§ Order for Second Reading read.
§ 3.47 P.m.
§ The Minister of Health (Mr. Aneurin Bevan)I beg to move, "That the Bill be now read a Second time."
In the last two years there has been such a clamour from sectional interests in the field of national health that we are in danger of forgetting why these proposals are brought forward at all. It is, therefore, very welcome to me—and I am quite certain to hon. Members in all parts of the House—that consideration should now be given, not to this or that sectional interest, but to the requirements of the British people as a whole. The scheme which anyone must draw up dealing with national health must necessarily be conditioned and limited by the evils it is intended to remove. Many of those who have drawn up paper plans for the health services appear to have followed the dictates of abstract principles, and not the concrete requirements of the actual situation as it exists. They drew up all sorts of tidy schemes on paper, which would be quite inoperable in practice.
The first reason why a health scheme of this sort is necessary at all is because it has been the firm conclusion of all parties that money ought not to be permitted to stand in the way of obtaining an efficient health service. Although it is true that the national health insurance system provides a general practitioner service and caters for something like 21 million of the population, the rest of the population have to pay whenever they desire the services of a doctor. It is cardinal to a proper health organisation that a person ought not to be financially deterred from seeking medical assistance at the earliest possible stage. It is one of the evils of having to buy medical advice that, in addition to the natural anxiety that may arise because people do not like to hear unpleasant things about themselves, and therefore tend to postpone consultation as long as possible, there is the financial anxiety caused by having to pay doctors' bills. Therefore, the first evil that we must deal with is that which exists as a consequence of the fact that the whole 44 thing is the wrong way round. A person ought to be able to receive medical and hospital help without being involved in financial anxiety.
In the second place, the national health insurance scheme does not provide for the self-employed, nor, of course, for the families of dependants. It depends on insurance qualification, and no matter how ill you are, if you cease to be insured you cease to have free doctoring. Furthermore, it gives no backing to the doctor in the form of specialist services. The doctor has to provide himself, he has to use his own discretion and his own personal connections, in order to obtain hospital treatment for his patients and in order to get them specialists, and in very many cases, of course— in an overwhelming number of cases—the services of a specialist are not available to poor people.
Not only is this the case, but our hospital organisation has grown up with no plan, with no system; it is unevenly distributed over the country and indeed it is one of the tragedies of the situation, that very often the best hospital facilities are available where they are least needed. In the older industrial districts of Great Britain hospital facilities are inadequate. Many of the hospitals are too small—very much too small. About 70 per cent. have less than 100 beds, and over 30 per cent. have less than 30. No one can possibly pretend that hospitals so small can provide general hospital treatment. There is a tendency in some quarters to defend the very small hospital on the ground of its localism and intimacy, and for other rather imponderable reasons of that sort, but everybody knows today that if a hospital is to be efficient it must provide a number of specialised services. Although I am not myself a devotee of bigness for bigness sake, I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.
In addition to these defects, the health of the people of Britain is not properly looked after in one or two other respects. The condition of the teeth of the people of Britain is a national reproach. As a consequence of dental treatment having to be bought, it has not been demanded on a scale to stimulate the creation of sufficient dentists, and in consequence there is a woeful shortage of dentists[...] 45 the present time. Furthermore, about 25 per cent. of the people of Great Britain can obtain their spectacles and get their eyes tested and seen to by means of the assistance given by the approved societies, but the general mass of the people have not such facilities. Another of the evils from which this country suffers is the fact that sufficient attention has not been given to deafness, and hardly any attention has been given so far to the provision of cheap hearing aids and their proper maintenance. I hope to be able to make very shortly a welcome announcement on this question.
One added disability from which our health system suffers is the isolation of mental health from the rest of the health services. Although the present Bill does not rewrite the Lunacy Acts—we shall have to come to that later on—nevertheless, it does, for the first time, bring mental health into the general system of health services. It ought to be possible, and this should be one of the objectives of any civilised health service, for a person who feels mental distress, or who fears that he is liable to become unbalanced in any way to go to a general hospital to get advice and assistance, so that the condition may not develop into a more serious stage. All these disabilities our health system suffers from at the present time, and one of the first merits of this Bill is that it provides a universal health service without any insurance qualifications of any sort. It is available to the whole population, and not only is it available to the whole population freely, but it is intended, through the health service, to generalise the best health advice and treatment. It is intended that there shall be no limitation on the kind of assistance given—the general practitioner service, the specialist, the hospitals, eye treatment, spectacles, dental treatment, hearing facilities, all these are to be made available free.
There will be some limitations for a while, because we are short of many things. We have not enough dentists and it will therefore be necessary for us, in the meantime, to give priority treatment to certain classes—expectant and nursing mothers, children, school children in particular and later on we hope adolescents. Finally we trust that we shall be able to build up a dental service for the whole population. We are short of nurses and 46 we are short, of course, of hospital accommodation, and so it will be some time before the Bill can fructify fully in effective universal service. Nevertheless, it is the object of the Bill, and of the scheme, to provide this as soon as possible, and to provide it universally.
Specialists will be available not only at institutions but for domiciliary visits when needed. Hon. Members in all parts of the House know from their own experience that very many people have suffered unnecessarily because the family has not had the financial resources to call in skilled people. The specialist services, therefore, will not only be available at the hospitals, but will be at the back of the general practitioner should he need them. The practical difficulties of carrying out all these principles and services are very great. When I approached this problem, I made up my mind that I was not going to permit any sectional or vested interests to stand in the way of providing this very valuable service for the British people.
There are, of course, three main instruments through which it is intended that the Health Bill should be worked. There are the hospitals; there are the general practitioners; and there are the health centres. The hospitals are in many ways the vertebrae of the health system, and I first examined what to do with the hospitals. The voluntary hospitals of Great Britain have done invaluable work. When hospitals could not be provided by any other means, they came along. The voluntary hospital system of this country has a long history of devotion and sacrifice behind it, and it would be a most frivolously minded man who would denigrate in any way the immense services the voluntary hospitals have rendered to this country. But they have been established often by the caprice of private charity. They bear no relationship to each other. Two hospitals close together often try to provide the same specialist services unnecessarily, while other areas have not that kind of specialist service at all. They are, as I said earlier, badly distributed throughout the country. It is unfortunate that often endowments are left to finance hospitals in those parts of the country where the well-to-do live while, in very many other of our industrial and rural districts there is inadequate hospital accommodation. These voluntary hospitals are, very many of them, far too small and, therefore, to 47 leave them as independent units is quite impracticable.
Furthermore—I want to be quite frank with the House—I believe it is repugnant to a civilised community for hospitals to have to rely upon private charity. I believe we ought to have left hospital flag days behind. I have always felt a shudder of repulsion when I have seen nurses and sisters who ought to be at their work, and students who ought to be at their work, going about the streets collecting money for the hospitals. I do not believe there is an hon. Member of this House who approves that system. It is repugnant, and we must leave it behind —entirely. But the implications of doing this are very considerable.
I have been forming some estimates of what might happen to voluntary hospital finance when the all-in insurance contributions tall to be paid by the people of Great Britain, when the Bill is passed and becomes an Act, and they are entitled to free hospital services. The estimates I have go to show that between 80 per cent. and 90 per cent. of the revenues of the voluntary hospitals in these circumstances will be provided by public funds, by national or rate funds. [An HON. MEMBER: "By workers' contributions."] And, of course, as the hon. Member reminds me, in very many parts of the country it is a travesty to call them voluntary hospitals. In the mining districts, in the textile districts, in the districts where there are heavy industries it is the industrial population who pay the weekly contributions for the maintenance of the hospitals. When I was a miner I used to find that situation, when I was on the hospital committee. We had an annual meeting and a cordial vote of thanks was moved and passed with great enthusiasm to the managing director of the colliery company for his generosity towards the hospital; and when I looked at the balance sheet, I saw that 97½ per cent. of the revenues were provided by the miners' own contributions; but nobody passed a vote of thanks to the miners.
§ Major Guy Lloyd (Renfrew, Eastern)What was the right hon. Gentleman doing?
§ Mr. BevanI can assure the hon. and gallant Member that I was no more silent then than I am now. But, of course, it 48 is a misuse of language to call these "voluntary hospitals." They are not maintained by legally enforced contributions; but, mainly, the workers pay for them because they know they will need the hospitals, and they are afraid of what they would have to pay if they did not provide them. So it is, I say, an impossible situation for the State to find something like 90 per cent. of the revenues of these hospitals and still to call them "voluntary." So I decided, for this and other reasons, that the voluntary hospitals most be taken over.
I knew very well when I decided this that it would give rise to very considerable resentment in many quarters, but, quite frankly, I am not concerned about the voluntary hospitals' authorities: I am concerned with the people whom the hospitals are supposed to serve. Every investigation which has been made into this problem has established that the proper hospital unit has to comprise about 1,000 beds—not in the same building but, nevertheless, the general and specialist hospital services can be provided only in a group of that size. This means that a number of hospitals have to be pooled, linked together, in order to provide a unit of that sort. This cannot be done effectively if each hospital is a separate, autonomous body. It is proposed that each of these groups should have a large general hospital, providing general hospital facilities and services, and that there should be a group round it of small feeder hospitals. Many of the cottage hospitals strive to give services that they are not able to give. It very often happens that a cottage hospital harbours ambitions to the hurt of the patients, because they strive to reach a status that they never can reach. In these circumstances, the welfare of the patients is sacrificed to the vaulting ambitions of those in charge of the hospital. If, therefore, these voluntary hospitals are to be grouped in this way, it is necessary that they should submit themselves to proper organisation, and that submission, in our experience, is impracticable if the hospitals, all of them, remain under separate management.
Now, this decision to take over the voluntary hospitals meant, that I then had to decide to whom to give them. Who was to be the receiver? So I turned to an examination of the local government hospital system. Many of the local authori
49 in Great Britain have never been able to exercise their hospital powers. They are too poor. They are too small. Furthermore, the local authorities of Great Britain inherited their hospitals from the Poor Law, and some of them are monstrous buildings, a cross between a workhouse and a barracks—[An HON. MEMBER: "And a prison."]—or a prison. The local authorities are helpless in these matters. They have not been able to afford much money. Some local authorities are first-class. Some of the best hospitals in this country are local government hospitals. But, when I considered what to do with the voluntary hospitals when they had been taken over, and who was to receive them I had to reject the local government unit, because the local authority area is no more an effective gathering ground for the patients of the hospitals than the voluntary hospitals themselves. My hon. Friend said that some of them are too small, and some of them too large. London is an example of being too small and too large at the same time.
It is quite impossible, therefore, to hand over the voluntary hospitals to the local authorities. Furthermore—and this is an argument of the utmost importance—if it be our contract with the British people, if it be our intention that we should universalise the best, that we shall promise every citizen in this country the same standard of service, how can that be articulated through a rate-borne institution which means that the poor authority will not be able to carry out the same thing at all? It means that once more we shall be faced with all kinds of anomalies, just in those areas where hospital facilities are most needed, and in those very conditions where the mass of the poor people will be unable to find the finance to supply the hospitals. Therefore, for reasons which must be obvious —because the local authorities are too small, because their financial capacities are unevenly distributed —I decided that local authorities could not be effective hospital administration units. There are, of course, a large number of hospitals in addition to the general hospitals which the local authorities possess. Tuberculosis sanatoria, isolation hospitals, infirmaries of various kinds, rehabilitation, and all kinds of other hospitals are all necessary in a general hospital service. So I decided that the only thing 50 to do was to create an entirely new hospital service, to take over the voluntary hospitals, and to take over the local government hospitals and to organise them as a single hospital service. If we are to carry out our obligation and to provide the people of Great Britain, no matter where they may be, with the same level of service, then the nation itself will have to carry the expenditure, and cannot put it upon the shoulders of any other authority.
A number of investigations have been made into this subject from time to time, and the conclusion has always been reached that the effective hospital unit should be associated with the medical school. If you grouped the hospitals in about 16 to 20 regions around the medical schools, you would then have within those regions the wide range of disease and disability which would provide the basis for your specialised hospital service. Furthermore, by grouping hospitals around the medical schools, we should be providing what is very badly wanted, and that is a means by which the general practitioners are kept in more intimate association with new medical thought and training. One of the disabilities, one of the shortcomings of our existing medical service, is the intellectual isolation of the general practitioners in many parts of the country. The general practitioner, quite often, practises in loneliness and does not come into sufficiently intimate association with his fellow craftsmen and has not the stimulus of that association, and in consequence of that the general practitioners have not got access to new medical knowledge in a proper fashion. By this association of the general practitioner with the medical schools through the regional hospital organisation, it will be possible to refresh and replenish the fund of knowledge at the disposal of the general practitioner.
This has always been advised as the best solution of the difficulty. It has this great advantage to which I call the close attention of hon. Members. It means that the bodies carrying out the hospital services of the country are, at the same time, the planners of the hospital service. One of the defects of the other scheme is that the planning authority and executive authority are different. The result is that you get paper planning or bad execution. By making the regional board and regional organisation responsible both for the planning and the administration of the plans, we get a better result, and we 51 get from time to time, adaptation of the plans by the persons accumulating the experience in the course of their administration. The other solutions to this problem which I have looked at all mean that you have an advisory body of planners in the background who are not able themselves to accumulate the experience necessary to make good planners. The regional hospital organisation is the authority with which the specialised services are to be associated, because, as I have explained, this specialised service can be made available for an area of that size, and cannot be made available over a small area.
When we come to an examination of this in Committee, I daresay there will be different points of view about the constitution of the regional boards. It is not intended that the regional boards should be conferences of persons representing different interests and different organisations. If we do that, the regional boards will not be able to achieve reasonable and efficient homogeneity. It is intended that they should be drawn from members of the profession, from the health authorities in the area, from the medical schools and from those who have long experience in voluntary hospital administration. While leaving ourselves open to take the best sort of individuals on these hospital boards which we can find, we hope before very long to build up a high tradition of hospital administration in the boards themselves. Any system which made the boards conferences, any proposal which made the members delegates, would at once throw the hospital administration into chaos. Although I am perfectly prepared and shall be happy to cooperate with hon. Members in all parts of the House in discussing how the boards should he constituted, I hope I shall not be pressed to make these regional boards merely representative of different interests and different areas. The general hospital administration, therefore, centres in that way.
When we come to the general practitioners we are, of course, in an entirely different field. The proposal which I have made is that the general practitioner shall not be in direct contract with the Ministry of Health, but in contract with new bodies. There exists in the medical 52 profession a great resistance to coming under the authority of local government —a great resistance, with which I, to some extent, sympathise. There is a feeling in the medical profession that the general practitioner would be liable to come too much under the medical officer of health, who is the administrative doctor. This proposal does not put the doctor under the local authority; it puts the doctor in contract with an entirely new body—the local executive council, coterminous with the local health area, county or county borough. On that executive council, the dentists, doctors and chemists will have half the representation. In fact, the whole scheme provides a greater degree of professional representation for the medical profession than any other scheme I have seen.
I have been criticised in some quarters for doing that. I will give the answer now: I have never believed that the demands of a democracy are necessarily satisfied merely by the opportunity of putting a cross against someone's name every four or five years. I believe that democracy exists in the active participation in administration and policy. Therefore, I believe that it is a wise thing to give the doctors full participation in the administration of their own profession. They must, of course, necessarily be subordinated to lay control—we do not want the opposite danger of syndicalism. Therefore, the communal interests must always be safeguarded in this administration. The doctors will be in contract with an executive body of this sort. One of the advantages of that proposal is that the doctors do not become—as some of them have so wildly stated—civil servants. Indeed, one of the advantages of the scheme is that it does not create an additional civil servant.
It imposes no constitutional disability upon any person whatsoever. Indeed, by taking the hospitals from the local authorities and putting them under the regional boards, large numbers of people will be enfranchised who are now disfranchised from participation in local government. So far from this being a huge bureaucracy with all the doctors little civil servants—the slaves of the Minister of Health, as I have seen it described—instead of that, the doctors are under contract with bodies which are not under the local authority, and which are, 53 at the same time, ever open to their own influence and control.
One of the chief problems that I was up against in considering this scheme was the distribution of the general practitioner service throughout the country. The distribution, at the moment, is most uneven. In South Shields before the war there were 4,100 persons per doctor; in Bath 1,590; in Dartford nearly 3,000 and in Bromley 1,620; in Swindon 3,100; in Hastings under 1,200. That distribution of general practitioners throughout the country is most hurtful to the health of our people. It is entirely unfair, and, therefore, if the health services are to be carried out, there must be brought about a re-distribution of the general practitioners throughout the country.
§ Captain Crowder (Finchley)Does that mean the number on the panel or the population?
§ Mr. BevanThe population. Indeed, I could amplify those figures a good deal, but I do not want to weary the House, as I have a great deal to say. It was, therefore, decided that there must be redistribution. One of the first consequences of that decision was the abolition of the sale and purchase of practices. If we are to get the doctors where we need them, we cannot possibly allow a new doctor to go in because he has bought somebody's practice. Proper distribution kills by itself the sale and purchase of practices. I know that there is some opposition to this, and I will deal with that opposition. I have always regarded the sale and purchase of medical practices as an evil in itself. It is tantamount to the sale and purchase of patients. Indeed, every argument advanced about the value of the practice is itself an argument against freedom of choice, because the assumption underlying the high value of a practice is that the patient passes from the old doctor to the new. If they did not pass there would be no value in it. I would like, therefore, to point out to the medical profession that every time they argue for high compensation for the loss of the value of their practices, it is an argument against the free choice which they claim. However, the decision to bring about the proper distribution of general practitioners throughout the country meant that the value of the practices was destroyed. We had, therefore, to consider compensation. 54 I have never admitted the legal claim, but I admit at once that very great hardship would be inflicted upon doctors if there were no compensation. Many of these doctors look forward to the value of their practices for their retirement. Many of them have had to borrow money to buy practices and, therefore, it would, I think, be inhuman, and certainly most unjust, if no compensation were paid for the value of the practices destroyed. The sum of £66,000,000 is very large. In fact, I think that every one will admit that the doctors are being treated very generously. However, it is not all loss, because if we had, in providing superannuation, given credit for back service, as we should have had to do, it would have cost £35 million. Furthermore, the compensation will fall to be paid to the dependants when the doctor dies, or when he retires, and so it is spread over a considerable number of years. This global sum has been arrived at by the actuaries, and over the figure, I am afraid, we have not had very much control, because the actuaries have agreed it. But the profession itself will be asked to advise as to its distribution among the claimants, because we are interested in the global sum, and the profession, of course, is interested in the equitable distribution of the fund to the claimants.
The doctors claim that the proposals of the Bill amount to direction—not all the doctors say this but some of them do. There is no direction involved at all. When the Measure starts to operate, the doctors in a particular area will be able to enter the public service in that area. A doctor newly coming along would apply to the local executive council for permission to practise in a particular area. His application would then be re-referred to the Medical Practices Committee. The Medical Practices Committee, which is mainly a professional body, would have before it the question of whether there were sufficient general practitioners in that area. If there were enough, the committee would refuse to permit the appointment. No one can really argue that that is direction, because no profession should be allowed to enter the public service in a place where it is not needed. By that method of negative control over a number of years, we hope to bring about over the country a positive redistribution of the general practitioner service. It will not affect 55 the existing situation, because doctors will be able to practise under the new service in the areas to which they belong, but a new doctor, as he comes on. will have to find his practice in a place inadequately served.
I cannot, at the moment, explain to the House what are going to be the rates of remuneration of doctors. The Spens Committee report is not fully available. I hope it will be out next week. I had hoped that it would be ready for this Debate, because this is an extremely important part of the subject, but I have not been able to get the full report. Therefore, it is not possible to deal with remuneration. However, it is possible to deal with some of the principles underlying the remuneration of general practitioners. Some of my hon. Friends on this side of the House are in favour of a full salaried service. I am not. I do not believe that the medical profession is ripe for it, and I cannot dispense with the principle that the payment of a doctor must in some degree be a reward for zeal, and there must be some degree of punishment for lack of it. Therefore, it is proposed that capitation should remain the main source from which a doctor will obtain his remuneration. But it is proposed that there shall be a basic salary and that for a number of very cogent reasons. One is that a young doctor entering practice for the first time needs to be kept alive while he is building up his lists. The present system by which a young man gets a load of debt around his neck in order to practise is an altogether evil one. The basic salary will take care of that.
Furthermore, the basic salary has the additional advantage of being something to which I can attach an increased amount to get doctors to go into unattractive areas. It may also—and here our position is not quite so definite—be the means of attaching additional remuneration for special courses and special acquirements. The basic salary, however, must not be too large otherwise it is a disguised form of capitation. Therefore, the main source at the moment through which a general practitioner will obtain his remuneration will be capitation. I have also made—and I quite frankly admit it to the House —a further concession which I know will be repugnant in some quarters. The doctor, the general practitioner and the 56 specialist, will be able to obtain fees, but not from anyone who is on any of their own lists, nor will a doctor be able to obtain fees from persons on the lists of his partner, nor from those he has worked with in group practice, but I think it is impracticable to prevent him having any fees at all. To do so would be to create a black market. There ought to be nothing to prevent anyone having advice from another doctor other than his own. Hon. Members know what happens in this field sometimes. An individual hears that a particular doctor in some place is good at this, that or the other thing, and wants to go along for a consultation. He gets a consultation and pays a fee for it. If the other doctor is better than his own all he will need to do is to transfer to him and he gets him free. It would be unreasonable to keep the patient paying fees to a doctor whose services can be got free. So the amount of fee payment on the part of the general population will be quite small. Indeed, I confess at once if the amount of fee paying is great, the system will break down, because the whole purpose of this scheme is to provide free treatment with no fee paying at all. The same principle applies to the hospitals.
§ Mr. Sydney Silverman (Nelson and Colne)Before we leave that point, I should like to ask whether we are to gather from the right hon. Gentleman that a doctor will be entitled to receive a fee for consultation from a patient who is on some other doctor's list?
§ Mr. SilvermanI always understood it was improper for a doctor to see a patient who was being treated by another doctor.
§ Mr. BevanHe would not be treated by another doctor, but would be on the panel of the other doctor. We are hoping when our scheme gets going properly that everybody will be on somebody's panel, and unless an individual on someone else's panel is able to pay a fee no one will be able to pay a fee.
§ Mr. Logan (Liverpool, Scotland Division)If a patient can get specialist advice under the scheme what necessity will there be for him to pay for a consultant?
§ Mr. BevanI hope there will be very little necessity. Nevertheless, this is a field in which idiosyncrasies are prevalent. If an individual wishes to consult, 57 there is no reason why he should be stopped. As I have said, the fact that a person can transfer from one doctor to another ought to keep fee paying within reasonable proportions.
The same principle applies to the hospitals. Specialists in hospitals will be allowed to have fee-paying patients. I know this is criticised and I sympathise with some of the reasons for the criticism, but we are driven inevitably to this fact, that unless we permit some fee-paying patients in the public hospitals, there will be a rash of nursing homes all over the country. If people wish to pay for additional amenities, or something to which they attach value, like privacy in a single ward, we ought to aim at providing such facilities for everyone who wants them. But while we have inadequate hospital facilities, and while rebuilding is postponed it inevitably happens that some people will want to buy something more than the general health service is providing. If we do not permit fees in hospitals, we will lose many specialists from the public hospitals for they will go to nursing homes. I believe that nursing homes ought to be discouraged. They cannot provide general hospital facilities, and we want to keep our specialists attached to our hospitals and not send them into nursing homes. Behind this there is a principle of some importance. If the State owned a theatre it would not charge the same prices for the different seats. [Interruption.] It is not entirely analogous, but it is an illustration. For example, in the dental service the same principle will prevail. The State will provide a certain standard of dentistry free, but if a person wants to have his teeth filled with gold, the State will not provide that.
The third instrument to which the health services are to be articulated is the health centre, to which we attach very great importance indeed. It has been described in some places as an experimental idea, but we want it to be more than that, because to the extent that general practitioners can operate through health centres in their own practice, to that extent will be raised the general standard of the medical profession as a whole. Furthermore, the general practitioner cannot afford the apparatus necessary for a proper diagnosis in his own surgery. This will be available at the health centre. 58 The health centre may well be the maternity and child welfare clinic of the local authority also. The provision of the health centre is, therefore, imposed as a duty on the local authority. There has been criticism that this creates a trichotomy in the services. It is not a trichotomy at all. If you have complete unification it would bring you back to paper planning. You cannot get all services through the regional authority, because there are many immediate and personal services which the local authority can carry out better than anybody else. So, it is proposed to leave those personal services to the local authority, and some will be carried out at the health centre. The centres will vary; there will be large centres at which there will be dental clinics, maternity and child welfare services, and general practitioners' consultative facilities, and there will also be smaller centres—surgeries where practitioners can see their patients.
§ Mr. Sidney Marshall (Sutton and Cheam)Will the executive councils have anything to do with the public health centres, or will the latter be managed entirely by the public health authorities?
§ Mr. BevanBy the health authorities. The health centre itself will be provided by the local health authority, and facilities will be made available there to the general practitioner. The small ones are necessary, because some centres may be a considerable distance from peoples homes. So it will be necessary to have simpler ones, nearer their homes, fixed in a constellation with the larger ones.
§ Mr. MarshallWill the executive councils have anything to do with it? That is the question I asked.
§ Mr. BevanThe representatives on the local executives will be able to coordinate what is happening at the health centres. As I say, we regard these health centres as extremely valuable, and their creation will be encouraged in every possible way. Doctors will be encouraged to practise there, where they will have great facilities. It will, of course, be some time before these centres can be established everywhere, because of the absence of these facilities.
There you have the three main instruments through which it is proposed that the health services of the future 59 should be articulated. There has been some criticism. Some have said that the preventive services should be under the same authority as the curative services. I wonder whether Members who advance that criticism really envisage the situation which will arise. What are the preventive services? Housing, water, sewerage, river pollution prevention, food inspection —are all these to be under a regional board? If so, a regional board of that sort would want the Albert Hall in which to meet. This, again, is paper planning. It is unification for unification's sake. There must be a frontier at which the local joins the national health service. You can fix it here or there, but it must be fixed somewhere. It is said that there is some contradiction in the health scheme because some services are left to the local authority and the rest to the national scheme. Well, day is joined to night by twilight, but nobody has suggested that it is a contradiction in nature. The argument that this is a contradiction in health services is purely pedantic, and has no relation to the facts.
It is also suggested that because maternity and child welfare services come under the local authority, and gynæcological services come under the regional board, that will make for confusion. Why should it? Continuity between one and the other is maintained by the user. The hospital is there to be used. If there are difficulties in connection with birth, the gynæcologist at the hospital centre can look after them. All that happens is that the midwife will be in charge—the mother will be examined properly, as she ought to be examined—then, if difficulties are anticipated, she can have her child in hospital, where she can be properly looked after by the gynæcologist. When she recovers, and is a perfectly normal person, she can go to the maternity and child welfare centre for post-natal treatment. There is no confusion there. The confusion is in the minds of those who are criticising the proposal on the ground that there is a trichotomy in the services, between the local authority, the regional board and the health centre. I apologise for detaining the House so long, but there are other matters to which I must make some reference. The two Amendments on the Order Paper rather astonish me. The hon. Member for Denbigh (Sir H. Morris-Jones) informs me, 60 in his Amendment, that I have not sufficiently consulted the medical profession——
§ Sir Henry Morris-Jones (Denbigh)That is not the wording on the Order Paper. I said there were no consultations.
§ Mr. BevanI intend to read the Amendment to show how extravagant the hon. Member has been. He says that he and his friends are
unable to agree to a measure containing such far-reaching proposals involving the entire population without any consultations having taken place between the Minister and the organisations and bodies representing those who will be responsible for carrying out its provisions.I have had prepared a list of conferences I have attended. I have met the medical profession, the dental profession, the pharmacists, nurses and midwives, voluntary hospitals, local authorities, eye services, medical aid services, herbalists, insurance committees, and various other organisations. I have had 20 conferences. The consultations have been very wide. In addition, my officials have had 13 conferences, so that altogether there have been 33 conferences with the different branches of the profession about the proposals. Can anybody argue that that is not adequate consultation? Of course, the real criticism is that I have not conducted negotiations. I am astonished that such a charge should lie in the mouth of any Member of the House. If there is one thing that will spell the death of the House of Commons it is for a Minister to negotiate Bills before they are presented to the House. I had no negotiations, because once you negotiate with outside bodies two things happen. They are made aware of the nature of the proposals before the House of Commons itself; and furthermore, the Minister puts himself into an impossible position, because, if he has agreed things with somebody outside he is bound to resist Amendments from Members in the House. Otherwise he does not play fair with them. I protested against this myself when I was a Private Member. I protested bitterly, and I am not prepared, strange though it may seem, to do something as a Minister which as a Private Member I thought was wrong. So there has not been negotiation, and there will not be negotiation, in this matter. The House of Commons is supreme, and the House of Commons Must assert its 61 supremacy, and not allow itself to be dictated to by anybody, no matter how powerful and how strong he may be.
§ Sir H. Morris-JonesWould the right hon. Gentleman apply that doctrine to the Miners' Federation?
§ Mr. BevanCertainly. That is exactly what I did. The hon. Member was a Member of the House at the time, and he should remember it These consultations have taken place over a very wide field, and, as a matter of fact, have produced quite a considerable amount of agreement. The opposition to the Bill is not as strong as it was thought it would be. On the contrary, there is very considerable support for this Measure among the doctors themselves. I myself have been rather aggrieved by some of the statements which have been made. They have misrepresented the proposals to a very large extent, but as these proposals become known to the medical profession, they will appreciate them, because nothing should please a good doctor more than to realise that, in future, neither he nor his patient will have any financial anxiety arising out of illness.
The leaders of the Opposition have on the Order Paper an Amendment which expresses indignation at the extent to which we are interfering with charitable foundations. The Amendment states that the Bill
gravely menaces all charitable foundations by diverting to purposes other than those intended by the donors the trust funds of the voluntary hospitals.I must say that when I read that Amendment I was amused. I have been looking up some precedents. I would like to say, in passing, that a great many of these endowments and foundations have been diversions from the Chancellor of the Exchequer. The main contributor was the Chancellor of the Exchequer. But I seem to remember that, in 1941, hon. Members opposite were very much vexed by what might happen to the public schools, and they came to the House and asked for the permission of the House to lay sacrilegious hands upon educational endowments centuries old. I remember protesting against it at the time—not, however, on the grounds of sacrilege. These endowments had been left to the public schools, many of them for the maintenance of the buildings, but hon. Members opposite, being concerned lest 62 the war might affect their favourite schools, came to the House and allowed the diversion of money from that purpose to the payment of the salaries of the teachers and the masters. There have been other interferences with endowments. Wales has been one of the criminals. Disestablishment interfered with an enormous number of endowments. Scotland also is involved. Scotland has been behaving in a most sacrilegious manner; a whole lot of endowments have been waived by Scottish Acts. I could read out a large number of them, but I shall not do so.Do hon. Members opposite suggest that the intelligent planning of the modern world must be prevented by the endowments of the dead? Are we to consider the dead more than the living? Are the patients of our hospitals to be sacrificed to a consideration of that sort?
§ Major LloydHenry VIII did it.
§ Mr. BevanHe was a good king, too; he had many good points. We are not, in fact, diverting these endowments from charitable purposes. It would have been perfectly proper for the Chancellor of the Exchequer to have taken over these funds, because they were willed for hospital purposes, and he could use them for hospital purposes; be we are doing no such thing. The teaching hospitals will be left with all their liquid endowments and more power. We are not interfering with the teaching hospitals' endowments. Academic medical education will be more free in the future than it has been in the past. Furthermore, something like £32 million belonging to the voluntary hospitals as a whole is not going to be taken from them. On the contrary, we are going to use it, and a very valuable thing it will be; we are going to use it as a shock absorber between the Treasury, the central Government, and the hospital administration. They will be given it as free money which they can spend over and above the funds provided by the State.
I welcome the opportunity of doing that, because I appreciate, as much as hon. Members in any part of the House, the absolute necessity for having an elastic, resilient service, subject to local influence as well as to central influence; and that can be accomplished by leaving this money in their hands. I shall be 63 prepared to consider, when the Bill comes to be examined in more detail, whether any other relaxations are possible, but certainly, by leaving this money in the hands of the regional board, by allowing the regional board an annual budget and giving them freedom of movement inside that budget, by giving power to the regional board to distribute this money to the local management committees of the hospitals, by various devices of that sort, the hospitals will be responsive to local pressure and subject to local influence as well as to central direction.
I think that on those grounds the proposals can be defended. They cover a very wide field indeed, to a great deal of which I have not been able to make reference; but I should have thought it ought to have been a pride to hon. Members in all parts of the House that Great Britain is able to embark upon an ambitious scheme of this proportion. When it is carried out, it will place this country in the forefront of all countries of the world in medical services. I myself, if I may say a personal word, take very great pride and great pleasure in being able to introduce a Bill of this comprehensiveness and value. I believe it will lift the shadow from millions of homes. It will keep very many people alive who might otherwise be dead. It will relieve suffering. It will produce higher standards for the medical profession. It will be a great contribution towards the wellbeing of the common people of Great Britain. For that reason, and for the other reasons I have mentioned, I hope hon. Members will give the Bill a Second Reading.
§ 5.0 p.m.
§ Mr. Richard Law (Kensington, South)The right hon. Gentleman the Minister of Health has received an ovation from the Benches behind him for a speech as eloquent, as unconvincing, and as disingenuous as any I have ever heard from him. The right hon. Gentleman had a great opportunity with this Bill. He had the chance of bringing to the House of Commons proposals which would have been warmly welcomed by every party in the House and by every section of opinion, lay or medical, outside. Instead, he has preferred to bring to the House these proposals which are in fact feared and distrusted by the great majority of [...]se who will be called upon to make [...]effective. The right hon. Gentle- 64 man might have done so much without doing this. He might have done so much more if he had been content to do a little less.
It is surely a most extraordinary thing that the right hon. Gentleman the Minister of Health, who has absolutely no administrative experience of a great Government Department, and who has no great knowledge, either practical or theoretical, of the very important subject matter with which this Bill is dealing, should have set his own intuition and judgment against all those best informed in the medical profession and in the hospital services outside the House. In fact, the right hon. Gentleman has done just that. The British Hospital Association and the British Medical Association are opposed to this Bill. [Laughter.] I do not know why hon. Members laugh at the mention of the British Medical Association. The British Dental Association is also opposed to this Bill, and the three Royal Colleges have criticised it with varying emphasis.
§ Mr. LawThe three Royal Colleges have criticised the Bill with varying emphasis—[HON. MEMBERS: "Answer."]—and for various reasons. I think I am right in saying that the Royal College of Surgeons passed a resolution condemning aspects of the Minister's proposals in the most categorical terms. The Royal College of Obstetricians did the same. They said, if my memory serves me, that the Minister's proposals were likely to lead to a great increase in maternal mortality. [Interruption.] That was, I think, the purpose of a document which I have certainly seen and which emanated from the Royal College of Obstetricians. And even——
§ Dr. Morgan (Rochdale)rose——
§ Mr. Law—the powerful advocacy of its President, Lord Moran, was unable to influence the Royal College of Physicians to give support to the Minister's proposals for taking over the voluntary hospitals.
§ Mr. BevanI must ask the right hon. Gentleman to amplify his statement, which otherwise might cause a great deal of alarm. Does he say that the Royal College of Obstetricians have placed on 65 record a declaration that the consequence of the Bill will be to raise the maternal mortality rate? Will he quote the resolution?
§ Mr. LawUnfortunately, I have not the document and therefore I am unable to quote from it. [HON. MEMBERS: "Withdraw."] If I have misquoted it I will certainly withdraw, but my impression is——
§ Mr. John Paton (Norwich)rose——
§ Mr. LoganOn a point of Order. Is it not the custom of this House to withdraw a quotation if it cannot be substantiated?
§ Mr. Deputy-Speaker (Major Milner)That applies only to official documents.
Dr. MorganvI have a copy of the document sent out by the Royal College of Obstetricians. May I present it to the right hon. Gentleman and ask him to quote the relevant passage?
§ Dr. Haden Guest (Islington, North)I have been recently in personal contact with the Royal College of Obstetricians and the statement of the right hon. Gentleman is absolutely untrue.
§ Mr. LawI must thank the hon. Gentleman for passing me the document because I can now give the quotation. I said—and I am in the recollection of the House —that this document stated that the proposals of the Minister with regard to certain aspects of the Bill increased the chances of maternal mortality. If I gave the House the impression that that was said, in those exact words, I was wrong and of course I withdraw. This is in fact what the Royal College of Obstetricians said in this document:
The Royal College has considered these questions"—that is, the question of duality of administration which, I think, the Minister touched on—in its recent report on a national maternity service. In that report the Royal College gave evidence for its conviction that the care of the pregnant woman, whether at home, in the clinic, or in hospital, is a responsibility which cannot be discharged with the maximum safety to the two lives at stake if it is shared between different administrative bodiesThat is what the—[Interruption]. We can pursue this argument for ever, but the plain fact is, as the Minister knows, that the Royal College of Obstetricians have very serious misgivings about the 66 proposals in this Bill. I therefore hold that I am fully entitled to claim that the expert opinion of the Royal College is opposed to the Minister's intuitions and judgment on this matter. When the Minister interrupted me a few moments ago—I do not complain since perhaps I gave him cause—I was going on to speak of the Royal College of Physicians and to explain to the House that in spite of his own advocacy and in spite of his great authority, the President was quite unable to bring the Royal College to endorse his view that the Minister, in taking the hospitals into his own control and ownership, was doing a good thing.The plain fact is that everybody of informed and expert opinion outside this House is against the Minister on one part of the Bill or another. The Minister rides off by talking of sectional and vested interests. I have known the Minister fairly well in this House. I think he has the sort of mind which, when anybody disagrees with him or holds a different view, makes him fasten immediately upon phrases like "sectional interests" or "vested interests." It is a monstrous perversion of the ordinary usage of words to describe great, responsible, professional bodies such as I have been mentioning as vested or sectional interests. I would like first to make clear, as far as I can, the position of those who sit on these benches with regard to the principle of a comprehensive, national health service available to all.
§ Dr. MorganI would like to have my document back.
§ Mr. Deputy-SpeakerThe hon. Member is not entitled to speak unless the right hon. Member who is addressing the House gives way.
§ Dr. MorganSurely I am entitled to ask the right hon. Gentleman to have the courtesy to return my document.
§ Mr. LawCertainly. I regret to say that I have marked it. I am sorry. I was saying, and I hope I shall now have the chance to finish my sentence, that I am anxious to make clear our position on these Benches in regard to the principle of a national, comprehensive, 100 per cent. health service. Of course we accept that principle today, as we accepted it in 1944, when the Coalition White Paper was published. I assure the Minister that on this side of the House we are just as anxious 67 as he is, or any of his hon. or right hon. Friends by his side or behind him are, to give the people of this country the fullest possible benefits which can come from the acceptance of the principle of a comprehensive service. I hope the Minister will understand that. We accept the principle, and we accept the consequences that flow from it. We understand, for example, that once we are committed, as we are gladly committed, to the principle of a 100 per cent. service, we require an enormous expansion and development in the health services as a whole. We understand, once we accept the principle, that we are committed to a far greater degree of coordination, or planning as it is usually called, than we have ever known before. Incidentally, I must say how very much surprised I was at something which the Minister said, and which indicated how much he has learnt in his period of office as Minister of Health. Running through his speech was the idea that he did not like what he called "tidy paper plans." That is a very great advance for the Minister, because it is not long ago that I heard him saying in this House that he could not use the private builder method because the private builder did not fit into a tidy paper plan. The right hon. Gentleman said that the private builder was a non-plannable body and did not fit in.
I was saying that we accept the consequences that flow from the principle, and if my right hon. and learned Friend the Member for North Croydon (Mr. Willink) had still been Minister of Health, had the General Election result gone another way, I do not doubt that he would have introduced, before this, a Bill which would have differed from this Bill only in that my right hon. and learned Friend would not have attempted to control, own and direct the hospital service of this country or to interfere with that age-old relationship which exists, always has existed, and in our view ought to continue to exist, between a doctor and his patient. Therefore, the right hon. Gentleman is not entitled to say—he has not said it, but he might— that we will the end without the means. We will both the end and the means. We will this end, a comprehensive and efficient health service. We are willing to support any practicable means that will give us that end. 68 But we differ from the right hon. Gentleman on this issue. We believe that the right hon. Gentleman could have reached his end, and a better end, by other means, and by better means. We believe that he could have established a health service, equally comprehensive, better coordinated and far more efficient, if he had not been determined to sweep away the voluntary hospitals; if he had not been determined to weaken the whole structure of English local government by removing from the field of local government one of the most important and vital responsibilities of local authorities; and if he had not sought to impose upon the medical profession a form of discipline which, in our view and in theirs, is totally unsuited to the practice of medicine, an art, a vocation, however you like to call it, which depends above all else upon individual responsibility, individual devotion and individual sympathy.
§ Mr. LawI will come to that point. The right hon. Gentleman said that the Bill covered a tremendous field, but he did not cover the whole field himself, and I certainly will not attempt to traverse the whole field. Before the Debate ends, very important questions have to be answered on the administrative structure which runs through the Bill, and particularly whether it is desirable to divide the health service into three watertight compartments by vertical lines: the hospital and consulting services in one division, the general practitioner services in another, and the local authority services in a third. There is the question of the dental service, to which the Minister referred. I would like to say in passing that no Bill of this kind can cure the appalling dental conditions to which the Minister referred. They can be cured only by education and nutrition, among other things.
There is the question of opticians. There is the further question of the employees of hospital contributory schemes and why they are being left out of the operation of Clause 64, which compensates those who have been concerned with voluntary hospitals. That seems to me to be a most grievous injustice, and I hope we shall be able to persuade the Minister to change his mind on that. These and other matters will be developed, I have no doubt, either now or at a later 69 stage, by others of my hon. and right hon. Friends on this side of the House. I propose to confine myself in the main to the two fundamental issues of principle which seem to me to divide us from the Minister, the question of the hospitals services in Part II of the Bill, and the question of the general practitioner services in Part IV.
Why is the Minister determined to take over the ownership of the hospitals? It seems to me that the burden of proof must be upon him. It is for him to show why it is necessary for the State and for the Minister to take over the hospitals. It is not for us to show that it is not necessary. I say that because, as I understand the policy of the present Government, that is, as far as it is possible to understand it, nationalisation as a principle and for its own sake is not a part of that policy. We have been repeatedly told, for example, by the Lord President of the Council, that the Government would not take over an industry unless it could be shown demonstrably that the change would be for the benefit both of the industry and of the community. I am quite certain that the Lord President would not apply any more sordid standard than that in the case of the health services and medicine.
It is, indeed, only a little more than 12 months ago that the Lord President of the Council, speaking in this House, explained why it would be wrong for the State, for the Government and for the Minister of Health, to take over the hospital services in this country. What he said was so interesting that I would like to repeat an extract from it. He was speaking on a Motion on local government, and referring to a speech by the hon. Member for South Tottenham (Mr. Messer), the Lord President said:
My hon. Friend the Member for South Tottenham‥‥was absolutely right.Why was he absolutely right? This is what the Lord President of the Council said:He said that as a local government man he did not mind what we did with electricity, gas, water and drainage. What he wants to keep in his hands as a local government man are the human services like health, education and housing. I think he is right.The Lord President then went on:When you come to economic undertakings, you have to find what is the best administrative and managerial set-up for effi- 70 cient running of the industry, but when you come to human services, efficiency has to be balanced with humanity.At a later stage in that same speech the Lord President of the Council said that in his view there were certain matters—things that he called "engineers' questions rather than human questions"—which could be dealt with on a national rather than a local basis. Having said that, he went on to except the hospital services from those engineers' questions. He said:The other service is hospitals. There the view of the Minister of Health and the Government was that it would not be right to take the hospitals over into a national concern. I think that is quite right, but it is the case that hospital administration is beyond the administrative ability of a large number of county boroughs. It is even beyond a large number of county councils. Therefore the Minister was driven and I was dragged with him, to swallow the joint board doctrine‥‥—[OFFICIAL REPORT, 15th February, 1946; Vol. 408, c. 506 and 512.]The Lord President of the Council has been dragged a good deal further by the Minister of Health. When the Lord President was speaking in the House he was only reaffirming something to which he was committed by the Coalition White Paper. Not only was the Lord President committed, but the present Prime Minister and the present Foreign Secretary were committed. Therefore, I say we are entitled to know what has happened in the last 12 months that has made what was then wrong right today. We are entitled to know what the arguments are that have convinced the Lord President of the Council, the Prime Minister and the Foreign Secretary that they made a mistake when the Coalition White Paper was issued.
The Minister has not really given any solid justification for the case for taking over the hospitals. He has told us that the present hospital services are inadequate. He has told us that the present hospitals are badly distributed. He has said that some of the buildings, in particular of municipal hospitals, are monstrous buildings. I would not deny, and I do not think anyone would deny, that the present hospital service is inadequate from the point of view of a comprehensive service, that it is badly distributed from the point of view of a comprehensive service, and that some of its buildings and equipment are completely out of date and out of tune with the necessities 71 of what we are all seeking to do in establishing this health service. But surely the main reason for the inadequacy of the hospital service, the weaknesses in the distribution of hospitals, the out-of-dateness and old-fashionedness of the equipment and buildings, is simply that the finance has not been available. Once we accept the principle of the comprehensive service, once the community accepts the principle that it is going to pay for that service, that difficulty disappears. I cannot see why the mere fact that the service was inadequate in the past, when there were no funds to support it, would make it inadequate today I do not see that that is any argument at all for the Minister taking the service over.
§ Dr. Haden GuestDoes the right hon. Gentleman not think that the views he has expressed are modified by the very comprehensive reports of the hospital services which have been made either by the Minister of Health or the Nuffield Provincial Trust all over the country, showing the inadequacy in very great detail?
§ Mr. LawI do not think that affects my argument at all because I am not defending the adequacy of the existing system, in terms of a comprehensive service. I am not doing that, but the hon. Member has reminded me of something else, and that is that in these hospital surveys, which do, as he says, reveal great deficiencies in one of our services, a very striking thing is how at least one of the surveys says that the cooperation, and the anxiety for cooperation, between the local authority hospitals and voluntary hospitals was very great indeed. As that is one of the arguments which is used for taking over the hospitals—that it would be impossible to make local authorities and voluntary hospitals agree on any other basis than the State taking them over—it is very useful for hon. Members to bear in mind that in one of the surveys an exactly contrary implication is given, and it is stated that the two parties are doing their best to get along together.
§ Mr. Medland (Plymouth, Drake)Which survey is that?
§ Mr. LawThat is the survey of the West Midland area, published, I think, at the end of last year or the beginning of this.
I want to say one more thing on the Minister's arguments about taking over 72 the hospitals. He said that if the State was paying 90 per cent. of the cost of the hospitals, as it would be according to his calculations when these proposals came into force, it was impossible to maintain them as voluntary hospitals. I cannot see the force of that argument, especially in the light of something the Minister himself said later in his speech because, surely, if the community demands certain services and is prepared to pay for them, there would be nothing inherently improper in the community paying to the existing hospitals a fee to cover the relevant services. It would then be open for the existing hospitals, under the existing control, to improve upon the standard laid down by the State. I think the Minister himself said that was a desirable thing; he said that if he were building a State theatre, he would not have all the seats of the same quality and at the same price; the State should lay down the standard and everybody should be encouraged to improve upon that standard. I think the Minister was speaking of the general practitioner services and the dental services, but the same argument is equally applicable to the hospital services.
If anyone were suggesting that either the voluntary hospitals or the municipal hospitals should stay outside a national scheme, I could understand the Minister's attitude on this, but nobody is suggesting that they should stay outside; everybody admits that they have to be brought into a comprehensive scheme. If anybody were suggesting that the present hospital service system was adequate, I could understand the Minister's attitude, but nobody is suggesting that either. All I am trying, and all I would like, to suggest to the Minister is that a hospital is essentially a living thing, with a life and a purpose and an identity of its own, and that it is not just part of an administrative machine. I would suggest to the Minister that if the region is the right area—and I dare say that it is desirable that the hospital services should be centred on a university—then let him make the regional board not a controlling and an administrative board, not a directing board, but a planning board. Let the board create the plan, if necessary under the final authority of the Minister. Let the board create the plan and let the hospitals, whether existing or to be created, whether voluntary or municipal, carry out the plan. The Minister, by his 73 financial sanction, would have ample powers to see that the plan was in fact carried out. It might not be so tidy on paper, but the Minister would not object to that—apparently, he would rather like it—and I believe it would prove in the long run to be a far more effective method of coordinating and developing the hospital organisation than the one the Minister has chosen.
The Minister said a lot about how repugnant it was to a civilised society that the hospitals should be dependent in any way upon charity. I just do not agree with him. I do not believe that the developments of modern science—the invention of the atom bomb or anything else —have altered the ordinary Christian virtues that we have always accepted. Indeed, I think the kind of society that the Minister pictures, in which it is repugnant to society for anybody to give of his charity to hospitals and, I suppose to anything else——
§ Mr. BevanI hope the right hon. Gentleman is not going to misrepresent me continually, if I may say so. What I said was that the hospitals ought not to be dependent upon charity. I said it was repugnant, certainly.
§ Mr. Messer (Tottenham, South)It is being dependent that is repugnant.
§ Mr. LawI accept the Minister's version of what he said and I would not deny it for a moment. But if that is all he means, I do not see why he does not let the voluntary hospitals continue as individual institutions with their own identity, so that people can continue to give to them. Of course he says that there is power in the Bill for the individual to give to the regional board, but that power really does not mean anything because it is inconceivable to me that anybody will give anything in trust to the Minister from now on when they know what he does with existing trusts.
§ Mr. MedlandThey give money to the Chancellor of the Exchequer sometimes
§ Mr. LawFor these purposes the Minister—and I am not wishing to be offensive —has shown himself to be entirely untrustworthy, in the literal sense of the word, and it is really absurd to suppose 74 that the people will give of their charity to the Minister, or to the regional board under the Minister, as they have been giving in the past. Indeed, it is quite clear from the Bill that this is not expected, because it will be seen from paragraph 4 of the Financial Memorandum that the whole financial background of the Bill is on the assumption that these payments from individuals will stop——
§ Dr. MorganLook at pages 16 and 17 of the White Paper.
§ Mr. LawYes, of the White Paper, but we are discussing the Bill. It seems to me that the kind of society which the Minister is apparently envisaging—he did not say it was, but it seemed to me to be the background of his remarks—is a society in which everybody pays to the State what he must, and takes from the State what he can. That is not the kind of society which will be very attractive to the people of this country. I think the Minister misunderstands altogether the nature of this problem as far as charity is concerned. I think he regards is as a few rich people trying to do down the Chancellor of the Exchequer, trying to buy their way through the "eye of the needle" by charitable bequests. It is nothing of that kind at all. The workers, the poor people of this country, have an enormous affection for their own hospitals and they are very proud and glad to be able to contribute.
§ Mr. MedlandQuite right.
§ Mr. LawI believe that to be true, and that is something which the Minister is destroying under this Bill.
§ Mr. MedlandThey will still be able to do it.
§ Mr. LawThe Minister told us that he will give the fullest possible power and discretion to the regional boards. He still has not told us how they are to be manned. I have no doubt that his intentions at the present time are quite harmless, but what we are concerned with now is not what is in the White Paper or what the Minister said in his speech; we are concerned with what is in the Bill, and the plain fact of the matter is that the Bill on almost every page, as soon as it gives power to a board or committee—whether composed of professional representatives or of elected local authority representatives, or whoever it may be— 75 takes it back again at once. That begins on page 1 of the Bill and goes on right through to the end. At the foot of page 1 in Clause 1 we see that the Minister is establishing a Central Health Services Council to advise him, and in the Schedule we see that that Council is on the whole extremely well composed; the Royal Colleges are represented ex officio and so on. Then, in the very next sentence, we learn that the Minister may, after consultation with the Central Council, by Order vary the constitution of that Council.
That runs through the whole of the Bill, from beginning to end. Whatever the power the Minister gives, he holds in reserve authority to withdraw it and concentrate the whole service on himself. When we look at what is in the Bill from that point of view, and when we consider what we know of the policy of the party opposite with regard to these matters, it is hardly surprising that most people feel extremely nervous of the tendencies which are implicit in the Bill. It will hardly be surprising if few people are soothed and assuaged by the comforting words the Minister has spoken. The Minister may pass, or the Minister may change his mind, but this Bill will still be there. I would not build too much hope on the attitude of the Minister as he expressed it in his speech.
I can understand the attitude of the right hon. Gentleman in regard to voluntary hospitals better than I can understand his attitude in regard to municipal hospitals, because municipal hospitals are free from any of this taint of private benevolence, or charity. I cannot see why the Minister condemns the just with the unjust. Still less can I understand how he has been able to persuade his colleague, the Lord President of the Council, who has always come before us as a great champion of local government, to accept it, or how he has been able to persuade another colleague, the Home Secretary, who has had great experience of local government. Is it the case that these two right hon. Gentlemen believe that local authorities are unable to live up to their responsibilities, that they are unable to bear the heavy responsibility —among the most important of their responsibilities—of hospital provision? Those two right hon. Gentlemen may 76 believe that, but we on these Benches do not.
§ Mr. MesserThe right hon. Gentleman is aware that after the 1929 Act, county councils and county borough councils were entitled to hospitalise their services. Does he know that 68 out of the total number have not yet done so, and are still living under the Poor Law?
§ Mr. LawWhat the hon. Member for South Tottenham (Mr. Messer) says is perfectly true; a large proportion of local authorities have not hospitalised their services as they might have done under the Act of 1929. But the local authorities had a very short period, only eight Years until the outbreak of war, and it was a period of very great difficulty. Although the standard of local authority hospitals is not in general as high as the standard of voluntary hospitals in this country, I can see no reason why, with time and with the kind of assistance which will be given by the financial implications of a comprehensive health service, the standard of the voluntary hospitals should not be equalled very quickly.
I have spent rather more time than I had intended to spend on the question of the hospital services, but I must say a word about that other important part of the Bill, Part IV, the general practitioner service. Here, again, there is a broad measure of agreement between us. We are agreed on this side of the House that there is a shortage of doctors and that doctors have to be fairly distributed. But there are two principles to which we attach enormous importance. The first is the principle that the doctor's only loyalty and only responsibility should be to his patients. The second principle is that as far as his judgment is concerned, the doctor should be responsible to nobody else but himself, and certainly he should not be responsible to the State. Running through Part IV of the Bill there is a wholesale denial of both these principles. The Minister would not admit that, but I say there is a wholesale denial of both those principles. There is the assertion that the doctor is responsible not so much to his patient but to the Minister, through some Government body or another. I think I am right in saying that every body or committee set up under this Bill has to act within regulations, not specified, which will be laid down by the Minister.
§ Mr. BevanI am sorry to interrupt the right hon. Gentleman; he is very courteous in giving way so frequently. But it is very important that statements he makes should not go out without being put right when they misrepresent the situation so fundamentally. There is nothing at all in the Bill, no power whatever, which confers on the Minister the right to make a regulation which interferes between the doctor and his patient.
§ Mr. LawI find that very difficult to understand, because under Clause 33 the doctor makes his contract with the Executive Council, and
it shall be the duty of every Executive Council, in accordance with regulations— presumably those regulations emanate from the Minister—
§ Mr. BevanThe existing position is not being changed at all. At the present time there are insurance committees responsible for administering the general practitioner service under the National Health Insurance Act. Where there are complaints against a doctor, as indeed there may be, that committee is responsible for investigating them. All that happens in this Bill is that I have put in an additional protection for the doctor—more than he has got under the existing law. So far from the relationship between doctor and patient being weakened, this Bill actually puts the doctor in a stronger position.
§ Mr. LawI do not see how the Minister can say, or how I can know, that the existing position has not been changed, because the position as it will be under this Bill will be governed by regulations, the existence of which I do not know and the nature of which neither I nor anyone else, except perhaps the Minister, can guess. I do not see how the Minister can expect me to accept that the position will be exactly as it is today.
§ Dr. MorganWhat is it today? May I ask a question?
§ Mr. LawI have been a very long time, I am afraid, and I want to get on, in order to give other hon. Members a chance. It is not so much the existence of the local executive committee; it is the fact that the doctor is to receive part of his salary as a fixed payment from the State. The Minister said it was not from the State, it was only from the executive committee. That is merely a play upon 78 words. The fact is that the doctor is to be paid, in part, by the State. He is to work in premises which are owned, staffed and managed if not technically by the State, by the State as represented by the local authority; and his field of work is to be defined for him by the State. I say that those three things add up to the beginnings of a wholetime State medical service. It is incomplete at the moment, it is still only embryonic, but it is the first step, and the step that counts, towards a fulltime medical service.
I do not think it is possible to be surprised that so many doctors feel it is in fact that first step, in particular when one considers once again what is the declared policy of the party opposite. Here is an interesting statement from the Socialist Medical Association:
The proposals in regard to the payment of doctors fall short of the policy we have advocated, and which the Labour Party has, in the past, accepted. We still insist that the best service, the perfect doctor-patient relationship, and the highest form of team work will be possible only when the service becomes one employing whole-time salaried officers, and we shall watch the basic salary system very closely indeed.[HON. MEMBERS: "Hear, hear."] That is the statement, and the House has heard the reception which it has got from hon. Members opposite. [An HON. MEMBER: "Do you agree with it?"] I certainly do not agree with it. It is hardly surprising if, in spite of the soft and soothing words which the Minister has used this afternoon, the medical profession still believes that it is being driven along towards a full-time salaried State service, a form of service which is absolutely incompatible with the two principles I enunciated a few moments ago. Will the doctor be a better doctor because he is paid a salary? I say he will be a worse doctor, because all his prospects of material advancement will depend, not on the service that he can render to his patients, but on the impression which he is able to make on his administrative superiors.
§ Mrs. Jean Mann (Coatbridge)Is it not the case that his medical superiors will be his own colleagues on the medical practices committee?
§ Mr. LawI do not think that affects my argument at all. It is not a question of who the administrators are, but of whether the practice of medicine as a science and 79 an art will be made subservient to administrative considerations. I say that that is what happens when the doctor is paid a salary and that that does not make a doctor a better doctor It makes him a worse doctor. From the point of view of the patient, who is the one who matters, it is far better that the material prospects of the doctor should depend upon the impression the doctor makes on the patient, and not on the impression he makes on his administrative superiors.
When these provisions become effective, if they become effective, the doctor will be under great temptation to make himself known to these people and these bodies, to seek their favour, to cultivate them. He will be under great pressure to limit the issue of certificates to his patients.
§ Mr. Kirkwood (Dumbarton Burghs)Is that the experience of the Foreign Office?
§ Mr. Walkden (Doncaster)The right hon. Member is arguing the case that it would make the doctor limit the issue of certificates. Is he not conversant with the practice which was much evident right through the war, of the maldistribution of certificates, or a too generous distribution of certificates to people who should never have had them at all?
§ Dr. MorganThat is not true.
§ Mr. LawThe hon. Member for Doncaster (Mr. Walkden) has underlined the point I was trying to make, that the doctor will be under pressure to limit the issue of certificates. The plain fact is that the payment of doctors by salary means that the doctor will depend less and less upon the confidence he has earned with his patients and more and more on the impression he makes upon governmental bodies of one kind and another.
I wish to refer to the sale of practices. The Minister said it was the sale and purchase of patients. He knows perfectly well that that is humbug. He knows perfectly well that when a doctor buys a practice, he is not buying patients. When a doctor sells a practice he is not selling patients, he is not selling bodies, he is selling the goodwill he has earned with his patients. If he has been a diligent doctor, if he has been devoted, forgetful of himself, if he has worked his hardest in the interests of his patients, the value of that goodwill will be high. If he has 80 been a bad doctor, the value of that goodwill will be low. Conversely, when a doctor is buying a practice he is not buying patients, he is only buying an opportunity to serve his patients. If he does not make use of that opportunity he loses his practice. What the Minister is doing by forbidding the buying and selling of practices is to remove one more material inducement which a doctor has to give the best service he can to his patients.
§ Mrs. Florence Paton (Rushcliffe)Does he serve for the love of it?
§ Mr. LawThat interruption is typical of the outlook of many hon. Members on the other side of the House. They do not think of human beings at all. They would never regard a doctor as a human being. They regard people as either black or white. They would say that it is perfectly right and proper for a miner or a building operative to be interested in the of his labour, and in trying, to improve his position and that of his family; that is right and noble, but they will not apply the same principle—at least the hon. Member does not seem to do so—to the doctor. The doctor is human, and just like the miner or the operative, he is bound to be interested in his material conditions, in the welfare of his family, the future of his children.
To deprive him, in his practice, of the inducement to improve his material position, to improve the prospects of his children, is to do harm, not to him but to his patients. It is to do harm because it will reinforce the tendency already begun, with the payment of the decreasing capitation fee and so forth, to sit back and look for his future and remuneration, not to an increase in the value of his practice, not to the impression he makes on his patient, not to the creation of goodwill. Again, it will force him to look to his administrative superiors. I believe that will have a very harmful effect upon the practice of medicine.
We on these benches are in no way opposed to the principle of a comprehensive service. We support that principle and we will give the Minister every support we can in making it effective if he will only reconsider and modify his proposals about the hospital service and his proposals in Part IV of the Bill. We object to Part IV of the Bill because it destroys the existing relationship between 81 doctor and patient, it removes some of the incentives—not all of them but some of them—which the doctor at present has to serve his patient. It involves the unnecessary expenditure of £66 million of the taxpayers money. In our view it means that even if, by a combination of threats and bribes, the Minister persuades all the medical profession to work under him in making this Bill effective, the doctors of the future will not be as good as the doctors of today. The bad effects of this Bill, in so far as they are bad, on the points on which I have been speaking, may not be seen now or in six months' or a year's time but they will make themselves evident in 10, 15 or 20 years' time. By then it will be too late to do anything about it. I think the same is true of the hospital services. We are opposed to the Minister's proposals because they weaken local interest and initiative and the feeling of responsibility of the individual for his own hospital. The proposals weaken the fabric of local government.
The Minister is dealing in these matters with something very different from housing, something in some senses which is far more important than housing. It is more important because if the Minister makes a mistake here, as I believe he is making a mistake, that mistake is irremediable: there is nothing we can do about it. If the House passes this Bill in its present form it means that we are taking a step from which there will be no going back. I believe it would be a fatal step. Therefore, I hope that between now and the end of our discussions, which I imagine are likely to be fairly protracted, the Minister will be able to consider very carefully the points that have been put to him. I hope he will consider more carefully than he has yet done, the points put by those who are interested in the hospital services and in the practitioner services, and by all those bodies of which in my judgment the Minister spoke with scant courtesy when he referred to them as "sectional interests" and "vested interests." I ask the Minister between now and the time when this Bill leaves the House, to consider very carefully the representations which have been made to him by people —I obviously do not mean myself—who know far more than he does of this subject, and who are likely to be far better judges than he of the tendencies which he has set in operation by this Measure.
§ 6.5 p.m.
§ Dr. Comyns (Silvertown)I am grateful indeed for this opportunity to address the House for the first time, upon a subject in which I am deeply interested. For all that, I confess that I complain of the usual symptoms of nervousness perhaps common to most maiden speakers, and I ask the House for a generous dose of the indulgence which it customarily gives on such occasions. For my part, I promise to be as brief and as non-controversial as I possibly can be in the circumstances. My pleasure at being able to take part in this Debate is not diminished by the fact that seated on the benches opposite, is an hon. Member who some 20 odd years ago, took me severely to task for indulging in what he was then pleased to term "pernicious" political propaganda among my fellow students. According to the Oxford Dictionary, "pernicious" may be defined as "fatal" or "ruinous." However, mindful as I am of my promise not to be too controversial, I will leave it to my hon. Friends on this side of the House to judge whether Socialism would, in fact, have been as ruinous to the people of this country as the Tory politics advocated and supported by the hon. Member for the Scottish Universities (Sir J. Graham Kerr).
As an active medical practitioner in the Division which I have the honour and privilege to represent in this House, namely, Silvertown, I want quite emphatically to welcome this Bill. I congratulate the Minister on his speech this afternoon although I must admit I cannot agree with some of his arguments, a number of which I thought were ingenuous, if not ingenious. No one in the House or outside will deny that a Measure to provide for the establishment of a comprehensive medical service is long overdue. Every one must agree that the present medical services of this country need to be thoroughly overhauled, developed and improved. Despite this, unfortunately, we find that a good deal of the opposition to this Bill—I regret if this remark disturbs the right hon. Member for South Kensington (Mr. R. Law) —is based on narrow sectional interests. Surely, the test of any Measure of such a nature, intimately affecting, as it does, the welfare of every citizen of this country, should be the greatest good not 83 to a section of the community, but to every man, woman and child.
A great deal has been said and written of the reaction of the medical profession to this Bill. It has been said that the Bill met with the disapproval of the majority, and even that strike action was being contemplated. So far as the question of a strike is concerned, I can think of no body of men and women less well organised and less likely to agree to such a serious step. It seems that the history of 1911 is about to be repeated, and that the medical profession will once again be in an undignified and sorry plight. It would be foolish, however, to deny that there is, in fact, a strong measure of opinion which is frankly critical of certain parts of this Bill. I have read a number of reports of various meetings of the profession; I have attended one or two myself, and have talked to scores of doctors on the subject. The impression which I have gained is that, for the most part, the adverse criticism of the profession is based on lack of information, or on wrong information which has been given to them.
To me, it is a matter for serious regret that the leadership of this profession is not as inspired as it might be and that it has failed to keep abreast of public opinion. What does the average doctor want? He wants the opportunity of doing first-class work himself, and not to be just a clerk filling out certificates, or acting as a sorting office for different diseases and illnesses, and having to despatch his patients to one hospital or another for treatment. He requires, and rightly, a decent income, corresponding to his professional status in order that he may be free from financial worries and enjoy a reasonable amount of leisure. Not least important, he would like to have the opportunity of working with his colleagues, without the fear at the back of his mind that some part of his practice might be filched from him. Granted all these things, not only the doctor but the public at large would benefit enormously. It is my sincere belief and conviction that most, if not all, of these things can be obtained within the broad framework of this Bill.
I wonder if hon. Members on both sides of the House fully realise that, for years past, many doctors have been, and still are, working under the most unsatisfactory 84 conditions both in rural and in urban areas. In many cases, only a strong social conscience and the age-long tradition of their profession have made work possible at all. It is, therefore, with much satisfaction that I welcome the decision of the Minister to set up health centres. If they are equipped and staffed as they should be, and as I believe it is the Minister's intention, that they shall be, they will certainly offer a tremendous incentive and encouragement to all who will be able to work in them to give of their best.
I now venture to offer a few words of criticism on another aspect. I note with regret that the Minister has deemed it wise, or expedient—I know not which—to perpetuate one feature of the present unsatisfactory system which some of us had hoped to see disappear for ever. Personally, I deprecate the fact that it will still be possible for a particular doctor to give two standards of treatment, one within and the other outside the service. When everyone is entitled to free service, it is difficult to see why anyone should want to go to a doctor outside the public service unless he expects a better standard of service than that which the doctor usually gives to his public service patients. True, there are certain conditions, as the Minister pointed out, which the doctor must observe before he can treat patients for private fees, but it is my considered opinion that these conditions will offer no great obstacle to a widespread practice, and that much abuse may well result. I therefore ask the Minister if the privilege of combining public and private service will be in any way detrimental to the public service, and, if so, will he withdraw that privilege?
A good deal of the discussion on this Bill revolves, ostensibly, around the question of free choice—the right of a patient freely to choose his doctor. What is the standard by which the layman assesses the degree of competence of any doctor? Has he, in fact, any real medical knowledge by which he can do so? Before the war, before we had a Minister of Transport, the public were very prone to assess the medical skill of a doctor by the year and make of his car, or, on occasions, by the number of new hats which his wife was seen to be wearing. Surely, of far more importance to the patient than a personal choice, based, of necessity, on unscientific prejudices, is an assurance of a high standard of competence. In any 85 event, is there, in fact, any large measure of free choice existing today, and is it exercised to any extent? In most rural areas, we find that there is only one doctor, or a partnership of doctors, available for all patients in time of need. In urban areas, where a greater choice is more readily available, we find that very few people indeed bother about it at all. As the Minister has pointed out, even when an entire practice changes hands and a new doctor comes into the district, very few—not more than about five per cent. of the patients on the list—feel it necessary to do anything at all about it. It is my belief that free choice, when applied to medicine, is simply a catch phrase which will not bear serious analysis.
I do not propose to take up the time of the House any further, but this must be said. We may argue about different aspects of the Bill as going too far or not far enough, according to our individual points of view, but the fact remains, and it would be foolish to ignore it, that the Bill forms a framework within which a much improved service can be developed. Surely, therefore, it is up to all of us, in the interests of the people we represent, to cooperate and improve the details in order that a service worthy of the times we live in can be brought into being.
§ 6.18 p.m.
§ Viscountess Davidson (Hemel Hempstead)It is my pleasant duty to congratulate the hon. Member for Silvertown (Dr. Comyns) on his interesting and informative speech. I think I had better leave the hon. Gentleman the Member for the Scottish Universities (Sir J. Graham Kerr) to deal with his former pupil, but I am sure the House will share with me the hope that we shall have the pleasure of hearing the hon. Member often in our future Debates. On one matter, all hon. Members are in full agreement; namely, that our health services should be so improved that all shall be able to obtain the best medical treatment. But we disagree with the Government on the best method of obtaining that treatment. Will this Bill benefit the individual citizen? Will he or she be better looked after, better cared for, receive kinder and more efficient attention? If so, then I am sure the Bill will be welcome, but, if it is likely to have the contrary effect, that is all the more reason why we are entitled to examine 86 it extremely carefully before we make the drastic changes which are suggested.
May I first ask the Minister a question? Prevention is better than cure, and much preventive treatment is done. May I ask what will be the position of, may I call them "the unorthodox practitioners?" I have personal knowledge of the excellent work they have done, and thousands of people have great faith in their treatment, much of which is preventive. What will their position be under this Bill?
Can they continue their treatments, or will the Bill place insuperable difficulties in front of them? Could a scheme similar to that in the Insurance Act, be applied under this Bill to the patients of those practitioners so that they could make a cash payment and make their own arrangements for medical treatment? Much has already been said about the position of the doctors and much more will be said in the course of this Debate. We are told that many doctors are in full approval of this Bill. I have not met them. I have received deputations and I have talked to many of them, and they are deeply apprehensive of what will happen to the medical profession when this Bill becomes law, viewing it not from any selfish motive, but in the light of how it will affect their individual patients.
It is true that because of the fairly reasonable compensation offered, many older doctors who have carried on during the war will very likely retire. It is also true, no doubt, that many younger men coming into the profession will welcome the Bill because it offers a certain degree of security. They do not know what freedom of action they may be losing, because they are inexperienced, and it will not be until they find themselves on the same basis as other salaried servants of the State, bound hand and foot and unable to act on their own initiative, that they will regret the terms of the Bill, and then it will be too late. The men who enter the medical profession do not do so for reasons of security; they do not enter it for reasons of reward. They usually enter it because they have a vocation, a call, a very great urge to give service to their fellow men and women.
The buying and selling of practices which has been much maligned and which is very little understood by the general public is, in itself, very often a safe 87 guard. It gives the doctor the independence he requires. As has already been said, he sells not his patients, but the goodwill which he has built up because he has been a good doctor. The better doctor he is, the greater value the practice. That is a safeguard to his patients, and the new man buying the practice has to keep up the same standard. He is not buying patients; he is buying the goodwill. Again, this is a safeguard to the patients which, to my mind, is the all-important matter. I am afraid that the keen, brilliant man will not join a profession where he will have no free scope for his abilities, but will be subjected to control and interference. Very likely, he will take up other work, or will go abroad. Who will suffer then? The men, the women and the children who will be served by a profession of the second best and the mediocre, who will remain.
The Minister has frequently referred to the fact that under the Bill the family doctor will still be available. The public like the family doctor. They look on him as a friend as well as a medical adviser. It is clever wording and I think a good many people will be taken in, but I cannot see how the family doctor will remain. The patient will attend a clinic, and he or she will have to consult the doctor on duty at the time. There is no guarantee, when doctors work on a strict rota, which doctor patients will find when they arrive at the clinics. There will be no freedom of choice of doctors in hospitals, and patients will have to take the consultant appointed by the region. How is it possible, therefore, to assure the patient that he or she can be certain of the family doctor? The personal and the individual touch will be lost; the patient will not gain, the doctors will not gain, and no one, in the end, will benefit.
There will be no partnerships in the way in which we have understood them in the past. As far as I can see, it will not be possible for a partially retired older doctor to continue in practice, the older doctor who can be of such value to the younger man of his choice who is gradually taking over and carrying on the practice and learning to know and understand the patients. It is true that there will be groups of doctors, and I suppose they are to form a kind of partnership. But those doctors will not 88 be free to choose who they will have with them. Any man, as far as I can gather, may be foisted on them by the region. In such circumstances, I cannot see very much hope for that close cooperation between the doctors which is so essential to the welfare of the patient.
The Minister assures us that doctors need not come under this scheme. They can stay outside and take private patients, but all hospitals are to become the possession of the State, and the Minister will be all-powerful. Is there any guarantee that those doctors' patients will be admitted into the State-owned hospitals? May they not be refused admittance because they have preferred to consult a doctor who is not inside the scheme, and is this not a form of undue pressure being exercised on the free individual? One cannot help feeling that the Minister, in introducing this new scheme, would actually seem to be determined to prevent doctors from rising to great heights in their profession. It appears to me it is his never failing desire to level down standards, and not to lift they up. British medicine has always been in advance of medicine in other countries, but the result of this rightly called "most backward plan" will be that it will lose its position and its prestige in the eyes of the world which have been gained by the enterprise, initiative and the freedom of the members of what has been in the past one of the greatest professions.
As to dentistry, we on this side of the House are in full agreement with what the Minister has said. It leaves a great deal to be desired, and we all want to see a vast improvement in dentistry in this country, but, as has already been said, what really matters is education. The use of the toothbrush from the earliest years is as essential as anything else, and education is as essential as making it possible for everyone to have proper dentist treatment.
Next with regard to the hospitals. The war has taught us a great deal and we all realise that there are many faults and weaknesses, and room for great improvements in our hospital system. But could not those improvements have been made without destroying some of our most valuable assets? The combination of the voluntary hospital and the local authority hospital has maintained a local interest which means much to the patients and to 89 those who live in the district. Under this Health Bill a hospital will no longer be managed by people who understand and know the area it serves, or the people who require that service, but by a board centred miles away, whose members will be appointed by the Minister. The spur to improved efficiency in the individual hospital is lost, and the human approach is jeopardised. It is universally thought that most of the voluntary hospitals are seriously in debt and have no assets, and that the State is taking over merely a liability. In many instances that is far from true, and the State is taking over assets and funds belonging to individual hospitals, given and bequeathed to those hospitals for many different reasons. May I instance one hospital in which I am interested? In its balance sheet for 1945, assets of £159,000 and liabilities of £15,000 are shown—a clear asset of £140,000 which belongs to that hospital and to the patients whom it serves in that locality.
Local hospitals have played a very great part in the life of the local community. They disappear, and with them the spirit of service, the personal interest and the enthusiasm of those who take a pride in their hospital. What remains? I fear another impersonal cog in the machine of State, with the result that the patients, in whom we are most interested, will not benefit but will lose.
May I say a word about the research work which has been done in voluntary hospitals? They, because of their supporters and many friends, can call for help and quick action if any special research work is needed. May I instance a recent case? A new and very important apparatus was required for vital experiments on the brain. An "S.O.S." was sent out to a few friends who had always been interested in the hospital. The money was guaranteed, the instrument purchased and the experiments are now in operation. There was no relay, because of the appeal that hospital made to the sympathisers who loved their hospital. In the future, from my own experience of Government Departments, I conclude that that kind of appeal will go through all the machinery of Government Departments via regional bodies, and I wonder after the ball has been thrown from one to another, and the Treasury have had something to say about it, whether that instru- 90 ment will be available until after a wait of many years, when perhaps the patients will be dead.
I return to another extremely important subject, that of the district nurses. This magnificent organisation which touches the lives of all and sundry is run by the Queen's Institute, and associated bodies. It supplies the district nurses, and their standard of training is very high. It is a national body and the chances of promotion are wide. It would indeed be tragic if this excellent organisation ceased to serve the community. The Bill leaves their position very uncertain. According to Clause 25, so far as I can understand, some local authorities may use them and some may not. May we have some assurance that these district nurses will continue to function? Those who live in the country know the value of their work and training, personal interest, and their esprit de corps. The patients will be the sufferers if the work of these district nurses ceases. What kind of guarantee have we of the standard of training, if the local authorities do not use them?
I would like to ask the Under-Secretary what will be the position of a very small section of hospitals, but a section which is of vital importance; I refer to the hospitals for the dying. I have personal knowledge of the work done by these hospitals. Theirs is a Christian work. They exist usually through the charity or personal interest of people who have given or are giving money for the purpose of helping those who have not long to live, and nowhere else to spend the remaining months of their lives. They are staffed by remarkable people. They are attended by devoted doctors. Theirs is a grand work, and a spiritual work. I dread to think what will happen to these hospitals if they become parts of a crowd of impersonal hospitals, run by regional boards.
I have already spoken too long; I know that many other hon. Members wish to speak in this Debate, but I seldom burden the House, and I feel very strongly about the Bill and all that it may mean. During this Session we have watched the passage of many Bills through this House. I believe very few, in the long run, will bring more happiness or prosperity to individual citizens. I admit that this is a period of very deep unhappiness for many of us. We have been through the 91 tragedy and horror of six years of war, during which we, as a nation, have risen to very great heights. Now we have to witness a deterioration setting in, which I feel is due largely to the actions of the present Government. I realise that many hon. Members opposite are most sincere in their beliefs, and are convinced that all the schemes which on paper sound so good will, when put into effect, have a beneficial result. I fear many of them may prove to be wrong because—and I say this in all sincerity—I feel that they are basing their beliefs on the wrong foundations. They give the impression that they are playing to the gallery, that they are bribing with promises, and appealing to the worst side of human nature instead of the best. They are gradually killing the finest characteristics of our people—the spirit of enterprise and of individual attainment. It appears to be a case of "What can I get, what can I take and what can I procure for myself?" and not "What can I give, how can I help, how can I serve?"
To my mind this Bill saps the very foundations on which our national character has been built. It is another link in the chain which is binding us all to the machine of State. It is giving more power to the Minister and to the caucus. It is depriving the individual of yet more of his long-fought-for freedom. The Government believe that they can do as they like, because of the large majority sitting behind them. But the majority of today may be the minority of tomorrow. Toleration is the basis of successful democratic government. The rights of the minority must be respected, and no majority should exercise its mandate beyond the endurance of the public, or bitterness will result, and may lead to civil war.
§ Mr. KirkwoodWhat was that?
§ Viscountess DavidsonYes, it is true. May I finish by quoting a sentence which appeared at the end of an article written by one of our best-known historians? He points out the danger of allowing the caucus to take to itself too great power, for all through history the result has been the same, disastrous. I apologise for reading the whole of it, but I would like the House to hear it: 92
In recent years our senior civil servants; taking advantage of overburdened and too often inexperienced legislators, have introduced into Bills about to come before Parliament Clauses giving themselves judicial powers over their own actions. Such powers would have made the hair stand up on the outraged heads of Victorian constitutional historians and philosophers, who never tired of proudly pointing out that it was the absence of any special Droit administratif that saved Britain from the fate of the Continental tyrannies. Their diagnosis of the weakness inherent in so many European States was, of course, perfectly correct. Since their time we have seen that weakness produce terrible and almost unimaginable results. Belsen was the ultimate consequence of bestowing super-legal powers on the executive and the separation of political power from moral right. When Germans today declare that they could not prevent what was being done in their joint name at Belsen and Buchenwald, they are probably far nearer the truth than we give them the credit of being. Their offence was not so much that they let their executive commit frightful crimes against human justice and decency as that they had long allowed to their executive the right and power to do whatever it pleased to do. Let us see to it that we do not make the same mistake, or—if we have already made it—that we undo it before it is too late.
§ 6.40 p.m.
§ Dr. Clitherow (Liverpool, Edge Hill)I congratulate the Minister upon introducing this Bill which, I am sure, will affect every person in this country for the better. I was very glad the Minister indicated that he had had consultations with various bodies, and that he explained the difference between consultations and negotiations. Had negotiations taken place he would have been unable to change certain parts without being placed in a difficulty. The hon. Member for Silvertown (Dr. Comyns) and I do not always see exactly alike, although perhaps we go 95 per cent. of the way.
Speaking anatomically, the Bill is but a skeleton. The master brain controlling the nervous system is in place, in a skull well protected by the hard, bony majority possessed in this House; the nerve tracks are in positon to move the future muscles and coverings, which will be supplied at a later date by regulations; the intestines are ready to accept, digest, absorb and reject whatever may be offered. The regulations by which this Bill will work will be tremendously important. I personally would like to see all regulations treated as those referred to in Clause 69 (I) with reference to Clauses 63 and 64, that is, that a draft is made and receives approval of each House of Parlia- 93 ment by Resolution. By passage through the House this Bill will receive the breath of life, and I hope that the new Adam thus created will not have too much original sin of previous Acts. If carried out with good will by all concerned, having only the ultimate better health of the people as its object, the Bill will become a credit to the country and a pattern for the world.
The Bill must be viewed from the fundamentals of what we want, and three main points are indicated. First, the best that medical science can provide must be available to all, from the time of conception until the time life passes. Secondly, health workers must have good conditions and fair rewards for their work, according to their qualifications, ability and responsibility. Thirdly, professional freedom, professional discretion, and professional education should be available to all health workers. Up to the present the doctor has usually been forced by a system of vicious circles, to be a slave of circumstances. He has had to work hard at his studies for six years or more after leaving school, and, after walking the wards for what is virtually pocket money he comes out into the world, at 25 years of age, or more, with little money. If he wishes to become a general practitioner, he must saddle himself with tremendous financial burdens. If he wishes to specialise he stays in the hospital; he takes his higher qualifications and then waits, as a hard working and grossly underpaid registrar, then a junior, and, when he is getting on in life, at last obtains a post on a known hospital staff ℄perhaps. In both cases, usually he never has the chance to enjoy life as other people do.
From my experience I can assure the House that most newly qualified medical men recognise, in their acquired right to practise medicine, the privilege of serving and helping humanity to live a healthier, longer and happier life. This Bill will give the doctor the opportunity of realising his ideals while he still has them, instead of the system that spells slavery for so many years. In effect, I claim that the Bill offers to doctors the life spoken of by Henry VI:
So many hours must I tend my flock; So many hours must I take my rest; So many hours must I contemplate;… So minutes, hours, days, months, and years, 94 Pass'd over to the end they were created, Would bring white hairs unto a quiet grave. Ah, what a life were this! how sweet! how lovely!Salaries are wanted by many doctors, more especially the younger ones who, quite often, have no connection with the British Medical Association. But behind the wish for salaries there is, however, more than mere economic compulsion. The possibility of everyday consultations between general practitioners depends upon the removal of the competition for patients. With salaries as the main basis of remuneration this can easily be achieved. These consultations are more necessary than appear at first sight. They are not specialist consultations; they are consultations which take into account the industrial, home and habit background of the patient. Up to the present this side of the patient's life has been sadly overlooked. The specialist can be out of touch with the everyday life of the industrial patient, being usually in the rut of his own speciality, and quite often of fixed ideas.May I ask the Minister if it is his intention to continue with the existing Central Panel Conference, or with any similar body? If it is, would the Minister consider making such a body a statutory one, and specify its constitution, so preventing it from being manipulated by its present parent body, the British Medical Association, and presenting the views of the dominant specialist opinion in that body?
Could the Minister declare in what direction he intends the maternity services to develop in the future? If he can do this he may remove a lot of misapprehension due to the brief references in the Bill. I make this request because the only advantage I see defined in the Bill is to ensure that hospital booked cases will have antenatal treatment by the obstetrical team who will be available at the time of the confinement. I can assure the House that the coordination of the full maternity service, antenatal and confinement, is in the best interests of mother and child, and the team gets to know the patient and most of her ways and habits.
It is an undoubted fact that this kind of teamwork does keep down maternal and infantile rates. I have in mind the fact that in Liverpool we have been running clinics in association with our municipal hospitals, several clinics to each 95 hospital. The work has been supervised by the obstetrical staff, who are available for the confinement. As I read the Bill, it would appear to me that this growing practice of clinics associated with hospitals is likely to be disrupted and have a setback if the emphasis is to be on health centre and domiciliary treatment for midwifery under the control of the local authority, while the service I have in mind, which I personally believe is the best for the mother and child, is at the hospital level with a coordination not possible under the dual system.
I should like to comment on the fact that the local authorities were first introduced to midwifery by the 1902 Act, and between that time and 1929, when the local authorities were instructed to provide hospitalisation to the ratepayers, this introduction had ripened into what we might a courtship between the local authorities and the maternity units. The 1929 Act, with its compulsion upon local authorities to provide hospitalisation, commenced the process of a marriage in leading to a single control of clinics and maternity units, which has been of the greatest value. The apparent double control of maternity services as far as the clinics are concerned is, in effect, the making of a divorce. I can assure the Minister that those hospitals working with clinics as a team do not want this divorce. I would ask the Minister to remember the injunction of the marriage ceremony: "Let not man put asunder." I would be happy to know that it is in the mind of the Minister to provide full maternity hospital service for those who desire it in the future, and that all those who desire hospital service shall have their clinics controlled by the obstetrical hospital team of their choice. I think this is reasonable and in the best interests of the patient and child. This would leave the domiciliary cases for the local authority to control, and to provide with a midwife nursing service. Frankly, I do not mind whether it is the local authority that controls it or an executive committee or the hospital board. For maternity purposes the whole service should be continued by a single body. If the double control is to continue, as it appears from the Bill, it will lead to a disruption of what is beginning to be a logical conclusion, and I feel that some means must be found to co-ordinate and not separate the maternity services. 96 In Clause 32, covering the various practitioners' committees, the Bill states that the Minister "may recognise" these committees. Could we have an assurance that, where these committees are formed according to the requirements of the Bill, the Minister "shall" recognise them, and thus do away with the feeling of ambiguity that these apparently permissive words cause in the mind of the layman? I am sure that the medical profession as a whole views with the greatest distaste the making of a special crime, with special and extremely heavy penalties, for the medical man who sells his practice. It is recognised that some steps must be taken to prevent such an offence, but I think that if it is left to the courts to decide whether there has in fact been any attempt to sell a practice, it will be better received by the profession than if it is left to a certificate of the Minister, even though the Bill provides that no prosecution will be undertaken without the consent of the Attorney-General.
Speaking as a pharmacist, and in touch with the representatives of that profession, I should like to inform the Minister that the members of the pharmaceutical profession are almost unanimous in their intention to assist the Minister to the best of their ability to make their part in the new service a complete success. This Bill does recognise the part that the pharmacist plays in the health service of the nation, a part which, in the past, has been taken far too much for granted. I am of the opinion that the Bill will give the pharmacist a fuller part to play, and it will give the profession the chance to practise the craft in which they have been trained and educated. The original National Health Insurance Act provided that State prescribing and dispensing should be separated, and carried out by each section best qualified. I welcome the continuance of this principle in the Bill, both as a registered medical practitioner and as a pharmacist, as being in the public interest. During the last 30 years pharmacists have given the Ministry an efficient and helpful service in over 14,000 pharmacies, widespread over the whole country, and there is a feeling amongst the pharmacists that they are capable of still giving the same efficient service. But the Minister must provide a full service in the health centres, pharmaceutical as well as any other. which I hope will definitely include 97 clinical pathology and X-rays in every one. The background to an efficient dispensing service must be based upon these 14,000 widely dispersed pharmacies, which will continue to provide sound, efficient, comprehensive and convenient dispensing service for the public.
In the past pharmacists have accepted the dispensing of National Health Insurance prescriptions as being a means of proclaiming their professional standing to the public. This was somewhat in the nature of an advertising medium, because from this recognition he obtained the more lucrative private dispensing and associated sale of proprietary and patent medicines. I hope that one result of this Bill will be a lessening of self-medication and a restriction of the sale of patent medicines, but I would ask the Minister to consider that, at once, the dispensing of State medicines will become a considerable part of the pharmacist's work instead of a minor part, as it is at present. and that when remuneration is considered this fact must be borne in mind. There will be no private dispensing left, and I can assure the House from personal knowledge that the present dispensing fees will be totally inadequate under the new conditions, and proper wages cannot be paid. Pharmacists are grateful for the recognition of their part, and they feel that their representation on certain bodies is not as strong as they would wish, but I can assure the Minister that the pharmaceutical profession accepts the main provisions of the Bill with enthusiasm.
In taking my medical course I had to take the prescribed syllabus covering diseases and abnormalities of the eyes. I have had close contact with this side of medicine for some time, and I realise to the full how important it is that ophthalmic and refraction treatment should be fully available to all. Many times I have come across people suffering needlessly through having been treated by a quack, or through using spectacles supplied by a pedlar, store or other unqualified source. The fact that we are so dependent on one another today means that we rely on the eyesight of other people to a tremendous extent, and many innocent persons may easily be injured through some individual's defective vision which has been tampered with. The provision of optical services in this Bill is more than welcome. I am sure from the reactions I have noted among opticians that they are prepared to play 98 their part, particularly as the Minister has stated in the White Paper that they are to have proper professional status. Could the Minister tell us what he meant by proper professional status? At present the qualified optician is qualified by examination of his own free will, but anybody is free to give advice or supply glasses without any training or qualification at all. During the last 16 years the National Ophthalmic Treatment Board have had their clinics boosted high, yet during that time 90 per cent. of those needing treatment under the National Health Insurance Act went to qualified opticians.
Surely, the Minister considers qualified sighttesting opticians as capable refractionists; he must, because he includes them in the scheme, but he indicates that they are eventually to be part of the specialist and clinic scheme. Could I suggest that, rather than placing them entirely under the surgeons in the hospitals and clinics, it might be better to see that, by law, nobody could treat eyes without proper qualification, and then to use these qualified refractionists, as he does pharmacists, in the pharmacies, hospitals and health centres? If he does not, I fear that many people will go without proper glasses and many abnormalities of the eyes will go undetected for a long time, for I am sure that the experience we have had of National Ophthalmic Board clinics does not indicate that the public want to go, in the first instance at any rate, to either a hospital or clinic when it is, possibly, plainly a matter of refraction. It must be remembered that a qualified refractionist is the first to recognise disease or abnormality and to refer the patient to the hospital.
My final point, and one which is most important, is one on which I would like an indication from the Minister as to his position. In Clause 47, we read that any dispute under the Bill or regulations will be decided by the Minister or a person appointed by him. Is there any right of appeal to the courts, should any person find himself aggrieved by such a decision? I am sure the Minister would be the last to approve of the autocratic power wielded by the General Medical Council, who recently made two decisions, both miscarriages of justice, which have caused the constitution of that body to be questioned. One was declared to be unfounded by the courts of the land, and the other was condemned by Mr. Justice Charles. 99 I am sure the Minister does not want to be in this position, and I would not like to think that this power was delegated to his Department, or any other, for without the knowledge that a person has the right of appeal to the courts, I feel certain that we shall have started an absolute bureaucratic complex which will be welcomed by many Departments. Will the Minister give us an assurance that the courts will always be available as a last appeal? I must say that this Bill is greatly overdue, and it goes a long way towards making for better curative medicine. I sincerely congratulate the Minister upon its introduction.
§ 7.0 p.m.
§ Commander Maitland (Horncastle)Not so long ago in this House we were discussing the whole question of special security as implemented by the National Insurance Bill, and at that time I thought —indeed, I have always thought—that the greatest social security that any Government can confer on the people of this country is good health and a good education. Therefore, I feel that the Bill we are discussing today is far more a social security Bill than the Bill we discussed in the past in these stormy economic times. Today I am going to talk for a few minutes about how this Bill affects the countryside, because I am certain that the Minister will agree that the countryside, where there are scattered populations and districts, presents a very special problem. I must say that I think the right hon. Gentleman's speech was a little urban—[An HON. MEMBER: "Urbane or urban?"] No, urban. I should like to refer to the hospital survey. The Minister referred to it in his speech. I think it is appropriate to refer to it now because it will be at the elbow of the Minister and the regional boards when they come to decide what they will do with the various hospitals. The Hospital Survey, for which I have the greatest admiration and to which I should like to make my tribute, because it is a magnificent effort, is, I think, a little harsh when it comes to reporting on the cottage hospitals. I say that from my experience in my district. I speak with great diffidence, but that is the opinion of the medical profession in that part of the world. It is suggested in that report that the cottage hospital should be the site for the health centre. I am not at all certain that in these scattered districts that 100 will always be the right thing. I am pretty certain it will not where doctors are living a long way apart from each other. I hope the right hon. Gentleman will tell us what he is going to do about the health centres in the country.
Then there is the tendency to transfer people away to the bigger hospitals. We do not much like that in the country. I realise, as we all realise, that the patients' safety is absolutely paramount. It is the one important thing. Where, however, this transference is a matter of convenience only, the patient should be considered In the country, where we have big distances, it is important to people who have their nearest and dearest in hospital to be able to see them, but if they are 18 or 19 miles away in a big hospital in a town it will not be easy for them to get there, because our transport is not as good as it might be. Also, it is not easy to take the time off, and it is very expensive. Therefore, I hope the right hon. Gentleman will give the small hospitals in the country, as distinct from those in the towns, special consideration, and will reconsider the whole question of their use and not lump them in generally with the small hospitals in the towns.
To come to the Bill, I was very much encouraged when the Minister gave us his description of the democratic way of life, because I entirely agree with him. He said that it was not sufficient to put a cross against a name once in four years, and that what one had to do was to go in and work for the hospital. I entirely agree with him. That, I believe to be democracy. But let me describe how the local cottage hospitals work. I have four in my district. They have every year an annual general open meeting to which anyone can go. It is not necessary to subscribe in order to go. Anybody can go and everybody does. At that meeting the committee of the past year report, and are elected or not, as the case may be, for the coming year. That, I maintain, is direct democracy. What are we going to have instead? We are going to have a "wishy washy" form of indirect democracy, and the Bill does not make it clear how we are going to get it. If we are lucky we may get a chance to elect a member who, if he is lucky, may get the chance to get somebody on to a hospital management committee. I ask the Minister to think 101 really seriously about that point. It is very much worrying the people in my part of the world.
Another thing that is worrying them is this question of taking away the endowments. Two of our hospitals are memorial hospitals. I do not want to sentimentalise about memorial hospitals, but, after all, the virtues of mercy and compassion are Christian virtues, and we cannot just stamp them out by Acts of Parliament. They cannot be delegated. You cannot delegate your conscience to a Minister, even if he is a Welshman, and I do ask the Minister to consider this in the sympathetic way that he should.
Consider for a moment the people who work in the hospitals and who work for them. They often are not the sort who go in for local government. They are generally a different sort. They do not like the controversy and the battle and the fight of local government. They like working together for something they love. What is to happen to them? Why should they not have their job? I do not think they have under this Bill——
§ Mr. BevanI appreciate the difficulties, but, of course, all this will be explained in detail when we come to the Committee. There will be house committees for each unit within the management of the hospital group, and there will be the hospital management committee itself. In fact, I attach the utmost importance to the house committees and local contacts.
§ Commander MaitlandI am glad to hear that, and I would ask the right hon. Gentleman a question about it in a moment. I am grateful for the interruption. I regard the hospital management committees as key points in the Bill as it affects hospitals. But as the Bill is presented, the point is not clear. The people in my area are very much up in arms about it, and they are people whose ancestors were Cromwell's Ironsides. They are not moved very easily, but when they get up against things they are rather tough opponents. [An HON. MEMBER: "They have fallen from grace."] They have presented a petition to me. I must read it to the House, because it carries me to the next point. It was signed by over 10,000 people, and it was signed in a short space of time although the signatories are scattered. It was done without any political prompting. I give 102 my word to the House about that. It says:
We, the signatories of this petition, having learned that the Government have tabled a Bill which involves the transfer to the State of the buildings, equipment and invested funds of the several cottage hospitals, urge you to oppose such a Measure by every means in your power. We desire that our hospitals shall be allowed to play their part in any scheme for a national health service which does not entirely deprive the hospitals of their local management and local interests.Local management and local interests. This represents what the Minister rather pushed on one side when he spoke.
§ Commander MaitlandThey want to play their part. I want to make suggestions how they can. The Minister referred just now to the whole question of the hospital management committee. He did not mention it in his speech. I am in agreement with him about the representation on the regional boards. They are so big. I think you have to wash out a great deal of the human interest if you divide the country into, I think, 16 parts. As regards hospital management committees, I cannot see why they should not have individual representation of the various hospitals in their group. I am very glad the right hon. Gentleman is nodding his head. I hope we may come to agreement about that later. But in order to make that effective there is one further point I would ask. In these country districts, which are scattered, it is not just sufficient to say that the group controlled by the management committee shall be in respect of a certain number of beds. There must be a question of an area being brought in as well. In some districts we may have to have a small number of hospitals served by one hospital management committee. It may be just as effective, and it will be necessary to get that personal touch.
I was talking the other day in my constituency to a clergyman about this Bill, and he said that one did not have to look very far to find two causes for the greatest misery in the world—one is cancer, and the other is rheumatism. I should like the Minister to tell us something about that. The country would have been very grateful if, instead of this skeleton Bill, we had had something concrete about these two terrible diseases. 103 How much more welcome would this Bill have been by everyone concerned if that had been so. Because this affects me, I want to talk for a few moments about the question of rheumatism. Rheumatism causes far more misery and far more unhappiness than is generally known. I speak on this with very great feeling, because I was crippled with rheumatism myself for some time. The trouble with rheumatism is that people laugh at it and think it is funny, but it is far from that and I promised myself that I would try and do everything I could for those people who suffer from this disease. I am very surprised that no mention is made in this Bill to the spas. Of course it is quite easy to laugh at the spas, "decoking Blimps" and all that sort of thing, but the right hon. Gentleman knows, and there is a Committee examining the whole question, what very valuable work they have done in the past.
I am certain that there is a place for spas in this Bill. They need help to carry on these centres where rheumatism has been treated for generations past. I ask the Minister to use his great powers to help the spas, and to make their great knowledge available in a larger measure to the people in the areas they serve. I have little more to say, except to add in passing, that this Bill shows it has been introduced. without enough thought in regard to its immediate impact upon the country. In my constituency there are two elderly doctors who have just managed to hang on until now. They are infirm and cannot go on very well. What is going to happen to them during this interregnum before the D-Day of this Bill? They cannot sell their practices, and they cannot go on working. How, too, are the hospitals going to carry on in the meantime? These are things which really needed forethought, and if this is an example of forethought and planning as carried out by the Government, I think there is a good deal to be said for carrying on in some measure the hospital scheme we have at the moment.
§ 7.14 p.m.
§ Mr. Sargood (Bermondsey, West)In addressing the House for the first time, I do so with the diffidence which is usual on such occasions, but I am fortified in the knowledge that the House is usually very indulgent, and I hope that on this 104 occasion Members will extend their indulgence to me. Let me say at the outset that here in London we consider that we have the greatest municipal hospital service in the world. Those of us in control of affairs in the London County Council support the main proposals in this Bill. I do not pretend for a moment that our support is not given with some regret, because it will mean that we shall have to relinquish control of that very great hospital service. Nevertheless, we realise that in this Bill there are the possibilities of a very great national health service, and we are not opposed to merging the lesser in the greater. In that merger, there will be many complex problems.
If I may cite an example without pleading a special cause, I would put forward the example of London. According to Clause II of the Bill, a university having a school of medicine is to be associated with the provision, by the regional hospital board, of hospital and specialist services, so far as practicable. The London University not only has 12 such schools of medicine instead of one, but it is also the natural university centre for a population of some 14 million people in South-East England. The gathering grounds of these 12 teaching schools naturally overlap, and the problem is further complicated by the post-graduate teaching hospitals in London. This makes it clear that arrangements which may be comparatively straightforward in other areas, and in their application to the country generally, may not be applicable to London. Therefore, I ask the Minister, before he finally decides on the form of a regional board applicable to London, to give it very careful consideration and take into consultation representatives of the London municipalities.
During his statement the Minister deplored the possibility that, if a certain course were not taken, there might result the setting up of a number of nursing homes. I was very much struck by the fact that in the Bill before us he proposes not to interfere with mental institutions which are run for private profit. I ask the Minister to reconsider that point. When you have institutions run for private profit the incentive will be not to get rid of the patient, because by doing so the proprietor of the private mental institution will be deprived of his income. If it is deplorable to have private nursing 105 homes, I suggest that it is equally deplorable for the Minister to allow the continuance of private mental institutions run for private profit. I make the distinction that it is the factor of private profit I want considered, and not necessarily institutions run by private persons, many of which are excellently managed. Where profits are involved, it is obviously in the interests of the proprietor to keep a patient as long as possible, and not get him cured and out into the world.
There is one very important omission from the Bill. With all the seriousness I can bring to bear, I want to impress this particular problem on the Minister's attention. I refer to the question of the setting up of some organisation for the bulk purchasing of supplies for the hospital services. I find no reference in the Bill indicating that the Minister has in mind the setting up of some such separate organisation. That is a very important factor. If we look at the sums of money involved, we find that expenditure on supplies, equipment, medicines, drugs, blankets, and all the necessities which go to make up the hospital services, is somewhere in the order of an annual sum of £20 million to £25 million. One has only to look at the fact that a 5 per cent. limit between spending too much and saving, would easily mean a saving or a loss of over £2 million a year. If we are to have the position of each regional board having its own buying organisation, I must point out that it would result in unnecessary competition, overlapping, and variations in the standard of equipment to be provided. I ask the Minister to give that point further consideration. Moreover, there is the important point of public accountability, and the provision of warehousing facilities and transport, all of which, if left to the regional boards, would mean a certain amount of waste.
My final point, which I will put briefly because brevity is appreciated in the House, concerns the Board of Control. As a member of the London County Council I have had many opportunities of watching the Board of Control. A more futile body I have yet to meet, and I am surprised to learn that the Board are to continue, although, under this Bill, they will lose many of their functions. I urge the Minister to consider, before the Bill becomes law, if he cannot find a better way of dealing with the safe- 106 guarding of the liberty of the subject than by continuing the Board of Control.
§ 7.23 p.m.
§ Mr. York (Ripon)I offer my congratulations to the hon. Member for West Bermondsey (Mr. Sargood) on making, as I think the whole House will agree, a thoroughly constructive and helpful speech. I hope that we shall have many more contributions from him upon this and many other subjects. I think also that the hon. Member is to be congratulated upon the excellence of his delivery.
I now turn to a subject mentioned by the hon. and gallant Member for Horn-castle (Commander Maitland), although only too briefly. That is the question of rheumatics and rheumatism. This matter is not touched upon in the White Paper. On page 5 there is a paragraph dealing with diseases in which one might have expected to find rheumatism mentioned. Reference is made to special hospitals, maternity accommodation, convalescent treatment and rehabilitation, and there is a long list of diseases, some of which I might not be able to pronounce properly if I read them out; but not one word do we see about a disease which has a more devastating effect on the industrial and home life of this country than any other single disease. One-seventh of the industrial incapacity in this country is caused by rheumatism, and if that is not a sufficiently strong fact to make every one conscious of the appalling incidence of this disease, then I think that it is only necessary for him or her to wait for those dreaded pangs which come to so many of us in due course. There should be a special service to deal with this matter in this comprehensive scheme.
The control of hospitals and, even more important, of research will pass to the Minister of Health. All the initiative, drive and energy will pass under the control of the Minister and through him to the regional boards. Under the local and private ownership of hospitals this drive and energy were directed from practically one source only, and that was the spa towns, which are fairly well distributed over most of the country. In the spa towns and their doctors are concentrated all the best equipment, all the best knowledge, and all the best facilities. Moreover, great developments were being planned by the authorities and voluntary hospitals in those areas. Some of them 107 were local authority hospitals, but the majority were voluntary hospitals. Under the plan of the Minister of Health all the drive will be in danger of being lost, because of the loss of local interests and local enterprise. I, therefore, urge the Minister of Health—and I hope that the Parliamentary Secretary will not fail to tell his right hon. Friend of this particular point tonight—to press on with the work of the advisory committee which his predecessor set up to advise him on rheumatic diseases and their treatment.
I also hope—and this is a very important point—that he will see to it that rheumatism will be scheduled as a special disease and a special service set up to deal with it. I urge him to ensure that the local interests which have been built up in these spa towns is not wasted and dissipated in his centralising scheme. I know that the Bill, as it stands, can provide means to promote this service, but what I do not know is whether there is sufficient determination and drive in the Ministry of Health to put those powers into operation. That is why I press on the Parliamentary Secretary, and through him the Minister of Health, to see that something is started in regard to this matter. Let me make clear, from the outset, that the part which these spa towns play in this service is not primarily dependent on medicinal waters. These play a purely secondary although useful role. The important point to know is that the waters were the starting point from which this great service for the cure of rheumatism was built over the past 100 years or so, and the spas have now a complete and comprehensive range of treatment for the cure of various types of rheumatic disease. Most of the progressive authorities already have a wide range of treatment, and these spa towns have, what is more important still, the specialised medical knowledge and medical keenness.
The present position is that in most parts of the country a good deal of work is being done by the local general hospitals where they have the necessary facilities available but—and this is a point which I have checked with my medical friends, so that I shall not say something which is unjust—the general practitioners throughout the country are not sufficiently knowledgable about this disease to treat 108 sufficiently seriously the early diagnosis of rheumatism, the early treatment of which would prevent unnecessary suffering and hardship. Specialist equipment and specialist medical knowledge have been concentrated in these few areas because facilities are available. If these facilities had not been available, or had not been sufficiently inclusive, then those towns would not have attracted the best medical brains, as they did. Therefore, the spa towns are obviously the starting places for the additional services and facilities which will be necessary under this new health service. In research the same thing applies. The greater part of research work on rheumatism is, again, concentrated in the institutions surrounding these spas, including, of course, a few universities. I know that in my own constituency, the Harrogate hospitals work in close touch with the Leeds University, and the research of the two parties is going on together. The Royal Baths Hospital at Harrogate may be termed the teaching hospital for rheumatics in that region.
As to the future, if we are to attack this disease, as I believe it should be attacked, we have to be far more energetic and probably far more resourceful in research and in the provision of better equipment and facilities. Professor Davidson, the very well-known professor, of medicine from Edinburgh, was asked by Harrogate corporation to make a report on how that town could best develop its spa facilities for the treatment of rheumatism. May I quote a sentence, which has nothing to do with Harrogate, but illustrates the shortage of equipment and facilities? He says:
The shortage of institutional accommodation throughout the whole of Great Britain for this type of case— he is referring, of course, to chronic rheumatism—is one of the most urgent problems facing the new service.That means that of all the special services, including tuberculosis and possibly even cancer, rheumatism must be given a very high priority.In every region the Minister would be well advised to carry out the projects which have already been worked out in a number of these spa areas for development, for increases in the size and number of beds, and for increases in physio- 109 therapeutic equipment. These projects in my opinion, would have been far better left to the institutions which were going to carry them out, but the Minister, with the big battalions behind him, will, no doubt, ensure that his scheme goes through. Therefore, all I can do is to recommend to him that he should take up the projects which have been worked out with loving care by men and women who have put in long years of concentrated effort upon this single disease. That is the institutional side but there is also the clinical side. Out-patients' clinics will be necessary. I believe that the health centres will not be sufficiently large to cater for this particular type of disease, and I should think myself that it would be necessary to have additional rheumatic out-clinics, possibly attached to a general hospital. This means that there must be a better appreciation by the ordinary practitioner of the seriousness to our industrial life of this disease, and a lead must be given by the Minister of Health.
These two parts of the service obviously come within the scope of the Bill, but there is a third part which does not, so far as I can see. That is what I would call the intermediate stage, a very large group of patients—I believe sufferers is a better expression—who require skilled remedial treatment under medical supervision following hospital diagnosis. These classes are called by my medical advisers ambulatory, which means that at the moment they can walk to the nearest baths.
They can be divided into two classes—those benefiting by treatment at their local general hospitals, where I hope there will be separate specialist sections and the second type who need to go to a regional centre perhaps because home conditions are not satisfactory for cure or treatment, or perhaps because working or business conditions do not help to create the holiday atmosphere in which the necessary treatment can be effective. Therefore, I say that the provision of these special centres must be a very urgent part of the whole service, and it can be very well carried out by the expansion of the present facilities which are mainly to be found in the spa towns. In cooperation with the local specialist doctors and the local authorities, there is no reason at all why everybody under this service should not have a comprehensive range of treatment for this disease. The only demand which will be 110 made upon the hospital service will be for hostels; or it may be that as an alternative in the interregnum period some accommodation allowance should be made out of the health fund or from the Treasury, to those hospitals which exist in certain spas today. There are miners' homes, police homes. I see no reason why those homes should not be included in the service. I have said enough to inform the House, if hon. Members are not already well aware of it, that the disease of rheumatism is the most devastating in the country. Unless the Ministry of Health determines it shall make rheumatic treatment a special service, then the Minister of Health cannot claim that he has set in motion a comprehensive health service.
§ 7.37 p.m.
§ Miss Bacon (Leeds, North-East)I rise in this Debate not as a doctor, nor a dentist, nor a chemist, nor even as a member of a hospital committee, but simply as one of the millions of potential patients affected by this Bill. Earlier in the Debate this afternoon the hon. Member for Hemel Hempstead (Viscountess Davidson) said that minorities ought to be considered. While agreeing to some extent with this, it can sometimes go too far, and in this case particular interests, because they are so well organised, are able to impose their will over an unorganised and less articulate majority. My experience in many parts of the country among ordinary men and women leads me to believe that the Minister has overwhelming support for this Bill and for the measures contained in it. It is true that there are some defects, but those defects are matters of detail and the Bill, on the whole, is the greatest Measure for human wellbeing ever introduced into this country. Some hon. Members opposite and some whom I shall describe as vested interests outside, have denounced this Bill as taking away the freedom of the individual, and introducing into our health services what they call a "soulless bureaucratic machine." What loss of freedom can there be in giving to everybody irrespective of any conditions whatsoever a free choice of doctor, free consultant services, free hospital services, and, in fact, free medical and surgical service of every kind? This Bill gives to thousands of people freedom which they have never before enjoyed, freedom to consult a doctor or specialist without thinking of the cost. 111 With regard to the hospitals, I support the Minister entirely in taking over all hospitals, both local authority and voluntary, and organising them on a regional basis. Most local authorities, while they are sorry to lose their hospitals, agree that this is for the public good, because it is impossible to organise efficiently a local authority hospital service. Local authorities are of varying sizes; some are very small and some exceedingly large. We all know that in many cases, in a county borough, the large hospital in that borough serves not only the borough but the surrounding county districts as well. If we had a local authority hospital service we should have to have joint boards. That being so, I think it is much better to have a clearly defined region. The voluntary hospitals, through their organisation, the British Hospitals Association, are fighting this Measure in a document which they have issued. They refer to the transfer of the hospitals and their endowments as "taking away their hospitals and confiscating their property." But whose property is it? Whose endowments are they? The money which belongs to the voluntary hospitals is the people's money, which has been contributed by workmen's contributions, flag days and charity concerts. This money, while being technically transferred, is to be used in a much more economical way than at present for the benefit of the people who contributed it.
§ Mr. YorkDoes the hon. Lady think that the citizens of Leeds will be pleased if their hospital money is spent in Bradford?
§ Miss BaconI am coming to Leeds in a moment if the hon. Gentleman will allow me to proceed, because Leeds is a rather shining example, in some respects, in regard to a National Health Service Bill. In the circular issued by the voluntary hospitals they say:
…the whole cost of the hospital services will be defrayed by the Exchequer, and the extent and quality of the services will, therefore, be determined by the consideration of cost instead of need.That is ridiculous. In the past, have voluntary hospitals never had to consider the cost? Have they only been able to consider need? Have they always had the money for the improvement which they would have liked to have made in their hospitals? Of course they have not. All this is now to be possible, and I hope 112 that among the improvements we shall see, in addition to improvements in layout and equipment, improvements in outpatients' departments, which are rather pathetic in some hospitals.I hope we shall see nurses, particularly probationer nurses, being given better remuneration than they obtain now. While we have had some suggestions for raising the salaries of trained nurses we have had no suggestions yet for raising the remuneration of probationer nurses. It is true that the teaching hospitals are to be outside the regional authority, and that they are to have some measure of independence. While this may be desirable from some points of view, particularly because of their close connection with the universities, there are certain features about this which need watching. I understand that some municipal hospitals will probably become teaching hospitals, and that there will be more reluctance on the part of local authorities to hand over hospitals to become teaching hospitals under a separate board than under a regional authority. I have one criticism with regard to hospitals, namely, the provision in public hospitals for private paying patients. I know it is argued that we must give people the right to pay for privacy. But this is a legitimate argument only so long as those who desire privacy, and who have not the money to pay for it, are not denied it. Some people say that it would be purgatory to be in a long ward. It would be for me, I know, but it would also be purgatory for many more who cannot afford anything else. Therefore, I hope that in our hospitals of the future we shall see the end of the very long wards, and the provision of small wards with only four to six beds.
The proposals regarding paying patients go much further than the provision of privacy. They allow specialists to treat and operate on private patients for fees, and I suggest that there might be a grave danger here, particularly in the teaching hospitals, where consultants will have a great deal to say as to what goes on. If we are not careful it will be much easier to enter a hospital, as it is now, as a private paying patient than through the normal channels. It has been said that a hospital will get no advantage by having a private patient. That is so, because the money that patient pays for his private room will go into the central fund, whereas the money which he pays to the 113 specialist who performs an operation upon him will go to the specialist. While the hospital may not gain, the specialist certainly will. These private beds are analogous, in some respects, to private practice, which is still to be continued by doctors in the public service. The doctors are to be paid a basic salary plus capitation, but, in addition, they can take any number of private patients they wish. While there is a limit to the number of patients a doctor may have on his list under the public service, there is no limit, so far as I can see, to the number of private patients which he can have in addition.
It has been argued that this will be limited, that because everybody is covered under the public scheme, it will only operate occasionally. But it is open to abuse. There is nothing to prevent a doctor having a very large private practice in addition to his public practice. It is possible for a doctor to say to a patient, "I am very sorry, my public list is full, but I can take you on my private list." There is a maximum for a public list, but there is no maximum at all for his private list. Who will be neglected if the doctor takes on more patients that he can cope with? We all know the answer. It will not be the private fee-paying patient. This Bill also provides for doctors' assistants, but in practice the only doctor who will be able to afford an assistant will be the one who has a large private practice. Again, I am rather fearful lest the assistant will be looking after the patients on the public list, while the doctor who employs him looks after his private patients.
These two things are, in some respects, fundamental. Why should anyone pay when everyone can get the service free? There is only one answer. It is because they will obtain, or believe they will obtain, better service by paying a fee than by using the public scheme. But it is not only those who pay we are concerned about; it is those who do not pay. Sick people are prone to a feeling of inferiority, and if the general public think that there will be a better service for those who can afford to pay for it then confidence in the State scheme will be shaken.
This matter is really psychological. Not only must people get the best, they must also believe they are getting the best. It has been suggested that snobbery enters into these things, but there is a great deal of understandable sentiment when a very 114 near relative is ill. I have known people spend their life's savings in order to give private treatment to one of their relatives, believing that they were getting better service. This afternoon my right hon. Friend the Minister of Health said that if we were to have a State theatre, we should not have the same prices for all seats; but one cannot compare this health service with comfortable seats in a theatre. We cannot afford to have any secondrate seats in an operating theatre. We must see that money is not allowed to determine this, and we must see that the best is the standard.
I come now to group practices and health centres. I believe the decision to set up group practices and health centres is one which will be of great advantage both to doctors and to patients. The general practitioner is very important, and we in the Labour Party have always said so, but if his service is to be used to the best advantage, we must give him the best equipment, which it has never been possible for him to have in his surgery when working alone. There is still a great deal to be done in research, particularly in respect of the two dreaded diseases of cancer and tuberculosis, but nevertheless, a great deal has been done in the last few years. What is serious and what is avoidable is the fact that the knowledge that has been discovered has not always been used to the full. There is still a great deal of wrong diagnosis which is not the fault of the doctor. It is due to the fact that he has not had proper equipment, that entry into hospitals for his patients has been difficult, and that consultants have been able to be called in only as a very last resort when the patient was nearly dead. I hope we are to see an end of these things through group practices and health centres. In Committee I hope we shall look very carefully at one or two things, particularly the maternity services and the school medical services, in order to see that we do not get a dual control.
If I have enlarged on some of the defects of the Bill, it is not because I believe they are the most important parts of the Bill. The Bill is fundamentally right, but we want it to be the best possible Bill. I know that many of the defects are not due to the desire of the Minister, but to undue pressure which has been exerted, and some of them are the price which has had 115 to be paid for the Bill; but we on this side believe that the limit has been reached with the concessions that have been made. I think we should be doing doctors a disservice if we said that all of them are opposed to this Bill. They are not. Here I come to Leeds, which was mentioned a few minutes ago by the hon. Member for Ripon (Mr. York). In the City of Leeds, a part of which I represent, the branch of the British Medical Association has come out in support of nearly all of the proposals in the Bill, including the abolition of the sale and purchase of practices, and the public ownership of all hospitals and their organisation on a regional basis. Leeds, I believe, has been regarded as one of the black spots of the British Medical Association, which is discovering that it has more black spots than it thought it had originally. The Bill will confer great advantages on all sections of the community, and particularly on the middle classes, who have always been outside every scheme of National Health Insurance. They will feel its benefits very much indeed.
Some people have said that this Bill deals only with ill health, and that in order to deal with the promotion of good health, we should deal with environment, cleanliness, food and housing. I think that hon. Members have received, in the past week, a very excellent publication which has been sent to them by the British Medical Association. This publication says:
A man needs not only a roof over his head, but a house which he can make a home for his family; not merely food to stave off hunger, but food of the right quality and quantity to give him adequate nourishment, and at prices within his reach; not merely work, but a congenial occupation suited to his individual capacity.That comes from a book published by the British Medical Association. I have here a slightly different kind of book which some hon. Members will recognise. In this book it is stated:The nation wants food, work and homes. It wants more than that. It wants good food in plenty, useful work for all, and comfortable labour-saving homes that take full advantage of the resources of modern science and productive industry.I am very pleased indeed that the British Medical Association agree so much with the pamphlet on which we fought and won the General Election. This Bill is only one of the Measures which we are putting 116 into operation to bring about that social improvement which the British Medical Association say they desire, and which all hon. Members on this side of the House equally desire.
§ 7.58 p.m.
§ Sir John Graham Kerr (Scottish Universities)In craving the indulgence of the House, to speak for a few minutes, I do not propose to criticise many of the innumerable points in this Bill, which have been raised in the course of the Debate. I wish to make a few remarks on a point of general importance, namely, upon that great unit of our medicine, the medical school and voluntary hospital I think everyone will agree that the whole future of any medical service depends upon the quality of the recruitment to the medical profession, and that, again, depends upon two things; first, the quality of the recruits, and secondly, the perfection of the training.
I have had a little experience of this sort of thing. In this House I happen to be one of the representatives of two of the greatest medical schools in the country, the University of Edinburgh, in which I was a medical student, and the University of Glasgow, in which I was an active member of the medical faculty for 33 years. I was a member of the board of management, and, what is far more important, of the inner circle of the board of management, called the medical committee, of one of the greatest hospitals in the country, the Royal Infirmary of Glasgow, great in size—according to the last figures I could get, its income was £214,000 in the year, and its expenditure nearly £200,00—but great also in something that matters much more. The Royal Infirmary in Glasgow is often spoken of, with justice, as the birthplace of modern surgery.
What are the conclusions that I have come to from my experience? First, let me go back to the question of the quality of recruits in medicine. I saw a good deal of all the different faculties in the University, and I can say, without fear of contradiction, that the best of the whole lot were the medical students. If ever there was a great movement that had to be carried through, it was the medical students who were the life and soul of it. Why did we get these brilliant recruits to medicine? No doubt some of them were attracted by 117 the high ideal of administering to the sick, but the ordinary young student is a practical creature, and is not swayed entirely by sentiment. I found that the great attraction to these students was the glamour of the prizes they saw before them—what seemed to them comparative wealth, and dignity, and the possibility of high honour. These young men were not the type who would be attracted by the principle of safety first, and salaries and promotion by age. It was the great possibilities of their future that brought them. If this Bill goes through in its present form, a large proportion of these brilliant young men will be wise enough to see that they should go in for some other line—for industry, for example—or, if they are so keen on medicine, they will go overseas to places where the career has the scope of which they dream. So much for the quality of the recruit.
How are these young men trained? They have as their teachers the leaders in medical science, surgery, medicine and obstetrics That is what the university student wants. He does not want a professor who "gramophones" off the latest things from the latest textbooks; he wants the big personality that he knows is one of the leaders in his subject. That is where he gets his inspiration. How is it that the leaders in medicine and surgery are willing to give hours of their busy days to such work? No doubt in many cases they too are moved by high ideals, but there is also a very potent practical attraction. These men, who do their teaching partly in university lecture rooms but more, their clinical teaching, in the wards of the voluntary hospital, know the practical advantage that comes to them from giving their unpaid services there. It means that they get to know their clientele for later work in the profession. They know that these students, when they emerge into the world as practitioners, will tend to come back to their old teachers for consultations or operations.
Need I say anything to drive home the truth of what I have already said about the great men who are willing to take up this task of teaching in the voluntary hospitals? I wonder if any hon. Member has ever read an account of a hospital ward in pre-Listerian days? There were none of the modern great operations of surgery performed then. There were no abdom- 118 inal operations, and none of the really difficult operations of today. Practically all that was done were simple things like amputation, and what was the result? Patients who underwent a mere amputation, which today would never be thought of as involving any danger at all, in those days underwent a very considerable probability of death; because the hospital wards were infested with such diseases as hospital gangrene, erysipelas, and pyæmia. I read the other day that in a single week in one ward of such a hospital there were five deaths after simple amputations as the result of pyæmia. Then Joseph Lister came on the scene. He had the intellect to see that the trouble with all these hospital diseases was something like what Pasteur had found to be the case in processes of fermentation. They were due to microbes, and he developed in that Royal Infirmary in Glasgow the antiseptic system which developed later into the aseptic surgery of today.
I might take any number of examples but I will take a case from medicine. How many of us have read about the ravages of smallpox in the old days? How many of us have come across the quaint custom—as it seems today—that a person hiring a new servant took care to see that he or she was pockmarked and, therefore, free from danger of developing smallpox? Then along came a great individual, Jenner, and the result is that today smallpox has become very nearly non-existent. With regard to that other horrible disease, diphtheria, I remember so well when I was a boy, or even later when I was a young man, the terror it produced. If a case of diphtheria arose in a family the parents were reduced to despair. Here again there came a great individual, one who made experiments on animals. I happen to be a lover of animals and nobody prays more than I do for the day when there will he no need to experiment on these beautiful creatures any more, but that day is not yet come. In this particular case one of the great leaders of medical science developed the antitoxin method which has dragged myself and many other people back from the edge of the grave.
The few words I have said are enough to indicate the sort of opinion that I have formed, out of experience, as to this Bill and its results. I hold that if a Government, voted into power in a period of postwar unrest and disgruntlement, were 119 to force the Bill through Parliament as it stands at present, they would be guilty of pitiful treachery to those who have passed, pitiful treachery to great Socialists. I do not mean my many friends who are great individualists but, who, in order to evade recognition, clothe themselves in an outer garment of Socialism. It is not to them I refer but to the real Socialists, who have given of their means for the succour of the poor and needy, and whose memorials are to be seen in the voluntary hospitals of the country—not merely the big hospitals of our great cities but those wonderful little cottage hospitals that dot the scenery of our land. The Government would be guilty, too, of a crime against the people whom they were entrusted to govern.
§ 8.11 p.m.
§ Mr. Anthony Greenwood (Heywood and Radcliffe)Rising, with all humility and with great respect for the traditions of the House, to address you, Sir, for the first time, I would crave that indulgence which is customarily accorded to those who are what the noble Lady the Member for Hemel Hempstead (Viscountess Davidson) called "inexperienced legislators." I am reminded of what Mr. Valiant-for-truth said towards the end of "The Pilgrim's Progress":
Though with great difficulty I am got hither, yet now I do not repent me of all the trouble I have been at to arrive where I am.I regard it as a privilege to be able to speak tonight in support of this great Measure of social advancement. Criticisms of the Bill have been made in the course of the Debate, but I am sure that the Minister would not for a moment claim that this is a perfect Bill. I do not suppose there ever will be a perfect Bill. The Bill bears a great deal of evidence of compromise, compromise between the interests of the public, of local authorities, of voluntary hospitals and the medical profession. I see nothing wrong in compromise, so long as the Minister does not compromise either with his principles or with his honour. Compromise, if properly used, is constructive, and I believe that it has produced a Bill which commands general support. The Minister has added to those great qualities which we knew he possessed, the quality of adaptability, in which I am sure hon. 120 Members opposite would have preferred to find him lacking.Against that background of support, I wish to bring forward two points which I hope will not be interpreted as criticism of the Bill. The first relates to the scope of the Bill. I wish the Bill had been more a positive Health Bill than it is at the present time. It seems to concentrate not on the promotion of health, and not even upon the prevention of disease, but upon the cure of disease when it has developed. It is an unfortunate fact that very few people in this country, or perhaps in any other country, realise that they are ill until fairly late in the course of their disorder. Research carried on at the Peckham Health Centre and based upon periodic health overhauls, showed that only one man in 10 is really fit, that six people out of 10 have some disorder of which they are not aware and that three people out of 10 are definitely sick. That is a very heavy burden indeed, and I am sure that in present circumstances we cannot afford to carry it. When we remember that, even in 1936, recognised disease was estimated to cost the nation £300 million a year, it will be appreciated what an enormous burden we are carrying at the present time. I am sure that in due course we shall be forced to the conclusion that periodic health overhauls are essential to the health and wellbeing of the people of this country.
The weakness to which I have referred is particularly noticeable about the health centres, which seem to me to be more disease centres than health centres. They are to be places to which the public will come only when a disorder is fairly far advanced and when valuable time has been wasted. They will be associated in the minds of the public at best with discomfort and at worst with actual pain and suffering. The kind of health centre I should like to see established would call for co-operation between the Minister of Education and the Minister of Health. They would be places to which the public would go for intellectual and physical relaxation and where the active promotion of health would be an important but unobtrusive part of everyday life. I very much hope that when materials and labour are more available than they are at present, the Minister of Health will consider enlarging his scheme in order to bring within it health centres of the kind to which I have referred. 121 The second point relates to the voluntary hospitals. Like other hon. Members I have received representations from the voluntary hospitals in my constituency. I appreciate the anxiety that they feel, but according to my interpretation of the Bill I think their anxieties are completely groundless. As we have seen this afternoon, different people can interpret the same words in different ways. It has been reassuring to find that the Minister of Health was able to give us an assurance in respect of the management committees of the voluntary hospitals. I am very glad that there will be a reasonable measure of representation of the existing management committees on the new beards of management. I hope that the house committees to which the Minister referred will contain suitable local representation and will have power to co-opt, in order to ensure a reasonable measure of continuity.
I have given most careful consideration to the case of the voluntary hospitals. It has been said that State control will destroy the human atmosphere in the hospitals and the personal relationship between hospital and patient. That is a complete and serious misstatement of the situation. It is my contention that the human atmosphere depends entirely upon the personality of the medical and nursing profession and is in no way dependent upon the kind of ownership of the hospital. I can only feel that my assessment of human nature varies from that of the right hon. Member for South Kensington (Mr. Law).
We have heard today what I regard as serious criticisms and reflections on the medical profession. If we carried them to their logical conclusion we should be forced to believe that doctors would do their work better if paid more money, and a surgeon would perform an operation better for 20 guineas than for five guineas. I believe, as the noble Lady the Member for Hemel Hempstead said, that medicine is a vocation. Men and women do not go into that profession in order to make money but, like scientists, teachers, and soldiers, in order to serve their country and their fellow men. I hope that that will remain the spirit of the profession for a long time to come.
The right hon. Member for South Kensington referred to planning in terms which forced me to the conclusion that he did not altogether approve of it. I would remind him that we were given a 122 mandate to plan the economic and social affairs of this country. We have to appreciate that we are embarking upon a period in the history of this country when State control will be extended to a number of spheres of social activity which hon. Members opposite would no doubt prefer should remain sacrosanct. That is not going to be the case. It is essential that we should see that a spirit of humanity prevails. It is time that hon. Members opposite appreciated that we in the Labour movement are not pledged to Socialism merely because we believe that it means greater efficiency or because we believe it will present a neater administrative picture, but because we believe that only through Socialism can we give full scope to human individuality and to the rights of man. In the Bill we have an opportunity to give a practical demonstration of the beliefs which we have held for so long. I cannot imagine a better demonstrator of this than the right hon. Member who has risen to Cabinet rank with the rich emotional and intellectual life of the Welsh coalfields as his background.
§ 8.20 p.m.
§ Sir Ralph Glyn (Abingdon)I believe I heard the hon Member who has just resumed his seat inform the House that it was his maiden speech. It seems hard to believe. He spoke with such assurance and with a spirit of youth that carried him along. I think, as a very old Member of the House, I may say that his speech, as a maiden speech, went very near the line of controversy, but that does not matter, because it was obvious to all hon. Members that he was so convinced of all he said, and what this House wants is sincerity and not humbug. I am sure we shall all look forward to his contributions to this House. I have no idea how old the hon. Gentleman is, but I hope he will always live to see this Parliament recognise young men who come in with new ideas and have the strength of character to say what they feel and give the impression to all who hear them that they believe all they say.
I rise tonight with some difficulty and diffidence. I feel very intensely that on both sides of the House during the course of this Debate we have not really faced the situation which the House must face in regard to the health services of the country. We occasionally say before 123 business begins that we must discuss our affairs without prejudice and to the good health and wealth of the Realm, and I believe nothing is more important at the present time than a complete reorganisation of our health services. Therefore, I feel great difficulty personally in opposing the proposals of the Government on this occasion because I put my faith in what the Minister said, that on the Committee stage he would be willing—and he said it with great distinctness—to consider all the proposals made on the Committee stage and that he would try, if he thought they were workable, to bring them into the scheme in the Bill. I cannot imagine anything more disastrous than that, having produced these proposals, there should be by some mischance a long delay before putting them into force. I have been on teaching hospital governing bodies for 30 years and I know something about the feeling of the medical profession. I deprecate very much any remarks that are made which seem to indicate that doctors think only of cash. All the doctors I know undoubtedly got something far greater than mundane things. They had a call to serve their fellow men, and there are very few doctors I have met who put their service to their fellows second to their financial position.
There are various things that I dislike very much in this Bill. Speaking generally, I believe the things I dislike are capable of moderation or of turning round a little. I have been very much fortified by the remarks of the Minister today because I believe he has honestly approached this question with a great sense of responsibility. I do not think that party or party views should be brought into a matter of this kind where we are standing at the crossroads of something which is far more serious than any party question. I shall be unpopular, I know, with others of my own party for saying that—[HON. MEMBERS: "No, you will not"]—but there are occasions—I have been in the House a very long time ℄when one must say exactly what one feels without any fear. My considered opinion is that if ever there was a case where there should be cooperation between people for the good of the country, it is in regard to the health of the people.
My great regret is that industrial medicine and care have not been brought into 124 the Bill. I hope the time may come when they will be introduced. I believe, too, that the question of mental care is long overdue. I hope the Minister will accept proposals for hospitals which have medical schools, and perhaps some universities which are not at the moment engaged on the medical side, to study these questions of diseases of the mind. The war has taught us a great deal, and there has been a great advance in the study of lunacy and mental deficiency. I have had opportunities of seeing people who a few years ago would have been put aside as useless to the community but for whom great use was found in the war and who were able to do very great work. These are the sort of things which I think are of very great importance.
Mention has been made of rheumatism, cancer and various other diseases of that kind, and I want to ask the Minister one thing which I hope he will bear in mind. One hon. Member mentioned the great help that is given by certain hospitals to those who are incurable, hospitals where they give care and attention and nursing to those who cannot be taken care of in their own homes. To my mind, they stand outside the ordinary range of hospital, but there is a very great need for extending them. I hope the Minister will, therefore, allow such religious organisations—there are many of them—which cannot be compared with the ordinary general hospital, to contract out of this scheme or to be in some other position so that they can continue to look after these people. I have known cases, and we have all known cases, of men suffering agonies from cancer and there has been no room for them in hospital and no proper means of nursing them. The family has had to sit up in relays to try to help them. That is a pitiful situation in 1946. Something has to be done, and I am not satisfied that this Bill deals with the problem. Therefore, all of us must concentrate on those things which impinge most hardly on the population of the country.
Some time ago I was privileged to go through all the hospital and nursing systems of Sweden and I have a very high opinion of what is being done in Sweden.
§ Mr. MesserIt is a State system.
§ Sir R. GlynIt is partly State. It is not altogether State. Some hon. Gentlemen today have been criticising the fact that 125 specialists in hospitals should have private patients. In Sweden there are several large hospitals operated by the Red Cross in which the specialists from the State hospitals function. I have been through all of them. There is an admirable service throughout Sweden to deal with what the Minister called the health centre. We do not know enough yet, and I rather think the Minister has been wise in not dotting the i's and crossing the t's of the health centre because it must vary in different parts of the country. There is no doubt that in Sweden, which is not afraid of calling things by their proper names, there has throughout the past 50 years grown up a tremendous feeling for the prevention of diseases. I agree very much with the hon. Gentleman who spoke last. It is on the prevention of disease that we must really concentrate.
That brings me to a point I want to emphasise about the nursing services. An hon. Lady mentioned the Queen's Institute of Nurses. I have for many years known something about the work of the Queen's Institute in this country and in Scotland. There is a no more devoted body of women throughout this country than the Queen's Nurses. In the West of Scotland they have to proceed sometimes in the most appalling weather, under inadequate arrangements for comfort and transport, to get to a case. I have never known them fail in their duty.
All this business of nursing is almost dismissed in a paragraph in the present Bill. I know the Minister could not mention everything today, but I like to think that in his concluding words he had specially in mind the question of district nursing and domiciliary work. The Queen's Institute of Nurses was established, I think, in 1887, and Florence Nightingale contributed to its formation. She was one of our greatest women, to whom this country should always pay tribute, for she did more to teach the world about the care of patients through nursing than anyone else. There are today over 8,000 of the Queen's Institute nurses. We who live in this country know them. We know how important it is that the standard of nurses should be upward, and I beg the Minister to be willing to consider the establishment of a statutory body of status and position, closely allied to the Central Medical Board, in whatever way he may think best, which will ensure that there shall be uniformity of inspection and of training of the nurses. 126 There is a great deficiency of nurses today, a deficiency in numbers but not in anything else. What is the cause of it? I think the cause is that they have not been sufficiently recognised for the wonderful work they do in preventing people, through their contacts, from becoming so sick that they have to go to hospital. In regard to maternity cases, they dealt with 84,000 last year—a large number—and it is an indication of their efficiency that the mortality was only one in a thousand. Remember, they deal with cases under appalling housing conditions, and if these devoted women can so help to bring children into the world with only the loss of one in a thousand under those conditions, surely it justifies the methods of training and the standards that have been set ever since 1887 by the Queen's Institute. The terms of the Bill lay down that the nursing services shall be under the local health authority of the county or the county borough. That is all right. I do not think there is anything to quarrel about in that, but it would be terrible if we removed the esprit de corps and the general standard that have now been reached after all those years, and removed the possibility of uniformity by allowing each local health training centre to be its own master as to what should be the standard. That is one of the most vital things for the health of the children before they go to school, and here is a link with the Ministry of Education and what is to be done to improve the health of the children when they are in school.
I would like to make this suggestion: I believe a great deal more can be done than is being done, by having films and lectures in the winter evenings in village institutes and also in the schools, because half our trouble comes from ignorance—ignorance of the facts. We have listened to a remarkable speech from the hon. Member for the Scottish Universities (Sir J. Graham Kerr)—[An HON. MEMBER: "Why was it remarkable?"] It was remarkable because few Members speak with greater knowledge, and have made a greater contribution to the medical knowledge of this country than the hon. Member for the Scottish Universities. His fear is, as are all our fears, including the Minister's, that anything should be said in this Debate which would prevent young men coming forward as medical students. We in Parliament may talk about Bills such as this, but what really matters is 127 that we should go on recruiting the right type of man into the medical profession. The standard which has been reached in the past has been high. I believe it is possible so to amend this Bill in Committee that when it comes to Third Reading, we can be proud of a Measure which will not only safeguard the freedom of the patient, which is all important, but will ensure that the right type of people are encouraged to take up medicine. Incidentally, I also hope something will be done to encourage the right type of people to come forward as dentists. Unless we can do something to encourage such people to practise dentistry, we shall be in an appalling condition. It is quite impossible for the ordinary person in the country district to have a denture fixed and the poor people go about mumbling for weeks because there are not sufficient dentists and mechanics. One of the greatest professions in small engineering is that of the dental engineer. People do not realise what tolerance has to be reached. This may be something which we can teach disabled Servicemen. If the Minister of Labour would consider it, I believe there is great scope for men who have no legs or are otherwise incapacitated for other work.
I am very much concerned about what may happen in the interim period between now and the time when the Bill becomes an Act. I must say in all fairness to the Minister that I believe the teaching hospital with which I am associated will be able to go ahead under better conditions than we have ever had. I hope that between now and the Committee stage, the Minister will be able to give an assurance to everyone in the country that through some machinery of a regional character endowments which have been given to specific hospitals will be earmarked if possible for those hospitals. Everyone's conscience would be happier if that were done. There must be more links between the teaching hospitals and the general hospitals to group them together. More must be done to evacuate beds so that more patients can go into hospital for surgical treatment. Far more must be done in regard to ambulance services. I do not agree that it is necessary to carry out major operations in a cottage hospital. I think that is nonsense. The war has taught us that, with penicillin, patients can he transferred quite safely. A person 128 who has been seriously injured on the road can be taken to a hospital where he can get the best attention and will not take up a bed in a cottage hospital which should not be occupied for that purpose. The reverse is equally important—a patient could be taken out of a general hospital in order to free that bed for someone waiting for it.
The hospital with which I am connected has enjoyed what we describe as a "windfall" because it is very near this building and very near the Strand and traffic in the Strand is no respecter of persons. Very often people have been brought in who are well able to pay for treatment and who have left £20,000, £5,000 or £1,000 to the hospital. That, I believe, is because of the accident of location and also because there is a great density of pedestrian traffic crossing the Strand, greatly to the advantage of this hospital. But it is the spirit of giving which matters. We must see that good treatment in a hospital is not regarded as obtainable by simply pushing a bell and making complaints.
We want people to be grateful for the devoted service of nurses and the rest in hospitals. We want people to be cooperators in hospital, because a tiresome bunch of patients can do a lot to upset other patients. There has to be instilled into the whole thing the spirit of working together. Therefore, I feel it is very difficult to vote against the proposals put forward by the Minister. I feel it is difficult, because I believe the Minister seeks the cooperation of all those who are interested in the health of the country. I do not think that that cooperation should be refused.
There are certain principles in which I believe, and which I shall not forgo. Some of these principles are rather bumped and bruised by some of the proposals of the Minister, but I daresay that in the Committee stage he will be able to consider the constructive suggestions made. Irrespective of where we sit in this House, we must realise that we shall face five years of great difficulty in which, on account of the effects of the war and the shortage of labour and materials, we shall not be able to erect the hospitals which people expect. We have got to tell our constituents that many of the things contained in this Bill to which they look forward cannot come quickly. We therefore have to concen- 129 trate, I suggest, on the nursing services which I have tried to describe. I beg the Minister to do what he can to maintain that standard and to keep the Queen's Institute as the authority. I also believe that we must concentrate on the prevention of disease in this period, and, as the Minister said, do all we can for maternity and child welfare and for children in schools. In due course, let us hope we shall achieve for the adults of this country a medical service carried out, not by ignorant people, not by bureaucrats, but by those best competent to judge. I hope that the Minister will agree with what was said by an hon. Member on the other side of the House, that all regulations should be laid in this House, so that we can all feel we have a hand in what will be a most important thing in the next few years, not to condemn action by an individual but to cooperate with that individual for the good of the country.
§ 8.43 p.m.
§ Dr. Morgan (Rochdale)I am indeed proud to take part in this Debate. I have lived for this day for the last 30 years. I have heard two great speeches delivered here today, one by that charming professorial tutor who first enlightened me in the delightful vistas of zoological learning, when, as a small boy, a Socialist from the tropics, I arrived penniless, friendless and alone in the great city of Glasgow. I went to the University, and for my first two months I sat entranced at the feet of a very great man, who gave me all the enthusiasm and all the learning and all the keenness for scientific interpretation of clinical signs in the human body which I have had throughout my life. He was a delightful tutor, a very gracious helper, and all through life, although we have differed politically, he has always been perfectly generous towards my scientific outlook.
This is not my ideal Health Bill, but I must say that I like it very much. The Minister is to be congratulated on producing the finest Health Bill that could possibly be introduced as a compromise under present conditions. I have been able to hear the discussions in the British Medical Association, to hear them in the councils of the T.U.C., of the Socialist Medical Association and of the Labour Party upstairs, and I realise that in introducing this fine administrative structure 130 for carrying out the health scheme of the future, the Minister has done as fine a piece of compromise health work as is possible in this country at the present time.
Reference has been made to Henry VIII taking over the monasteries. I only wish to remind the Minister that Henry VIII also was of Welsh descent. Although the Minister is taking over the hospitals for the specific purpose of helping the public, Henry VIII took over the monasteries in order to help his parasitical followers. The medical profession has a history. I love my profession; make no mistake about that. Today when someone charged my profession with certain things I jumped up at once and said they were not true. No man worth his salt, trained in true medicine, can but feel deeply when his profession is involved. I see nothing in this Bill which will disturb the great relationship between the profession and the public and the profession and the individual patient about which some of my colleagues talked a lot. The medical profession have asked for many things which are granted in this Bill. They nave asked for national coordination and control of research. That has been granted in the Bill. Really, when I hear some of my medical colleagues speak about the petty criticisms they have of the Bill, I begin to realise that some of my profession are so keen about their work, their livelihood and economic interests that they want to see the problem not only through a telescope, but through a microscope. They want porridge, golden syrup and all the necessary accessories put before them, before they can make a decision at any time.
I like very much the coordination and unification of the hospital system. I have always thought the difference made between entry into one hospital and entry into another a tragic thing, leading to puzzling confusion and mistreatment. I refer to the discrimination between the finances, and between the consultant's skill and technique, in one institution as against another. I think the unification of the hospitals on regional lines is one of the finest things we could have in this country. If that were the only thing done by this Bill, I would accept it. But in addition to that it does many other things. I think everything in this Bill will depend on the Minister's regulations. I hope when the Minister is making his regulations, he will make them as elastic, fluid and workable as he can, so as to 131 secure the good will of the health workers of the country. I refer not only to the doctors, but the dentists, pharmacists, nurses and everyone else in the health institutions.
Reference has been made to the shortage of nurses and the wastage in nursing. The hon. Member for Abingdon (Sir R. Glyn) gave his opinion on why there is a shortage of nurses. He said he did not think the work of nurses was sufficiently recognised. There may be a case there, but I do not think that is the real reason. The shortage of nurses exists because, in our present institutions, both local authority and voluntary, the conditions of pay and work of the nurses until recently have been a thorough disgrace.
There has never been the opportunity in some institutions, which are voluntary institutions, for the staff to be allowed to join their own trade union; in fact, every possible obstacle has been placed in their way, by advice from the top, to prevent them joining their trade union in order that they might make organisational representations rather than personal vindication of their conduct. I could give the House some very good examples of the type of treatment which was involved. I hope the Minister, in framing his regulations, will see that the schemes—regional, central, local authority and G.P. practices—will allow both the professional side and the workers' side to have joint consultation and negotiating committees at all levels. If he does that, the feeling of anxiety which has been complained of will be removed.
Reference has been made from the Front Opposition Bench to the case of a woman about to be delivered of a baby, who if she stayed at home, would be under one authority, if she went to an ante-natal clinic would come under another authority, and, if she had to go to hospital, would come under still another authority. Well, what happens now? If she stays at home, is she not under one doctor, employed by one authority or insurance committee? If she goes to an ante-natal clinic, is she not under a different authority, and, when taken to hospital, whether a local authority or voluntary hospital, is she not under a different authority again? Why all this petty partisan criticism in a great 132 scheme of this kind concerning the health of the country? I hope that this matter of the difficulties between the different authorities will be resolved and that there will be a proper junction between all of them under the regulations which the Minister will make so that this scheme will be as smooth and perfect as possible.
I have always been interested in the unification of hospitals and in the national ownership of hospitals, but I realise that there are certain hospitals, especially local ones, with special claims. The Quakers' Hospital at York has a special aspect, a meditative, contemplative aspect which is very valuable in certain mental cases. When a hospital of a special kind is taken over, I presume that the Minister, as I feel sure will be the case, will not interfere with the unorthodox type of medical treatment which is given, and which is different from that given in other types of hospitals. It is essential that these hospitals should be treated as special cases, and allowed to carry on the very special form of treatment which they give. I am liberal-minded enough to say that these hospitals with a special outlook should be treated in a special way. I hear that the Royal Masonic Hospital is prepared to turn itself into a nursing home, rather than be included in this scheme. I do not know if that is correct or not, but I do say that these hospitals have a special outlook and need special care. The Manor House Hospital, with which I am associated, which is a voluntary hospital supported by the country people, is an example. I am not asking that none of these hospitals should be included in the scheme. All I am asking is that their special peculiarities should receive special consideration from the Minister.
Take the case of the hospital for the dying in Hackney, where cancerous cases go just to die. I have seen nothing so pathetic as these patients going in there in their last moments to spend their last days in pain and suffering in spite of morphia. They are thinking more of leaving the world and going into eternity than of saving their skins. I feel sure that the Minister should make regulations in order that the special aspect of these hospitals should not be lost in the Bill. That is the only idea which I think might receive some special consideration in the course of this Bill. I am sorry that industrial medicine is out of the Bill. 133 I presume that Service hospitals are not to be taken over and are to be left in the hands of the three Services. There may be reasons for this, such as military discipline and that hospitals in Service areas cannot be taken over and run as civilian hospitals. What is to happen to Government hospitals like those of the Ministry of Pensions? Are they to be taken over and included in the scheme or are they to be left in the hands of the Departments concerned and, if so, why? I am convinced that a claimant for a pension should go into a hospital where he can get an independent opinion and not to one under the Department concerned with granting his pension I am not saying that the professional opinion given in any of these hospitals is not up to standard. I have never seen any false certificates. I have never given a wrong certificate in my life and neither has any one of my colleagues that I know about. There may be some black sheep here and there, as there are among lawyers. If the Ministry of Pensions hospitals are to be left out, the Minister will have to give some excuse for that being done. Time and time again pensioners have come to me and told me that they thought they were being asked to enter such hospitals in order that they might be done out of their pensions. That aspect may be wrong, but it exists, and I ask the Minister to give some consideration to it.
The right hon. Gentleman the Member for South Kensington (Mr. Law) made a very Jeremiah speech this afternoon. He really did not know his case and I am sorry, as a medico, to have to say so. I do not know whether he is a lawyer or not, but he certainly did not know his case. For example, he spoke of the views of the Royal Colleges as if he were dealing with the pronouncements of a Papal Encyclical. The Royal Colleges are self-elected bodies and chartered, it is true, but they have no democratic backing. They are not legal, and although they give diplomas after examination, they really have no standing. They are not universities. But I am not challenging their professional ability in any way.
I have never attempted to dictate policy. If my advice has not been taken I have said, "Well. that is my advice." The limitation of the professional expert is well known. He can see a microscopic point when he cannot always see the complete picture. To state that opinions 134 given by men with big names should be treated as if they were beyond criticism, is ridiculous.
I could say a lot on this Bill, and I only wish I had more time. But I wish to mention two things. First is the question of the laboratory, blood transfusion and research services which the Minister is keeping in the hands of his own Ministry. I want to see the democratisation of the organisation which he sets up for these services. The research service is kept in the hands of a very small clique under the direction of the Privy Council. I want it to be democratised, to include the local hospitals and the research which is done by G.Ps. The same remark applies to blood transfusion and laboratory services. They should be democratised from the top to the bottom. My other point is with regard to ambulance services. In this respect there is a great blot on the Bill. I know the Minister has been approached in this matter and I know he has dealt with it very sympathetically. I agree that the local authorities have been very generous in their attitude to this Bill, and have agreed to give up their hospitals, but the Minister has hesitated to ask them to give up their ambulance services. I ask him to consider afresh the question of ambulance services from the regional point of view. In this Bill the local authorities are the bodies likely to have the control of setting up ambulance services. Not only is there tear of discrimination between different areas, but there is in this Bill power for local authorities to farm out by contract the ambulance services to private contractors who, so far as we know, may supply the ambulance services without any steps being taken to safeguard the terms of employment and conditions of work of those employed by the contractors. It would be a wise step to consider the advisability of allowing the ambulance services to be run, if possible, on regional rather than on local authority lines.
I began by paying tribute to my profession. I love my profession. I know many of its members are frightened at the prospect of being made State servants, and they have a case. So far, as run by the present system of society, there has been no governmental medical service which has been a success. I shudder when I think of the Colonial medical ser- 135 vices of which I know; I tremble when I think of the prison medical services and pensions services. I conceive future medical services on entirely different lines. I believe that with democratic regulations, with consultative committees, a good Minister, good administration and a good department, we in this great pioneer country in social welfare could build on the lines which the Minister has presented in this Bill, a fine health service which would be an example to the world, which would redound to our credit down the ages, and give hope to this civilisation of which Great Britain is at the pinnacle. It is a delight to me to be able to support this Bill. I hope the few comments I have made, will, at any rate, receive consideration later on.
§ 9.5 P.m.
§ Mr. Emrys Roberts (Merioneth)I want to deal with a particular aspect of this Bill—which I, with my colleagues, warmly welcome—namely, the provision of consultant services in the rural areas. The aim of any comprehensive Measure of this description is that all parts of the country shall be effectively served by efficient hospitals, properly staffed and adequately equipped. They should be properly staffed by consultants readily available in sufficient numbers, and with sufficient skill, to attend to the people who need them. In that respect the rural areas in particular have suffered in the years gone by. I would like to say a special word for North Wales, which is mainly a rural area. In the three counties of Merioneth, Caernarvon and Anglesey, with a population of 200,000, I believe the minimum number of beds for an efficient service is 2,000, one for every 100 of the population. Yet I doubt if at the moment there are 500 beds in that area. The result is that patients are waiting for from six to nine months for admission to hospital. People who should be treated as in-patients are being treated as out-patients. In the whole of Merionethshire there is not a single fever hospital, and people have died on the way to a fever hospital which was a considerable distance away. That is a disgrace in a civilised community. There are some consultants resident in the area. but others have to be drawn from Liverpool and Manchester, a comparatively long distance away. 136 It is an area where much of the housing is bad, where there has been ill nourishment as a result of unemployment before the war and where the slate industry accounts for a high rate of respiratory and rheumatic diseases. Incidentally, I regret that industrial diseases and services are not included in this Bill. I am anxious that this bad state of affairs should come to an end, and I see the possibilities of it in this Bill. But that will depend upon its administration. Much of this Bill is left to regulations. I hope the Minister has not yet decided how he will constitute his regional hospital boards. I want to make this point now in case I do not get another opportunity. If we tie up the rural areas with the great industrial centres too much we shall not get an efficient medical service in the rural areas. In regard to North Wales, in particular, if we link it up with the great industrial centres of the North West I do not see the possibility of an adequate, self-served area and medical unit being developed. We have a Welsh National School of Medicine. I ask the Minister when he comes to draw up his regions to treat the whole of Wales as one region. Let us have a transitional period, by all means, during which we can draw on the services of surgeons outside, from Liverpool or elsewhere. But I ask the Minister to consider with the greatest concern the provision of a full consultant service for this area, which has been so badly neglected in the past.
There is the possibility in this Bill, if it is properly administered, of the poorest family—and I hope it is only a short space of time before poverty is banished from this realm—living in the most remote hillside farm or in the most isolated hamlet, being able, with swift ambulances at their disposal, to call for the finest skill which highly trained surgeons can give, and being given the best treatment that modern hospitals can give, without fear of the cost in money.
§ 9.11 p.m.
§ Mr. Messer (Tottenham, South)I must confess to a feeling of grave disappointment in regard to this Debate, because I had imagined that we were going to get some opposition to the Bill. There has not been any opposition. There has not been any constructive criticism, apart from what has come from this side, and I hope that the Minister will regard whatever criticism does come from 137 this side as being intended to be helpful. I think that it is only right that those of us who have very definite views on what we believe to be the most important social service should say quite frankly what is in our minds, and I propose to do that tonight.
One thing that the Minister has done is to bring order out of what really was chaos. Nobody can say that there was anything like system in these general health services My own view of the Bill is that it is not a health service Bill; it is a medical service Bill. A health service can, broadly speaking, be divided into three parts: the preventive health service, the curative and remedial service and—this is not touched on in the Bill—after-care and rehabilitation. A man or a woman who is sick is not just a case—he is a citizen, a human being, and it is not enough to have a health or medical service which is merely going to cure him of a particular complaint. There are many types of complaint which leave the patient quite unable to go back to the job he used to do and it is necessary for him to have some measure of rehabilitation to enable him to become a wage earner and a self-respecting citizen.
Those are the three aspects, and I must confess that the preventive service, the first section, is not sufficiently emphasised in the Bill. What will happen is that the local authority, the county and the county borough will still have charge of that service. It is my view that there would be much less need of hospital beds if there were much more concentration on sanitation, land drainage, sewerage, and services of that description. I believe that it is far wiser to prevent a patient becoming a patient than to cure him afterwards. I will not spend too much time on that aspect of the matter because everybody must admit that the curative service at the present time is responsible for a lot of effort which is not shown in the results achieved.
Let us take the general practitioner service. The panel system was an attempt to bring within the reach of every working man the opportunity of treatment without his having to put his hand in his pocket and pay for it at the time he was ill. But the service is very unsatisfactory, not because the doctor is lacking in any essential qualifications, not because the doctor is inefficient or less human than 138 anybody else, but because of the nature of the organisation or, rather, the lack of organisation of the service. It does not enable the man to make the contribution that is necessary. What usually happens is that a doctor sets up in practice or buys a practice centred in just an ordinary villa residence, in which one large room is the waiting room and a smaller room is the consulting room. There is no opportunity for a full diagnosis or examination to disclose all that should be discovered. It is no exaggeration to say that there are in our hospitals at the present time patients who would not have been there had there been the opportunity for that full diagnosis.
There is the man who has had pleurisy and has been under the doctor for weeks and months until the general practitioner himself, dissatisfied because he cannot discover the cause of the condition, which was just that of pleurisy when he started to try to cure it, sends his patient to the tuberculosis officer. That officer has got what the general practitioner has not—the facilities for a correct examination. He is able to test by X-ray and to disclose the tuberculosis from which the patient is suffering. Then the patient goes to a sanatorium. Incidentally, at the present time there are somewhere in the neighbourhood of 4,000 people waiting to go into T.B. beds. That is because there is lack of accommodation and lack of staff. It is because we have not got the nursing staffs, nor have we the domestic staffs, and it is not possible to attract them because they are not being attracted in the right way. There are people who have had to undergo operative treatment for tuberculosis, pneumectomy, and all the cures for tuberculosis that could have been avoided had there been the general practitioner service to meet the needs of the people. The opposition to this Bill surely does not agree that that sort of thing ought to continue. Surely, it cannot be considered right that one is entitled to be ill only at certain hours of the day because the doctor says on his brass plate "10–11.30" in the morning and "6–7.30" in the evening. Nobody can suggest for one moment that the general practitioner service, with that large number of people waiting to go in to see the doctor, is the right form of organisation Moreover, it is entirely isolated from and unconnected with every other form of service. 139 The general practitioner service has nothing to do with the hospitals.
We come to the hospitals. There has been talk of there being two systems in this country, the voluntary hospital system and the municipal hospital system. We have not anything of the sort. There is no hospital system in this country. The voluntary hospitals are individual, separate, independent units. There is not any coordination. There has been some slight improvement since Lord Nuffield took an interest and did something to bring in a little organisation, but still the hospitals are all individual, independent units. It is not true when we refer to the municipal hospitals, because the standard up and down the country is widely varied. You can go to Lancashire, which is not too bad, and to other parts of the country where there simply is no hospitalisation at all, where the only sort of hospital which can be found is the old infirmary. In East Anglia from Cambridge up to the coast, after you leave Cambridge, what hospitals do you find? There has not been any national organisation or any national standard about the hospital services. What the Minister has done is to bring some order out of that chaotic condition. Regarding the environmental services, he has attempted to bring that in line, but I am not sure that he has done it in the way that I would have done it if I had had my way.
There are three essentials for a successful and popular health service. The first is that it is comprehensive, including everybody and every aspect of the health service. This Bill still keeps certain aspects of the service separate. It is not comprehensive in its control and direction. It is not unified, and in my view it is not democratic. To be democratic, I agree with the Minister, is not a question of counting heads; you have to be as near to the people as you can. The right hon. Gentleman who opened for the Opposition quoted a speech I made in this House some time ago. I said something then which I still believe to be true. Broadly speaking, there are two types of social services. The first is the mechanistic socialist services; the social services which affect people in a mass and not so much as individuals. It does not matter very much who it is that administers those services. It does 140 not matter much how it is done, providing it is done. If you have an abundance of pure water, it does not matter who is responsible for its distribution. If you have an abundance of cheap electricity, gas, and so on, all these things can be done remote from the people as a whole. Providing they are done cheaply and you can ensure efficiency, it does not matter very much who does them.
The second type of social service is the human social service which affects the individual. In that type of social service are education and health. These are important not merely because of what is done, but because of the way in which it is done. They are important because you can get mechanical efficiency which still does not do all that is required. Anyone who walks the hospital wards knows quite well that the atmosphere of the hospital is as important as the cleverness of the doctor. I am not suggesting that in State hospitals we cannot get a good spirit, but what I do say is that the patients themselves should be in close individual contact with those who administer to ensure that the spirit shall be felt in the whole of the administration. I could not quite agree with what my hon. Friend the Member for Rochdale (Dr. Morgan) said. I know that hospitals, like schools, have individuality. You can have an organisation like the London County Council, which in my view is over centralised, where you see so many hospitals so much alike. Their uniformity is not a good thing. But you can have hospitals under another type of control, which provides local colour and borrows something from the place where they happen to be.
It is necessary in work of this description that the human aspect of it should be considered. What the Minister has done is to say: "I am the final arbitrator in deciding who shall man every stage of administration." The National Health Service Council will be the advisory and planning body, and I think that is quite all right. I think that for him to choose the people who are to advise him is the right thing, but when we get to the lower level of the regional board, surely there is something to be said for it being a representative body. Why this loss of faith in the elective principle? Why lose faith in what we believe to be democracy? Why should the regional body be a purely appointed body? I do not know how the 141 Minister is going to decide, from the names which are submitted to him, who are the best persons for the job. Under the Bill, he is going to consult organisations. What organisations? If he consults the organisations which represent the local authorities, will he consult the County Councils Association? That is an overwhelmingly Tory body, and they may not nominate me. [HON. MEMBERS: "Yes, they would."] The possibility is that they would, because I have many friends among hon. Members on the other side, who have been able to overcome their political scruples when they have recognised real quality. How is the Minister going to determine, when the names are submitted to him, that they are not merely the names of popular members of an organisation, but the names of people who have some knowledge of the job? How is he going to decide that? [An HON.MEMBER: "How is the public to know?"] The public, in the final analysis, have a certain amount of horse sense in the people they choose. That is why I am here. When the public elect a local authority and it throws up certain failures, they do not get re-elected. At any rate, that is the responsibility of the public. On the elective principle, the patient has some check on administration, whereas accountability, under this Bill, is only to the Minister and Parliament through the Minister. I know that the Minister was democratically elected a Member of this House, but the public did not elect him as Minister of Health. They did not say: "What experience have you had in health administration?" I want to come to what I regard as a rather important aspect of this service.
§ Mr. BevanBefore the hon. Member leaves that point in his most interesting speech, I must say that it leaves the whole thing in the air. His speech is too abstract. How does he propose to apply the elective principle for regional purposes?
§ Mr. MesserIf my right hon. Friend wants to know, I will tell him. I see no reason why you should not have your planning body appointed by the Minister and if he will take cognisance of the reports of Gray and Topping and the Nuffield Trust, the information at his disposal would give him what is really required, and which does not exist now. 142 That is the catchment area for health purposes. The lines of demarcation of local authorities bear no relation to the needs of health. Although I know what the Labour Party policy is in regard to this matter I never have agreed with it, because I have always believed in the regional principle. Take the county councils and the county boroughs. There is nothing mystic or magic in the name of a county borough or a county council. Can it be said, therefore, that a county council like the West Riding County Council, which covers something in the neighbourhood of 1,600,000 acres, can be compared with the Rutland County Council which, incidentally, can raise £450 from a penny rate? Canterbury, which is a county borough, has got a population of 18,000, less than one of the wards of the town in which I live. It is clear that unless the Government are going to do what should have been done long ago. namely, reform local government, they must decide that there is a natural area for certain services and organise for it.
The Minister's Advisory Committee would plan these catchment areas, and when that is done there should be an elected body. The one weakness in my view is that he has separated this service from the other services with which it was connected and made it completely an ad hoc service. I am not sure that that is a good thing. When these catchment areas have been decided the Minister can have elected a governing body like the old school boards prior to 1902. That special health body within a region could appoint the regional body plus the necessary professional representation. That is where we would have got the elective principle, and it would have been possible. If that were not possible then the Labour Party held a conference to no purpose. Labour policy has been declared very plainly in regard to this matter, and I would like to quote this from it: