distinctions in 582 the treatment and cure of disease. I want the House to try to picture the kind of machinery that the White Paper outlines. We are going to divide the general practitioners in the country into four categories. We are to have, first, the salaried practitioner which we have heard about, the man who, we are told, is mediocre and who lacks incentive, and who will be third-rate. I do not support those views at all; in my opinion, when you give a doctor a salary, you get the best out of him. He is not preoccupied all the time with how to find rent, rates and taxes. He does not, as did the old doctors in the last century, long for a good epidemic of smallpox, or scarlet fever. A salary gives a man security. He is then able to concentrate on the very important work of maintaining the health of the community.
The White Paper does not envisage the health centre as I have thought of it, and as I have seen it in the Soviet Union —a centre where disease is prevented. I am afraid that the White Paper only pictures the health centre as a miniature outpatient department. I have already said that the salaried practitioner will be free to apply himself to his work, and to his work alone, but, unfortunately, he is to be allowed to take private patients outside the health centre. What will that mean? It will mean, perhaps, a doctor arriving late at the health centre, because a wealthy old woman down the road has a headache and wants her pulse felt and is willing to pay a large fee for the purpose. Or, he may have to see patients at the health centre too quickly, and rush through them, because there is an old man down the road willing to pay a large fee. We are going to allow the old abuses, of which we all know.
The second category that, we are to have are doctors working at home, on a capitation basis. We are to have two of these grades of doctors—a section willing to work in their own homes on a capitation basis alone and another section willing to work on a capitation basis, and taking paying patients. Next, we are to have the doctor who takes private patients only. I want the House and the Minister to realise what this will mean. This surely is not conducive to harmony within the profession. The Minister told us yesterday that he was anxious to create co-operation rather than 583 competition, but surely this will create all sorts of anomalies., I would remind the House that the medical officers of health and the doctors working in our municipal hospitals, are the only doctors in the country who are prohibited from taking fees. If they take fees, they are subject to severe penalties. Here we are proposing that publicly-paid doctors will be allowed to take fees. It is a departure from one of the most important principles observed in Government Departments. That kind of thing is not allowed in any Department in Whitehall, and it should not be allowed in the medical profession. We are creating this anomaly, and, instead of fostering co-operation, we shall find hostility and resentment among these doctors.
The ideal is to take the private profit motive away from medicine. I am told that that will be very difficult to do, but if the salaried medical officer is given an adequate salary and good conditions, he should not be allowed to go out and sell his skill elsewhere. You will have the old social discriminations. You will still have people feeling that, if only they could pay the doctor, they would get proper treatment. You will still have Mrs. Jones ion one side of the street going to the health centre, and Mrs. Brown, who has a little more money, on the other side of the street saying "I see the doctor in his private house. You go to him at the health centre but I go to his private house." My father was a doctor, my husband is a doctor and my sister is married to a doctor, and I know the world about which I am talking. That which is in the White Paper looks delightful, but we want to translate it into something practical. To allow a salaried medical officer in the health centre to take on private patients outside will discredit the health centres from the very start.
Thirty years ago, when the National Health Insurance scheme was introduced, it was decided that the most practical basis on which to pay the doctors was the capitation system. Surely, We have learned, after 30 years, that the number of insured patients on a doctor's list is not a true reflection of his skill and ability. We know that when a patient chooses a doctor, the patient generally says, "Is he, or is she nice?" Why nice? A charming bedside manner alone is not enough and it should not determine the number of 584 patients treated or the amount of the quarterly cheque. We have to protect the people against themselves. In these days medical science has advanced and we want to give the people the best doctors, and not those simply with the most charm. Let me illustrate the point. When a patient goes to a hospital, is it left to the patient to choose his doctor? Is he taken to the hospital and asked, "Will you have that rather gruff and ugly looking surgeon over there or that rather charming, good-looking young house surgeon over there?" If it was left to the patient he or she might say, "I like the look of the house surgeon." We do not do that. We direct the patient to the right doctor. In our general practitioner service we are not going to do that but to pay the doctors on a capitation? basis irrespective of capacity or ability, and I say that that is wrong.
I would like to remind the House of what the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) said in 1911, when a Member in the House of Commons challenged him and said "This Bill is not popular." The right hon. Gentleman replied:I am not in a position to judge but I agree with him. I do not think that it is the prime consideration for us. The first thing for us to consider is whether we are doing the best for the community we represent.I ask the Ministers whether they feel that they are doing the best for the community, as far as the hospital service is concerned. It is said that we are to have a reorganisation of the hospital service. How can we reorganise the hospital service when 1,000 voluntary hospitals of the 3,000 hospitals in this country to begin with are outside the service? The White Paper expresses the hope that they will come in—that is all. What a waste of precious time. Other countries have shown that the one standard hospital is the ideal to be attained. Why not profit from their experience? What are we going to do about teaching in the hospitals? Are women in the post-war world still to be denied entry into the teaching hospitals? Are they to be denied the right of medical education -in London because the doors are barred by a group of elderly men, whose attitude to women is reminiscent of the Middle Ages? I know the answer. The Government hope to starve the voluntary hospitals into submission. That is the answer. 585 But this process may take a long, long time and I want to remind the Ministers that disease and death wait for no man. Throughout the country, there is an urgent need for more and better hospital accommodation, and I do ask the Ministers to be bold. This is a step forward but it is a faltering, not a bold step. I ask the Ministers to be bold, to grasp this nettle, and make adequate provision, and I am sure, they will have the lasting gratitude of the poor and needy in this country.
§ Mr. Francis Watt (Edinburgh, Central)
As the only representative here from the City of Edinburgh, which is one of the greatest medical centres, I approach this matter with considerable diffidence and a sense of responsibility. That is not lessened by the fact that every voluntary hospital in that city objects to this White Paper, on grounds which appear to me to be substantial, and I cannot help thinking that if anything arising out of the scheme were to happen to damage those hospitals, that damage would extend not merely to the institutions themselves but to the medical profession, that great institution of which we people in Edinburgh are justly proud. From the days when, long ago, Simpson discovered chloroform and Sir William Jenner vaccination, to the present day, when we hear of a patient travelling all the way from South Africa to get the assistance of an unrivalled brain specialist in Edinburgh, I feel that whatever they do, the object of the Government must be, to do nothing which will diminish or lessen this scheme and this ability, but, if possible, to expand it and make it available to a wider circle. I am sure we all agree, irrespective of party, as a principle of modern government, that no one should be debarred from receiving the appropriate medical or surgical attention, merely because of poverty. But great difficulties arise in endeavouring to carry out that principle. The new Minister of Health has, clearly, gone to great trouble and, in this connection, it would only be proper to say that his predecessor deserves some credit for bringing in a scheme which has an admirable object in view. But I am somewhat embarrassed when I find these institutions opposing it, and when I find that there is strong opposition —I put it no higher than that. There have been speeches in its favour, but 586 there has been strong opposition from a responsible section of the doctors.
I would have thought that when a scheme of such gravity and such importance was being launched, the Government would have put out its White Paper some time before the Debate. This is, after all, a matter upon which we Members of the House are perhaps not very competent, not being for the most part skilled in medical 'matters or very familiar with hospital management. We may find ourselves in a difficulty in arriving at a conclusion. I would have been very glad indeed, had there been time to receive further guidance. But, there it is—the scheme as it has now been brought before the House. It seems to me that when the new Minister of Health discovered what was then only a skeleton in the Department of Health, he might have paused a little before he proceeded to clothe the skeleton with flesh and bring it before the House. I think he need not have been in such haste to show his devotion to the principle of Sir William Beveridge. As I say, however, here it is and it is for us to decide.
It is said that this is only a matter of principle, that the House is expressing no considered view, that the matter will be investigated and so on. But principles have an awkward way of getting fixed, and being embodied in legislation which, at the time, was not thought probable. We must ponder very deeply (before we embark upon a scheme which has such far-reaching effects, a scheme which, undoubtedly, takes away to a consider able extent, the freedom in government which the voluntary hospitals enjoy, and the freedom to practice—
Would the hon. Member give us some reference for the surprising statement that autonomy is being taken away from the voluntary hospitals? It is an important point. Give us the reference.
§ Mr. Watt
If I am wrong on this matter, it is one that I would like cleared up. As I understand it, there is to be the Secretary of State for Scotland at the head, and he is to have advisory councils, in which representatives of those voluntary hospitals will take part but those advisory councils will have no power at all.
§ Mr. Mathers (Linlithgow)
Mr. Deputy-Speaker, in view of the fact that the hon. Member is obviously making a statement under a misapprehension, will you allow the hon. Lady who opened the Debate today to repeat the categorical statement she made on this point, in order to remove the misapprehension of the hon. Member?
§ Major Lloyd (Renfrew, Eastern)
On a point of Order. Is not the hon. Member entitled to express his view, even if other Members disagree?
§ Mr. Deputy-Speaker (Mr. Charles Williams)
A question has been put to me on a point of Order. The hon. Member who is addressing the House is making his own speech. Other people may disagree, but his speech will be answered in due course in the Debate. If the hon. Lady who opened the Debate wishes to intervene, I have no doubt the hon. Member will give way.
§ Miss Horsbrugh
I think I tried to make it clear to those who have not had the time to study the White Paper in detail, that the management, the autonomy, the identity of the voluntary hospital remains with the governing body. It remains with the voluntary hospital, whether it wishes to contract, to do work laid down in the scheme, or whether it wishes to remain out, but the government and the ownership—if I can put it like that—of the voluntary hospital are in no way changed. There is absolutely no direction of doctors—they can practise with perfect freedom.
§ Mr. Watt
That may be very well, but it does not alter the fact that the hospital has no share in the direction of the scheme which will be enjoyed by a Government Department, and will, in fact, undoubtedly affect its business. If I am under any misapprehension on the subject of the White Paper, it goes to 588 show that I have not had time to read it, and that the Government have rushed this important Debate and that we should have had more facilities and more time to study the matter.
§ Mr. Gallacher
On a point of Order. Is it in Order for an hon. Member to take part in the discussion of a White Paper which he has not read?
§ Mr. Deputy-Speaker
I have listened to speeches on White Papers by hon. Members who have said they have read them, and yet seemed to know nothing whatever about them.
May I suggest, Mr. Deputy-Speaker, that it is not respectful for an hon. Member to come to this House and blatantly admit that he is discussing something he has not read?
§ Mr. Deputy-Speaker
It is not a matter of disrespect. There are varying qualities of discussion. The hon. Member is in a free House and he is keeping within the Rules of Order. I certainly cannot rule him out of Order on that.
§ Mr. Watt
I have read it as fully as it deserves. That is one question, but another very important question is that the voluntary hospitals, one and all, are apprehensive about sections of this Paper and I doubt very much whether any remarks made yesterday by the Minister, or to-day by the hon. Lady, will do anything in any material way to remove the cause of apprehension. There are two matters upon "which the voluntary hospitals would have liked a different arrangement The first is the question of control. In 1942 they represented a scheme in Scotland to my right hon. Friend the Secretary of State, that there should be a joint council on which they and the local authority would have equal representation. That suggestion does not appear to have been accepted. They are also very apprehensive on the matter of finance. So far as the question of control is concerned, I take it that anything which my right hon. Friend the Secretary of State can do, when he winds up, to remove the apprehension, he will do. But I think the matter of finance is much more difficult, and I do not see anything in the scheme, outlined in the White Paper, which means anything other than the complete doom, be it soon or late, of the voluntary hospitals.
589 The assumption—which I think is quite erroneous—upon which the Government appear to proceed is that, although taxation is just as likely to be as high after the war as it is to-day, from some unknown fund people will still be able to exercise benevolence at the same rate as before, and the voluntary hospital will still be supported by donations. It is difficult to visualise anything other than a severe fall in the donations to those voluntary hospitals. There is another matter, A great deal of money is given to the voluntary hospital to-day by working people by way of subscriptions for what to them is a very valuable and important institution, but, in post-war days, these people will be called upon to make substantial weekly payments, far in excess of anything they have hitherto done, under the new Beveridge scheme. It is unreasonable to suppose that if they make contributions under the Beveridge scheme, they are also going to make contributions to the voluntary hospitals. I have here the figures for 1943 of a very large Scottish hospital. The ordinary annual income was £132,000 and, of that sum, not less than £30,000 came from donations, £6,000 from grateful patients, and £32,000 from workpeople making contributions. It is reasonable to suppose that all those figures will substantially, if not entirely disappear, and there will be a great loss in revenue. Where in this White Paper do we find any guarantee that the hospital will receive enough to keep it going.
The White Paper may be regarded by some a great State document, but I do not think it is. It is a rambling document, extending to 85 pages, and is rather difficult to understand. We have had several explanations of it and no doubt we shall have a few more. I find that £100 is the figure which it is thought should be the grant per bed.
§ Mr. Watt
I am glad to find that my hon. Friend has not read the White Paper either. He will find it on page 83. The figure of £100 is suggested. I do not say that we shall necessarily stick to it but suppose this is the figure. The cost per bed, in a voluntary hospital in Scotland to-day, is in the region of £300. That difference of £200, can be bridged in only two ways, either by payment for services —and we do not know what they will be 590 —or by contributions and subscriptions which the hospital would gladly accept.
§ Mr. Messer
Does the hon. Member realise what he is saying? The £300 per bed per annum is very much higher than the cost of a bed in a municipal hospital.
§ Miss Horsbrugh
At the present moment, under the emergency scheme, a hospital is being paid a certain sum for keeping beds empty, and a full sum if patients are in the beds. If my hon. Friend will look at the White Paper—I know the hospital he is referring to, the £300 beds are in teaching hospitals—he will find that, in addition to the flat-rate of £100, there is an amount for services rendered and an extra sum if it is a teaching hospital.
§ Mr. Watt
I am not directly concerned whether the hospital I am referring to is a teaching hospital or not. The substantial fact is that instead of the cost working out at £270, it works out at £307. This may be an artificial rise, but that is the figure I am putting forward in order that the House may be aware of the gap which must be met. For my part, I would like the Secretary of State for Scotland to give us some idea of what we can expect in the case of voluntary hospitals, whether they are teaching hospitals or not What proportion is likely to be met, and what proportion will fall on the ordinary revenue? If the Minister can help us in that direction, I shall be grateful. But it seems to me -that the whole difficulty about voluntary hospitals could have been overcome by simple means. A block grant might have been created on the same principle as in the case of universities, and might be distributed from a central pool. In any case, I see no reason why the voluntary hospitals should be treated in this very speculative fashion, because it is impossible for them at the moment to know whether they can continue to exist or not.
In the Hetherington Report there is a rather illuminating passage which 591 shows, quite plainly, what the voluntary hospitals can expect. That passage, to some extent, finds its way into the White Paper on page 23. The White Paper is very vague on the matter, whereas the Hetherington Report was quite definite, but if the Government embellish their proposals what will happen is this: if a voluntary hospital is in difficulties the local authority will get control and the way they will get it will be very simple. The Hetherington Report recommended that where an individual voluntary hospital was unable to carry on without further assistance the local authority should determine whether and, if so, on what conditions assistance should be given. The Report says:We recommend that on application by a local authority, in appropriate cases, the Secretary of State should, after inquiry, be empowered to take cognisance of the situation and, if necessary, to order the transfer of the voluntary institution to the local authority.If the Government follow that out in their detailed arrangements then, sooner or later, every voluntary hospital in Scotland, whatever its traditions, will pass into the hands of the local authorities. I am sorry that I have detained the House so long but, after all, I have the largest voluntary hospital in Scotland in my constituency, and a few more, besides, and I wish to see their view adequately represented. They do not come here in any sense of wanting to embarrass the House or the Government in necessary measures for the treatment of the sick. All they want is to continue to do their very good work in peace and security and to know that what they have built up in the past will not be lost in a few years' time. I think it is a matter of great regret that, for reasons best known to themselves, the Government apparently did not consult the medical authorities about the main points of their scheme. As I understand it, they took the matter into their own hands as regards its more important aspects. I do not know whether the Department of Health for Scotland or the corresponding body in England thought that they could formulate a scheme themselves without the best expert assistance in the country but their conduct makes us think that they did. If that be so, then this is bureaucracy of the very worst type. While I am entirely of the opinion that steps should be taken to get adequate treatment for the sick, I do not think the method outlined in the 592 White Paper is the appropriate or proper method. Speaking for myself, and with the support of my colleagues in Edinburgh, who have discussed the matter with me, I feel the gravest apprehension about the whole matter.
§ Mrs. Hardie (Glasgow, Springburn)
I do not intend to follow the hon. Member for Central Edinburgh (Mr. Watt), nor do I intend to criticise the White Paper unduly. I realise, as much as anyone, its limitations but I hope that what the Government have said, namely, that this is part of a general scheme of social improvement, is true. I am one of those who believe that, if we had decent housing conditions, proper nutrition and education on health matters, we would not need the large number of hospitals, nurses and doctors which we have to provide. It is rather depressing if we are to regard ourselves as a nation of invalids. I do not think we should. The amount of preventable sickness which exists today is past speaking about and I think it will be agreed that about 90 per cent, of our children are born in poverty. However, I do not want to enlarge on that because I know my right hon. Friend the Secretary of State for Scotland realises that by providing the necessities for health, we shall be supplying all the doctors and nurses who are needed. I welcome the attempt to co-ordinate the different services and treatment which our people are getting to-day. It is important that we should have these services linked together and that medical treatment should be linked with preventive services such as maternity and child welfare services, school medical services and factory welfare services. Some extension should also be made of treatment and rest centres for the adolescent workers. Care should be taken to get hold of them before they become chronic invalids, through tuberculosis, or rheumatism, or other such crippling diseases. If that were done people would not have to spend a long time in hospital.
I am very keen about positive health treatment, which has been neglected. The White Paper has been described as a Paper dealing with diseases and I agree that it does not give any hope of action for positive health. I, with one or two Glasgow Members, met some doctors, who represented the medical profession in Glasgow, to discuss the question of doctors 593 being asked to come under a public authority. I am not so upset as some of my hon. Friends about the doctors' attitude. None of us likes to have a boss. When I was a shop worker the shop worker's dream was to have her own shop. Women, generally, dream of escaping from economic servitude. I could quite see that these doctors had built good practices; that they were kings in their own castles. The idea that they should work under a boss was abhorrent to them and I have a certain amount of sympathy with them. But times have changed, and the problems which are to be tackled cannot be solved by men working alone in their own districts. I put the point of the young doctor and how difficult it was for him to establish himself. One doctor admitted that when he was an assistant he had to find something like £1,000 with which to buy a practice. He had no money and what happened was that he had to get his parents to guarantee the sum. He had to work for a long number of years to pay off the debt hanging over him before he could have a decent living. I have been told by a doctor in London that the young men are in favour of the scheme, and that it is the older men with established practices who object.
§ Major Lloyd
What evidence has the hon. Member on which to make such a statement when, in fact, there are no facts available?
§ Mrs. Hardie
I only said I was told. I am not stating it as an absolute fact. One can understand it, because they had to start from scratch. I was on the Glasgow school board when medical treatment and inspection were first introduced. The doctors opposed it bitterly and did not show any willingness to come under a local authority. In fact, there was a strike of doctors. The same arguments were put forward, that we should only get the lazy, inefficient doctors to go on to this medical service. The argument went very much against us, and, at the outset, only one full-time medical man was appointed, but that was so unsatisfactory that it was decided before long to enlarge the staff and the bulk of them were made full-time medical officers. The service became very popular. It was a good job, with reasonable hours, and the opposition fell away. I was also a m ember of the insurance committee when the Insurance Act was put in force. The great 594 majority of the doctors opposed the scheme on the ground that it would injure private practice and be a bad thing for the profession. But the scheme has been the making of many doctors. They were never so prosperous and never had such a well-guaranteed income. I am sure that, once this scheme is put in force, the doctors will change their attitude and discover that working under a local authority is not such a bad thing as they thought it would be. Some people feared the possibility of coming under a Labour council. Ii there are any people who will spend money and support the doctors in any scheme they want to put forward, it will be the Labour Party. It will be your Tory bodies, dominated by believers in private enterprise, who will be niggardly with those schemes. Once the scheme is started and the doctors start to work it, they will find that it is not so very objectionable after all.
§ Dr. Russell Thomas
I do not think the hon. Member is correct in saying that doctors will welcome the scheme. Those in my experience who do are generally unsuccessful doctors and those who wish for economic security.
§ Mrs. Hardie
There is always the argument that, if you give a man a secure job, he becomes slack. It may be that some people who get into jobs under public authorities, and even people who get safe seats in Parliament, do not make any special effort, but I believe that with the bulk of people in the medical profession, if they are really interested in their work, it will not have that effect at all. I do not adopt the silly notion that a doctor who becomes a public servant has no thought about the money he receives, but I am sure it is not the money the doctor receives that makes him take up the profession, because there are many professions where much higher remuneration is given for much less effort. I cannot believe that, because a doctor obtains security, he will go slack. The medical officers in Glasgow are some of the finest and most capable men you could get, who are really interested in their jobs. The only thing that keeps them back is that they have not had enough money provided by those responsible for them.
A great deal of nonsense is talked about the choice of doctor. Why should people make a choice? If I want a doctor, I do not care who he is as long as he knows his 595 job. If you get a skilled doctor, what does it matter whether you know him or not? The less you know him the better, I should have thought. If he knows his job, that is all you need to know. There is a good deal of sentimental nonsense talked about the family doctor. If I want a doctor I ask a friend to recommend one, and it generally works all right. As for hospitals, I know that there are some very fine voluntary hospitals and there are also some much better public authority hospitals than there used to be. Glasgow people used to be dubious about going to a public authority hospital because it was considered like resorting to the Poor Law. They preferred the voluntary hospitals. I do not criticise them for that, because there are some very fine voluntary hospitals in Glasgow, but I do not see why they should have any objection in coming into this scheme.
Most of the voluntary hospitals in Scotland are kept up by contributions from working people. There are some donations but the bulk of their revenue comes from that direction. If the workers have to pay more for their medical treatment through insurance, they will not contribute as much to voluntary hospitals as they have done in the past. All my working life, I have paid so much a week, and in most works so much a week is kept back from wages and goes to the hospitals. That was a very good scheme as far as it went, but it does not compare with a properly-run public authority hospital. I am sure they will be forced to come into the scheme, and I hope they will not find any difficulty about it, and I am sure the doctors will find that it is not so bad as they imagine. It is more satisfactory to pay through rates or taxes and have hospital accommodation provided.
I do not understand the attitude of mind that anyone who is interested in a hospital has a vested interest in it and that, rather than have any interference with this little bit of interest, they are prepared to sacrifice patients and children. It cannot be denied that this comprehensive scheme will be a great improvement. There is nothing more depressing than to see women and children sitting for hours in the out-patients' department before a doctor can attend to them and often sent away because the doctor has not time to attend to them, and having to come back next day. I was passing a big hospital 596 in my division and saw a little boy coming out with his leg bandaged up. He was hopping on one foot to get to a tram and I said to mysE006Cf, "We call ourselves a civilised nation." I thought of the big, fat, lazy people in Rolls-Royce cars, while no provision could be made to take this child to a tram. Women and children, as well as the workers, are going to get treatment at home or in the surgery. They will not need to hang about the outpatients' department. For that reason I welcome a scheme which will take all sections of the community so that all will have the same treatment and no one will be forced to suffer this misery.
Not much has been said about nurses. If there are to be hospital extensions, we must have more nurses. It is a tragedy that the nursing profession has been treated so badly in the past that we have a serious shortage. I cannot say whether we shall be able to make it up but conditions will have to be considerably improved, because, next to doctors, I do not know anything more important than having good nurses. Scotland is noted for its large number of people who have bad teeth. Many children suffer because their teeth have not been properly attended to. It is not only that they suffer a good deal of pain and discomfort but it affects the whole of their health. I note in the White Paper that there is a difficulty about dentists. I hope the Department will go ahead with that branch of treatment and see that it is not neglected. I am also interested in mental cases. When we were co-ordinating the health services in Scotland I proposed that mental treatment should be brought under the Health Department. Very few supported it and it was not accepted. I think doctors would agree that the line of demarcation between physical and mental illness is very thin, and it is very difficult to determine what physical cause there is for a mental ailment. It is a great mistake to segregate mental cases and put them under a different authority from physical illnesses. Similarly there is a very thin dividing line between sanity and insanity. Some of the cases that are not very bad are certified and put into asylums, and the way they are segregated always worries me tremendously. It would be better if mental cases were brought under a proper health procedure, so that the cause of the illness, whether it is glands or defective 597 diet, could be ascertained. I hope that the Secretary of State will consider having all mental cases under the Health Department instead of leaving them to a separate board. I welcome the White Paper so far as it goes and hope that the Government will push forward with it.
§ Major Lloyd (Renfrew, Eastern)
Unlike my hon. Friend the Member for Central Edinburgh (Mr. F. Watt), I claim to have read the White Paper more than once. In fact, I regret to have to say that the more I look at it the less I like it. I say that with regret because I have such a respect for my right hon. Friend the Minister of Health and for my right hon. Friend the Secretary of State for Scotland who are called upon to defend the White Paper. I venture to suggest that neither of them wrote it, that there are very few words or sentences in it that were written by them, though they may not be in a position to refute or otherwise my rather pertinent or impertinent suggestion. I want to get to the background of this White Paper. I wonder who wrote it. I wonder what was the attitude of mind of the people who have been conceiving it, I do not believe it is really the child of my right hon. Friend the Minister of Health, nor, in fact, the child of my right hon. Friend the Secretary of State. I believe that the major influence behind it comes from a very powerful organisation of which I want to say nothing disrespectful. On the contrary, they have done much good and clever work, but their influence in State affairs is very substantial.
I believe that the influence which originated the contents and wording of this White Paper came from the organisation calling itself P.E.P.—Political and Economic Planning, I believe, is the official term. I prefer an expression that I would have used myself to interpret those mysterious initials, "Perfect Examples of Planning." The influence of their work in investigating the position of the health services is most apparent in the White Paper. I had the opportunity of reading their original ideas on this subject many months ago, and the similarities are amazingly striking. The subservient way in which their views have been copied into this White Paper is amazing. It is not the first time that the views of this organisation have been copied in White Papers by Government Departments.
598 Everything apparently depends in modern democracy upon the right atmosphere being created before a White Paper is issued or a Bill is presented to Parliament. This is done by that strange hybrid figure the journalist-cum-public relations officer, who is paid highly, and, I have no doubt, richly deserves his reward for creating the right atmosphere and putting out the right kind of stuff, so that to some extent democracy can be all prepared for the food which is to come to it and which it is requested to swallow with little or no difficulty.
There is a hidden hand here beside that of the organisation of P.E.P. It is, of course, the magic touch of Sir William Beveridge. The atmosphere was created before the White Paper was produced that to say anything against the idea of a national health service or the necessity to reform and improve the present services was akin to (blasphemy. This White Paper is rather like the curate's egg; parts of it are excellent. There are many features which are most attractive. The whole of it is most attractively worded. It remind me of the coloured pictures on seed packets which keen gardeners like I am are buying just now. If we have had a good deal of experience of these things we know that it is difficult to produce anything like the coloured pictures on the seed packets and that we have to take the descriptions in the charmingly worded catalogue with a certain amount of salt. I look upon this White Paper in much the same light. It is most attractively worded. Almost every paragraph is full of bird lime, and J can imagine how difficult it is for an ordinary person to get up and dare to commit the blasphemy of criticising it. There is, however, one sentence in it which appeals to me, in which the Government invite criticism. I propose to take the Government at their word and say what I think about it.
Candidly, I do not like it. It is not that I do not like what is stated and most attractively presented, but I dislike the under-currents in it. With regard to improving the medical profession and the health services, I do not deny that it is possible to improve them. Everything is possible of improvement. We must advance and progress and improve the important health services of the country as we must everything else, but I do not believe that the right way to improve the 599 health services is to put the great free independent medical profession under the control of a thinly disguised bureaucratic organisation. I will not discuss the question of the voluntary hospitals. Much has been said about them, and I am bound to admit that much that Ministers have said has gone a long way towards allaying my own original misgivings with regard to the financial position and future status of the voluntary hospitals. But I am by no means satisfied yet. I still think that ultimately, in spite of what has been said, in spite of what Ministers sincerely and honestly intend, there will be a tendency for the voluntary hospitals to lose status and autonomy. I hope that the guarantees which have been given will be fully implemented. I am sure that the Minister who gave those guarantees will endeavour to see that their promises will be implemented when the Bill is brought forward. We shall watch the Bill very carefully to see that every form of guarantee and safeguard which will assure the status, autonomy, independence and good administration of the voluntary hospitals is completely implemented, in spite of the fact that we know well that they are bound to lose an immense amount of voluntary financial support.
I am far more concerned with the fact that we have never had sufficient assurance from the Front Bench with regard to the status of the medical profession. I believe that the doctors are deeply concerned and anxious about the position in which they will find themselves under the Bill which will arise out of this White Paper. If the medical profession, as I believe, is deeply suspicious and anxious and is prepared to resist any attempt to place it under a bureaucratic Civil Service, and if that feeling is strong and widely expressed, as it may well be by a big majority of the profession, it will find substantial support in this House, at any rate on this side of the House. If the doctors decide to fight strongly, I would like to assure them of the great support they will receive, not only in the House of Commons, but in the country as a whole. I hope that the medical profession will not too readily surrender their inherited rights and freedom.
I cannot believe that the Central Medical Board which is proposed in the White Paper can do anything but injure, gener- 600 ally speaking, the prestige and freedom of the medical profession. That Board is the central feature of the White Paper and it is the feature which I dislike most. It seems to me quite unnecessary. Why should there be control of the medical profession to the degree proposed? Who will appoint tine personnel of the Central Medical Board? Will they be elected freely by the professional bodies or appointed by the Minister, in fact, by the bureaucratic machine, to regiment and order about the medical profession? Hon. Members may think that my fears are unwarranted and that I have perhaps exaggerated the position. I accept the fact that if one reads the White Paper literally there is little justification for my fears, but what worries me is that it is far too attractively worded. I do not like the underlying tone of it. It rouses fears and misgivings in me and, I believe, throughout the medical profession. If to that extent I am representing their views I am proud to have this opportunity of doing so.
I want to say a word with regard to the advisory bodies. I am not satisfied that the advisory bodies, both central and local, are to have the status which I should like to see them have. In fact, I believe there will be a tendency for them to be ignored to some extent by the executive authorities which, as far as I can see, need not accept their advice at all. They can look at it and put it in the waste paper basket. I want to have an assurance that the advisory bodies shall have an opportunity of presenting an annual report of their views, and that the report shall be published not after it has been censored and blue-pencilled by the Minister or the Department or somebody else, but published untouched as written by the advisory bodies themselves. If they are dissatisfied, let them say so, and let the public and Parliament know what they think. I would like to feel that there is a complete and untrammelled freedom for these bodies to say exactly what they feel and think. The subject of the great nursing profession is touched upon sympathetically in the White Paper, and I have no doubt that the Area Joint Boards and the Regional Councils, which will be making their plans, will take into sympathetic consideration the amenities and conditions of this noble profession, which has had a raw deal ever since the days of Florence Nightingale. There is a grand opportunity 601 in this new Bill to improve the status and conditions of the nursing profession, the most honourable, the most self-sacrificing of all the professions.
With regard to mental hospitals, the hon. Member for Springburn (Mrs. Hardie) made some remarks with which I am in complete agreement. In Scotland we are not at all happy about what the White Paper says of mental hospitals. We have some magnificent mental hospitals in Scotland. They are entirely of a voluntary character and seven of them have Royal Charters. The number of their beds is about one-quarter of all the sick beds in Scotland. I am informed, although I cannot vouch for the accuracy of the statement, that, taking Great Britain as a whole nearly 50 per cent, of all the sick beds for people ill from whatever cause are occupied by mentally sick patients. The position of mental hospitals in a great national scheme for improving the health services is of fundamental importance, and yet it is dismissed in the White Paper in eight lines out of 83 pages. That is not enough to give the slightest satisfaction to those who are deeply concerned in the question.
What will be their position? Are they to be roped into the scheme? Are they to be encouraged to come in? If so, will they be in the same status as that intended for the voluntary hospitals? They are voluntarily subscribed to and they depend on voluntary support. That support will almost certainly largely disappear. Are they to be put on the same basis as the voluntary hospitals and taken into full partnership in the great schemes which will be planned by the joint boards or the regional councils? I am speaking on behalf of those who are deeply concerned with these hospitals and who, for some months, tried to get assurances, but got none. The query sticks out like a sore thumb, and I hope that the Secretary of State will be able to do something to assure those concerned with the administration of these hospitals that they will be brought into the scheme, that their services will be enlisted and that they will be treated with the same sympathy and understanding as the great voluntary hospitals.
I do not want to take up more of the time of the House. I have spoken frankly and I am most grateful to those who must differ from me for the courtesy with 602 which they have listened to me. I hope that the Bill, when it is brought forward, will contain very different proposals from those in the White Paper because if it does not then it will be fought line by line upon matters of major principle, on which many Members feel strongly and in regard to which, I believe, they represent a great part of the people of the country.
Mr. McNeil (Greenock)
I am fairly certain that my hon. and gallant Friend who has just spoken need expect nothing but courtesy from this side of the House when he puts a reasoned, vigorous case. Perhaps I might be allowed to say that I frankly regret I cannot say the same about his colleague the hon. Member for Central Edinburgh (Mr. Watt). I am a moderate man and a very junior Member of this House, but I think it proper that I should say that it is hardly in accordance with the best usages in this House, that a Member should tax us with having a not very well-informed case, and that he should bring forward questions which have been discussed at previous Sittings of the House. Perhaps I might also be allowed to say to my hon. and gallant Friend the Member for East Renfrew (Major Lloyd) that, while I greatly sympathise with his concern about mental hospitals, I fear he was inaccurate in one respect and unjust in another. I think that if he makes inquiry he will find" that the proposal about the Central Medical Council, whose personnel is to be nominated by the Minister, after consultation with the bodies concerned, has been, in principle, approved by the British Medical Association. I think I ought to say also that I am sure he was misinformed about the P.E.P. Report to which reference is made in the White Paper. Speaking from memory I think reference is made to the "valuable and mainly factual report" published by P.E.P., which indeed it is. I consider it a most valuable one.
§ Mr. Kenneth Lindsay (Kilmarnock)
May I say also that it was largely doctors who were engaged on the Report for three years, working to get the facts. I think it is a little unfortunate that in his very vigorous speech the hon. and gallant. Member for East Renfrew (Major Lloyd) did not give it more credit.
My hon. Friend the Member for Central Edinburgh complained 603 about undue urgency having been shown in connection with the White Paper. These deliberations have been going on, more or less, since 1930, and, certainly from this side of the House, we have been pressing the Government for the last six or eight months to hurry it forward. I cannot think there has been any undue urgency about it. I should like to join in the congratulations to the many Ministers concerned in its production. If we think we see, here and there, the hand of the Secretary of State for Scotland we, naturally, are not greatly upset but are very grateful for the work he has done. While I do not in any way minimise the importance of this Report, I think we must remember that it is an ambulance service. The vigorous discussion we had two days ago upon housing was more basically concerned with health than the finest consultant service. Similarly, the Debate last week on the relationship between wages and work and food, was more basic than this comprehensive service. The hon. Member for Springburn (Mrs. Hardie) pointed to the fact that there was a great area in which we might expect education for positive health, and I regret there is so little reference in the White Paper to that subject. The health of this country will continue to rest upon housing and food, positive education, and, of course, a comprehensive service. We should be very foolish if we expected to have health and if we neglected any one of those four pillars upon which the nation's health rests.
There is one aspect of the voluntary hospitals problem to which I want to refer. I do not think the treatment of the voluntary hospitals as set forth in the White Paper is anything but just. If there is such a volume of support within the country as has been claimed for the voluntary hospitals, then, of course, there is no fear for them. I would be the last person to deny the glory and the work of these voluntary institutions, but I consider it will be for the benefit of the whole community if they come within an integrated hospital service. I would like to ask my right hon. Friend if, in his reply, he could give a more precise definition of the first of the grounds laid down in the White Paper for the inclusion of the voluntary hospitals. It is stated on page 23 of the White Paper: 604Each hospital will be required to maintain the services which, under the approved hospital plan, it undertakes to maintain, and generally to comply with the plan.I thought, until we heard the hon. Lady, the Parliamentary Secretary, that that meant quite clearly that each voluntary hospital would accept direction of its specific functions within the area scheme. I am fairly certain that this is the intention of the Paper, and yet, as I look at it again, there is no doubt that this is a vague phrase:it undertakes to maintainThis is important. I have consistently felt, and I think that fair evidence has been submitted to this House already to maintain the viewpoint, that except for such extra-area units as the right hon. Gentleman referred to yesterday, for neural surgery and the like, each hospital unit of a non-specialist kind should, in point of fact, be a general hospital. Quite plainly, they are not general hospitals just now. As long as we have the voluntary hospitals, which are mainly the teaching centres carrying a load of acute, picturesque and dramatic sickness, and the local government hospital carrying exclusively a load of chronic sickness, we have two different types of hospital. There are two consequences, and one of them is teaching. I rather regret that the House has not got the Goodenough Committee Report. We shall, probably, have to revise some of our conclusions about the White Paper when we see that Report. I am clear that as long as we have this unreal position, which has grown up for historical reasons, we shall have, quite often, a lower level of doctoring in the local government hospital than in the voluntary hospital and certainly a lower level of nursing, because the material is not there.
Moreover, apart from the teaching side, there is an additional social reason why we should try to move towards this creation of a real general hospital. As long as we segregate the chronic sick, we are, in fact, saying to the chronic sick that we are putting them in public authority hospital wards, so that they can die as comfortably as possible. That is putting it rather hard, and perhaps is overstating it, but I know that that is the impression some of these aged people have in their minds. I see administrative advantages in reorganising our general hospitals to remove that conception from their minds.
605 There are two other points to which I should like to refer. It is not clear, from Chapter 5 which deals with the Scottish service, what function is to be allotted to the emergency hospital. It is fair to say that that subject is not precisely dealt with, and I have no doubt that that is not an accident. I have no doubt that the Secretary of State for Scotland has a reason for this delicacy of treatment. I hope that he may find it opportune to enlarge upon that subject when he replies to the Debate. I shall probably find myself differing from him, because, if we have area treatment, as is implied in the Scottish chapter, I think we shall be creating another contradiction, a third machine, in trying to run these hospitals from Edinburgh as non-area units. But, as I have said, I should be very stupid to make any judgment before I have heard my right hon. Friend speak on this subject.
My hon. Friend the Member for Spring-burn also referred to industrial medicine and perhaps my right hon. Friend will find time to deal a little more fully with the place of industrial medicine within the reorganisation scheme for Scotland. I think we can fairly say that in Scotland—and all credit is due to the right hon. Gentleman in this regard—we have seen more advance over the last 12 months than other parts of the country, and we all rejoice in it. One can see it developing, but although the matter is referred to in the appendix it is not treated at all fully in the body of the White Paper. Perhaps my right hon. Friend will say in his reply what he means to do.
Finally, may I plead most earnestly for a larger part in the scheme than seems presently allotted to education? I know, of course, that the Parliamentary Secretary referred to the fact that there were certain omissions from the White Paper in order to make it the plain and readable document that it is. I appreciate that, but if we are to develop the health centre there is a great opportunity for developing group education. Some people are pessimistic about the possibilities of group education for positive health. I am not. I now think there is a growing volume of evidence to support my view. Some of us feared, for example, that when attendance at the antenatal clinic was no longer the title to supplementary food, we should see the attendances drop off, but this has not been the case. In my division they have 606 actually gone up. I do not want to found a case on it. It is a small area and it would be rash to draw conclusions from it, but I am told that, in Scotland, in the last year, despite the fact that extra food was available through the Ministry of Food scheme without attendance, 77 per cent, of all the new mothers attended a clinic of one type or another during the last year. That is a most heartening figure, and justifies the confidence that repose in those people that if we offer them education for health of a suitable and attractive type, they will want it.
Most warmly I congratulate the right hon. Gentleman, and most earnestly I plead that we should have legislation as quickly as possible. There is no part of the country where the need is so great as Scotland and where deterioration of health over the last 100 years has been so dramatically and tragically portrayed as in our country. I never want to indulge in competitions of misery, and I never find any satisfaction in pointing always to the dreary things, but I must say that although we were never a great people we were always a very healthy and vigorous people, and we can be so again quite quickly. I wish the right hon. Gentleman and his associates every speed and every fortune in that piece of work.
§ Commander Galbraith (Glasgow, Pollok)
I do not think there has been sufficient time for the public, or even for the medical profession, fully to digest the contents of this White Paper, and there has, as yet, been no expression of organised opinion from either of those parties. But I find in certain places that uneasiness exists as to what may be the outcome of the proposals contained in the White Paper. In opening this Debate yesterday, my right hon. Friend spoke of the necessity of giving the utmost freedom to the individual, whether it be patient or doctor. I think the words he used were that they must not be dragooned. Freedom for the patient in this matter is summed up in the phrase, "free choice of doctor," which has come into general use, but those words convey far more than their actual meaning.
To me, they mean that whole human relationship which exists at present between the doctor and his patient. I find that in that connection uneasiness arises because so much stress is laid in the White Paper on the salaried form of service. It gives one the impression that 607 the intention of the authors of the White Paper is really to have eventually a full-time salaried service, and under such a scheme as that I do not believe that that human relationship which at present exists between doctor and patient can exist in the future. Further, I believe that it would not be in the best interests of the patient, nor would it lead to that progressive advance of medical science which is the desire of every one of us.
The argument in the White Paper on why there should be a salaried service in the health centres, struck me as being very thin indeed. It stated that you could not have any other kind of remuneration because the doctors working in such places could not reasonably be asked to compete with one another. That, to my view, is the wrong way of putting it. It is not really the doctor who competes for the patient, but the patient who competes for the doctor. The patient finds in one doctor a greater sympathy and greater understanding, he believes him to have a greater skill and wants to get that doctor. It is not a case of the doctor competing for the patient at all. I cannot see how, if we are to have a salaried service in the health centres, we are to remunerate those doctors who have those qualities and who take on their shoulders a greater amount of work and greater responsibility. I would suggest that the only reasonable way in which they should be remunerated is either by capitation fee or by joint salary and capitation fee.
I turn for a moment to the question of the freedom of the doctor. In the White Paper, the young doctor is, so far as I can read it, to be forced into spending some of his early years in the public service. I think it would be right if we were to lay it down that doctors, when they qualify, should serve an apprenticeship of a year or two as assistants, but I think it quite wrong and highly undemocratic that they should be directed, in time of peace, into one service.
§ The Secretary of State for Scotland (Mr. T. Johnston)
I am sure that the hon. and gallant Member is making that statement quite inadvertently. The Minister yesterday gave a most explicit and careful explanation on that point and showed that it was entirely erroneous.
§ Commander Galbraith
I thank my right hon. Friend for his intervention. I heard what the Minister had to say. Nevertheless, my right hon. Friend will agree that what I have said represents what appears in the White Paper, and it is the White Paper of which I am speaking at the moment. I hope that when the matter is considered further and when legislation is brought before the House, what my right hon. Friend said yesterday will appear in that legislation. I am quite certain it will. But I was referring at the moment to what appeared in the White Paper in regard to the freedom of doctors. The next thing I have to criticise in the White Paper is the limitation which is placed on practice. We are told that doctors may engage both in the public service and in private practice, but where they engage in both, those men who have large private practices will get a smaller public practice. I do not think that that is the right way at all of dealing with the matter. Surely the only criterion should be: Is the doctor conducting his public practice efficiently? If he is doing so, then the number of private patients he has should be left entirely to his own discrimination.
The voluntary hospitals have been spoken of a good deal in this Debate. I would like to say just one or two words further in that connection. It is obvious that the operation of the inclusive charge must deprive the voluntary hospitals of revenue, and yet it is laid down that they can only participate, as I understand it, in this new scheme, if they meet a proportion of their costs from voluntary funds. It seems to me as if the voluntary hospitals are, in some way and to some extent, to subsidise this new service. They are not to be paid in full for the service they render. I suggest that if that position is to be maintained, then the voluntary hospitals, as such, are as good as dead, and that would be a very great loss to the nation indeed. Surely, here the contract should be that the voluntary hospitals ought to be fully paid for any service they render.
There is one other thing that strikes me as being somewhat extraordinary—why these hospitals, which are absolutely essential to the operation of this new scheme, have no direct share in the administration. I wish to suggest for the consideration of my two right hon.
609 Friends, the possibility of co-opting on to the hospital committees of the new joint authorities, some representatives from the voluntary hospitals. Surely, they would make a great contribution to these committees, because after all the voluntary hospitals have a very great and wide experience which should be of incalculable value to these committees. In that connection I am glad to say that the Scottish scheme seems to me to be much better arranged than the scheme for England and Wales in so far as there is a regional hospital advisory committee, which consists of equal numbers from the joint boards and the voluntary hospitals with an independent chairman, but at the moment, that regional advisory council is only-to advise. It has no executive function whatever, and I would like to suggest that its functions should be widened to include the planning of the whole area. The position at the moment is that in these regions there will be a number of joint hospital boards, each responsible for the planning of their own area inside the region. Would it not be better that the region should be planned as a whole, and that the joint boards should be left to carry the plan into effect? Anyone who knows anything at all about the medical service in this country must realise the need of a more comprehensive service than that which exists at the present day. But do let us see to it that, as far as is humanly possible, it is brought about in such a way as will ensure the fullest freedom for everyone concerned. Do not let it try to regiment medicine or the people, and do let us see one thing, if it is at all possible, that the teaching hospitals should retain their autonomous position. There is a danger otherwise that they will become standardised in their teaching and restricted in what they wish to do, and that will not be for the advance of medical science.
§ Mr. Gallacher (Fife, West)
I shall talk only for a short time, but it is necessary that I should say a few words to the wild extravagant obstructionists on the other side. The hon. Member for Denbigh (Sir H. Morris-Jones) said that this White Paper was imposing on the doctors conditions that Members on this side of the House would have protested against had they been imposed upon the miners. All I would say to him is: Wait until we have a few doctors in gaol for refusing to 610 accept "direction," and then perhaps we will discuss that question. The hon. and gallant Member for East Renfrew (Major Lloyd), who is notorious for opposition to all forms of progress, made a speech here of a very dangerous character. He offered an incitement to the medical profession, such as would have led him and his associates, if it had been made to the workers by any Member on this side when the Essential Work Order was introduced, to demand action against that Member. The Essential Work Order was introduced, and the trade unions, the workers, and this side of the House accepted it, because they believed it necessary to win the war. The White Paper is issued—an attempt is made to co-ordinate and to bring in an organised form of medical service in a terrible war against disease —and the hon. and gallant Member for East Renfrew says, "Let the disease spread as it may: doctors should resist this scheme."
§ Major Lloyd
I must, with all respect, contradict the hon. Gentleman. I never said, "the scheme as a whole": I said, "the functions of the Medical Board, as outlined by the White Paper."
§ Mr. Gallacher
That is an important part of the scheme. To knock down a platform it is not necessary to make a frontal attack; all you need to do is to knock down some of the props, and the whole thing falls. The important thing is that he called upon the doctors to resist the scheme. The hon. Member for Springburn (Mrs. Hardie) said that she had been speaking to a young doctor, and she was told that the young doctors want the scheme. I was speaking to four doctors this week discussing the White Paper, and they declared that the young doctors, in and out of the Army, were in favour of the scheme. I will say something more, and prove it to the hon. and gallant Member, if he and his associate from Edinburgh want proof. I say that not only do young doctors want the scheme, but Scotland wants the scheme. Will he challenge that?
§ Major Lloyd
The hon. Member has no more justification for making that statement than I should have for denying it. Nobody knows.
§ Mr. Gallacher
If the hon. and gallant Member likes, we will test it at any time, at any place in Scotland. The hon. and gallant Member for Pollok (Commander Galbraith) talks of freedom of choice. When he speaks of all that delightful opportunity, of whom is he talking—the mass of the people of this country? No, he is talking about himself and a select few. What freedom of choice have the masses in any town? There is a series of medical practitioners: you cannot tell one from another—
§ Commander Galbraith
I think there is room for choice. In the area where I live, I find that one doctor has two-thirds of the practice, showing that the people use their freedom of choice.
§ Mr. Gallacher
What happens in a factory? I have been in a factory, and I know. A lad will say, "Where should I go for a doctor?" Somebody else says, "So-and-so is a very nice fellow, and his consulting room is at such and such a place." The other lad says, "That is very convenient for me; I will go there." It is not a question of his qualifications; it is the location of his consulting room that decides it. In my town, which has been notorious in the past for its devotion to an outside show of religion, a young medical man coming may be told, "Go to such and such a church, and you will get any amount of patients." When you have a medical practitioner with an enormous mass of patients, as a result of the panel, what opportunity is there for personal intimacy or friendship with his patients? He has to hurry around as quickly as he can, touching one here and one there.
I ask those Members who talk about freedom for the doctors whether they will get up in this House, or in any part of the country, and demand that the medical officers of this country be freed from the terrible bondage which now exists, and that we have no more local authority medical officers in this country. Was there ever such nonsense as they talk? Some of the finest men in this country have been medical officers. Who will mention any finer doctor than the doctor 612 referred to by the Secretary of State last week, Dr. McGonigle, a medical officer who has presented such valuable material to the Ministry of Health and to the country as a whole for the protection of the health of the people? Ask the British Medical Association what their experts thought when they went to Soviet Russia? Ask for the report which they made when they came back. Where do you find such opportunity for initiative and advance in medical science as in the Soviet Union? And there is not a private practitioner in the whole country. So I could go on. I never heard such an attempt to hold back the chariot of progress as is made by these unfortunate hard-headed weaklings on the other side.
I would like to talk about the White Paper, now that I have dealt with some of these arguments. The drafting is remarkably fine. I have an idea that the full document was drafted by a different person than the person who drafted the other document, but I will not go into that question. The White Paper sets out what is the desire of everyone to have every man, women and child in this country brought in for care and for treatment. It is the finest conception which has been put forward yet in connection with the care of the health of the people of this country. Another grand conception is the proposal for the health centres; these should not be treated as experiments but as essential services growing all the time. But between the proposal for the care of the people and that for the health centre, there is all this compromise, to safeguard the freedom of the doctors. I was speaking to the students in Glasgow on Monday, many of them medical students, and I said to them, "Lads, there are many great services which can be given in the years ahead. What an opportunity some of you have, if you put, as you should, the service of the people before fee-grabbing." Do not let us have any more of this talk about freedom of the doctors for fee-grabbing; let us have freedom for the doctors to give the greatest possible service to the people of this country. Make it clear to the doctors and nurses, on whom so much depends for the advancement of the welfare of the people of this country, that, wherever doctors and nurses are brought into the scheme, they are going to get a remuneration that will not be under, and may be over, the 613 general average of the fee-grabbing general practitioner. Make it clear that there will be no attempt to get cheap service or cheap labour on the part of doctors and nurses, but that they are going to get every possible encouragement to advance their work and to make the scheme a real success; to ensure that the health and well-being of the people of this country will be safeguarded for the future.
§ Dr. Peters (Huntingdon)
I want to draw the attention of my right hon. and learned Friend not so much to what is in the White Paper as to what has not been put into it. Often we lawyers, when in courts, notice not so much what our opposite number is saying as what he does not say, and I want to refer, if I may, to the research side of this great subject. I have been deeply interested in healing people for many years and have made a very comprehensive study of different kinds of healing. Among the things omitted from this scheme are those branches of healing, such as those of the osteopath and that sort of thing, and I want the Minister to take a very broad view so that they may come within his cognisance at some early date. It is very true that these people have to formulate schemes which will be acceptable to any reasonably-minded Minister and I do hope they will do so, so that people may have the right to be cured by any particular means which may be appropriate to them.
There is one other side which is also very important. The Ministry of Health, as I understand it, has, from the legal point of view, no power to insist upon the investigation of any particular kind of healing. I remember raising certain questions in the House some time ago, and really, and I say this with every reserve, I was appalled at some of the answers which the predecessor of the present Minister gave to me. Appalling ignorance was shown by his Department with regard to some of the most scientific methods of healing that are known today. If the Minister has no such powers to order an investigation, I urge him when he drafts his Bill, to take power so that he may have some means of guiding research or organising research to look into this or that.
Dealing with just one class of case, cancer, there is the method of the late Dr. Marshall, a most eminent specialist, 614 which the Minister himself will not look at and in which the Cancer Campaign people are not interested. That is only to mention one. Surely, it is a very sad commentary if we have reached a stage when bodies such as that will not take the trouble to look into something which might give alleviation to something like— we do not know exactly—70,000 or 80,000 people dying of cancer every year in this country. His idea was that the basic trouble was in the bloodstream and that it is due to the appearance of ferrous oxide. That may very well be, but why cannot the Minister look into it, or, if he has no power to do that, why cannot he bring his persuasive powers to bear on the Cancer Campaign people to look into it? On the question of voluntary hospitals, I am just as concerned, and I have had representations from my own county hospital. I would ask the Minister to consider especially the poorer areas, such as Huntingdonshire, which I have the honour to represent, where there are not many people in the whole county. Where you have got a county hospital which has been a voluntary hospital, it does seem to me that some special accommodation and consideration will have to be given. Further than that, I hope that when we get the scheme working, and I am all for it, we shall not have too much regimentation.
One other point. When the Minister gets right down to it, I want him, if he will, to arrange that we do not lose the facilities for transport which we are having during the war. There will be a tremendous lot of ambulances which could be taken over, and there will be the services of the W.V.S. and so on. These might be able to give still greater service in minor fields, so that, if you cannot get at once the services of specialists all over the country, people can be taken speedily to those places where they can get treatment. With those few words I am very glad to be able to say that, of all the State documents put before us for consideration, I have not read one with greater pleasure, and really, for a lawyer, and an eminent one at that, to produce such a document, when for a lawyer to produce anything that people can read at all is a marvel, is a good augury for the future understanding of the very great and complex difficulties with which we shall have to deal in considering the scheme.
§ Mr. Kenneth Lindsay (Kilmarnock)
I little thought that so few Scottish Members would be speaking to-day, and, although I did want to say a few things, I purposely refrained from trying to catch your eye, Sir. I listened to the hon. and gallant Members for East Renfrew (Major Lloyd) and Pollok (Commander Galbraith), who raised the issue of freedom. We had the same issue last week over the choice of a school. May I say this? Is it not time we gave up talking about something which rarely exists? If you can afford to make a contract with a headmaster or a doctor, you can certainly get a free choice, but once you universalise the system, whether of health or education, you are then on an entirely different basis. There must be some give and take. I am talking with experience of my own family. My own brother is a doctor, and I have purposely asked him and others how much freedom of choice actually exists in this country. I say that it does exist, but not to the extent mentioned by hon. Members opposite. The two hon. Members have raised it to the level of arguing that it is the main issue, and I think they are misleading the House.
In my constituency the position is that the local doctors say, rightly or wrongly, that they have not yet had time to consider this White Paper in full. I think it is only right that I should pass this information on. My own view is that it is a great State document. I welcome both this one and the one on Education as fine conceptions put forward by this Coalition Government, and I think it is one of the good and positive things which are coming through this amalgamation of minds, although there may be obvious differences on other matters. Therefore, I welcome that and would add that in my own constituency we have a magnificent contributory scheme from the workers to the local hospital, and there is a strong feeling that that must be preserved in whatever new scheme is put forward. It is deeply ingrained in the life of the area and a very large proportion of those working in the pits and elsewhere regard the hospital as partly belonging to them.
I am not going to talk in any detail about the White Paper, because it is far too big a matter to examine in a few minutes, especially with these new attempted controls, both central and local.
616 Though I welcome the White Paper, fundamentally, really I am much more interested in positive health and adolescence than in anything else. In this country it is possible for an adolescent to go from the age of 14 to 18 without any dentistry service at all. [Interruption.] Exactly, that is why I am interested in the Teviot, McNair and Goodenough Committees. It is not generally appreciated that there are 30 committees, six of them official, sitting on professional training of one sort or another? It is high time that we had some conception of how the trained men are to be found to carry on these social services. Closely in accord with the work of my friend Philip Morris, Director General of Army Education, we should start that work now.
I plead with the two Departments in England and Scotland to hasten the production of these various reports. No longer most it be necessary to spend £1,500 pounds over six years, as it was in my family in order that my own brother could become a doctor, and then afterwards have to find other thousands in order to obtain a practice. That will be an impossible position for men who are returning from the war. Experience in the Army is that, between the ages of 18 and 19, you can up-grade men in six months to a degree no one had thought possible, and if you could start that process at the age of 14 instead of 18, you would save not only a large amount of wasted opportunities, but life itself. For these and many other reasons with which I have not time to deal, I would like to support the White Paper and wish it a safe passage into a Bill.
§ Mr. Eccles (Chippenham)
In the two or three minutes available to me, I have not the time to congratulate my right hon. and learned Friend, as I would like to have done. We all want a comprehensive health service, and he is going to take a big step towards getting it. I want to say a few words about the economics of the medical profession. My father, grandfather and great grandfather were members of the medical profession and I only went from Harley Street to Wimpole Street to get my wife, so that I know something of the bread and butter side of medicine. Up to now the medical profession have enjoyed a reasonable share of the national income. The proof is not in pounds shilling and pence, but in the 617 fact that they have kept in the forefront of the world's medicine. Other occupations have not been so fortunate. The clergy and the farmers, between the last two wars, were receiving a declining share of the national income, with the melancholy consequences that are familiar to all hon. Members.
§ Mr. Eccles
I know nothing about the remuneration of the lawyers. The White Paper indicated that the share of the national income going to the medical profession is to be substantially lower than before. Consider the £30,000,000 a year which the general practitioners and the chemists together are to get, and take away the amount that the chemists will get in proportion to their present payments and it leaves £21,500,000 for the general practitioners. That means nine shillings per head of the population. I do not know what limit the Minister will put on the panel but 2,000 patients is certainly a high figure. So, a general practitioner with a full panel will receive £900 a year, and some pension which will add to the value of his income, but that is not the average income that is going to the general practitioner. We cannot have all the panels full. There must be some competition, so that £600 or £700 a year will be the average income of the general practitioner. If you take the number that will probably be needed—and I hope that the right hon. Gentleman the Secretary of State for Scotland will tell us how many will be needed—and divide this number into £21,500,000 a year it will amount to the same income, something like £500 or £600 in a year. That is not enough to maintain the quality of this great profession.
The other aspect of the payment is how the money will be distributed from the central pool to the doctors. The majority of doctors, and in my judgment the best doctors, consider that the method of salary payment is not likely to promote efficiency in their profession. This brings us up against the issue of fixed salaries versus competitive rewards, as inducements to energy and progress. If we could put aside all private interests and prejudice, and try objectively to get the best information about these two different means of payment, which would be the best body of experts to consult? Surely we 618 should value no opinion higher than that of the doctors? The doctors know more about human nature than anybody else. They see the people trying to keep healthy, to keep sane, to better themselves and to reproduce themselves. What is the advice of the doctors going to be? They are being asked, and I am prepared to prophesy that they are going to say that unless their profession is paid according to merit and services rendered, the quality of their doctoring will go down. Therefore, I ask the right hon. and learned Gentleman, before he introduces his Bill, to make sure of two things: first, that the share of the national income which he proposes shall go to the medical profession shall not be lower than at present, taking into consideration the fact that there will be more doctors; and second, that he will do his best to devise means for distributing these central funds to the doctors which will ensure the maximum of free competition among doctors, without which the high standard of the medical profession, of which we are all so proud, will not, I believe, continue.
§ Mr. Mathers (Linlithgow)
I wish to add my voice to the chorus of Scottish Members who have participated in this Debate and to be on the side of those who are optimistic about its results. So far as Scottish Members are concerned in the area of the Debate which is being allotted to us, we are not divided here to-day as Conservatives and Labourists but as optimists and pessimists and that clearly has been the tone of the speeches made by Scottish Members to-day. I know that the Secretary of State for Scotland wants full time to make his reply to the comprehensive Debate which has taken place, and I want, in the moment or two at my disposal, to make a. point which arises out of an observation made by the hon. Lady the Parliamentary Secretary. She made reference to the fact that it would be possible for the voluntary hospitals to be provided with means for making charges in certain circumstances. On this matter, the Scottish position is very different from the English, because, in the main, if not exclusively, the Scottish voluntary hospitals are working under charters that do not provide for payment of any kind to be made. They are, in the real sense, free voluntary hospitals and a different set of circumstances therefore surrounds the Scottish position, compared 619 with that in England. Legislation will be required to deal with the Scottish position to a greater extent than, with the English position, in respect of arming the voluntary hospitals with powers to make charges for treatment, and I hope that the Secretary of State may be able to enlighten us on that point when he replies.
I have only this to say in conclusion, that in my belief the great voluntary hospitals will be anxious to participate in the greatest scheme ever designed to meet the health needs of our people. I know their public-spirited nature, and I think that the pessimistic ideas that they wish to stay outside, and that they will have to be crushed into submission to a State medical scheme, are without any foundation. I believe they are sufficiently public-spirited to wish to come into this scheme and play a full part in it.
§ The Secretary of State for Scotland (Mr. T. Johnston)
The proposals in the White Paper which have been debated in this House for the past two days, are not the proposals of any individual Minister in this Government; they are the proposals agreed to by all sections in the Government. They are Government proposals, and we have ventured unitedly upon a course of conduct wherein we hope to organise the provision of a personal good-health service for everyone in this country. The present arrangements do not make that provision effective, with this result, that there is, admittedly, a vast mass of preventable pain and suffering, and quite an unnecessary loss of national income.
The health insurance system, for example, does not provide medical attention for the dependants of insured persons. Apart from manual workers, there is the £420 income limit for entry into insurance, and for the insured persons themselves—and this is the important point I wish to bring before the House—there is a wide and wholly indefensible disparity in benefit and treatment. Approved societies to-day are organised on an area basis, or on a craft basis, sometimes indeed on a theological basis, and sometimes on a large mixed society basis; with the result that, according to the general standard of health in the craft or the community in which insured persons are organised, will depend the extent of the health advantages which these insured 620 persons now receive beyond the statutory minimum. For example, there is the Teachers' Provident Society which, because of the normal average health of each member, is able to give 100 per cent. dental benefit, convalescent benefit, medical and surgical appliances benefit, ophthalmic benefit, nursing benefit, and so on to its members. At the last valuation, the funds of that society—and there are others I could name—were exceedingly prosperous. That society had assets and expectations amounting to £7 8s. per member in its pool.
On the other hand, there are organisations like the Scottish Miners, or the Durham Miners, or the Northumberland Miners, or the Lancashire and Cheshire Miners, or the Amalgamated Weavers, or the Transport and General Workers, the Boiler Makers, the Seamen, the Boot and Shoe Operators, who could give no additional benefits whatever to the statutory benefits provided by law. Some of the societies I have mentioned can only continue to exist by a periodic draw upon central funds to square their accounts. Moreover, there are societies so prosperous that they are enabled to pay their members 28s. per week during sickness, as against the statutory rate of 18s. per week paid by a vast number of other societies.
Clearly, disparities of this kind are wholly indefensible, but they arise from the very nature of the organisation of persons by area, by craft or trade or employment into health societies. They are not the fault of the approved societies at all; they are the fault of the layout of the present system. The worst case I know of is that of one society where the members' state of sickness is eight times worse in its chronic cases than its neighbour. That means that health expenditure is eight times heavier, while income is diminished. There are, indeed, about 3,000,000 insured persons in Great Britain to-day who do not draw any non-statutory benefits—dental, ophthalmic or any other. Twelve per cent. of all the insured men, and 19 per cent. of all the insured women draw no more when sick than the minimum statutory benefit.
Again, in our present layout, there are some areas and communities so grossly under-provided with a general practitioner service compared with other areas that it causes comment. There is Hastings, for example, where the ratio of general 621 practitioners to population—of course this is a pre-war figure—was one general practitioner to every 1,178 persons; in South Shields, there was one medical practitioner to every 4,105 persons. In Scotland similar disparities appear. In my own constituency there is one town, Bridge of Allan, where there is one medical practitioner to every 980 of the population, whereas in Greenock there is one medical practitioner to every 3,535 of the population. Thus in England and Wales, at the outbreak of war, the number of people to each general practitioner varied from under 1,200 to over 4,000. By comparison with the national average, Bournemouth, for example, had an excess of 90 doctors. At the same time there were five areas in the Midlands and North East of England with a total deficiency compared with the national average of 200 doctors. The spa or—as I have heard it described—the bath-chair type of area, is liberally served, possibly because wealthy sufferers tend to congregate in these areas.
§ Mr. Johnston
I say "possibly," I do not want to put it any higher than that. No one would deny that, in addition to the disparities to which I have referred, there is urgent need for improving the diagnostic facilities at the disposal of the average doctor. We have heard a great deal in this House about how doctors, voluntary hospitals and local authorities are to be treated but we have not heard very much about how the patients, the consumers, may ultimately be treated under this scheme. The diagnostic facilities available to the average general practitioner are grossly insufficient. Frequently, he has to examine his patients in ill-equipped private surgeries without X-ray or blood-testing apparatus. One hon. Member spoke to-day of the lack of contact between the general practitioner and the preventive side of the health service. A great deal can be said upon that point but if we were to make the areas co-terminus, the areas of our medical curative services to coincide with our preventive services, it would mean that we should require so to widen the areas of control, say, of housing and normal health services, that we should begin to lose the last vestiges of democratic control in local government.
§ Mr. Johnston
I beg my hon. Friend to be careful on that point. We may lose a great deal more than we should gain by rigidly running a co-terminity over the services in this country. If, for example, we took the health regions which we must apply to Scotland, owing to the great dispersal of our population in the rural areas, we should require to have administration areas for housing so wide that we would lose the last vestige of any democratic control whatsoever. While that is true, we have to face the difficulties which have been pointed out.
Since the war began we have been experimenting on a big scale in Scotland with the provision of extra diagnostic facilities for war workers. We invited general practitioners to send cases difficult to diagnose to the regional medical officer. These cases may be patients in a debilitated state or showing symptoms suggesting the need for more expert examination and diagnosis. Where necessary, the patient is then referred to a specialist or consultant; and, where necessary, is admitted to hospital for special investigation. Or he may be sent to a convalescent home for a period of rest. Where a change of work is desirable because of his physical condition the Ministry of Labour is consulted, and has been highly successful in finding suitable new occupations. The experiment has been highly successful and is known as the "Supplementary Medical Service Scheme." Hon. Members who are interested can get details in the Stationery Office publication "Experiments in Social Medicine," available through the usual procedure, a document which is highly illuminating. By this experiment, close contact between the consultant, the hospital and family doctor has been achieved voluntarily by concurrence and agreement. Everybody has been quite happy and over 7,000 cases have been dealt with under the scheme, with the warmest appreciation from doctors and patients alike.
What the Government propose is that there should be an all-in service, providing a complete range of personal health services for every man, woman and child; that there should b£ a general practitioner service open to everybody; that there 623 should be a consultant and specialist service, where necessary, for everyone; that there should be treatment in hospital, including maintenance while there; that there should be a dental service, as soon as the requisite number of skilled dentists and nurses can be obtained. It would be wholly wrong to give the idea that after a Bill is passed embodying these proposals in legislation, we can supply a complete dental service. We cannot; the dentists are not there. They will require to be trained.
§ Commander Galbraith
Surely that ought to apply to all services. The impression is getting about that that will apply only to the dental service. Surely we shall not be able to introduce a complete medical service at once.
§ Mr. Johnston
That is true; there are degrees. There is no question, however, but that in dentistry we are worse off for specialists and assistants than in any other sphere of the services with which we are attempting to deal at the moment. We are short of doctors, of ophthalmic surgeons, of all sorts of specialist consultants, and of nurses. We snail be short of dentists for many years to come. I am not sure whether we cannot augment our dental service to some considerable extent by trained nurses, but that is another question. We propose that there shall be an ophthalmic service as soon as the required increase of people in the profession can be obtained; we propose a home nursing service and a rehabilitation service. Let me say a few words about rehabilitation, which is a long and ugly word.
§ Mr. Johnston
I think it could be better explained as a fitness service. At all events, we have experimented here too. During the war we have taken over the greatest luxury hotel in Scotland.
§ Mr. Johnston
That hotel, at Glen-eagles, has been converted into a rehabilitation centre for injured colliers. I hope to see the day when we shall have rehabilitation centres for other workers than colliers. The success of that experiment has been most marked. We have men now back in the pits who came to us with broken backs. Instead of having, as they 624 would have had before, a lifetime of misery to look forward to, perhaps sitting at the fireside and drawing disability benefit till they died, these fellows are now having themselves refitted for industry. I think every section of the House will welcome that experiment. We propose also that there shall be a co-ordinated hospital service available to everyone. Above all, our proposals will greatly improve the diagnostic facilities at the disposal of the average general practitioner. All these services will be freely available to everyone.
Now may I say a word or two about the way we propose to deal with the medical profession. We propose to bring no compulsion whatever upon doctors as to whether they will come into the public service or stay out. If they choose to come in there will be a variety of options. They may prefer a capitation fee service. If so, they will be limited to a permitted number of patients, as they are now under National Health Insurance. They may come in on a salary basis or they may come in on an admixture of both. Here, again, we have experimented and explored the possibilities. For the last 30 years we have had the Highlands and Islands medical service, some outline of which will be found on page 72 of the White Paper. In that service all the North of Scotland with a wide variety of types of community is covered by the medical service where the doctor is paid partly by salary from the State and the local authorities, to a smaller extent through the Insurance Fund, because the crofters are outside the insurance system, and partly also from private practice. There is no inhibition or prohibition from treating as a fee-paying patient any sporting tenant or wealthy individual who comes along at the time of the deer shooting. [An HON. MEMBER: "Fleecing the rich."] That is one way of describing it. It has worked for 30 years satisfactorily, and with the acceptance of both doctors and patients in widely-scattered rural areas. I believe some Canadian Provinces are so impressed by this service that it is to it they are looking in creating a medical service for themselves.
There are other experiments which will require to be considered by the medical profession. There is, for example, the Peckham experiment, there are proposals for grouped practices and there are proposals for salaried service at health 625 centres. Doctors may opt to engage in group practice on a salary basis or to be employed in health centres on a salaried basis. We have tried to produce a scheme with a considerable amount of flexibility. We realise that, in building the new service on the solid foundation of the old, there is room for experiment. In any case the new service cannot be put into operation all at one time. There must be a transitional period while the old is gradually merging into the new. In this transitional period the flexibility of the scheme will obviously be of the greatest advantage. Among the more obvious examples of flexibility and experiment we can get examples from New Zealand, Russia, Sweden and other lands. We propose to discuss with the profession a salaried service for doctors at health centres, or on some other basis not involving competition. Some doctors want a capitation fee service. For separate practices we propose a capitation system. Between these two we can provide either a salaried service or a capitation fee service for doctors working in recognised groups outside health centres or for doctors in single-practice areas. We propose to discuss the whole question of payment, including these options, with the medical profession. Whatever system is adapted, we feel that it must be a cardinal point of policy that the number of patients any doctor can undertake to treat shall be limited.
§ Commander Galbraith
That is in the public service. You are going to limit the amount of private practice, if he carries it on with public practice?
§ Mr. Johnston
The point is that any doctor may choose to come into the public service or stay out. If he stays out, he can take any number of patients he chooses. If he comes into the public service he comes in on a basis either of capitation fee or salary, or a mixture of both. If he comes in on a capitation fee basis, he has, as now, a limit to the number of patients he is paid for by the State service.
§ Commander Galbraith
My right hon. Friend has not got my point. The point is that the doctor in the public service will be allowed, while carrying out his public practice, to carry out a private practice. Will the total number of his patients, both panel and private, be restricted, or will he have full liberty, while 626 carrying out his public practice, to have as many private patients as he likes?
§ Mr. Johnston
Obviously not. If a man is allowed to spend nineteen-twentieths of his time on private practice he will not be in a position to treat effectively the number of patients which we should otherwise allot him if he were not so treating private patients.
§ Mr. Alexander Walkden (Bristol, South)
The panel patients might feel they were being sacrificed and that this expert man was giving an undue proportion of his time to rich people who employed him.
§ Dr. Summerskill
It has been said that the number of private patients will be limited. Can the right hon. Gentleman tell me how it is possible to limit private patients?
§ Mr. Johnston
I did not say that the number of private patients could be limited. I said that the number of public patients, for which we pay, should be limited. We propose to discuss with the profession the whole question of the selling of practices. This, I think, is a most degrading system. It is clear that we must come to some arrangement so that the selling value is not enhanced by the inclusion of the additional classes now being brought into the public service for the first time. We say that doctors in the public service may, if they so choose, arrange with the Central Medical Board to engage in a limited amount of private practice. To the extent that they so engage their public remuneration will be diminished. There has been a fear expressed that this may involve duality or conflict of interests and that a doctor may devote undue attention to his private as compared with his public patients. To that I can only say, as set out in the White Paper on page 34, that the details of the arrangement will be for discussion with the profession, but that clearly we must ensure that the care of patients under the new public arrangement does not suffer in quality or quantity by reason either of private commitments or other public engagements. Second—
§ Mr. Johnston
I have listened for two days and I think we ought to be allowed to state what our position is.
§ Dr. Thomas
This is an important matter to a certain section of the community. When the right hon. Gentleman says that a doctor, when he enlarges his practice owing to bringing in the dependants of insured persons, must not have any extra compensation, does he bear in mind that the doctor is also losing a considerable amount of private practice by these people joining up under the State?
§ Mr. Johnston
I am not going to answer that. It has nothing whatever to do with my point. I am trying to meet a real difficulty, the difficulty of a possible duality of interests, and I am saying what has influenced our minds in the way we have approached this problem and in the decisions to which we have come. The first point I have put is that it is essential in our discussions with the profession that we make sure that the public service does not suffer in quality or quantity by reason either of private commitments or other public engagements. Second, we have no evidence of any such conflict of interests to the detriment of the public in our 30 years' experience of the Highlands and Islands medical system. Third, there is no possibility, even if we desired, of stopping all private practice: It has not been attempted anywhere in the world, and I would say to my hon. Friend the Member for West Fife (Mr. Gallacher) that it was not attempted even in Russia. I took some care in studying these matters to find some relevant evidence on the point. Professor Sigerist, in a book called "Socialised Medicine in the Soviet Union," declares that, even after the civil war with famine and epidemics ravaging their land, the Soviets never decreed the abolition of private practice. When I was in Moscow some years ago, private practice was certainly going on, but the point is that at no time—
§ Mr. Johnston
I will give some other evidence on the same point. In a book called "Soviet Communism," by Beatrice and Sidney Webb, in the edition published in 1937, we find that the same evidence is available, that at no time did the Soviets ever attempt, whatever else they tried to nationalise and make 628 compulsory, to abolish private practice. They say:Private practice is not forbidden but only a small proportion—chiefly some of the elder men in the larger cities—enjoy any appreciable income from this source. And there are a few who hold no salaried appointments, but devote their time between private patients and research.There is another land from whose experience we have had to learn—New Zealand. In New Zealand there is a great proportion of the doctors operating on a fee for service basis, and only 16 in all New Zealand are on a salaried basis. Even those 16 are allowed to charge fees for accidents and emergencies outside their areas. What the Government are trying to do here is to make the best use they can of experience of other lands.
§ Mr. Johnston
Our own experience in the Highlands of Scotland is that it is possible to produce a workable scheme which will receive the concurrence, agreement and good will of the vast majority of the medical practitioners, whose good will is so essential to any scheme. The essence of our proposal is that every doctor shall be allowed to opt as he chooses, and if my hon. Friend is correct that the vast majority of the doctors are hostile to coming into this State service, that will easily and quickly be demonstrated. It is not we who are afraid to put this to the test. We say the doctors shall have the right to choose, and I invite the House of Commons to support us in giving that option. I am afraid I must skip some of the points I wanted to take, and I will say a word now about the present layout of our hospital service.
By general admission these hospital services require considerable improvement. Whatever else we disagree about we can agree about that. In pre-war years Lord Nuffield saw this so clearly that he donated the sum of £1,000,000 for the re-organisation by regions of the hospital services of this country, municipal and private. I know something about this because I happened to be the Scottish Trustee of the Fund. There are presently three distinct kinds of hospitals in our hospital system: there are the voluntary hospitals, the local authority hospitals, and, although there has been hardly any mention of them in this Debate, there are 629 the State hospitals. In addition, of course, we have a vast number of privately-owned nursing homes. The great bulk of discussion has ranged round the provision made for voluntary hospitals. In England and Wales there are over 900 voluntary hospitals, with about 77,000 beds, and in Scotland there are 220 voluntary hospitals with about 14,000 beds. The revenue of these voluntary hospitals is £18,000,000 to £20,000,000 a year. Teaching schools are practically—not entirely—all associated with the voluntary Hospital system. Of these voluntary hospitals 293, say one quarter, were run in a sample pre-war year with a deficit and were hard pushed to make ends meet. The revenues of these voluntary hospitals have been derived in the past from benefactions and legacies, from payments by local authorities for services, payments from patients, contributory schemes and interest on investments. In Scotland in 1938, investments provided 21 per cent, of the total revenue, and in fact legacies and investments together made up 44 per cent.
Voluntary gifts have been stimulated in many ways, and I agree with the hon. Member who said that sometimes the methods were not too commendable. We had flag days, for instance. It always appeared to me not very dignified for "a great nation to provide partly for its hospital services by funds secured by the activities of students dressed up as Red Indians, stage Highlanders, nigger minstrels, Mickey Mouse, Lady Godiva and Charlie Chaplin, all holding tin cans below the noses of the charitably disposed. It is not a very commendable way for a great service to finance itself. Surely there must be a better way—
§ Mr. Johnston
In post-war years the administrators of voluntary hospitals must face the actual facts. Rich benefactors will not be so numerous. Costs of administration will be increased. There will be added payments required for nurses and staff. Building costs will be heavier, and equipment costs will be heavier. Above all there will be thousands and thousands of people who may feel that, as they have a large social security tax to pay, that tax should cover hospital contributions. Added to that, about one quarter of the hospitals start out with a 630 deficit. These are some of the reasons which would appear to justify the proposals for inviting local authorities to discuss terms with the voluntary hospitals. The arrangements made must be contractual and designed to make the most effective and co-operative use of our hospital facilities—voluntary, local authority and Government—in order to prevent overlapping and waste. This was the aim of the Nuffield Hospital Trust. I do not know whether there is anyone in this country who would argue against coordinated and efficient and effective service. I would like to say a word about Government hospitals. We have in Scotland seven large base hospitals, providing about 7,000 beds. They were provided for war emergency services, they are splendidly equipped and situated in beautiful surroundings. They will make a great addition to the hospital service which we hope to have by the agreement and co-operation of all concerned in the near future.
The benefits of co-operation have been secured already in one or two areas. In Aberdeenshire and Kincardineshire, and in Gloucestershire, there have been arrangements for the transfer of convalescent patients from key hospitals to other hospitals. This reduces the time of occupation of beds in key hospitals and results in freeing beds in these hospitals for other patients requiring surgical or specialist treatment unobtainable in the other hospitals in the region. Co-operation will ensure that accommodation is utilised to the fullest extent. We propose that through local authorities—joint authorities covering larger areas—comprehensive plans should be prepared for a complete hospital and consultant service in those areas. Those plans will be submitted to the Secretary of State, who will then consult through the Regional Hospitals Advisory Councils with the voluntary hospitals and other interests in the region. He will satisfy himself that the plans are comprehensive and that the arrangements and layouts are equitable, and he will satisfy himself that the voluntary hospitals are getting a square deal. Thus we hope to make the best use of all the services which are available in this land now for the cure of disease. There is no antagonism whatever to the voluntary hospital. Why should there be? Indeed, I will personally pay them a tribute. They have a long and honourable record of 631 public service. They are possessed of great experience of hospital administration and affairs. They are the chief hospitals to-day for training doctors. They are possessed of great endowments, investments and property.
We invite them, therefore, as autonomous organisations to co-operate in making the new health service a success. I know they are willing to co-operate. We have met them. We have discussed problems with them. They certainly never gave me the impression they appear to have given to the hon. and gallant Member for Renfrew. They appeared to be most willing to co-operate. Indeed, they have cooperated with us during the war, most markedly. There are great difficulties over the waiting lists of these hospitals. Some areas have very large waiting lists. When I approached the voluntary hospitals in Scotland they willingly arranged for large numbers of their waiting list patients to be treated in the State hospitals and to pay the State 30s. a case for those we treated: We have treated by agreement some 26,000 patients from the waiting lists of the voluntary hospitals. There is no ill-will or antagonism. There is nothing but the greatest co-operation today, on this matter of the treatment of these patients from the waiting list.
§ Sir Waldron Smithers (Chislehurst)
Is the right hon. Gentleman aware that, so far as I can ascertain, the voluntary hospitals will not come into this scheme in its present form, because it is only a matter of time under the present scheme for the voluntary hospitals all to become national and State institutions?
§ Mr. Johnston
Who lives longest will see most. I venture to prophesy that the overwhelming majority of the voluntary hospitals in this land will not only come into this scheme but will come in gladly, and will co-operate with us. I venture to suggest that, before very long, that will be demonstrated clearly.
One of the strongest arguments for a co-ordinated hospital service is the existence of these unnecessary waiting lists. I wonder whether I may let the House know what the position has been regarding these waiting lists. I believe there is no delay in the treatment of really urgent and acute cases, but in other cases, as the Scottish Health Services Committee 632 Report states, the average period of delay in obtaining treatment say for ear, nose and throat cases, tonsils and adenoids, was up to 70 days. Individual doctors report to us that the average periods there were greatly exceeded in their practices. For example, a number of doctors in Edinburgh, Glasgow and Lanarkshire, gave me the following, as the periods of delay which were not unusual: hernia, up to two years; minor gynaecological, six months to 12 months; chronic appendicitis, six months; loose cartilage in knee, six months; tonsils and adenoids, six months to one and a half years. What delay, unnecessary suffering and pain those figures show. I remember visiting Peel Hospital, near Galashiels, with Lord Craigmyle, and seeing a patient who had been seven years waiting for admission— he was an old collier—to another hospital. Other patients at Peel have waited five years or six years elsewhere, before being admitted to the hospital. That is the sort of condition that we seek to remedy by co-ordination now, and by co-operation and concurrence.
I am perfectly certain that we can, if we will, wipe out vast areas of unnecessary suffering, pain and disease in our land. In connection with our experimental efforts, to which I have referred, may I quote a letter we have received from Sir John Fraser, professor of surgery at Edinburgh University? Sir John says that he has read the Memorandum on Health and Industrial Efficiency, and he says:It is an impressive document, and I believe that no one who has national and humanitarian interests at heart can read it without being moved by the story of the problems which it describes so vividly and the account of the steps which are being taken to deal with them. You speak of the developments as 'experiments in social medicine'; they are such, but they mean something more. They seem to me to represent a milestone on the road of social progress, and the ground which you have covered so effectively is an avenue which will lead to a healthier, and therefore to a happier, Scotland. There are those, they are a multitude, who will bless the Department for the efforts which it is making to lighten the burden of what is to so many a via doloroso.Last night I turned up a book on medicine and health in New Zealand, and I found there a quotation which seemed to me to epitomise the ideals in our White Paper. I commend it to the House. It says: 633An appendix is an appendix, and a knee joint a knee joint, whether their owners have large bank balances or not, and they require the same careful treatment. The streptococcus and other opponents of the human race are not respecters of persons. Experience of sickness and experience of health teach us what many of us are slow to learn in other schools, that we are all members one of another. Endeavour in health work should draw all sections of the community together and lead the way to happier times in the life of the human family.
§ Dr. Russell Thomas
May I ask the right hon. Gentleman a question before he sits down? I know he does not like disagreeable questions, but would he apply his mind to the question which I asked him earlier, despite the somewhat curt answer which he gave me?
§ Question put, and agreed to.
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.