§ Motion made, and Question proposed. "That this House do now adjourn." — [Mr. Collindridge.]
§ 8.26 p.m.
§ Dr. Santo Jeger (St. Pancras, South East)
The question of food priorities is a very wide one and I want to confine my-self to the special matter of milk only. Before I delve further into the subject, I want to make it quite clear that I have no criticism to make of the Government's policy in this respect, and that I have every admiration for the work of the Minister and his Parliamentary Secretary. I think they are doing a very difficult job extremely successfully. As long as we have food scarcity, we must have rationing, and while we have rationing, we must have priority for special needs. The Minister of Food on 29th October last issued a statement to the medical profession, which was published in the medical Press, to the effect that an excessively large amount of milk was being consumed. We were given figures. We were told that during the war period the weekly consumption of milk in this country was 900,000 gallons, whereas now the consumption is 1,300,000 gallons, an increase 295 of 44 per cent., or 400,000 gallons, which is not consistent with the statistics of disease.
The official explanation of this was that the certification of disease by the medical profession had become less strict. But there is another aspect, which is that the general health of the people is below par, that the figures that we are given of deaths, of infectious diseases, and of National Health Insurance disabilities do not represent the whole story, and that we are given no statistics whatever of minor illness. In my view, the increase in minor ailments has a great deal to do with the increase in the consumption of milk. The Minister went on to point out that there were three courses which he could adopt. First, he might cut the amount of milk which is given as a ration and in priority cases; second, he might reduce the number and the scope of the various categories of illness which receive priorities; and, third, he might appeal to the medical profession to adopt a more strict and accurate certification of diseases which require priority milk.
The profession was informed that he had decided on the third course and had kept courses one and two in reserve. I propose to say something about this matter of certification. Most doctors are exceedingly hard working and conscientious. They take a great deal of trouble in the case of those patients who need extra food priority in milk to provide them with careful consultation, examination and an honest decision. But there are doctors who are not quite so conscientious. I can recall not long ago being present at a conversation between two doctors. One said to the other, "You give me a certificate giving me priority in milk and eggs, and I'll give you one." The exchange was duly carried out. There are many doctors who give certificates ad lib to any patient who asks for one. Of course, a doctor with a wealthy patient has a vested interest in maintaining his contact with that wealthy patient and he does not like to refuse a request for a priority certificate. A refusal produces a disgruntled patient, and a disgruntled patient means no patient at all.
There was a letter in the "British Medical Journal" two or three weeks ago, from a doctor who said a patient had 296 approached him and asked whether she could have a priority certificate for milk. She explained that she was finding difficulty in providing food for her cat. The certificate was refused and the patient then said that she would go to another doctor who was not quite so strict. She went to the other doctor and, later, came back to the first doctor—the one who wrote the letter—and said that she had obtained the certificate and that her cat was now being extremely well fed. When a doctor is faced with the question of providing extra milk for a patient, he has to choose whether he will give a certificate for two pints a day or one pint a day, or whether he will refuse to let the patient have anything more than his normal ration of two pints a week. The various reasons for giving priority certificates are set out in the Schedule.
I think that the categories in that Schedule are a little too vague. There are some diseases which are completely absent from it—anaemias, varieties of debility and various psychological and nervous troubles which cause loss of weight. In my view, these diseases should be incorporated in the Schedule. Then, again, dyspepsia and colitis are exceedingly vague descriptions, which can mean almost anything. Everybody at some time or other suffers from dyspepsia, and that is a category in which a doctor will put those of his cases where diagnosis is difficult or indefinite. They all come under the category which is designated 2C. I am going to suggest certain new categories and conditions which should be included in the Schedule. First of all, there are the industrial workers who are confined to bed and who ought to get a certain amount of priority milk in the first ten days of their illness. The illness does not usually last longer than ten days, so that a priority certificate would cover the period.
May I now call attention to the plight of very small families who find it hopeless to try to manage on the present milk ration? Such families ought to have an increased basic allowance because two pints a week for members of very small families is not enough. Larger families, people who eat out and people who live in hotels can manage on their ration. The ration is adequate for such people, but not for the very small family. Nor is it adequate for the very old people who live 297 alone and who, in many cases, are invalids. Many such people pass many milkless days. Children get one-third of a pint of milk in school and an additional ration at home; they have two sources of supply. That is a very good policy and no one objects to it, but one cannot help comparing the ration given to children with that given to those at the other end of life who find it very difficult indeed to obtain a suitable diet.
Provision is made in the Schedule for convalescent children, so that when 'I suggest that a worker who has been incapacitated for some time, who has been receiving a priority ration of seven pints of milk a week, and who will find it very difficult to readjust himself to the normal two pints a week, should have an extra ration during convalescence, it is not something which is outside our experience. The children get it, and there is no reason why the workers should not have it. As I have already pointed out, doctors can give certificates for either 14 or seven pints of milk a week. There is a very big gap between two pints and seven pints, and an even bigger gap between two and 14 pints. If a patient needs a priority certificate, he must either be given one for seven pints a week or none at all.
Most of the cases that I have been talking about, and which are in the suggested new categories, are already getting extra milk. It is very difficult for a doctor to refuse to give some patients extra milk when they ask for it. I can recall one very deaf man who asked me whether he could have a certificate for extra milk. I shouted my lungs out in an effort to explain to him why he could not have it. He smiled very patiently and repeated his request. I explained again and, finally, in order to save time because there was a crowd of people in my waiting-room and in order to save my voice, I gave him the certificate. There are other patients which every doctor meets in his consulting room at various times who will not take no for an answer and to whom it takes less energy to give a certificate than to refuse it. Many of those people would come into the new categories which I have suggested should be enumerated in the Schedule.
Instead of a choice between two and seven pints of milk a week, I would suggest that we might have a new category of 298 three and a half pints a week. Many of the people whom I have been describing could easily fit into that category. Although that would mean that new people would be coming into the priority classifications, there would be a saving of milk because each of those people would be receiving less milk under the new category than they do at the present moment. Another suggestion I wish to make is that, in certain illnesses, a certificate which lasts for only one month is hardly adequate. A month is too short a period for some of the diseases named in the Schedule, and the continual coming back of the patient every month wastes time and energy and occupies the time of a doctor which could more usefully be employed in other directions.
There are one or two other suggestions which I would like to make. People suffering from a gastric or duodenal ulcer receive two pints of milk a day; tuberculosis patients and expectant mothers also receive two pints a day. I would suggest that, if gastric ulcer patients receive two pints a day because they are unable to digest other food, they should be called upon to forfeit their meat ration because it only goes to feed other members of the family, who thereby receive an excessive meat ration. I do not suggest that children, tuberculosis patients or expectant mothers should forfeit their meat ration. There are various other cases which could do with less milk than they are getting at the present time. Gastric ulcer patients who are not confined to bed, post-operative and certain ambulatory tuberculous patients, and many other patients could manage on one pint of milk a day. Then there are certain cases of temporary illness which would come into my suggested category of three and a half pints a week.
To relieve doctors of a great deal of responsibility, and to save them the trouble and time of arguing with patients and thereby acquiring an unjust and undeserved unpopularity, I suggest that they should not be called upon to give patients certificates authorising them to get extra milk, but that they should give statements of illness which could be taken to the food office where the decision would be made instead of in the doctor's consulting room. Many cases are perfectly simple, and it would be an easy matter for the people in the food office to decide whether such cases fitted into 299 the suggested categories for priority milk. In border-line cases, a panel of consultant doctors not engaged in general practice and, therefore, not having a vested interest in maintaining patients on an increased amount of milk, could decide whether such cases came within the suggested category. The amount of milk which would be used under this reclassification would increase the total consumption very little, if at all, and there would be a much more adequate distribution of the available milk.
§ 8.40 p.m.
§ The Parliamentary Secretary to the Ministry of Food (Dr. Edith Summerskill)
I must thank the hon. Member for South-East St. Pancras (Dr. Jeger) for raising this question, because it does give me the opportunity of explaining to the House the principles which govern the allocation of priority milk. We at the Ministry are fully alive to the fact that the people of this country take a great interest in this matter. Those who believe they should have extra milk on physiological or pathological grounds write letters to us, and sometimes use very strong terms, so that we are kept in touch, I think, with the different trends in the country. First of all, I should like to explain that the decisions which are made on priority applications are not, of course, made in any arbitrary fashion by an official at the Ministry. These decisions are made by our scientific advisers in cooperation with an advisory committee of the Medical Research Council. Also, of course, we take into account publications by people like Professor Cruickshank, the Professor of Physiology at the University of Aberdeen. I am quite sure the hon. Member who raised this question knows of the professor's recent book on food and nutrition.
So far as our allocations of priority foods are concerned, I think they do approximate to the recommendations of these very distinguished scientists. In the first place these priority categories—if I may say so, these pathological priority categories as distinct from the physiological, the expectant mothers, nursing mothers and so on—have been established on the advice of the special advisory committee of the Medical Research Council, and they take about 6 per cent. of the total consumption of milk in this country. Now, while on medical grounds it is important to provide 300 milk for these patients, we realise that there are certain loopholes, for certification. Therefore, we decided recently, be cause we were alarmed at the increase of claims for milk on health grounds, that a letter should be published in the medical-Press, drawing the attention of the doctors to the increase in milk consumption, and asking them to re-certify these patients
I agree with the hon. Member for South-East St. Pancras, that it is very difficult to get the hypochondriac and the neurotic type of person, or the person who thinks he or she ought to have milk because their neighbour is having extra milk, off the seat in the consulting room. The lay public does not understand the difficulties of the general practitioner sitting in his consulting room, with perhaps 10 or 20 patients in the waiting room outside clamouring for attention. He is a very harassed man, who tries to do his best under difficult circumstances; and sometimes he feels, knowing that there is a loophole in the Schedule to which the hon. Member has referred, that he will do as he is requested. Of course, he may be soft-hearted in only one case; but unfortunately there may be general practitioners all over the country doing exactly the same thing, and all these pints add up to a formidable total. That is why we felt we had to tell the medical profession of the difficulties which were facing us, and we have asked for their cooperation.
I must confess that the experience of the hon. Member, who said he knew of two doctors who decided to swap certificates, was a little unusual. I have not heard of cases like that. However, recently a certificate has come to the Ministry of Food, which was issued by a doctor, and on which he put:Member of the Society of Individualists. I make this valid for 52 weeks. This is an example of democracy at work.That is the doctor's protest against the Ministry of Food, which he feels should be included in his certificate. I would draw the hon. Member's attention to that when he asks that perhaps a certificate should be valid for longer than a month. I think perhaps he would not agree with 52 weeks. The doctor to whom I referred feels that patients should not have to go to a doctor monthly, or three monthly, or six monthly, but that yearly would be enough. I think I can tell hon. Members that such a thing would lead to lax certification.
301 Let me now deal with some of the points my hon. Friend has raised. I must admit, some of them are very constructive, and I can assure him we shall look at them all. First of all, the question of industrial workers. If my hon. Friend looks at the Schedule he will find that the industrial worker who is convalescent is covered by 2, a. I know the House will understand that it would be unwise to reveal the code number relating to the disease, because this is information which only doctors should have.
§ Dr. Summerskill
I observed that. Therefore, the hon. Member will realise why I am not relating the code number to the disease.
§ Dr. Summerskill
I thought the hon. Gentleman and I agreed just now that we would not relate the code number to the disease. I just mentioned the code number, and now the hon. Gentleman has mentioned the disease. Yes, I agree with him, but as a doctor surely he will agree that a worker who is convalescent is not working. Therefore, that will cover the worker for his illness and his convalescence, until he goes back to work. I think 2a does cover that point. The hon. Member said that there are no statistics for minor ailments. Well, I agree with him that our records leave a lot to be desired. But I wonder if this has occurred to him. If he again looks at class 2 he will see that as compared with class 1 the diseases in class 2 are minor. For instance, (a) might be minor, (b) might be minor, (c), which he has already quoted, certainly might be minor. The hon. Member would obviously have this information. I have made an inquiry, and have discovered that, so far as minor diseases are concerned, which are included in class 2a—and therefore we have a record of those—there has been no increase in consumption, which rather indicates that the small things, which are not recorded, have not resulted in an increase in consumption.
The question of records is one which must be examined by the medical pro- 302 fession, of course, and by the Government. I think the hon. Member will agree with me that all insured persons who are receiving medical benefit have their complaints recorded, so we have a record there. There is a loophole, of course, because for the first three days of an illness there is no obligation on anybody to record a complaint, because the patient does not qualify for medical benefit.
Again, there is a huge category which can be seen in this country, of whom we have no record at all: housewives. I dare hardly mention this category here, because the last time I spoke at this Box and mentioned the housewives I created an uproar on the other side of the House, and the din was so great that I could hardly continue my speech. Therefore, I realise that the housewives are not popular with the other side of the House, and if I dare mention what they suffer from I shall be attacked. However, as apparently tonight hon. Members opposite are not interested in priority allocations, perhaps I might mention this very large category of patients, the housewives, who, of course, are not insured, and therefore there is no record so far as medical benefit is concerned, and there is no obligation on the medical practitioners to keep any records. Thus, the hon. Member is right, but again, as a doctor, I should say to him—and I think he will agree with me—that apart from perhaps obstetrical complaints there are no minor illnesses to which the housewife is subject to which no other worker is subject. So, if we have a record of the minor illnesses of other workers, I think that reflects the minor illnesses of the housewives.
The hon. Member said that the categories are too vague. I agree with him, certainly in part. I always felt, when I was practising, that 2c was very vague; it could cover anything. But we have to give the doctors some latitude. They cannot be tied, of course, to this Schedule. If somebody comes in who is apparently suffering rather severely, and the doctor feels quite satisfied he could come under 2c, I think he should have the power to say so. But when we come to revise this Schedule, as, indeed, we must—and if doctors do not observe this warning in the medical Press, that is our next step —but when we come to revise the Schedule, we shall give special consideration to 2c, I can assure my hon. Friend.
303 The hon. Member asked that an increased ration should be given for those who live alone. It would be very difficult to do that administratively. We have a warm corner in our hearts for old people living alone, and the hon. Member will be glad to hear we are going to look at that question. That is not correct. We are going to look at the position of the old people. I do not think one could possibly differentiate between, let us say, a man of 65 who has just got his old age pension and who is living alone, and a spinster of 50 who is living alone. A man of 65 still has his teeth. It is sometimes suggested that once a person gets the old age pension he is no longer fit to eat a good meal. But he likes a good meal, and he very often has a good appetite, and, therefore, we cannot say that of course an old age pensioner, because he is 65, must have priority milk. I would remind my hon. Friend that there are 5,000,000 of these people, and that our pool of milk is limited. But we are going to look at the whole question to see if something can be done for some of them.
I think that the most important matter the hon. Gentleman has raised is the suggestion of a new category. He is quite right, of course: doctors are entitled to give either two pints a day or one pint a day. He has not mentioned the point, but I would remind the House, of the doctor who finds it difficult to get a patient off the chair in the consulting room; and the only alternative, apart from being very rude, is to give in, and give a certificate for seven pints a week. If we made a new category of three and a half pints a week, so we could remove the patient by giving a certificate for three and a half pints—well, it all sounds a little immoral, but we have to face up to these difficulties, which only doctors understand.
Now the question of gastric ulcers.
§ Dr. Summerskill
I must apologise to the House, for this all becomes a little technical. I see I am surrounded by the profession, so I am a little hesitant to air my own views on this question. The hon. Member who said "Hear, hear," is a surgeon, and, perhaps, does not agree 304 with medical treatment of gastric ulcers. But I would say to my hon. Friend that gastric ulcers are difficult to deal with, in so far as a person with a gastric ulcer may look quite healthy and may be able to go to work, so that the neighbour next door may say, "Look at that strong, fat man having his extra milk." But the neighbours do not know that the man has so arranged his life and so planned his diet that, while he has his two pints of milk, he may go on quite well, but that, if his milk were stopped, his condition would deteriorate. On the other hand, he may find things go on pretty well, and he might say to his wife, "I feel like a little mince." That is quite possible. If we did as the hon. Member suggested, and said to this particular category of patients, "If you have milk, we must forbid you meat," it would almost certainly mean that that category would be going backwards and forwards to the food office, saying, "Now I am better I want my meat ration back." Then, of course, when they got worse, they would ask for their milk back. Therefore, the administrative difficulties would be very great. I am glad to see that the hon. Member, whose professional work I so much admire, agrees with me on this matter. But we will certainly look into the three and half pint category.
Another point is the one about the month's validity. I do not think it is a hardship for patients to get their certificates renewed every month. Of course, there are diseases in respect of which the validity of the certificate is for three months. I think it might lead to lax certification if we made all the certificates valid for three months.
The final point raised by the hon. Member was whether a committee—I think, a professional committee—of medical men could decide the eligibility of patients for milk. Although on the face of it it does seem an excellent suggestion, it would be very impracticable. This afternoon I opened a Domestic Front Exhibition in a borough of London, and I took the opportunity of discussing the whole question of the administration of the Food Office and allied medical matters with the medical officer of health, and I did raise this question with him. He almost implored me not to give him more work. It is just a question of putting more work on a very heavily overworked 305 machine, and I am afraid we shall have to leave the general practitioner to decide.
I thank the hon. Member for raising these points. They are constructive. He knows the problems. We are going to look at the Schedule again, and I can assure him that every point he has raised will be most carefully examined.
§ Mr. Spence (Aberdeen and Kincardine, Central)
May I ask the hon. Lady to deal with two questions that arise in connection with these priorities due to the shortage of milk? Will she say what is being done to increase the milk supply, and can she give an assurance that no fresh milk is being used to make cheese?
§ Dr. Summerskill
The only way to increase milk is to increase the yield of the cow, and the cow is a temperamental creature and refuses to produce milk unless properly fed. We have had so many Debates on feeding stuffs in this House that I think the hon. Member must know that, until we have an increase in feeding stuffs, it will be impossible to get an increase in yield.
§ Mr. Spence
Will the hon. Lady answer the question about cheese? Can she give an assurance that fresh milk is not being used to make cheese?
§ Dr. Summerskill
Certainly, some milk would be. An hon. Member asked me— or, perhaps, a Question is to be asked me —about what is done with milk. We have sometimes a pool of it which is sur- 306 plus to requirements. Some of that is used for cheese; but, on the other hand, we do import a lot of cheese. We have not been able to use the milk as we should have liked to use it for the special cheeses for which we were famous in the old days, because we have to use it for liquid consumption.
§ Mr. Spence
But can the hon. Lady give the assurance that the quantity used to-day is not more than that which was used in normal times?
§ Dr. Morgan (Rochdale)
May I ask the hon. Lady to deal with the question of anaemics when revising the Schedule? Will she give special attention to anaemics, and to their classification in the Schedule? We are having a great deal of difficulty now in classifying the various types of anaemics, and people suffering from chronic benzine poisoning, and so on. Sometimes people have progressive anaemia going on. I would ask her to consider revising the Schedule thoroughly so that diseases and disabilities not now included will be included.
§ Adjourned accordingly at One Minute to Nine o'Clock.