NATIONAL HEALTH

HC Deb 12 June 1945 vol 411 cc1511-87

4.11 p.m.

The Minister of Health (Mr. Willink)

To-day my duty is to give the House a brief review of the health of the nation and of the work of our health services. That is a duty customarily laid upon the Minister of Health when the Health Services are chosen as the topic for a Debate of this kind. I cannot, in introducing the Debate, be unaware of the widespread public interest in the proposals for a comprehensive National Health Service. But to discuss these proposals to-day would clearly, I think, be out of Order. Indeed, only a few days ago, hon. Members on the opposite side were very insistent that this rule of procedure should be adhered to. All, therefore, that I think it will be proper for me to say—and I hope it will be in Order and the House with expect me to say this much—is that the discussions promised in the White Paper of 1944 have been proceeding actively, and, in so far as they have related to matters requiring legislation, they are now largely completed. This, too, I may make clear, that, in the discussions, there has been no question of any departure from the fundamental objects of the comprehensive service proposed in the White Paper and no question of diminishing the fullness of its range or departing from the principle of its universal availability. The discussions have been concerned with methods and with questions, not of scope, but of the administrative structure. But to describe our discussion on possible changes of method or structure would, I think, be out of Order, because that will be the subject of future legislation. This I may say—that the discussions have confirmed me in the belief that it will be possible to give effect to the great scheme foreshadowed in the White Paper in a manner which will command the general agreement of all those upon whose work it will depend.

Mr. James Griffiths (Llanelly)

May I ask for your guidance and Ruling, Mr. Speaker? The Minister of Health, in opening his statement, has made reference to discussions and negotiations taking place between him and his Department and certain representative bodies outside, and, from what he said, I thought that a reference to them would be out of Order. It is the desire of hon. Members on this side of the House who will be taking part in the Debate to ask questions of the Minister and to express opinions about these negotiations. Will you, Mr. Speaker, say if that will be in Order?

Mr. Speaker

Of course, as far as the matters which the Minister is negotiating with anybody are concerned, he may not wish to say how far he has got in his negotiations. Any hon. Member may ask what has happened; that is perfectly in Order.

Dr. Russell Thomas (Southampton)

Did not the Minister make it perfectly clear that these proposals require legislation and is not a discussion of them out of Order altogether to-day?

Mr. Speaker

I did not hear exactly what the hon. Member said, and so I cannot give an answer.

Dr. Thomas

The Minister made it perfectly clear that the proposals to which the hon. Member for Llanelly (Mr. J. Griffiths) referred would require legislation. Would not that put them entirely out of Order to-day?

Mr. Speaker

If the Minister wanted to give any long statement as of proposed future legislation on the matter, that, of course, would be out of Order, and a discussion could not be allowed. The hon. Member wanted to ask questions. There is no obligation on the Minister to reply to any questions which involve an answer which would be out of Order.

Mr. Willink

On a point of Order, Mr. Speaker. May I ask you for further guidance with regard to this matter? The discussions have been going on, as indicated to the House, on the basis of a White Paper and with a view to legislation. I feel in some difficulty about going into a matter which in its very nature was precedent to legislation and was being carried on with a view to formulating legislative proposals. May I ask for your Ruling as to whether I can to-day go into legislative proposals?

Mr. Speaker

No, certainly not. That would be out of Order.

Mr. J. Griffiths

This is very important. Actually the position, as I recall it, is that the House was asked some time ago not to approve legislation, but to approve proposals embodied in a White Paper about which, in recent months, there have been negotiations. The House was asked by means of a Motion of the Government to receive and welcome the White Paper. It was understood that there would be negotiations. There have been negotiations, and what has taken place, or is alleged to have taken place, is within the knowledge of some of us, and surely, it would be in Order for us, having been asked to give approval to it, to raise questions on what took place in the negotiations and on how far they are departures from the Government White Paper.

Dr. Edith Summerskill (Fulham, West)

In view of the fact that the matter discussed in these negotiations has been widely circulated in this country—in fact 70,000 documents on the matter have been sent to doctors—surely, the time has arrived when the matter should be ventilated in this House.

Dr. Thomas

Is not this the Supply Vote for Health Services which are already in being, and not for future proposals?

Mr. Speaker

It will be in Order for hon. Members to ask any questions they like, but it is within the discretion of the Minister as to how far he answers them, having regard to legislative proposals, which are not in Order on a Vote of Supply.

Mr. Willink

There is much that the House will want to know regarding our general health services and there will no doubt be particular questions raised by hon. Members in the course of the Debate. The range of the subject matter of this Debate is extraordinarily wide and I can review only a few sections during the lime which I would wish to take. My hon. and gallant Friend the Joint Under-Secretary of State for Scotland will deal with points raised in the Debate, and also with the Scottish position. Mine must be only a brief and broad survey of our health chart during the war period. It is still an encouraging and a cheerful picture, with very few shadows; and, indeed, it is an astonishing story when one considers how much the civil population has had to endure during the last 5½ years. May I just mention a few of 'their handicaps:

A steady deterioration in their housing conditions, caused by loss of houses and damage to houses by bombing, stoppage of new building, lack of repair, and mass movements of population.

Air raids, black-out conditions, loss of sleep, over-crowding, over-work in many cases, queueing at shops and 'bus stops and very little proper holiday.

Food rationing, a diet nourishing, no doubt, but inevitably rather monotonous, home life broken up to a very wide extent, with constant anxiety for relatives and friends.

The man-power and woman-power of the country have been mobilised to the utmost limit up to a very high age level. Many more people have been working, particularly many more middle-aged women, and most people have been working longer hours and doing a great deal of part-time duty in addition. In many areas the civil population has been more or less constantly in the front line. I mention these things because they must be brought into any appreciation of our wartime health record. The health services have had to operate under very heavy handicaps. About one-fifth of the medical officers of the public health services have gone into the Forces; and almost one-third of our general practitioners, who are, after all, the first line of defence in the health services. Our public health institutions—including sanatoria, fever hospitals, hospitals for the chronic sick—have often been hard pressed, with serious shortages of nurses and domestic staff. But I should like to pay a tribute to the general practitioner, who has had to struggle along doing two men's work and carrying many extra burdens. I think, for example, of the giving of all those certificates for priorities which were inevitable under war conditions. The general practitioners of the country have been among the most overworked men on the home front, and the country owes them a debt of gratitude. But I would also mention the hospital authorities, and particularly the matrons of our hospitals, who have carried on under the most serious difficulties and have done their jobs extraordinarily well.

One would have thought—indeed we did think—that the stage was set for serious happenings on the health front. But what did in fact happen? What is the position to-day? I should like to give the House a very broad picture and mention some of the lessons which, I think, we can learn from the experiences of the war. We have had no serious epidemic. Even the influenza virus has been kinder to us than it used to be in peace time. In six winters we have had only one influenza outbreak, and that was shorter and less severe than the kind we used to have before the war. The incidence of cerebro-spinal meningitis rose sharply in the early part of the war, but gradually came down again. Typhoid fever, another disease which increases under war conditions, has been less prevalent than in any pre-war year, and that in spite of all the damage to water mains and sewers; and in that matter we owe a very great deal to the skill and the energy of our water engineers. Generally speaking, infectious diseases have been less prevalent than in normal times, though I should mention one—there has been a marked increase in infective jaundice.

Turning to some of the statistics, the birth-rate has been rising Since 1941, and last year was the highest since 1925. The effective reproduction rate for 1944 is provisionally assessed at .99, that is, within 1 per cent. of a full replacement standard. This is the first time that such a figure has been reached since 1922, though we must be careful not to judge long-term population prospects on what may be an abnormal war-time trend. Not only have more babies been born, but fewer have died. Fewer mothers are being lost in child- birth; and I can summarise the steady improvement in the still-birth rate by saying that the chance of a baby being borndead is only three-quarters of what it was only six years ago. All the vital statistics for mothers and children are the best this country has ever known, and there is no doubt that, taking the situation as a whole, the health of the children of this country—including the school-children—has not only been safeguarded, but it has been improved. And the infantile mortality rate—which last year was 46 per thousand births, compared with the peace time record of 50.6 in 1939—is I believe, one of the most reliable guides to the state of the nation's general health.

As to grown-up people, the situation is not so easy to assess. The priorities for mothers and children have often been given at the expense of the general run of adults in the civilian population—milk, for example—and one would naturally expect grown-up people to suffer in health under the arduous conditions of life during the last five years. Yet there is no evidence that they have suffered to any appreciable extent. Of course there has been an increase in the amount of tiredness and minor ill-health—the lesser ailments, lesser from the doctor's point of view, but perhaps not always from the patient's. Most people are tired. They go sick more easily and they recover less quickly. That is only to be expected after going through so much for so long. Nevertheless, it is a great and undoubted fact that the nation has been spared the weakening of its all-out effort for victory which would have come if we had had serious epidemics or a general deterioration of health. We have succeeded in protecting the health of the nation and of the generation upon which the future of the nation depends. Again as to grown ups, in spite of the increase in minor ill-health I can give this consolation, that the more serious troubles have been no more prevalent, and indeed deaths from many kinds of disease have declined during the war. It has been calculated that civilians of all ages are living at least as long as they did in peace time, even on a calculation which has included, during six years, deaths as a result of air raids.

I have referred to lessons we have learned and we have learned some very useful lessons during the war. We have learned, if I may use the Prime Minister's phrase, that there is no better investment than putting milk into babies. The vitamin supplements, the milk and meals in schools, the National Milk scheme—these things must have had something to do with the improvement in the health of the children. I feel sure that they have had a great deal to do with it, and we have learned a great deal, too, about the practical application of what has been learned in the field of nutrition. The Government's food policy has been one of the main factors in the maintenance of health standards, and there has been a very high level of employment and high purchasing power over the country as a whole. We have proved also that soundly based health services will stand up to severe strain and that good health services are a very good investment for the nation. We have developed public education in the matter of health, and we have greatly extended both the range and methods of rehabilitation to speed recovery and to reduce disablement. We have organised a blood transfusion service, which has saved thousands of lives in war, and can save many more every year in peacetime as well. And as a result of our experience with the Emergency Hospital Scheme we know that hospitals of all types can work together for the common good, with goodwill and splendid results.

The last thing I would ever desire to do is to sound complacent in these matters of health, and having broadly painted the brighter side of the picture—and it is much the bigger part of the picture—I should like to refer to the other side, and to two dark shadows. I would say first that the mortality figures for the first quarter of this year do not maintain the improvement which we have been able to record in previous years. There was a slight set-back in the infant and general mortality rates.

Perhaps further progress in the sixth year of war was too much to expect. We had had, perhaps, the heaviest stresses and strains in South Eastern England and we had had a cold winter after three mild winters. Certainly, this is no time to relax our efforts. We must be vigilant, and everything possible must be done, as quickly as resources become available, to improve the conditions which bear upon the people's health and to strengthen our organisation for dealing with ill-health. When I say that the health of the nation has been good, I mean, of course, that it has been good in comparison with what it was before the war. We are very far from suggesting that it is as good as it should be, or can become, and, indeed, in my Department, we feel that the real importance of the fact that progress has been made during a period when we might well have been expected to lose ground, is that it only shows how much more we ought to be able to do when conditions are more favourable.

Earl Winterton (Horsham and Worthing)

May I ask my right hon. and learned Friend, before he leaves that point about the first quarter of this year, whether the relevant improvement in the birth rate compared with the death rate—that is to say, in regard to the increase in population—was or was not maintained? Has he the figures?

Mr. Willink

I have not the figures by me at this moment but I will try to see that my noble Friend has them before the end of the Debate. We must not think only of vital statistics and we do not; we are trying to find out more about the extent and the nature of all those other forms of ill-health, particularly minor ill-health, which are very important to those who suffer from them and to the general health and the productive power of the nation. These lesser ailments are not shown in our records, which cover only a limited number of illnesses, and, in many cases, they do not come to the notice of a doctor at all; but we are trying to find out more about them.

Of the two dark shadows of which I want to speak, the venereal diseases come first. These show a slight decrease last year over the previous year, for the first time since the war. We are hoping that this is the turn of the tide, but new cases are still more than double the pre-war figure, and this remains a serious problem. We are maintaining the widespread campaign of education which was started more than two years ago, and I believe that this campaign continues to receive the approval of the great majority of the public.

The second problem—I think the House will all know of what I am about to speak—is tuberculosis. It is a question which is causing concern to hon. Members in all parts of the House, and I say frankly that for some time it has worried me more than any other problem in the field of public health. It is not a question of a rising death rate—the number of deaths last year was practically the same as the pre-war low record of 1938. That is a remarkable situation in view of the conditions we have had, but there is a substantial increase in notifications of new cases as compared with before the war, and our problem is to provide accommodation speedily for those who need sanatorium treatment. We have the beds but we cannot get sufficient staff—nursing staff and domestic staff. I referred earlier to the heavy handicaps under which the authorities responsible for sanatoria have been working—my hon. Friend who is to follow me is familiar with that matter—and other institutions such as those which care for the aged and the chronic sick. The general woman-power situation is tighter than it has ever been, and the needs of the sanatoria are more pressing than ever. My right hon. Friend the Minister of Labour's problem is, and has been for a long time, to get sufficient nurses and domestic workers for the sanatoria at a time when there are so many other urgent needs which may seem to women and girls to have even stronger claims on their services, though, in fact, there is no work more worth doing than the restoration to health of men and women suffering from tuberculosis. My right hon. Friend is making his appeal in a new campaign addressed to both trained nurses and women without previous nursing experience, and I should like hon. Members to give it their support by every means in their power.

That leads me to say a few words about the general problem of nursing staffs. Even before the war there was a shortage of nurses and, during the war, in spite of a very substantial addition to the total number of nurses, the demand has steadily increased and it has become increasingly difficult to maintain quite essential services. The end of the European war will mean the disbandment of certain services employing nurses—such as the first-aid post service—and the reduction of others but, on the other hand, married nurses and other nurses with domestic responsibilities may now be unable to continue to nurse and there is an urgent need for more nurses to enable hours to be reduced.

The recommendations of Lord Rushcliffe's Committee have done very, much to improve and standardise the conditions and the remuneration of the profession, but all the problems have not been solved. The hours of work, still too long in many cases, can be reduced effectively only when we have more nurses. The more material amenities, the defects of many places where nurses must work, cannot be brought to a high standard everywhere without building on a scale which really is impossible at the moment. The staffing position is especially difficult in the tuberculosis service, in the mental hospital service and in the chronic sick hospitals, but there is a shortage of midwives as well as of nurses. One is partly a consequence of the other, because the vast majority of midwives are recruited from the ranks of State registered nurses, and the rising birth rate increases our problem.

My right hon. Friend the Minister of Labour has been advised by a National Advisory Council representative of the nurses and the midwives themselves, of the voluntary hospitals, and of the local authorities. That Council has extended its scope now to consider welfare and training so far as they may affect recruitment, and its advice is now available also to me and to my Department on matters that fall under my responsibility. We have made every effort to post nurses to services where they are most needed, including a requirement that newly-qualified State-registered nurses must serve for a year in one of the fields where shortage is very special, but we see the need for nurses increasing rather than diminishing. Many more are wanted, to meet both our current needs and the additional demand that will occur under the comprehensive health service, and any encouragement to recruitment which hon. Members can give will be most welcome to myself, because the building up of an adequate and effective service is a vital need if the health and welfare of the country is to be what we wish.

Captain Duncan (Kensington, North)

Can my right hon. and learned Friend give figures of the number of nurses required?

Mr. Willink

I will try to get a figure for my hon. and gallant Friend; I would not like to give it impromptu.

Earl Winterton

I apologise for asking another question, but will my right hon. and learned Friend, in giving consideration to this question, realise that one deterrent to nurses going into hospitals is that owing to the appalling lack of domestic labour in hospitals large and small, nurses have to perform domestic work? Will he bring that to the attention of the Minister of Labour?

Mr. Willink

Indeed, that matter is one which I have had very closely in my mind, and one which I have brought to the notice of the new Minister of Labour and frequently to that of his predecessor.

There are, I think, four other subjects on which I should like to touch shortly. The first is diphtheria immunisation. I ought to say a word about this because our campaign has been most successful. There is much still to be done, but there have been new low records, both of cases and of deaths, in each successive year since the immunisation campaign first got under way in 1941. The number of deaths last year was less than one-third of the pre war average, and the number of cases only just over half. For every three children dying of diphtheria before this campaign, only one is dying to-day. The number of cases notified last year was 28,000 below the pre-war average and 12,000 less than the previous low record. That progress is all the more remarkable when one takes into account the very severe diphtheria epidemics which have been spreading throughout Europe during this period. I have asked the local authorities to make a special effort this year to increase the level of immunisation. We have had enthusiastic co-operation already from local authorities, doctors, teachers, nurses, health visitors, and voluntary bodies such as W.V.S., the Red Cross and St. John. However, I do not believe it is yet realised that more children have been killed during the war by diphtheria than by the bombs. The figures are just under 9,000 deaths from diphtheria and about 8,000 as a result of the air raids. This is a powerful enemy but we have here an opportunity to win one of the great victories. If the great majority of children under 15 were immunised, instead of just over half as at present, and if every baby were protected as a matter of course at one year old, then we could get rid of diphtheria as an epidemic disease.

Let me deal next with what might have been a very serious matter indeed—typhus. When the Allied Armies swept over Germany there was a new danger, the danger that typhus might be imported into this country. Doctors throughout the country have been on the look-out for possible typhus cases since 1942, when the disease was prevalent in various parts of the Continent and in North Africa. A special warning was sent to medical officers of health then, and it has' been renewed recently. In 1942 my Department formed a special panel of consultants with experience of typhus, and the services of these consultants are available in order to assist diagnosis in any part of the country. A vigilant watch has been kept throughout the war at ports and air ports, and medical officers have done a tremendous amount of hard work in maintaining a close supervision of those who have newly arrived in the country and have been notified by the port officers as possible contacts. I should like to pay tribute to the way in which this vitally important work has been done. Twenty-one cases of typhus have, in fact, been diagnosed in this country. Fourteen of these are prisoners of war repatriated from Germany, and seven are medical students who were among the 100 volunteers who went for special duty in Belsen and other camps.All these cases were promptly isolated, and I am glad to be able to tell the House that no secondary cases whatever have occurred. Nor has any death occurred. Apart from these imported cases, there has been no case of louse-borne typhus in this country.

I feel the House will be interested to hear a letter which I received only a day or two ago from Field-Marshal Montgomery with regard to the work of those 100 young men. I am glad to be able to tell the House that all the seven to whom I have referred are out of danger. This is the letter: The work of the 100 medical student from London Hospitals, originally recruited for Holland and flown out to Belsen, has been so outstanding that I must write you this personal letter of gratitude. It was perhaps to be expected that they should be eager to help the victims of such atrocities, to suffer new experiences and to meet medical problems, but what was so gratifying was the great sense of responsibility and high discipline that they showed. Perhaps it was inter-hospital rivalry or just a natural esprit de corps, but the results were so good and the effect on their fellow workers so great, that they may all be proud of their work during this month. Of their medical work I am not in a position to speak, but their influence on the camp and on the sick was there for all to see. To the deans of the London Hospitals I wish to express our gratitude and my assurance that these boys have not lost, but rather gained in depth of experience and knowledge of humanity, by this month's work. Yours sincerely, (Sgd.) B. L. Montgomery, Field Marshal. I should like to say something about rehabilitation, because I do not think it is generally realised how much this has been developed during the war in hospitals within the Emergency Medical Service. The House has been concerned, through legislation introduced by the then Minister of Labour, with the great question of industrial rehabilitation and resettlement, but, of course, everything that is done in this field must depend upon what is done in the hospitals in the form of medical rehabilitation. Successful rehabilitation needs a full partnership of patient, doctor and employer. The House may be surprised to know that more than 11,000 patients in Emergency Medical Service hospitals are now taking daily courses of remedial exercises. In addition, 20,000 are attending hospitals daily for special exercises and remedial games. Of these 31,000 receiving rehabilitation, 15,000 are taking part in some form of occupational therapy. I think the House will agree that these figures are an impressive indication of the large measure of progress which is being made. Since my Department made a special survey in 1943 with the object of extending these facilities, the number of hospitals providing rehabilitation for their patients has increased from 150 to 300. The great majority of Service sick and wounded receive their medical rehabilitation in E.M.S. hospitals. More than 250 doctors have been given special training, and for hospitals handicapped by lack of accommodation—a very serious difficulty—the Ministry have provided 34 prefabricated buildings. Conferences have been held throughout the country for leaders of industry, personnel managers, welfare officers and industrial medical officers, to explain the whole process of rehabilitation, and the part which industry has to play in the resettlement of patients.

Dr. Haden Guest (Islington, North)

Can the Minister say whether the rehabilitation cases are all rehabilitation after some form of physical injury?

Mr. Willink

Most of the cases to which I am referring concern wounded men, but I am glad the hon. Member has given me the opportunity of making it clear that the process of rehabilitation is not concerned merely with the results of injury. There are many surgical and other conditions where the rehabilitation we have in mind, as forming an essential part of the health services of the future, must be included. We shall not relax in this matter. The Ministry of Health will retain their rehabilitation department and we shall endeavour to encourage rehabilitation as an integral part of the health services of the country.

There has been a significant development during the war of health education—and a new interest in the preventive approach to health. In encouraging this development we have had the valuable support of the Ministry of Information, the Central Council for Health Education, the B.B.C., the newspapers and the women's magazines. I am glad to say that health, rather than disease, is becoming news, and it is being realised that there is drama in prevention as well as in cure. There has been an increased demand for Health Educational Films for showing in factory canteens and to audiences in the rural areas. I think I shall have the support of all Members in all parts of the House when I say that this is an important wartime advance which I trust will not be lost in more normal times. We cannot make progress towards a healthier Britain without the backing of sound, instructed public opinion, and a wider and deeper knowledge of the proper care of personal health, and particularly the care of children.

Before I close I must say a few words about the part—a noble part—which the Emergency Hospital Scheme has played especially in the treatment of wounded men from North-West Europe. My Department undertook responsibility for all British Army casualties on arrival in this country. For the first time in our history, provision had to be made to receive casualties in England direct from the beach and the battlefield, until the Army could set up hospitals in Normandy. A few hours before the invasion, nearly 1,000 doctors, nurses and students were moved, with complete secrecy, from London to the coastal hospitals. And in the event the whole scheme worked most smoothly. Between D-Day and VE-Day, tha number of casualties from North-West Europe who passed through E.M.S. hospitals was 160,000. In the same period the hospitals in Greater London and the South-East treated more than 20,000 flying bomb casualties. Many of the hospitals were damaged by bombs. I think the House will agree with me that doctors, nurses, and all members of hospital and ambulance train staffs, can be proud of their share in this great campaign. Very careful planning was required to prepare for the invasion. As soon as the possible ports of entry were known, arrangements were put in hand: but alternative plans and considerations of security made it necessary to extend these preparations considerably beyond the actual ports and area which were ultimately involved. The ports used from D-Day onwards were Gosport, Southampton and Portsmouth. On the 23rd October the main port of disembarkation was changed to Tilbury. The original arrangements included the provision of three different types of hospitals. There were, first Coastal or Port hospitals at or close to the ports of disembarkation, for the reception of patients unfit to travel. These hospitals contained over 1,200 beds. The second type consisted of Transit Hospitals, corresponding in function to casualty clearing stations, reached from the ports by road or by a short railway journey. These contained over 7,300 beds. There were, finally, Home Base hospitals in which patients were retained and treated to a conclusion. Home Base hospitals consisted of the larger and more important hospitals in England, Wales and Scotland, to which casualties were taken by ambulance train from the Transit Hospitals. A very large number of beds were available in Home Base hospitals for the purpose, because some weeks before D-Day admission of ordinary civilian patients had been restricted to those in need of immediate treatment.

Provision was also made from the start for the reception and distribution of airborne casualties brought back from the Continent in empty transport planes to three aerodromes in the neighbourhood of Swindon. The general scheme for the reception and treatment of these casualties was similar to that for sea-borne casualties, with hospitals corresponding to port hospitals for those unfit to travel. The remainder of the casualties were, however, transported to Home Base hospitals direct by train, no intermediate use being made of transit hospitals as casualty clearing stations.

With the collapse of Germany, Service patients of another kind came under the care of the E.M.S.—liberated British prisoners of war, together with numbers of civilians released from enemy hands. Most of them were evacuated from the Continent in the same way as battle casualties, but many were sent to hospital from the reception camps where they were found to be in need of hospital treatment. Special forms of care were of course needed owing to malnutrition and other results of prison life.

All this work has been dome by an organisation unique in our history. Never before have the voluntary and municipal hospitals been welded together into an organic whole, working together under the regional and central direction of medical officers of the Government while preserving the internal autonomy of each hospital and the clinical freedom of the medical staff. Never before have the leading medical and surgical specialists placed themselves at the disposal of an organised medical service, and by their dispersal up and down the hospitals of the country spread their special knowledge amongst die medical profession as a whole, to the great benefit of the civilian population in general. And never before has it been possible on a national scale to separate out the patients requiring special treatment for special conditions—head injuries, facial injuries and burns, neuroses and so on—and to send them to centres set apart for them, where the most skilled staff and the best equipment are available.

I have taken, perhaps, too much of the time of the House but I hope hon. Members will feel that it was right and due that this story should be told and that they will agree that much credit is due to many for the health of the nation.

4.58 p.m.

Mr. James Griffiths (Llanelly)

Perhaps I ought to begin by offering a word of consolation to the Minister, for I believe that during his speech I heard the effects of "electionitis" in his throat. I think we ought to be profoundly grateful that ever since the beginning of the war successive Ministers of Health have been able to give us a report on the health of the nation which has been a magnificent tribute both to our people and the quality of the social services which we have built up in recent years. To-day, the Minister has been able to carry us one year further and to tell us that the health of the nation has been maintained despite the anxieties, worries and other things, associated with the war, which have beset our people for so long. There are many reasons for this, but I hope everyone will note that substantially we have been able to maintain our position on the health front because of the social services which we built up during the inter-war periods and during this war, and from which we are now reaping our reward. I hope that will be remembered, if there are any people waiting around at the end of this war with axes to destroy the social services; I hope it will be remembered if any proposal comes forward for setting up other May Committees.

For five and half years our people have been geared up to the most supreme effort in the whole of our history, and I want to express what is felt by many, that perhaps the dangerous stage on the health front is yet before us. It comes when the war is over. The war in Europe has ended, and already people are feeling a mood and spirit of relaxation after the enormous efforts they have made during the past five and a half years. We do well to remember that at the end of the last war Europe was swept by an epidemic which we called influenza, and that epidemic was responsible for more deaths than were caused by the war itself. Next winter the whole of Europe will be in a very serious position, with a grave shortage of food and coal. There are many people, doctors and experts having experience of the end of the last war, who feel that during the next 12 months, and particularly during the winter months, we shall face a most serious situation with regard to the health of the people.

I am concerned about the possibility that this situation may be accentuated and aggravated by the very regrettable reductions in rations. We all understand the reasons for which it has been neces- sary to make these reductions, but I have had very many representations from my own trade union, and I feel sure that the Minister of Fuel and Power has also received similar representations, expressing deep concern about the effects upon heavy workers of these further reductions. I ask the Minister of Health to take note of these representations. Those hon. Members on both sides who are connected with the organisations of the heavy industries, where the work calls for great physical effort, are very much disturbed about the possible effect of these reductions in the sixth year of war. Although I appreciate the reasons, I wonder whether the time has not come for the matter to be considered in relation to the need for safeguarding the health of the people. I urge the Minister of Health to consult with the expert advisers in all the Departments concerned to find out what can be done. The aim has been in the case of heavy workers and others to make up for the rations by the extended provision of communal meals, but I regret to say that there are large numbers of our people who do not take advantage of those meals, and therefore the problem has not been completely met by the communal provisions as they now are. The whole programme ought to be looked into again.

The Minister referred to the social services that have been built up during the war. I want particularly to press for the continuance and expansion of the splendid services set up to provide extra food, and food of a special kind, for mothers and children. I hope also that the provision of war nurseries will be continued. There has been a tendency to think that now the war in Europe is over the war nurseries can be disbanded, and I am afraid that some of them have been closed down. I hope the Ministry of Health will encourage the local authorities to keep the nurseries open. During the last two or three years, with the increased call upon women to go to work—a need which will continue for some time—the war nurseries have played a distinctive part and have made a big contribution towards the maintenance of the health of the children of the country. I regret that this is a disposition on the part of some people to think that the need for the nurseries is now less pressing and that they can now be closed. I ask the Minister to encourage the local authorities to keep them open, and I hope they will be helped financially. I hope that some of this work will be made a permanent feature of our social services. The other day, while on a visit to the North, I was able to see a delightful war nursery and to learn of the splendid contribution these nurseries have made during the war.

I want now to refer to one of those diseases which the Minister described as still being a darkening shadow—tuberculosis. As the right hon. Gentleman knows, my country has a frightfully bad record in this respect. Some time before the war, in a published list of the counties and county boroughs of England and Wales, 12 counties were put on a black list, and the five counties heading the list were in Wales. That disease is, I think, part of the price we are paying for bad housing, overcrowding and lack of fresh air and good food. It is a poverty disease. Its continuance is a reminder to us that we have not solved by a long way the problem of poverty in this country.

Dr. Russell Thomas

Is not the hon. Gentleman exaggerating? It is not altogether a poverty disease. People who are quite well off suffer from tuberculosis.

Mr. Griffiths

The hon. Member knows very well that once a disease begins there are no barriers. He knows that the latest figures and studies by Mr. and Mrs. Titmus prove clearly, in regard to tuberculosis and other diseases, that the incidence is greater among poverty-stricken people. I thought this was so well established that there was no need to argue it even with the hon. Member for Southampton (Dr. Russell Thomas). I heard with concern the Minister's statement that the figures for tuberculosis for the first quarter of this year are beginning to show an upward trend. Even during the war we more or less held our own. I am disturbed about the increase in the figures. It is a matter of prime concern that we should do everything in our power to prevent the disease, and when it has not been prevented, to ensure that early treatment is available, because all of us who have any kind of experience in dealing with this problem know that if the disease is to be cured at all, one of the essential things is to get hold of the patient very quickly and give early treatment.

This brings me to the question of sanatorium treatment and hospital treatment in Wales, about which I want to say a few words and offer one or two suggestions. The whole of this work in Wales is done by the Welsh National Memorial Association, and the local authorities have agreed to pool their resources and work together in this way. It is an example of the co-operation which I hope we shall have in a very much wider way in this field in the days to come. The Association, like all other local authorities dealing with this matter, is seriously hampered by difficulties, most of which have been increased seriously by the war. Reports which I have seen recently from the Association give some very disquieting facts. For example, I find that on 12th May of this year there were still 763 on the waiting list, and the Association's medical advisers take the view that the waiting list would be greatly increased were it not for the fact that the Association's representatives hold their hand in making recommendations for admission in order not to do the patients more harm than good by telling them that they have been recommended for admission and then finding that they cannot be accepted.

The Association is also seriously concerned about the plight of Service men and ex-Service men, Mid believe that the situation calls for special and drastic action. Already there are some 450 Service men and ex-Service men occupying beds in the Association's sanatoria, and there are 157 Service men and ex-Service men, including repatriated prisoners of war—I ask the Minister particularly to note that—who are on the waiting list. I hope that something will be done urgently to deal with this very serious situation. I think we ought to pay specially urgent attention to the plight of the repatriated prisoners of war who are waiting for admission to sanatoria because they have contracted tuberculosis.

There is another disease which is very much like tuberculosis—silicosis. There is a terrible incidence of silicosis in my area, and the situation is really becoming tragic. In South Wales there are 2,000 waiting to go before the medical board for certification. In one colliery in my native valley there has been one workman certified every day this year from 1st January to date. That is a terrible story. Let me tell the Committee what happens now. Generally speaking, a person begins to feel that his chest is getting tight and begins to cough. He goes to see his own doctor. The miners' organisation have arranged for these men to be examined by X-ray specialists. The X-ray specialists advise as to whether the men ought to go before a board or wait for some further time. Eventually they go before the board. By that time they have ceased work. After going before he board, they either get a letter stating that the board refuses to certify them or they get a certificate. That certificate is a certificate of doom. The day it come it means, for most of the men, that life is finished.

There is one thing which I have felt for some time ought to be done. I appreciate how difficult it would have been to do it during the war, but I urge that it should be done now. When a man gets a certificate, it has become second nature for him to think that he is finished and there is nothing to be done about it. I would like these men, before they get a certificate, and immediately they cease work on the advice of their own doctor, to be sent to some institution like a sanatorium for a period of three or six months, where they could get rest, fresh air, good food, and their health could be built up. I believe that is essential from a physical standpoint, and from a psychological standpoint it would be of immense value. We are beginning to find traces of this disease at a very early stage, and men are therefore leaving work before they reach the terrible stage in which there is nothing left for them to do but to go on coughing until death releases them. We are now getting them away from work earlier. One of the things we must do is to induce in the men a feeling and belief that they can fit themselves for a new life and that the disease is not the end of everything. At the present time, when they are certified, they do not go to hospital or to a sanatorium. Nobody bothers about that at all. All the men feel, when the certificate comes, is that it is a certificate of death. I hope that the Minister of Health, in association with the Minister of Fuel and Power, the Medical Research Council and the new research station which is being opened, will look at that aspect of the matter and give serious attention to it. I hope something will be done about it.

Let me say a word again about sanatoria, and their accommodation and this waiting list of 763. I discovered from figures provided by the Welsh Memorial Association that, despite this waiting list, there are 298 beds vacant because of the shortage of nursing and domestic staff. One of the things the war has taught us is the value of the woman who does the drudgery at home and in institutions. We used to use the word "skivvy." The skivvy is coming into her own. We are beginning to realise how important she is and that we cannot do without her. I hope in the future we shall realise that this wonderful service of work of domestic servants is entitled to a far better standard of life, and of prestige in our life, than it has had before. They have been at the bottom of the scale, but we are finding out that we cannot get on without them. A noble Lord referred in an interjection to the appalling shortage of domestic servants. Why is it appalling? There was no appalling shortage before the war because there was no alternative employment, and the reason why there is an appalling shortage now is because there are other jobs. I hope no one is looking forward to the day when domestic servants will be freely available again because of unemployment. I hope we shall realise that we are not entitled to domestic service unless we provide a standard of life and the prestige to which they are entitled. There is a great shortage of domestic and nursing staff in sanatoria, and this is perhaps the most difficult of all.

It is not merely a war-time problem, though it has been aggravated during the war. Before the war the problem of getting nurses and domestic staff for sanatoria was a serious one because of a view that is prevalent particularly amongst the mothers. It is the mother that you want to convince. If you want a girl to enter a sanatorium as a nurse or as a domestic servant, you have to convince the mother, and the mothers now are really frightened that if their girls go to a sanatorium the chances of being caught by the disease are very high. What are we going to do about it? I think that one of the things in planning our long-term programme is to make provision by which nursing and domestic staffs of sanatoria work fewer hours and, secondly, that they do not live in the institution but outside. I am certain that that is essential. I lived for 10 years very close to a tuberculosis hospital. I know the frightful difficulty about getting domestic and nursing staff in that place. It was an old mansion built by a famous personality in the last century, set amongst the mountains, judged to be very suitable as a hospital, several miles from the nearest village and many miles from a town. To ask them to go there was to ask them to sacrifice something. I believe we have to shorten the hours and increase the wages and, beyond all, to provide living accommodation outside, so that they go to work in the hospital and then come clear away from it. Both from the physical and the psychological standpoint that is very essential.

Now may I say a word about finance? The Association's call upon the local authorities in Wales for the next five years is increased by £158,000 per annum. The rate incidence on the average in Wales for the T.B. service alone is a shilling in the pound. In Merthyr Tydfil it is 1s. 3d. It is twice the average rate charge or the sanatorium T.B. service in England and it is becoming a very serious burden. I hope that when we give consideration to the future of local government, and to the financial relations between local authorities and the central Exchequer this will be borne in mind. Unless something fundamental is done about it we stand in danger of a breakdown of local government in ten years. The financial burden is becoming more than the local authorities can bear.

I want to come back to the problem with which the Minister began—the negotiations which have been taking place between him and representatives of the British Medical Association. Some time ago a White Paper was submitted to us by the Government outlining proposals for the establishment of a National Health Service. We had a very interesting and informative Debate and we agreed unanimously to a Resolution welcoming the proposals and approving them in general terms, and we hoped that in a very short time we should have a Bill implementing them. We were told that there were to be consultations and negotiations. When we have had Motions welcoming these White Papers and approving their general principles and have been told by Ministers that there are to be discussions and negotiations, we have been under the impression on all sides that the negotiations were to be about matters of detail and that, once we approved the principles, particularly the structure, that was a committal by the House and that any negotiations or consultations afterwards were to be about how the principle should be applied and the structure operated, and not about whether it was the right structure nor whether they were the right principles. If we are to set up a National Health Service there must be consultations, but the House is the final authority and it is for the House to decide. We did decide. The Government asked us to commit ourselves to the principles of the White Paper and to the structure in the White Paper. I believe there has been a departure from the committal of the House in these negotiations, for they have not been negotiations about details or about how the structure would be applied or how it should be modified. It is clear that there have been in these negotiations fundamental departures from the principles of the White Paper. This seems not to be negotiation. It has been capitulation. The Minister has not negotiated with the B.M.A. He has given in to them. When there are negotiations it is important that both sides shall have a clear idea of what they have agreed to do. I have negotiated with coal owners, whose representatives have had to report to their colleagues, and I have had to report to 150,000 men. I have said, "Before we leave this room let us get it perfectly clear what we are submitting, you as the owners' representatives and we as the workmen's representatives."

Mr. Willink

I was a little troubled when the hon. Member repeatedly used the word "negotiations." I think it is very necessary to bear in mind that the type of matter that he has just been discussing is something to which the word "negotiation" is perfectly appropriate, because agents are there acting on behalf of two bodies which desire to reach an agreement. I, however, have always used the word "discussions." I have not sought binding agreements. It is for Parliament to decide what the form of the service will be.

Mr. Griffiths

We will not quarrel about the words "negotiations" and "discussions." The important thing is that, first of all, the Government come to us, put certain proposals before us and ask us to approve them by a Motion which they table. They then go to the B.M.A. and put before them proposals which are fundamentally different. That is a letting down of the House—a betrayal of the House. I used the word deliberately. Let there be no mistake about this. When we have had discussions and submitted them to our two sides we must agree on what we have decided. Listen to what the B.M.A. say in a circular to their members—from the heads of the trade union to the members of the trade union: Recommendation A.—That the Association, though it regrets that the Government have not found it possible to accept the Association's proposals in to to, welcomes certain fundamental changes in the Government's proposals. There is a circular from those who have met the Minister and had discussions with him upon the scheme already submitted to the House, approved by the House in principle and in structure and without our authority or assent or without even telling the House of Commons, submits proposals to them which are fundamentally different. That is not discussion or negotiation. It is capitulation. In other words, the future health service of the country is settled, not as between the Government and the House of Commons, but as between the Minister and the British Medical Association.

Dr. Russell Thomas

On a point of Order. Is it in Order to discuss the Government's health proposals on a Supply Day? I think you, Sir, have given a Ruling on the matter.

Mr. Speaker

We are not discussing the proposals. The hon. Member said that he was talking about a memorandum from the B.M.A. which said that fundamental changes had been made. That is not discussing legislative proposals.

Dr. Thomas

I submit that the hon. Member's Statements have nothing to do with the subject matter of the Vote.

Mr. Speaker

The hon. Member may make any statement he chooses. I cannot rule that this is out of Order because the Minister may not feel able, under our Rules of Order, to give a full reply.

Mr. Griffiths

The charges I make are based on this document, which is a copy of a circular sent by the B.M.A. to their members, in which they say that the Government have submitted to them proposals which are fundamentally changed from the proposals submitted to the House. That is my charge, and I want to ask questions of the Government, because Parliament and the nation are entitled to know the answers. How do the Government square this with their manifesto? Are they promising one thing in their manifesto to the country and another thing to the B.M.A.? Do the present Government stand by the White Paper submitted by the last Government? If not, what are the changes they propose? Is it true that in submitting these fundamentally different proposals to the British Medical Association, there was an assurance that, if the members accepted them, the Ministry of Health would press them on the Government? That is what we are told has happened. There are doctor friends of mine who tell me that that is the basis on which they have been asked to decide on these new proposals, which Parliament has not seen and has never been told about. These proposals are a complete departure, and they mean that there will be no comprehensive National Health Service, but only a botched-up panel system. They are proposals which will not implement the proposals of the White Paper. We are entitled to ask the Minister to tell the House and the nation whether the Government stand by the proposals for a National Health Service embodied in the White Paper, and, if not, what changes they proposed to the British Medical Association and what are now the proposals by which the Government stand.

5.32 p.m.

Sir John Boyd Orr (Scottish Universities)

In rising to take part in this Debate, I crave the indulgence of the House. I understand it is one of the many pleasant features of this House that new Members who attempt to speak for the first time are granted special indulgence, and I ask for it because I have no experience in making political speeches. The discussion so far has been largely on matters concerning the treatment of disease. I want to make a few observations on the much more important question of the prevention of disease and to consider some of the bearings of the principles of preventive medicine on present-day economic problems.

The question of the prevention of disease is quite simple. We should regard health as the natural and normal state of human beings, and we should regard disease as something abnormal. Most of the diseases which at present afflict all classes of the population are diseases which could be prevented. The two great aggressors of health are inadequate food and inadequate housing. When I refer to the adequacy of housing, I do not mean only the houses themselves but hygienic houses in an environment free from endemic disease and safeguarded, as far as it can be, from epidemic disease. Psychological maladjustment causing fears and anxieties is also a potent cause of disease. If you consider health you will find that it is directly correlated with the incidence of these factors.

Take the average length of life of the population, which is the best indication of the health of the poorer classes, and you will find that health, is proportionate to the adequacy of food, housing and social adjustment. In New Zealand, a country in which there are practically no slums and no malnutrition, and in which there is social security, the expectation of life at birth is nearly 70 years. In the smaller democratic countries in Europe—Norway, Sweden, Denmark and Holland, where there are few slums and the standard of the working-class is fairly high, the expectation of life is 63 to 65 years. In England, where there. are slums, malnutrition and other effects of poverty, it is only 61 years. In Scotland, where housing and poverty are worse than in England, the expectation of life is only 57. There are other countries worse than Scotland. As we go down the economic scale, we come to South American countries, where the expectation of life is 40, and India, where it is only about 27. Life and health are directly correlated with the adequacy of the primary necessaries of life. We know that it is true from what we have done already in this country, and we have done a great deal in the last few decades. As we improve housing, tuberculosis and other infectious diseases decrease. The Minister of Health has abundant statistics showing that as we transfer people from slums to decent houses, these diseases decrease. In the same way, as food improves, health and physique improve.

I would like to refer to what has been done during the war in connection with food. When the war broke out it was essential that the fighting and working efficiency and the morale of the people should be maintained. What, therefore, did we decide to do? We produced and imported as far as we could the foodstuffs needed to feed the people, and we rationed and subsidised the food so that everybody could get it. Special provision was made for mothers, infants and heavy workers. Thus the distribution of food was as far as possible adjusted to the nutritional needs of people. We produced for consumption and distributed according to needs, which should be the principle governing all matters concerned with the primary necessaries of life. What has been the result? In spite of the scarcity of food, while the wealthy classes have got less than before and have suffered much inconvenience they have not suffered in health. But the diet of the poorer classes has been levelled up, and the increased consumption of protective foods and the change from white bread to the national loaf with 85 per cent. extraction has led to a great improvement in the health value of the diet. Proteins, calcium, phosphorus, iron and all the vitamins, with the possible exception of C, has increased in the diet of the working class from 10 per cent. in the case of some, to 40 per cent. in the case of others.

What has been the result on health? We have not yet got all the figures, and it will take some years before we have all the data, but we have indications that there has been a definite improvement in the health and physique of the working classes. In Glasgow, boys of 14 are three-quarters of an inch taller and three lbs. heavier, on the average, than they were before the war. The condition of teeth is an indication of health. In Glasgow before the war only 18 per cent, of children of five years of age going to school had teeth without obvious defects; now the percentage is 45. The infant mortality rate is also influenced by the feeding. The two main causes of a high infant mortality rate are bad housing and bad feeding. In spite of the fact that housing is worse the rate has fallen to lower than what it was before the war. A well-fed mother means a healthy infant at birth and a well-fed infant has a good chance of survival.

There are many indications of that kind showing how an improvement of the dietary of the people is followed by an improvement of health. I suggest that if we brought up the level of housing and feeding to the health standards which are well known, and we had an assurance of a sense of social security, we would prevent more than 50 per cent. of the disease which afflicts the working-classes. We would do more. We would add ten years to the expectation of life of children born to the working-classes, and they are the majority of the children in the country.

How quickly can we do this? Speaking as a fanner I know that we can do it with food quite quickly. We have increased agricultural production by 70 Per cent. during the war and we could increase production by another 70 per cent. if we had enough imported feeding stuff and the full equipment needed to make agriculture as efficient as agricultural science could make it; we could produce sufficient of the protective food to raise the diet of the whole population up to the health standard.

With regard to housing, I was appalled to read in the housing Debate how Members talked complacently about waiting 10or 12 years before we can complete a full housing scheme. Must we say to our returning soldiers that some of them may have to wait ten years before they get a house in which infants can be born in safety and children reared in health? They must have forgotten the enormous productive powers of modern science. In America, Canada and, I presume, also in this country, the capacity for production has increased by 100 per cent, during the war. They must have forgotten Pluto, the Bailey bridge and other great achievement of physical science in the rapid production of planes, tanks, guns and other munitions of war. If we attack the housing problem with the same united national effort and the same intensity of purpose as we attacked the munitions problem, we can provide for every family a decent house, with at least a w.c. in it, in half that time.

I will turn, to the bearings of the health problem on some economic questions. If we are going to produce houses in half the time that is usually mentioned, we must organise the resources of the country. That means a certain amount of control—and this is a difficult subject. There is a danger that controls may be retained beyond their period of usefulness. To Roosevelt's four freedoms we might add a fifth freedom—"freedom from filling up forms." But any Government which removes any existing controls or fails to impose whatever additional controls are necessary to enable the full resources of finance, material and labour to be devoted first and foremost to providing the things that people need to lead healthy lives, should be regarded as an enemy of the people.

In the early part of the war, when we were talking so much about building a new and better world, there was a good deal of planning. Indeed, planning broke out like an epidemic of measles. We had planning for every aspect of life, for trade, for exports, for industry, for new cities, and so on. The difficulty was that we were planning in water-tight compartments as if trade or industry or export markets were ends in themselves. What we lack is a master plan into which all the piecemeal planning will fit. What should be the ultimate objective of the plans that we make? I suggest that the ultimate objective of all planning should be the welfare of the people, and obviously the first step is to provide the physical necessities for a full and healthy life.

In the past we have placed too much importance on trade. The wealth of the country does not consist in its trade, its industries, its exports, or the amount of foreign credits. These are only means to an end. The real wealth of a nation consists of the health, the character and the intelligence of its people, and the real test of the efficiency of a Government is the extent to which it can provide environmental and social conditions such that every child born in the realm can attain its full inherited capacity for physical, mental and spiritual well-being.

Supposing we organise for this great objective and devote all the resources of the State to it, we need not sacrifice other interests. If we are going to produce all the food we need to bring the national diet up to the health standard then in addition to all we imported before the war, as was said in a Committee in another place, we have need to increase home production of protective foods from 25 per cent. in the case of some to 70 per cent. in the case of others. America, with more accurate estimates than we have here, say they have to increase their protective foods from 15 per cent. in the case of some to 70 per cent. in the case of others; that is, to feed the people of America and not for export. But agriculture cannot expand unless it has a great amount of industrial products. Many millions of pounds must be spent on agriculture in order to make it efficient. If to what is needed for agriculture we add all the industrial products needed for housing, furniture and other necessities the wheels of industry will be kept moving full speed and internal and external trade will increase. Our unemployment problem would disappear. That great man, Mr. Roosevelt, the late President of the United States, very truly said there are so many millions who have never been adequately fed, clothed and housed, that if we set out to provide these things there will be work for every man and woman willing to work. That is as true in Great Britain as in America.

If we set out to do this I think we will escape the frustration which came upon us after the last war, when we had children in the towns suffering from malnutrition when the land which should have provided the food they needed was lying idle, and when we had people in the country living in poverty while men in the towns who could have made the things they needed were rotting in unemployment. Men in the town and men in the country would all be fully employed, creating the new wealth needed to lift them out of their poverty and give them a standard of living which would enable their children to enjoy full health. Although that policy would bring prosperity in agriculture, industry and trade we ought not to do it for that purpose. This nation should do this thing because it is right. Twentieth century medical science offers this solution to some of the 20th century problems which to me appear to be insoluble by 19th century political and economic ideas.

5. 45 p.m.

Mr. Wootton-Davies (Heywood and Radcliffe)

I have been a Member of this House for nearly five years, and this is the first time I have been fortunate enough to follow anyone making a maiden speech. To-night I must count myself fortunate in catching your eye, Mr. Speaker, so that I may follow the hon. Member for the Scottish Universities (Sir J. Boyd Orr.) I am sure we have all been interested in what he has had to say and we will all look forward to what he will have to say in the future. One good reason why I should return to this House is that I want to listen to the hon. Member for the Scottish Universities. I offer my congratulations to the hon. Gentleman and would say to him that I think that most of us agree very much with what he said.

The Minister of Health made a speech which was a little difficult to understand. He said that as a nation we were tired; as a nation we had adequate but monotonous food. He pointed out the danger of some types of food being on the minimum side, and yet we were more healthy. I would like to ask my right hon. Friend, who mentioned diphtheria and typhus, if he has any information about the variation in diphtheria serum. I believe a suspected variation—I put it no higher than that—in this serum is one thing which holds people back from getting their children immunised. I know people who attend clinics, and they say, "Now we will get our child done; this batch is good." There may be nothing in this, but if it is a misconception it should be disposed of and it might increase the number of children who are taken to be immunised. The hon. Member for the Scottish Universities spoke about prevention, and I think that we ordinary people may be allowed to criticise doctors and say with truth that we bank more on prevention than on cure. It is rather extraordinary that in the year which the right hon. Gentleman has reviewed we have had full use of the sulphur drugs and of penicillin—

Mr. George Griffiths (Hemsworth)

May I ask when we have had full use of penicillin? We have never had it yet.

Mr. Wootton-Davies

I think that that is a question which can be addressed to the right hon. Gentleman.

Mr. Griffiths

But the hon. Gentleman said that we have had full use of it.

Mr. Wootton-Davies

There has been no difficulty in obtaining penicillin in my constituency. I believe it is now available to the civilian population. In spits of these new drugs, and in spite of the advance of science, people are not living longer and disease is still with us. That is where I agree with the hon. Member for the Scottish Universities that prevention is far better than cure. He said that good health was based on good food and housing; I would add that we must also be kept reasonably warm. If we had been kept reasonably warm—and we have not been kept reasonably warm during the past 12 months—we might have had a better bill of health.

Several times in this House I have pleaded for ordinary, plain, unadulterated, vital foods. I do not depart from that one bit. I hope the right hon. Gentleman will tell us something about duodenal ulcers. It is said to be a nervous complaint, but I would ask whether it is not due to some of these preserved foods that we are eating. It is a theory, and I would like to see some research made into it. Admitting that good health is based on good food, housing and reasonable warmth, I would ask the right hon. Gentleman if all the precautions have been taken in this country for providing us with good food. He has pointed out how milk assisted the school children. I would also point out the extent to which that band of women, often unpaid and unnoticed, who go to clinics day after day and week after week, has improved the health of the children. The Minister of Food has given cod liver oil and orange juice and this has improved the health of the children, but ever since the war commenced we have known of methods for increasing the milk supply of which we have never taken advantage. I think the hon. Member for the Scottish Universities will agree that two articles of our diet are important—proteins and fats. In last night's evening paper once again I saw that the Germans are said to have produced wood food richer than beef steak. I have been laughed at in this House for advocating the production of proteins from wood and straw. One has only to look at Hansard. I say to my right hon. Friend the Minister of Health that if he will exert his pressure on the Minister of Agriculture and on the Minister of Food who rejected these proposals, we might increase our milk and egg supply. We are wasting some 2,500,000 tons of straw. These things do count, but it is almost impossible to get Government Departments to realise the possibilities of science.

With regard to the question of nurses and sanatoria, all of us who have had to deal with industry know that the only thing is to spread the period of infection and rest. I hope my right hon. Friend will weigh the words of the hon. Member for Llanelly (Mr. J. Griffiths). These women who work in sanatoria with consumptive patients should have certain hours of work and of rest and fresh air. He said that this hospital and sanatoria treatment depends upon the humble man and woman who do the ordinary housework. There is one thing which might have gone wrong, and that is that at one time these nurses pursued these duties as a vocation, and now they expect to be paid. Good nursing, good homes, good food and good housing are essential.

6.0 p.m.

Dr. Edith Summerskill (Fulham, West)

The hon. Gentleman will forgive me if I do not follow him into the field of dietetics, but I propose to say a few words on nursing. May I apologise to the Minister for the fact that I may not be here to hear him answer my many questions, owing to the fact that the chairman of the Conservative campaign committee is giving a good deal of attention to me and my constituency, and I have to be there at about seven o'clock to-night.

May I say a few words on what the Minister described as the "black spots." I should say there are three black spots, not two, the dearth of nurses and the increase in the incidence of tuberculosis and venereal disease. First of all, the dearth of nurses. The hon. Gentleman touched upon a very important question, so far as nurses are concerned. He said that, unfortunately, women did not regard nursing to-day as a vocation. I must tell him that it is no good exhorting the modern girl to emulate Florence Nightingale. One must remember that that great woman had an independent income, which is a very important factor. Many people here talk about the conditions of nurses, but no one has said what, of course, is well known, but needs ventilating, that, in spite of the Rushcliffe's Committee's recommendations, the probationer nurse only receives £40 a year, or 15s. a week. A staff nurse receives £102 a year. The modern woman has changed. I am told by the employment exchanges that a domestic worker to-day, whatever her qualities, can demand £2 a week and her keep. Compare that with the probationer nurse who gets 15s. a week and is expected to devote 50 per cent. of her time to domestic work. The answer is there. Why does not the Government wake up to the problem and decide to improve the conditions of the nurses? The other black spots are related. The Minister talks about the increase in the incidence of tuberculosis. We have a shortage of nurses with the result that tubercular patients cannot enter sanatoria. They stay at home in the overcrowded conditions which we all know about in these post-war days infecting the family. The distinguished Member who has just spoken said, quite rightly, that ill-health can be traced to overcrowded conditions. In these post-war days we have over crowded conditions plus thousands of tubercular patients. Is it any wonder that the incidence of tuberculosis has not decreased?

Now, with reference to venereal disease. I do not like to say "I told you so," but a few years ago, at the beginning of the war, when the Government introduced Regulation 33B, which provided for a certain supervision over patients suffering from venereal disease, I said it would not work. I said the incidence would increase, and to-day we have a sorry picture. The number of venereal cases in this country has doubled, and still the Government deplore the fact, but what action are they going to take? As regards statistics of diseases, I am sorry the Minister did not tell us the incidence of rheumatism in this country, because it is such a disabling disease. When the hon. Member said that the conditions of last year had aggravated certain diseases, I think it will be found that rheumatism is one of them.

I want to devote the rest of my time to what the hon. Member for Llanelly (Mr. James Griffiths) has already raised, and which I raised on the Adjournment very recently—the document which has been circulated in this country embodying the proposals which the Minister has made to the British Medical Association. I have challenged the Minister in this House time after time, and I have persisted that he has made these proposals. The Minister has persisted that he has not made them and, in fact, he told me on the last occasion that he knew nothing about them. When I had the document here and read out to the House what was in it, the Minister said he did not know what document it was.

Mr. Willink

The hon. Lady must be very careful in what she is saying. If she proposes to quote what I said, I should, prefer her to quote it accurately.

Dr. Summerskill

When I raised the matter on two or three previous occasions the Minister expressed complete ignorance of it. I leave the Members of this House to judge. They heard him, time after time. The fact is that the document exists and has been circulated to 70.000 doctors, and has now been discussed in the lay and medical Press. I read out to the Minister, the last time, the first paragraph of the document in which it said: If these proposals are acceptable to the members of the British Medical Association, then the Minister will be willing to commend them to his colleagues.

Mr. Willink

The hon. Lady purports to quote words from the document without having it before her.

Dr. Summerskill

I think that is a little unfair. I had the document here the last time. It simply happens that I did not think for one moment that the Minister would deny the accuracy of the document which I quoted last time.

Dr. Morgan (Rochdale)

I can let the hon. Lady have a copy of the document.

Dr. Summerskill

I will quote from the document kindly handed to me by the hon. Member for Rochdale (Dr. Morgan). It says: They are proposals which the Minister will be willing to put to his colleagues as soon as he knows whether they commend themselves to the medical profession. Well, I ask the House!

Mr. Willink

The hon. Lady must realise that a moment or two ago she said I had promised to commend these proposals to my colleagues. She then quotes the document, in which the word "commend" is employed in the question whether the proposals commend themselves to the doctors.

Dr. Russell Thomas

On a point of Order. I believe this question has been raised with Mr. Speaker, and that Mr. Speaker gave a Ruling that the proposals referred to by the hon. Lady involve future legislation, and that references to these proposals should be very brief indeed.

Mr. Deputy-Speaker (Colonel Sir Charles MacAndrew)

As far as I can see, it is perfectly in Order.

Dr. Smnmerskill

I think the Minister and—if the word is not unparliamentary—his stooge, will agree with me, when I say—

Dr. Thomas

I object to the word "stooge" as being unparliamentary, and I must ask the hon. Lady to withdraw it. I will also ask the House to believe that I have never acted as a stooge to anyone, certainly not to the Minister of Health.

Sir Herbert Holdsworth (Bradford, South)

May I ask, Mr. Deputy-Speaker, whether a Member is entitled to use that word in regard to another Member?

Dr. Summerskill

If I have offended the hon. Gentleman, and if the term is not sufficiently precise, I withdraw it. Mr. Speaker ruled that it was quite in order for us to discuss in this House certain matters which the British Medical Association had already put before its members. I want to ask the Minister whether it is correct that he has agreed todrop—the word "drop" is used time after time in this document—the introduction of health centres throughout the country. I know he will say we are going to have experimental health centres. That is a delightful defence. What is an experimental health centre? We might have one in Scotland, one in London, and one in Wales, and the Government will hope that that will satisfy those of us here who believe that there should be health centres in every congested part of the country. I understand in these proposals the health centres are going to be dropped, although when a questionnaire from the British Medical Association was sent to all the doctors in the country, a majority supported the scheme of health centres.

Dr. Russell Thomas

Further to the point of Order I raised a moment ago. The hon. Lady is now discussing the setting up of health centres, and so on, which are all future plans and nothing to do with Supply.

Mr. Deputy-Speaker

I agree it would be out of Order to proceed on this line.

Dr. Summerskill

Health centres have been discussed for 20 or 30 years, and those of us on this side of the House have been urging health centres for many, many years. To suggest that during a Debate on health we cannot discuss health centres is absurd.

Mr. Deputy - Speaker

To-day is a Supply Day.

Mr. Willink

May I have your Ruling on this, Sir? The hon. Lady is seeking an answer from me as to whether the proposals in the White Paper, with regard to health centres, are still the proposals of His Majesty's Government or whether they have been modified, and, if so, in what direction. Any modification of the proposals in the White Paper with regard to health centres which would be consistent with the principles or purposes of that Paper would, I imagine, beyond all question, involve legislation. Will it be in Order for me, Mr. Deputy-Speaker, to answer such a question to-day?

Mr. Deputy-Speaker

It is quite in Order to ask questions so far as the White Paper is concerned.

Dr. Summerskill

In view of the fact that health centres are mentioned in the White Paper, I think I am in Order in referring to them. The Minister is clearly showing that he is trying to stifle discussion. I have never heard a Minister intervene on so many occasions.

Dr. Thomas

On a point of Order. May I suggest that the proposals in the White Paper are entirely concerned with future legislation and not with Supply?

Dr. Summerskill

It is quite clear—

Dr. Thomas

May I have your Ruling on that point, Mr. Deputy-Speaker?

Mr. Deputy-Speaker

I understand that the White Paper is concerned with policy.

Dr. Summerskill

It is quite clear that the Minister and his friends are not very happy about having this great betrayal ventilated before the Election. "Betrayal" was the word used by my hon. Friend the Member for Llanelly (Mr. J. Griffiths). This is the second time in this century that the poor and the sick, the most helpless section of the community, have been betrayed by the conservative section of the medical profession. The last time we had a strong Minister, Mr. Lloyd George. This time I am afraid that the Minister has not only capitulated, but has run away; he has not only run away, he is even trying to stifle discussion in this House, trying to prevent the progressive side of the House from pressing that the reforms in the White Paper should be implemented.

We have already heard from the Minister that the general practitioner is the first line of defence. The general practitioner comprises 75 per cent. of the medical profession. We had hoped that in our health centres the general practitioners would come together, would co operate, would exchange ideas and would gradually achieve a much higher standard of medical practice. Now the Minister suggests that the general practitioner should remain isolated. I know the general practitioner well. Most of them lead isolated lives, they are harassed, they are apprehensive as to the future. They have, unfortunately, to pander to the hypochondriac in order to pay their expenses. We had hoped that a new life would dawn for the general practitioner, that not only would he benefit but that his patients would also benefit. What has happened? This great reform, probably the greatest step forward promised in the White Paper, is to be dropped.

What of the voluntary hospitals? In the White Paper it is suggested that the voluntary hospitals land the municipal hospitals should be administered by one board, that the friction between municipal and voluntary hospitals should cease. That has gone. The voluntary hospitals and their associations are to remain. I see on the other side of the House many chairmen of voluntary hospitals. In thinking of voluntary hospitals we may be apt to think of our great London teaching hospitals with many hundreds of beds, but it must be remembered that of our 700 voluntary hospitals only 50 have 200 beds or more. Knowing hospitals very well, I say that the cottage hospital is an anachronism. What are the proposals of the Minister? These new proposals are designed to give the cottage hospital a new life, while continuing to deny them adequate staff. If they are carried on in the way they have been carried on in the past the general practitioner will still be allowed to undertake major operations. Those of us who know some of the cottage hospitals know full well that the innocent and ignorant public are often at the mercy of those who conduct cottage hospitals.

Another very important proposal in the White Paper was that newly qualified doctors should be sent to those parts, of the country to practise where there was a dearth of doctors. We all know that in places like Hampstead and Bournemouth the population of doctors is very high compared to the lay population.

Mr. Willink

The hon. Lady has complained of my intervention, but I must remind the House that there was no proposal in the White Paper that any doctor should be sent anywhere.

Sir H. Holdsworth

Could you, Mr. Deputy-Speaker, give us some guidance regarding this matter before we go any further? Very controversial questions are being raised. I am not objecting to that but they do more or less all involve legislation. As this is a Supply Day, shall we on these benches who do not agree with the hon. Lady on many of the contentions she is putting forward be quite free to discuss the whole of the question and answer the suggestions which she is making? Is she in Order in discussing things which involve legislation? I submit, with all deference, that we cannot deal with questions which involve legislation.

Mr. Deputy-Speaker

It would be out of Order to discuss the legislation required, but the proposals in the White Paper may be discussed.

Dr. Summerskill

I apologise to the Minister if that recommendation was not contained in the White Paper, but I think he will agree that it has been discussed and mentioned in this House and in this document—

Dr. Morgan

I will give the hon. Lady this document, even though I am against her.

Dr. Summerskill

My hon. Friend is only against me because he is on the Committee of the B.M.A. It is in the White Paper. This document has been very carefully prepared. It has three columns, in which are given the proposals in the White Paper, the recommendations of the B.M.A. and the alternative structure proposed by the Minister. The White Paper says: The Board must also be able to require the young doctor, during the early days of Ms career, to give his whole time to the public service where the needs of the service require this. What does the Minister say to that?

Mr. Willink

If the hon. Lady asks me to reply to that, I would say that it was made abundantly clear in the Debate on the White Paper, and has been made abundantly clear since, that the Paper did not propose a power to direct a young doctor anywhere. It was explained, if it needed explanation, by myself in opening the Debate, that the White Paper proposed for discussion, and modification if need be when the necessary legislation was introduced, that there might be cases in which, there being a shortage of doctors, a young doctor could not be authorised to take public patients and private patients as well. But no proposal was put forward by the Coalition Government for the sending of doctors about the country to places where they did not wish to go.

Dr. Summerskill

The Minister intervened just now because he said this question was not mentioned in the White Paper. I said it was, and I have read it to the House. I wish the Minister would inform himself more—that is his weakness—on what is a highly technical subject. It is proposed that doctors should be sent where the needs of the service require it. And this is the Minister's alternative structure, which is put to the B.M.A.: the proposed requirement that all doctors proposing to enter practice in new areas must obtain the Board's consent would be dropped.

Dr. Russell Thomas

Again on a point of Order. This particular document from which the hon. Lady is now quoting is not the White Paper, but a document which is completely unknown to hon. Members. Is the hon. Lady at liberty to go on reading it in that it concerns future proposals?

Mr. Deputy-Speaker

I understood the hon. Lady to be quoting from the White Paper.

Dr. Summerskill

You are quite right, Mr. Deputy-Speaker, these are extracts from the White Paper.

Mr. Willink

Is the hon. Lady telling the House that the last document from which she read was the White Paper? It is nothing of the kind.

Dr. Summerskill

Yes, the White Paper of February, 1944. I will read it again: The Board must also be able to require the young doctor during the early years of his career, to give his whole time to the public service where the needs of the service require this. Those are the words [Interruption.] I have been ladylike too long. Be quiet and try to behave like a gentleman.

Mr. Deputy-Speaker

The hon. Lady must remember that she is addressing me.

Dr. Summerskill

I think that you, Sir, will agree that I have been patient. I have never sat down and stood up so much during the seven years I have been in this House.

Mr. Deputy-Speaker

I will protect the hon. Lady.

Captain Strickland (Coventry)

On a point of Order. The hon. Member read a further document than that which she has just now quoted. The question of the Minister was whether that last statement was from the White Paper. I understand that the hon. Lady said "Yes"; and then referred again to the former statement.

Mr. Deputy-Speaker

That is not a point of Order.

Dr. Summerskill

I have just said that this document is so comprehensive—[Interruption.] It is a document that was circulated widely. It is divided into three columns giving the White Paper proposals, the B.M.A. proposals and the Minister's proposals for an alternative structure. It is possible for me to look at one document in which all three are contained. Having read the proposals in the White Paper, I said that the proposals of the Minister were that the proposed requirement that all doctors proposing to enter practice in new areas must obtain the Board's consent, would be dropped. The Minister has already told the House this afternoon that he is to direct nurses, after their first year, to those areas in which nurses are needed. Why is he willing to persuade nurses to go where they are needed, while he refuses to make young doctors go where they axe needed?

Mr. Willink

rose—

Dr. Summerskill

No, I am not giving way.

Sir H. Holdsworth

On a point of Order. Is not the right hon. Minister entitled to intervene to deny something?

Mr. Deputy-Speaker

I think it will be better if the hon. Lady were permitted to continue her speech.

Dr. Summerskill

Thank you, Mr. Deputy-Speaker. I appreciate your protection. In many parts of this country, as hon. Members opposite representing industrial constituencies know very well, there is a dearth of doctors, whereas in other parts of the country there are doctors who are fairly idle. It is suggested, therefore, that doctors should be directed, for the first few years after qualification, to the industrial areas where they are needed. This proposal has been dropped. This means, in effect, that the privileged will always be assured of medical treatment, but that the worker may have to sit for an hour or two in a surgery before he receives attention. If one goes to the East End of London one will see outside the doctors' surgeries queues of men and women who have worked all day, waiting for hours for attention. Surely the time has come to redistribute our medical population on better lines than that?

For years we have felt that the time had come to introduce a salaried service. Doctors who work in health centres should be paid on a salary basis. In the White Paper this proposal was fully set out. The Minister is willing that it should be dropped. We have heard to-day that one-third of the doctors of the country are in the Services. What is to happen to those young doctors when they return? Here is an excellent opportunity for them to practise their science in the health centres. Young, keen men, already accustomed to working together in the Services, could come to the health centres, and give of their best, and they would be happy to come there. Most of them are without practices; most of them are without large capital. It has been suggested that young doctors should not be handicapped if they have not the capital to buy practices. This was a chance for young doctors. It is to be dropped; and it is to be dropped in the name of freedom. I suggest that if a doctor works on a salary, he will be, for the first time in his life, experiencing real freedom: the freedom to tell the patient what he or she should be told, the freedom to refuse to prescribe a bottle of medicine when it is not needed, the freedom to tell the truth, the freedom to be able to dismiss the wealthy neurotic, and the freedom to welcome the worker who has real illness and needs time and attention. He has lost that freedom. The only freedom the Minister is giving him is the freedom to go to the moneylender when he comes back from the Services.

Every principle for which the Conservative Party stand at this Election has been violated in this document. They talk in their manifesto about the Socialists introducing a bureaucratic State. If these proposals of the Minister are accepted, every single proposal for an improvement in the health service will have to be discussed by nine committees, and, according to these proposals, the Central Council will be composed of 37 members, of whom only five will represent local authorities. The effect of this will be to conserve out-of-date methods of treating the sick and the poor, to uphold the charitable system, to thwart the brilliant young doctor without capital, and to preserve the privileges of those who make fortunes out of the ill-health of the workers.

6.34 p.m.

Mr. Storey (Sunderland)

I should not have intervened in this Debate if it had not been for the most unfair attack which has been made by the hon. Member for Llanelly (Mr. J. Griffiths) and the hon. Lady the Member for West Fulham (Dr. Summerskill). They have suggested that the Minister has dropped proposals which have been put forward by the Coalition Government and approved toy this House. He has done nothing of the kind. What the Government put forward were certain proposals for a health service, as a basis for discussion, both inside and out-side the House. What the House agreed to was that these proposals should be the basis of discussion. What has happened is that these discussions have taken place with the bodies most concerned, the B.M.A., the B.H.A., and the local authorities; and the alternative proposals which are now under discussion, which arc referred to in the document that the hon. Lady has quoted, are simply alternatives to the proposals which were put forward by the Government. They are proposals which are perfectly in order, and which the Minister said that he would put before his colleagues only if they were agreed by the bodies concerned. There will be no definite proposals put before the House until the Government have agreed to these proposals, and I think the House should wait until we have definite proposals in the shape of legislation. The hon. Lady has criticised these proposals. I would say only that the alternatives that the Minister is to put before his colleagues are alternatives which have been discussed by the B.M.A., representing the medical profession, and the B.H.A., representing the hospitals, and that they are proposals on which those bodies have agreed. I think the House should wait until the Government have decided on these proposals before any definite opinion is formed about them.

Mr. R. J. Taylor (Morpeth)

Is the hon. Member aware that young medical men complain that they have had no opportunity to attend the B.M.A. Conference, and that it is only the older men, in established practice, who attend, 'because they have the liberty to do so, while the young men are back at home looking after their patients?

Mr. Storey

On the contrary, the B.M.A. have circulated their proposals to the profession, and the negotiations have been held up for a long period, because of the difficulty of getting the members to discuss them. Even if the hon. Member is right in saying that the young men are unable to attend, surely that is a reason why we should wait for the Government's proposals before we express any definite opinion on them.

6.37 p.m.

Dr. Morgan (Rochdale)

I rise in this turmoil with some diffidence. I happen to be, as usual, in the position of having heard both sides before, not only in this House but outside. I have heard the workers' point of view; and I have heard the medical point of view, because I happen to be a member of the council of the British Medical Association. I hope hon. Members on this side will forgive me for saying that I am astonished at the anti-medical feeling which exists in some quarters, because the recognised organisation of part of the health workers, the doctors, has desired to enter into negotiation with the Government and with other bodies to discuss something which will affect the whole of the conditions of their work in future. This is a very radical change from the point of view of the profession, and I submit, purely from a trade union point of view, that it really is advisable for our side to grant, perhaps conde- scendingly, to the B.M.A., as representing the doctors, the right, whatever one may think about them and their policy, to enter into negotiations, as any other trade union has the right to do.

When trade unions, even big ones like the transport workers, the miners and the engineers, enter into negotiations, reports are not sent out every day as to the state of the negotiations. When the B.M.A. are negotiating with the Minister, they are entitled to respect the confidence of the Minister, as the Minister is expected to respect their confidence, and, in addition, they are expected to tell their constituent members what is going on. The position has been very difficult. I cannot understand all this fuss. I am employed by a very powerful trade union body and I see this sort of condition, about negotiations and confidence, taking place every day. For the life of me I cannot see why doctors should not be allowed to enter into negotiations with the Minister. We have heard that the Minister has entered into consultations with the local authorities and other bodies. It is no secret—you will see it entered on their minutes—that the B.M.A. has entered into discussions with the Trades Union Congress. Is there anything wrong about that? As the result of the Llanelly medical dispute, which was settled 'by the benevolence of the Trades Union Congress, there was formed a joint committee between the B.M.A. and the T.U.C. These bodies rightly discuss important problems interesting to both. Although I personally may disagree with some of the decisions made by the medical profession as a result of their discussions, I cannot see why the body which is truly representative of the profession should not have a right either to negotiate with the Minister or to express its views when something vital to the working of a scheme in which the profession is deeply involved is taking place.

Many of the proposals are alleged to have been violations of the original principles. I have read the report of the discussions, and I wish some Member would tell me where these principles are violated.

Mr. Gallacher (Fife, West)

Is it not the case that the principle underlying the White Paper was that the doctor should go where his services are most required, and that the principle of the B.M.A. is that a doctor shall go where he can make the most money?

Dr. Morgan

That sounds very nice, but it is neither true nor intelligent. There is no question that the doctor, like every other worker, expects to be paid, and he wants good conditions of work. He has an organisation which negotiates good conditions of work. I objected very much to certain terms of the White Paper, which I thought involved the directing of young doctors. I asked the Minister about it, and he gave me a personal assurance that it was not the intention of the Government to direct doctors intoparticular areas.

Mr. McNeil (Greenock)

Surely what the Minister said was that direction would be reserved for young doctors who opted for full-time State service.

Dr. Morgan

What I understood the Minister to say was that a young doctor, before he entered an area which was already in the discretion of the Central Medical Board or which was already fully doctored, would be required to have experience in a health centre. Every young doctor should have some experience in an institution before he goes into general practice. All this seems to me beside the point. What principles were broken in the discussions? The uniformity is still there, the availability is still there, the necessity for the fully-trained competence of the doctor is still there, adequate planning is still there, prevention is still there—although this Measure is very bad from the point of view of prevention. Where the Minister has allowed the B.M.A. to ask him to go in a wrong direction is in relation to the administrative structure. Unfortunately, in regard to the administrative structure, he has allowed the profession to put proposals before him which would give the medical profession a majority perhaps in most of the bodies.

I have gone through this scheme with a fine comb. Although I am very keen on seeing that my profession gets a square deal, I am also after a good medical service for the poor. I want to see the local authorities brought in and the rights of the medical profession saved. I cannot see why you cannot have decent Whitley Councils for the profession, at every level of the scheme, and, at the same time, allow people like the planning councils which will, presumably, take the place of the health service councils, to have a majority of the people who, after all, will pay for the scheme and who are prepared to listen to the wisdom of the professional side. That is my only objection, but I think it is a perfectly valid objection. I think that consultants in voluntary hospitals have seen to it that they get a big share in any proposed administrative system. They are to be represented as consultants, and as members of hospitals, and then there are the local authorities' representatives, some of whom must be medical men. With all respect to both sides, I think that, if negotiations are allowed to continue, things will right themselves in the ordinary way.

I want to make a point about health centres. I cannot see how the new proposals with regard to health centres should invalidate the establishment of health centres anywhere. I have read through this most carefully, and cannot see how the wording in any way suggests that. All it says is that health centres, when set up, are to be under central control and supervision so as to enable the experience of one centre to be gathered together for the benefit of the rest.

But I did not rise with the intention of touching on any controversial point. This question has reached a stage at which I do not think my hon. Friends on this side of the House should call me "Tory" because I happen to see good fruit in certain proposals. I do not see why, because I am a Socialist, I should necessarily be unfair or vilify anyone who is striving in my view to come to a correct conclusion. I may be wrong in this, but I am a doctor, accustomed to trying to diagnose cases, taking the good and the bad points and coming to the correct diagnosis. In this matter, because the public benefit is at stake, and the interests of the common patient are at stake, I do not think this manoeuvring for position between one section of medical opinion, represented by the British Medical Association, and other sections, represented by different associations, should be allowed to spoil the whole good picture, which will, ultimately, have to come in administering this scheme, which seems to me to be based on the right lines.

I want to ask the Minister some questions about nurses. I have had great correspondence on this matter and I speak with knowledge because I happen to be the representative of a very important union—the Hospital and Welfare Services Union, which is a body trying to organise the different numbers of professions and crafts engaged in all the health institutions of the country. I have been struck, in all the discussions which have taken place, in "The Times" and everywhere else, by the insistence on the lack of nurses and the fact that they will not volunteer for duty. Of course, they will not; is it not plain why they will not? It is the fact, which nobody ever mentions in this House or outside it, that the nurses and institutional workers are not allowed by their employers to organise in trade unions. When a doctor goes to a hospital, appointed by the governing body, whether it is a reactionary local authority or a voluntary hospital, nobody dares to tell that doctor "You cannot join the B.M.A. or the General Practitioners' Union." But, if nurses wish to join any union of their own they are told they are not allowed to do that voluntarily without permission from the matron.

I could give the Minister cases in support of this statement. I have a good case of a matron's tyranny against a nurse, in which a petty offence is being used to damn a girl's career for the rest of her life. The Minister knows all about that case, but he has not got the courage to stop the grant of public money to that institution until that case is put right. I know of a hospital where the nurses had a union branch 300 strong. They voluntarily began this trade union branch. Within a month it was down to 20 because the matron said their careers were at stake if they remained in the union. What opportunity is given the domestic staff of welfare, promotion and striving for something better? When they go into one of these health institutions, it is a blind alley in which their lives are going to be spent for some time. That is no way to run a public service. If nurses are allowed opportunities, it will be found that the administration will become better.

The case of the nurse I mentioned just now happened in a London hospital. The nurse served up to within three months of the required period in a London hospital. Owing to the distribution of hospitals during the war, she had not been seen by the matron during that time. The matron saw this young nurse at a lecture, and afterwards sent for her and said, "I do not like the way you dress your hair; it is too floppy, and it is not nice." The nurse said, "I cannot help myself; it cannot be altered. Everybody has tried, but that is the way my hair lies." The matron said, "Well, you are not fit to be a nurse and will not be allowed to be a nurse while you wear your hair in that fashion." They tried everything they could with that girl's hair—pomades and everything. [Interruption.] There is no Gestapo here, but this is a mild form of the Gestapo which is prophesied for England. When the nurse's certificate was nearly due, the matron sent for her and dismissed her. The girl's fiancé, who was risking his life bombing Germans, asked permission to marry her, and the matron said, "In this institution we give no marriage leave." They even wanted to insist on a search of her baggage, because it was alleged that she was supposed to be taking away a uniform for which the hospital had found the material and she had paid for the making-up. Eventually, the airman took his bride away and married her, and she has never been back to the hospital. [An Hon. Member: "Is the matron still there?"] Yes, the matron is still there.

I wrote to the Minister giving him full details and asking him whether, in an emergency hospital service, when public money was being provided for such institutions, he could not exercise his right as Minister of Health to see that public money was only given to institutions over which he had some control. He and his Parliamentary Secretary wrote back and said, "We are very sorry, but we cannot interfere with the administration and the rules in this hospital." [Interruption.] So public money is to be given to such voluntary hospitals as this—which is a teaching school—and when the matron acts in the manner I have described with one of the nurses who has passed all her examinations, the Minister tells me that he is helpless and can do nothing. That negative attitude adopted by Government Departments encourages the Gestapo in certain voluntary hospitals, and it is the reason why the nurses in these institutions do not want to volunteer and the reason why the nursing profession is in such a bad state as regards recruitment.

I could say a lot about rehabilitation, a subject on which the Minister has not touched, and about difficulties in local authority hospitals in the counties of Devon, Somerset and Hampshire and all through South-West England, where only the chronic sick are being treated because the Minister has not seen fit to give them sufficient grants to build up their services. I could say a lot in an attack on the Minister—[An Hon. Member: "Say it"]—but I only want to tell him that, whether he is Minister of Health in future or not, his career will be watched.

6.57 p.m.

Mr. Willink

I hesitate very much to intervene, and it is only because of the challenge put to me by the hon. Member for Llanelly (Mr. J. Griffiths) and repeated by the hon. Lady the Member for West Fulham (Dr. Summerskill) that I thought it was right—and I hope the House will give me permission—to make a very short statement on the position with regard to the White Paper, especially as it was I myself who, together with the right hon. Gentleman the Member for WestStirling (Mr. Johnston), conducted the great bulk of these discussions. Strong words have been used and it has been suggested that something has been done in conflict with the express will of the House. I want once again to make it clear that the House, I am sure, contemplated—because the White Paper said that it would occur—that the Debates on the White Paper would be followed by the widest discussion with all concerned, the leading groups among whom—there are many others—are the local authorities, the voluntary hospitals and the medical profession. It was then contemplated that the House would next hear of the Government's proposals in a Bill, which, it was hoped, would be largely agreed. It was plainly contemplated, whether from the point of view of the local authorities, the hospitals, the medical profession or anybody else, that there might be modifications within the general objects of a comprehensive health service.

Only last week, on a Supply Day, hon. Members on the other side—different hon. Members—were acutely anxious that there should be no departure by myself from the Rules of Order applying to a Supply Day, and I therefore endeavoured, before today, to instruct myself quite accurately as to what I could go into, bearing in mind that the necessity for legislation and matters involving legislation cannot be discussed in Committee of Supply.

Mr. McNeil

On a point of Order. Are we now having instructions from the Government to the Chair of this House as to how the Debate shall be run?

Mr. Willink

I was only explaining to the House the basis on which I was going to make this statement.

Mr. Logan (Liverpool, Scotland)

Are we to understand that the Minister has to go to Erskine May to find out what we can debate in this House when we ask for a specific reply from the Minister?

Mr. Deputy-Speaker

On Report of Supply anything involving legislation is out of Order and my difficulty is that I understand that this matter involves legislation. It is very difficult to raise the question without being out of Order.

Mr. Logan

Was the Minister in Order in what he was saying?

Mr. Deputy-Speaker

The right hon. and learned Gentleman was not out of Order.

Mr. Willink

I was merely endeavouring to explain to the House the rules within which I was myself trying to keep, and I thought that that would make the position clear.

Mr. Logan

And the Minister has to go to Erskine May. Is that it?

Mr. Willink

The details of proposals which may appear in a Bill which I hope will be presented by a Government constituted like the present one, would be matters into which I could not possibly go and, that being so, whether or not any hon. Member objected, I gather that I should be called to Order. But the Bill is not, as we had hoped, being introduced in the course of this Parliament. It is, I assume, to the taste, since it is by the choice, of hon. Members opposite that this Bill will be introduced in a new Parliament. All I can say is that, as far as I am aware—and I am really confident that this is so—no Government constituted as the present Government will in any way limit the availability of the Service nor its comprehensive character, nor will they fail in achieving any of the objectives of the White Paper. The hon. Lady the Member for West Fulham asked how the Government squared the Prime Minister's declaration of policy with the report of the British Medical Association on discussions with the Minister of Health? It really is not for the Government nor for the Prime Minister to square his declaration of policy with, some document issued by the British Medical Association. If the House wants to find a declaration of Government policy and objectives in the matter of health it will find it in the Prime Minister's declaration issued yesterday. If there is any syllable of conflict between the British Medical Association's report and that declaration of policy, the House must take it that it is the declaration of policy which it has to consider. When the hon. Member for the Scotland Division of Liverpool (Mr. Logan) asks whether agreements were made with any of these discussing bodies, I will tell him straight, as I have told people on many occasions, that no agreements of any kind were made. This was not an occasion for agreement, but a matter to be submitted to the House.

The only other question on which I really ought to say a word, is the question which the hon. Lady asked when I referred to the direction of nurses—Would there not also be direction of doctors? I ought to call the attention of the House to the fact that what I was describing was something that was going on with regard to the nursing profession in time of war, whereas she was referring to something which would have to be enshrined in legislation dealing with the future.

Mr. J. Griffiths

The right hon. and learned Gentleman has not replied to any of the questions which I put to him. We do not object to discussions; I do not at all. I said that it appeared from the document issued by the B.M.A. to their numbers that the Minister had put forward proposals to them which were a fundamental departure from the White Paper which we were asked to approve. We were asked to approve certain proposals, and after approving them, the Minister goes to the B.M.A. and puts different proposals before them.

Mr. Willink

What people consider to be "fundamental" is a matter for their own judgment and a matter of opinion. I was making a broad and general statement to the effect that no measure introduced in this field by this Government would abandon any of the objects of, or depart in any way from the complete availability of the comprehensive service outlined in the White Paper. There are sure to be some changes in the scheme outlined in the White Paper. Fifteen months' discussion do not result in no suggestions for changes, and some of them might commend themselves to the Government when it came to frame the Bill. I do not believe there is any change which could be described as fundamental, for the reason that all the changes in my mind relate to methods and not to principles, objectives, or scope.

7.6 p.m.

Dr. Haden Guest (Islington, North)

I was very glad to hear the Minister's statement, because what he has said does, to a certain extent, clarify the situation, but there is not the slightest doubt whatever—as is shown very clearly in this House—that there is a great deal of disturbance of the mental atmosphere in the medical profession. I suggest, as I took occasion to suggest on an earlier occasion, that it would be a very good thing if there could be a statement put before the country as to the present state of negotiations with the British Medical Association. Although I, as a member, know what the document which has been published suggests and a good deal about the negotiations, I do not myself feel justified in discussing this in the House of Commons, for one excellent reason, if for no other. They are not known to the bulk of the Members of the House and, therefore, it is extremely difficult to follow what the discussion is about.

Far from objecting to discussions with representatives of the medical profession, I want to make sure that the Minister has taken all steps to secure that those discussions are sufficiently extensive. I want particularly to ask him whether he is satisfied that the doctors in the Services have been sufficiently consulted with regard to the proposals which the Negotiating Committee and he and his advisers have been meeting to discuss. Perhaps I may give an example to illustrate my point. This arises not only from the incident that I am going to relate, but from my general experience. At the beginning of May I happened to pay a visit to Germany and went to a certain Army Corps, where I dined in the mess. It was not entirely a medical mess, but there were something like 12 senior medical officers there. Only two of those medical officers—and I stress the date; it was at the beginning of May— knew what were the proposals of the Medical Association. They had not had the documents. If the senior men had not had them, then a good many of the junior men occupied with regimental duties, M.O.s with battalions and various other units, would not have had the opportunity of really studying the proposals. There are difficulties in the Navy and the Air Force, but tremendous difficulties in the Army. There was, for instance, on 3rd and 4th May last, a special representative meeting of the B.M.A. That matter has been made public. Can the Minister say whether there were present at that meeting any representatives, as such, of the Army Medical Service, the Naval Medical Service and the Air Medical Service? One is entitled to ask that question. My hon. Friend the Member for Rochdale (Dr. Morgan), who is a member of the Council of the B.M.A., may know whether it is a fact or not.

I do not ask this merely because I consider that the Services ought to have a considerable amount of consideration in this matter, but because of the arithmetical factor. The Minister, in answer to a Question I put to him the other day, gave the figures of the numbers of doctors serving in the Services. He said that there were 2,405 in the Navy, 2,564 in the Air Force, and 12,200 in the Army, making the very large total of something over 17,000. The proportion of doctors in the Services to those on the register as medical practitioners is not less than 27.5 per cent., and, as the Minister himself said in answer to a supplementary question of mine, the proportion of doctors in the Services to the active members of the medical profession was no less than 31.3 per cent. I emphasise that if one-third of the medical profession have not been adequately consulted about these proposals, he is not standing on a very solid foundation.

Sir Joseph Lamb (Stone)

Are the doctors in the Services also members of the B.M.A.?

Dr. Guest

I am not able to tell the hon. Member how many are members of the B.M.A., but no doubt a number of them are. I am not going to commit myself to any figures, save to say that a considerable number of those doctors are members of the British Medical Association. Some of those doctors are in India, Burma, in the Middle East, North Africa, Italy, some were prisoners of war, and some were with the B.L.A. when it was in the midst of very active operations. The hon. Gentleman has had military service and will remember that, during very active military operations, it is a little difficult to keep track of correspondence which sends you large documents of the description of that "British Medical Journal" which I hold in my hand. You cannot do it. You cannot expect men engaged in active military operations to keep in touch with all the detailed discussions that we are having to-day. They have not the time. They are doing things which to them are more important, and which perhaps in the long run will be more important than some of the things that have been said to-day.

I suggest to the Minister that, if the medical men in the Services have not been adequately consulted, special steps ought to be taken to consult them. I know that a considerable number of doctors in the Services replied to the questionnaire sent out by the British Medical Association, and that it is the opinion in the Services that a very large number of the doctors serving—I am speaking of the Army at the moment—are strongly in favour of the White Paper as it was in the original form, without any particular modification, except some modification in the direction of more fully representing the State medical service proposals. There is another reason why the doctors in the Services, who represent perhaps the younger and more vigorous stratum of the medical profession in this country, deserve special attention, because they have had invaluable experience, particularly in the Army, and there has been the greatest possible, progress made in medicine and in surgery in the Army, much more than in civil life. These men are to a large extent the cream of the medical profession and ought to have adequate recognition in the discussions which are taking place.

I want to ask another question. I was very glad to hear from the Minister recognition of the extremely valuable part that has been played by the Emergency Medical Service in this country during the war. There are very large numbers of junior men in the medical service who also have been very fully employed, and I am not at all sure that those men have been adequately consulted either.

I wonder whether the Minister has any interim proposals to put forward in case there should be a gap between the demobilisation of doctors—which, like the demobilisation of other people in the Services, begins on 18th June—and the bringing into operation of some comprehensive medical service for the civilian population? The Minister mentioned the very excellent relations which exist in the E.M.S. between voluntary and publicly-owned hospitals. I was very glad he did so because it has not been emphasised before from the Ministerial side, so far as I remember. I had a very intimate connection with those hospitals at the beginning of the war when I was serving on the medical staff of the Eastern Command and I know that those relations were exactly like the relations of brothers.

Dr. Morgan

indicated dissent.

Dr. Guest

I know them probably more intimately than my hon. Friend.

Dr. Morgan

I think the hon. Member does not.

Dr. Guest

I could never quite understand some hon. Members on the other side who seemed to think there was bound to be a feud between the voluntary hospitals and the publicly-owned ones. I have no reason whatever to think that they cannot get on very amiably together. Has the Minister any interim proposals in case there is a gap? There is the possibility, by using the E.M.S., by prolonging its life—it is a temporary service for war purposes—to cover the first part of the peace-time period. There is a posibility of providing through the E.M.S. a full hospital service for all who require it, a full consultants' service, a full pathological service, and other services like X-ray and so forth. There is the possibility, by using the E.M.S., to get a full extension of T.B. services. I refuse to believe that the nursing and domestic service problems are insuperable. You will go a very long way towards solving these if you pay better remuneration and if you decrease the hours so that nurses do not have to work so long.

Dr. Morgan

They should join a trade union.

Dr. Guest

In the County Council hospitals of London, of course, they join a trade union. I had a deputation from a trade union of nurses the other day and I sent the right hon. and learned Gentleman a communication about them. They were complaining not so much of the long hours of work, although the hours were terrific, and not so much of tiredness and fatigue; they were complaining of the fact that the hours were so long, and the domestic work they had to do was so great, that they could not give the skilled attention to their patients that they knew the patients ought to have. The Minister wrote a sympathetic reply and referred to the things he has mentioned to-day—the shortage of staff for nursing and for the domestic service side of hospitals—a fundamentally important thing. I believe it is necessary at the present time to reconsider the financial aspect of this matter. We cannot allow the question of the treatment of tuberculosis and other important matters to be held up because we are not ready to pay nurses and the domestic staff of hospitals a wage which is adequate in the present economic circumstances. What is also needed is not only an extension of the tuberculosis service—I only mention this in passing because it has been brought to my attention—but the extension of the provision of maternity beds, especially in the present condition of housing when it is practically impossible for many women to have healthy confinements in their own home.

The E.M.S. does not provide for a service of doctors who would visit the homes and the service of doctors at their surgeries or at a health centre, but it would be quite easy for the E.M.S. service in any particular region to appoint temporarily on a salaried basis the number of doctors required to carry out domiciliary treatment in any area which was not doctored. I put this point to the Minister, and we are entitled to have a reply, I think, because the Minister knows as well as I do what is the alternative, but I do not think the House knows what is the alternative. I have in my hand a copy of the "British Medical Journal" for Saturday, 9th June, the supplement of which discusses the question of doctors coming back to this country before there is a medical service organised and having to buy themselves into practices. It says this: It may be asked: What will be the position of a doctor who has borrowed money to buy a practice under the proposed National Health Service? The Government has announced that it does not propose to make any alteration in the present custom of baying and selling practices in the Health Services Bill. I have not heard that pronouncement, though perhaps the Minister may have made it. A full inquiry into the whole question will be instituted after the new service has come into operation and experience of its working has been gained. If, as a result of the inquiry, the sale of practices is abolished or restricted by law the doctors affected will receive all proper compensation. This is the Government's decision communicated formally to the Association. I am not quoting from a confidential document, and I take it that the Minister agrees that that is the case. If that is the case, how extremely complicated you will make the initiation of your medical health service if you permit, as a preliminary deployment of medical forces, the encouragement of a large number of doctors buying practices by borrowing money from banks and associations lending money.

Dr. Morgan

I am sorry to interrupt the hon. Gentleman, but is it not a fact that the Minister agreed to put a proposal like this to his fellow Ministers in the Cabinet: The Government do not propose, therefore, to make any alteration in the present custom in the forthcoming Health Services Bill, but they propose that a full inquiry into the whole question shall be instituted by a Committee appointed for that purpose…. That is all that has been communicated so far as I know.

Dr. Guest

I was reading a statement in the current number of the "British Medical Journal," which I think quite accurately states what is the situation.

Dr. Morgan

It is in a letter.

Dr. Guest

It seems to me a most unfortunate situation because, if we put a large number of junior doctors coming back from the Forces in the position of having to buy practices or make some purely temporary arrangement, we are creating enormous difficulties not only for the medical profession but for the civilian population. It would be infinitely better to have some arrangement ready-made so that when the doctors are demobilised they can step straight into the service.

A national medical service on the lines of the White Paper is not possible now for reasons of time. The time no longer exists. This Government is going out of existence in a few days' time and another Government will take some time to be formed, and even then it will take time before a Bill can be tabled and longer time still before it can be passed. So there has to be an interval of some months, maybe a considerable interval. I suggest to the Minister that as a matter of emergency he might consider using the organisation of the Emergency Medical Service to bridge this gap between the present condition and the future proposals for a National Health Service. Not only will the civilian population suffer if there is a gap, but there will be a terrible financial burden put on the shoulders of the young men in the medical profession.

There is another aspect. If doctors are to have to buy their practices in this way in the future and the buying and selling of practices is going on, what is to become of the recommendation of the Good enough Report, that a larger pro portion of doctors should be recruited from the working classes? It must be most offensive to Conservative Members when I talk about members of the working classes becoming doctors, because many of them obviously dislike the members of the working classes very much. One of the recommendations of the Good-enough Report was that the distribution of doctors over the social classes of the community should be equalised. Do hon. Members realise that at present only six per cent. of the doctors come from, the working classes? And is it proposed that the Conservative Party want to keep the medical profession as an exclusive preserve for the moneyed classes? I personally object very strongly to that view, because it will make the medical profession a more monied affair than it is at the present time.

These ideas of restriction and of making it inevitable that large numbers of young doctors will have to buy practices and load themselves with a tremendous weight of debt extending over a long period of years, with the possibility of getting out of it if a National Health Service is introduced, do not smell good to me at all. I think there are some interests in the Government standing against the opening of the real way to the health of the people. I believe myself that medicine, given the freedom mentioned by our distinguished new recruit to this House, the Member for the Scottish Universities (Sir J. Boyd Orr), who spoke so eloquently this afternoon, can achieve tremendous emancipation for the forces of human life. I believe that it has already done so in regard to infant welfare and in regard to school children, but what has been done for these two classes of the population can also be done for the higher ages and for adults, and it is most important, in a population which is continually increasing in its average age, that the health of those of the higher ages should be maintained at a higher level.

At the present time, however, when we ought to be organising for a National Health Service of the most comprehensive kind, free from all financial trammels, we have this financial niggling standing in the way. What a gift to the Service man who is coming back from great service in the R.A.M.C, with perhaps many decorations for gallantry—the D.S.O., the M.C., the V.C., whatever you like—and when he comes back you say, "Your grateful country will allow you to borrow £5,000 or whatever it may be, to go on paying that over a period of ten years, allowing yourself a small proportion of your earnings every year to live on, and then you will find yourself at the end of that time with a fine property and be a fit member of some Conservative organisation."That is a most undesirable thing to offer to young medical men coming back from the Services. I think we ought to ask the Minister of Health with regard to these proposals to think again, and, when he has thought again, to go on thinking again until he brings something better forward for the country. As an interim proposal he might very well take up the question of using the E.M.S. to bridge the gap between the present and what may be the future, if the proper kind of Government is elected at the next Election, of a real National Health Service.

7.29 p.m.

Dr. Russell Thomas (Southampton)

I rise because I have risen previously to so many points of Order that I would like to make my own position perfectly clear. I thought the discussion would be confined absolutely to the Supply Vote and I did not think we should be allowed to discuss the White Paper and the future health proposals. I think that this discussion has gone a little outside the Ruling given in the early part of the Debate. For that reason I, at any rate, had to rise to points of Order this afternoon. I am not quite clear about the attitude of hon. Members opposite to the White Paper. I think they are tending to establish something which might be very inconvenient to them in the future, a sort of new constitutional idea about White Papers. They are giving these White Papers a kind of statutory significance, which I think is quite wrong and which will come back on their heads should they ever occupy the Government Benches, which is unlikely. When the White Paper on Health Services was issued some time ago, it was discussed for two days during which varying opinions were put forward. Because it had no statutory significance, and because they knew it would not become the law of the land, Members of the House declined to acquiesce in its proposals. It was quite clear that there were many things in that. Paper which were wrong. For instance, it appeared to many of us that its proposals would tend to enslave the medical profession.

Mr. Silverman (Nelson and Colne)

rose—

Dr. Thomas

No, I do not intend to give way.

Mr. Silverman

A Motion was passed, following the Debate on that White Paper.

Mr. G. Griffiths

The hon. Member does not now remember that.

Mr. Silverman

I only want to point out to the hon. Member for Southampton (Dr. Thomas) that the White Paper proposals were approved without a Division and that they became the declared policy of the House. It was not as if the White Paper had been simply put out in the Vote Office for discussion outside the House.

Dr. Thomas

The hon. Member was not in his place until a few moments ago, and although I agree that approval by this House of a White Paper is an indication to the Government to go forward, this White Paper has no statutory significance. Do not let us think that any of these White Papers have any statutory significance—

Mr. G. Griffiths

We know they have not.

Dr. Thomas

These White Papers are matters for discussion alone. The large mass of the people of the country considered that the proposals underlying the White Paper on Health Services tended to enslave the medical profession, that if they were followed out they would destroy the voluntary institutions throughout the land, and to which members of the medical profession have given such great and devoted service. As time has gone on it has become clearer to hospitals, the medical profession, to the public and probably to the Minister and the Government that the principles of the White Paper could not be enforced, because the public would not swallow it. The Minister since then has reopened negotiations with the British Medical Association, the hospital authorities and various other bodies, and I believe an interim document was published by the B.M.A. which was, I believe, nothing more than a basis for further negotiations. It is a summary of what the B.M.A. think of things up to date. I am not satisfied with that document at all; I do not think it is strong enough, but that is a matter of opinion. I cannot see that the Minister is bound by that document. He has denied that he has made any promises in regard to it. Furthermore, the B.M.A. cannot bind the utterances and acts of the Government.

Mr. James Griffith

I was not attacking the B.M.A., but the Government. The B.M.A. say that the Government made proposals to them which were a change from the old ones. I want to know what the B.M.A. say to the Government.

Dr. Morgan

The document said that they were proposals which the Minister would be willing to put to his colleagues as soon as he knew that they commended themselves to the medical profession. This was a set of views as the result of a discussion between the B.M.A. and the Government, and were put forward by the B.M.A.

Dr. Thomas

I think it is perfectly reasonable that the Minister should do that. I do not wish to keep the House any longer. I merely wish to make my own position clear and to deplore the new constitutional idea which hon. Members opposite are putting on the production of White Papers. That, I think, is highly dangerous, and will be especially so in the future.

Mr. McIntyre (Motherwell)

The Minister of Health indicated earlier to-day that in a general way there had been-some improvement in the health of the people, and that that might be due to the Government's food policy. In other words, the health of some individuals is better because they have been getting the present British Government's food ration. There is some truth in that, as my lion. Friend the Member for the Scottish Universities (Sir John Boyd Orr) told us this afternoon. An investigation in Glasgow showed that some increase in the height and weight of children had taken place during the war, but that is nothing for which the Government ought to pat themselves on the back; it is one of the most disturbing facts I have ever come across. It means that before the war, people were not able to buy even up to the amount of rations that they are getting now. The question is whether, as the war recedes into the background, the dole queues possibly come back—if the present Government is still in charge of affairs—people whose wages will be lower than their war-time wages will find themselves on a lower standard of living than even the war-time standard. I would hope that the policy in Scotland, of allowing the best of food, the best of the Aberdeen Angus beef, to be exported to the luxury markets of the London West End, where the need is not nearly so great, will cease, and that the food of Scotland will be given to those who require it most in Scotland, to those who have been, up to now, undernourished.

Captain Duncan

Does not the hon. Member know that in London the best meat goes to the poor people?

Mr. J. Griffiths

Neither of the hon. Members knows London.

Mr. McIntyre

If what the hon. and gallant Member says is true then London is very different from every other town and city and village in the whole world. I rather think, however, that he is looking through the wrong end of a telescope. If we are to see that the health of the Scottish people is improved then we must look to our land policy, and use all our resources for our own folk.

The Minister did not discuss the serious question of mental health, which has not improved during 'the war. In fact, if it was better no doubt the Government would be looking more anxiously to the General Election. I hope the Minister is aware of the general increase in neurosis which, even quite apart from that recognised by official statistics, is much more prevalent than it has ever been in the whole history of Scotland—

Dr. Morgan

And in England.

Mr. McIntyre

The Minister painted a glowing picure in other respects; but two of the chief indices of general health are infant mortality and the tuberculosis rate. Both are disturbingly high, the former about 68 per 1,000, which is nearly double the figure for England. We have not yet heard what the Under-Secretary has to say on these matters. No Government statement on Scotland has yet been made in this Debate which is very awkward, so we just have to reply to a review which may come later. I think the Government are showing a scandalous disregard for Scotland in this matter, no doubt because they have appointed someone as Secretary of State who is not able to sit in this House.

On the question of tuberculosis we find that the Government's scheme for mass radiography was publicised to a great extent. You could not walk along the street without realising that something was doing about tuberculosis. But I suggest in all seriousness, and as a medical man, that this scheme was largely a farce. What was the use of diagnosing people as having tuberculosis if you had not the beds to put them in? You have a waiting list in Glasgow, at present, of about 1,100 people. What is the use of increasing that number if you have not the beds to put them in? We are told that it is due to a shortage of nursing staff. That is due to the poor conditions in the hospitals, but it is also due directly to the policy of the Ministry of Labour for the last four years. I have had to stand the greatest abuse in a. Glasgow labour exchange for suggesting that a competent girl should become a nurse. She did, but not on account of the helpfulness of the labour exchange and at a time when advertisements on the hoardings were crying out for nurses. There was no seriousness behind the Government's pretensions when they said that they wanted nurses. They were conscripting girls away from Scotland, instead of allowing them to nurse in Scotland. They did not improve conditions in hospitals to an extent sufficient to attract nurses.

With regard to doctors throughout the public health services, I want to know how long the Government intend to keep the posts "frozen" and doctors from changing their positions. I had a letter to-day from a doctor in this service, in Scotland, asking how long he would remain "frozen" in his job by the Government. He is a man who has been in one position for a long time, and who has done well. If he is not allowed to move soon he will go abroad, with the permission of the Government, to take a job there. A competent man with knowledge and skill in public health work will then be lost to the country and the Government are crying out for doctors, but because of this "freezing" policy they will lose many of them.

We know that there are two sides to the whole question of health. There is prevention, which is a social and political and economic question; then there is the question of treatment. Unfortunately, doctors are being used not only for treatment but to certify whether a man is or is not honest in saying that he has a cold or something of that kind, and whether he needs two days off. I hope that kind of thing will soon be stopped; I hope we shall not see a medical Gestapo imposed on people to decide whether or not they are honest. I have had personal experience; I have been asked to give a certificate in cases where it has not been a question of a medical opinion, but a moral opinion. No one has a right to judge people on those matters and certainly it is not a question for the medical profession.

In conclusion, if we want to improve the health of the people of Scotland, the only way to do it is to make the fullest possible use of our resources in Scotland. It can be done. We can build the houses and we can grow the food. I sincerely hope it will be done somehow or other in the course of the next 10 years. Tuberculosis can be nearly wiped out if we have the will to do it. Unfortunately, I fail to see any signs of that in the Government at the moment, but I hope things will improve.

7.46 p.m.

The Joint Under-Secretary of State far Scotland (Commander Galbraith)

It has always seemed to me that the main aim of every politician and also of Parliament should be to use every possible endeavour to increase the happiness of the people. The measure of happiness that can be enjoyed by any individual depends probably more on health than on any other single agency, and so it seems to me quite natural that, for that reason, we have come to regard the health of the nation as one of our most important preoccupations and duties. It is, therefore, very fitting that in this last week of the life of one of the longest Parliaments in our history we should have devoted practically one full day to a Debate on the nation's health. The Debate has ranged over a very wide field indeed. There is practically no aspect of the problem which has not been touched upon in one way or another, and I think every hon. Member will agree with me that the Debate has not only been well worth while but highly valuable.

In a Debate on the Health Estimates Scottish Members have come to expect a general review of Scotland's health, and therefore it may be for the convenience of the House if, before I proceed to deal with some of the many important points that have been raised in the course of the Debate, I say a word or two about the health position of Scotland. In moving the Estimates last year, the right hon. Gentleman the Member for West Stirling (Mr. T. Johnston), the former Secretary of State for Scotland, was able to indicate that in the main Scotland's health had not deteriorated. I am glad to say the position has, on the whole, been well maintained during the past year. More generally, I can tell the House that, despite all the strains and difficulties of war-time, the trend of the health of our our people, as shown by the health indices, has with few exceptions been satisfactory, and in many respects better than in the immediate pre-war years.

The time at my disposal is limited, but I think the House would wish me to give one or two figures which bear out that contention. Stillbirths have been reduced by 9.5 per 1,000 births since 1939. The maternal death rate has fallen from 4.9 in 1938 to 3 per 1,000 live births in 1944. In 1938 maternal deaths totalled 432, in 1944 they were reduced to 293. But more impressive is it to realise that the 1944 rate is but half of what it was 10 years ago. Infant mortality, which has been the cause of much concern in Scot- land, has fallen from 69.5 per 1,000 live births in 1938 to 65 in 1944, the lowest figure ever recorded in our history, but a figure that is still far too high. The problems associated with infant mortality in Scotland were stated with great clarity and frankness in the report of the Sub-Committee of the Scientific Advisory Committee published in 1943, and I would like to take this opportunity of paying a tribute to the work of that Sub-Committee and of its Chairman, now a Member of the House, the hon. Member for the Scottish Universities (Sir J. Boyd Orr).

Mr. Gallacher

Is not the hon. and gallant Gentleman aware that the only tribute worth paying would be to remove the causes of the disease in Scotland?

Commander Galbraith

If the hon. Member will permit me to go on, I will say what we are doing in that respect. The report of that Sub-Committee has received the most careful consideration of the authorities, many of whom, I am happy to say, have plans in being for the expansion of their services against the time when additional premises and more staff can be made available. There is one age group to which I would like to draw the particular attention of the House. It is that of children between the ages of 1 and 5 years. The death rate in that group was only half in 1944 what it had been immediately before the war. It was six and a half times lower than it was at the beginning of the present century.

Our experience of diphtheria is very similar to that which my right hon. Friend the Minister of Health has given for England. Notifications of the disease have dropped from 10,210 in 1938 to 6,805 1944 Deaths from diphtheria among children have dropped from 430 in 1938 to 163 in 1944. The point which I wish to stress particularly, in support of what my right hon. Friend said this afternoon, is that out of these 163 deaths in 1944 only four occurred among those children who have been immunised. That low proportion surely gives the strongest possible support to the campaign for immunisation. In Scotland that campaign has now been going on for a sufficient length of time to enable the Department of Health in Scotland to assess the results, and it is amply satisfied that the compaign has enormously reduced both suffering and deaths among our child population; but as my right hon. Friend said, there is still room for further efforts and greater improvement. I do most earnestly hope that the local authorities and the parents will co-operate in seeing that as many children as possible get the protection which immunisation affords.

Those are the bright spots. I fear there are one or two dark spots on our record, and to these I must refer. My right hon. Friend the Minister of Health gave a very comprehensive survey of the state of the nation, in which he dealt particularly with tuberculosis. In Scotland tuberculosis is our greatest problem at this moment. While the notifications of non-pulmonary tuberculosis have remained fairly constant, notifications of pulmonary tuberculosis have increased from 4,793 in 1938 to 7,276 in 1944. Deaths rose from 3,431 in 1938 to 4,174 in 1941. Since then they have declined slightly to 3,935 in 1944. Whatever may be the cause for this increase in pulmonary tuberculosis, the problem is one which demands our utmost and active consideration. As in England, so in Scotland we have been able to make additional beds available for pulmonary patients, but even so over 1,700 cases are awaiting admission to our hospitals. As my right hon. Friend has said, the crux of the problem is lack of staff, especially nurses and domestic workers. The shortage of nurses is acute in many of our hospitals, but it is most serious in our sanatoria, and I hope, therefore, that the appeal of which my right hon. Friend has spoken to-day may come to the notice of thousands of our young women who have an aptitude for nursing and induce them to take up nursing as a career.

The shortage of medical manpower is another of our difficulties, and since the needs of the Forces in the Far East must be met—and they are relatively greater in a theatre where civilian medical resources are not available—we cannot, I fear, anticipate any rapid relief in the immediate future. In spite of that, our civilian health services are being maintained.

Mr. Mathers (Linlithgow)

Am I to understand that the hon. and gallant Gentleman has left the question of tuberculosis? He made rather an obscure reference to the rise in the incidence of pulmonary tuberculosis and he seemed to indicate that there was some doubt as to what was the cause. I hope that is not the position.

Commander Galbraith

There are many causes and many reasons for the rise. I said that whatever was the reason, it was a matter which needed the most serious consideration.

Mr. Mathers

But the causes are known?

Commander Galbraith

I think that may generally be taken as correct.

Mr. McIntyre

Did the Minister make a slip? It is not active consideration but action that is needed now. Sufficient is known of the causes. Am I right?

Commander Galbraith

There has still got to be very much consideration as to how the matter is to be dealt with.

Mr. Maxton (Glasgow, Bridgeton)

I apologise for interrupting the hon. and gallant Gentleman; as he is fresh to the job, I do not want to make his task any more difficult in the brief period he is likely to have it. I think he is leaving now the question of the shortage of medical men. He mentioned the difficulty of releasing medical men from the Forces because they are needed in the Far East. Can he say whether any steps have been taken to release young men from the Army to take up studies as medical students? I am referring to men in the early groups who are to be released shortly from the Army. Have any steps been taken either in England or Scotland to secure that young medical students will get out in time to start their medical courses?

Commander Galbraith

The hon. Gentleman is probably aware that medical schools are absolutely full at the present time and are turning out as many doctors as possible; and the matter of the demobilisation of doctors from the Forces comes under the ordinary demobilisation scheme.

Mr. Maxton

Am I to understand that, as far as medicine is concerned, boys who have never been in the Army are to have a higher claim on the limited accommodation in medical schools than those who are in the Forces now?

Commander Galbraith

I am not prepared to answer that question at this moment. It is a detail of which I am not aware.

Mr. Maxton

It is more than a detail.

Commander Galbraith

The hon. Gentleman can be certain that every facility will be given and is being given to the men in the Services to train themselves for their professions. I think he will find that that has been indicated by the Government already.

The school health services have shared in these staffing difficulties, nevertheless, the education authorities have continued their efforts to maintain a satisfactory standard. From the information available it can be seen that the physical education of schoolchildren, including their nutritional state, has not suffered as the result of war-time conditions, but the most impressive figures are these showing the increase in height and weight since 1930. In 1944 boys in Glasgow of five years of age showed an increase in height, as compared with 1930, of .93 of an inch and in weight of 1.98 lb., while boys of 13 showed increases in the same period of 1.67 inches and 6.82 lb. These figures, covering a period of some 14 years, are but a pointer to what may yet be accomplished, and lead me to emphasise the importance of our school health services. Surely it is our duty to tackle in the years of childhood such conditions as can be remedied and to ensure by every means in our power that our school children grow up into healthy citizens.

The increase of mortality from cancer provides a new problem. The increase between 1919 and 1944 was from 5,657 to 8,735, and that is the measure of the task that lies ahead. It is very much to be regretted that the intervention of the war has prevented progress along the lines of the Cancer Act, 1939. It is hoped that considerable advances in the way of providing facilities for earlier diagnosis and treatment will now be possible, but the success of any move in that direction depends largely on the willingness of all concerned to co-operate, because cancer administration demands the pooling of resources, both in regard to staff and equipment, if the best results are to be secured. I would appeal most earnestly to hospital authorities, voluntary and municipal, to get together and consider how best they can use their combined resources to give the maximum advantage to cancer patients. The officers of the Department of Health are willing and prepared to give any help in their power in the preparation of schemes to this end.

My right hon. Friend has called attention to the very substantial part that has been played in the war years by the Emergency Medical Service Hospitals. The demand for accommodation for civilian casualties in Scotland was fortunately light, and it has been possible to use for other purposes many beds which were provided as an insurance against air-raid risks. The House is familiar with the arrangement under which there have been treated in our emergency hospitals 34,200 patients from the waiting lists of the voluntary hospitals; and with the supplementary medical service, under which some 10,000 workers have been referred for examination or treatment in hospital. The Emergency Medical Service has provided some thousands of extra beds in well-equipped hospitals. With some alterations to adapt them to peace-time standards, these beds will go a long way to remedy the admitted shortage of hospital beds before the war. It will be the aim of the Department of Health to integrate these new hospitals with the permanent hospital system of the country. The precise method of doing so will be considered in relation to the post-war development of the hospital services generally.

Having dealt with Scotland, I should like now to deal with some of the questions which have arisen during the course of the Debate. My hon. and gallant Friend the Member for North Kensington (Captain Duncan) asked as to the number of nurses who were required. The total number of nurses employed by all the nursing services in Great Britain is a little under 200,000. The number of vacancies in these services is 32,000. These figures do not take into account additional demands for developments, such as the block system of training nurses, which means more nurses because it provides for separation of periods of study and of work in the wards, nor does it take into account the developments under the new health service.

The hon. Member for Llanelly (Mr. J. Griffiths) made what I might term, a typical contribution. I was only sorry that such heat was generated, both in his speech and in that of the hon. Lady the Member for West Fulham (Dr. Summerskill) on the question of the negotiations with the British Medical Association. My right hon. Friend has fully explained the position, but I think the hon. Member for Rochdale (Dr. Morgan) put the matter in its proper perspective. The fact is that my right hon. Friend only took the same course as any prudent Minister would take, the course which was followed by the former Secretary of State for Scotland. The hon. Member also asked for some information about war nurseries and whether or not they were to be closed down. I am informed that it is the intention—this has been made known to the local authorities—to offer these war-time nurseries to the authorities subject to an appropriate financial adjustment for their use.

They may be used either as nursery schools or as child welfare nurseries. The education and public health authorities are being asked to consider these various alternatives. Again, the hon. Member asked a question as to the upward trend of tuberculosis, which has increased between 1913 and 1943 by about 21 per cent. I am informed that this may well be due less to any actual increase in the incidence of the disease than to a greater number of cases being brought to notice through increased medical examination in connection with national service.

Mr. Wootton-Davies

Does the hon. and gallant Gentleman mean accurate diagnosis?

Commander Galbraith

Many more people have been examined by radiography and other means. Another point which the hon. Gentleman put to me was as to the fear of tuberculosis retarding the recruitment of nurses and domestic workers in our hospitals. I agree with the hon. Gentleman that the fear of tuberculosis undoubtedly affects recruitment for tuberculosis nursing, but I submit that this fear may be stronger in the parents of would-be nurses than in the nurses themselves. It is the duty of hospital authorities to take every precaution to safeguard the health of their staffs, and hospitals have been asked by the Health Departments and the Ministry of Labour to give nurses a medical X-ray examination and other tests before allowing them to start work in pulmonary tuberculosis wards. I am advised that there is no evidence that tuberculosis nurses run any greater risk of infection than those in a general hospital.

Mr. Gallacher

Why is it necessary to frighten nurses and staff by this special examination if there is no greater danger?

Commander Galbraith

It is a very wise precaution that every protection should be afforded to these girls, and I am surprised at the hon. Member raising that point. We had a very fine maiden speech from the hon. Member for the Scottish Universities. One felt almost inclined to agree with everything he said, but it struck me that he perhaps made things look a little too easy. I am in doubt whether I could make reference to the various points he raised, but I can say that his three principal points are, as everyone knows, having not only the full, but the active, consideration of the Government. Indeed, the whole House knows the Government's policy on these three points.

Mr. Gallacher

A policy of "do nothing."

Commander Galbraith

I cannot be led into an argument with the hon. Gentleman because it is completely out of Order to discuss any of the three points in this Debate. The hon. Member for Rochdale raised matters in connection with particular cases which have come to his notice, and I can, on behalf of my right hon. Friend, promise that they will be looked into. The hon. Member for North Islington (Dr. Haden Guest) wanted to know whether the E.M.S. organisation would be used to fill in the gap. We must have, as he suggested, a well managed transition from the E.M.S. to the full hospital service, and that matter has the attention of the Government.

The Prime Minister has said that the full development of our health services is our objective. I am certain that the House is agreed on that, and is agreed that it is our duty to see that everything possible is done to ensure that the skill, resource, knowledge and patience of specialist, practitioner and nurse are made available to all who need them, and that the mothers, the children and the aged receive every care which we can possibly give, so that our people may have the health to enjoy that freedom for which they have striven so valiantly during these last six years—a heritage, indeed, which is theirs.

It being a quarter past Eight o'clock, Mr. Speaker proceeded, pursuant to Standing Order No. 14, as modified by the Order of the House of 8th March, to put forthwith the Question necessary to dispose of the Resolution under consideration.

Question, "That this House doth agree with the Committee in the said Resolution," put. and agreed to.

Mr. Speaker then proceeded to put forthwith the Questions, "That this House doth agree with the Committee in the outstanding Resolutions reported in respect of Classes I to X of the Civil Estimates, and of the Revenue Departments Estimates, the Navy Estimates, the Army Estimates and the Air Estimates."

CIVIL ESTIMATES, 1945

CLASS I

CENTRAL GOVERNMENT AND FINANCE

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class I of the Civil Estimates, put, and agreed to.

CLASS II

FOREIGN AND IMPERIAL

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class II of the Civil Estimates, put, and agreed to.

CLASS III

HOME DEPARTMENT, LAW AND JUSTICE

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class III of the Civil Estimates, put, and agreed to.

CLASS IV

EDUCATION AND BROADCASTING

Question, That this House doth agree with the Committee in the outstanding Resolutions reported in respect of Class IV of the Civil Estimates, put, and agreed to.

CLASS V

HEALTH, LABOUR AND INSURANCE

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class V of the Civil Estimates, put, and agreed to.

CLASS VI

TRADE, INDUSTRY AND TRANSPORT

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class VI of the Civil Estimates, put, and agreed to.

CLASS VII

COMMON SERVICES (WORKS, STATIONERY, ETC.)

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class VII of the Civil Estimates, put, and agreed to.

CLASS VIII

NON-EFFECTIVE CHARGES (PENSIONS)

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class VIII of the Civil Estimates, put, and agreed to.

CLASS IX

EXCHEQUER CONTRIBUTIONS TO LOCAL REVENUES

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class IX of the Civil Estimates, put, and agreed to.

CLASS X

WAR SERVICES

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of Class X of the Civil Estimates, put, and agreed to.

REVENUE DEPARTMENTS ESTIMATES, 1945

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of the Revenue Departments Estimates, put, and agreed to.

NAVY ESTIMATES, 1945

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of the Navy Estimates, put, and agreed to.

ARMY ESTIMATES, 1945

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of the Army Estimates, put, and agreed to.

AIR ESTIMATES, 1945

Question, That this House doth agree with the Committee in the outstanding Resolution reported in respect of the Air Estimates, put, and agreed to.