NATIONAL HEALTH SERVICE

HC Deb 21 January 1949 vol 460 cc504-36

Motion made, and Question proposed, "That this House do now adjourn."—[Mr. R. Adams.]

2.46 p.m.

Sir Henry Morris-Jones (Denbigh)

The subject I want to raise this afternoon arises out of a question which I put to the right hon. Gentleman the Minister of Health on 2nd December last which I thought he might have taken the opportunity at the time of answering a little more fully. In the circumstances one feels that one ought to raise this matter of the many anomalies that are arising out of the National Health Service Act, and I understand that quite a number of hon. Gentlemen on both sides of the House will wish to take part in the Debate. I do not usually make long speeches in the House, Mr. Speaker, and I shall endeavour to be reasonably brief, but there are some matters of urgency that require to have attention called to them.

I regret the absence of the Minister from the Debate. I think he ought to be here. This is the first occasion on which this House, even though it is on an Adjournment Debate, has had an opportunity of discussing matters which can be discussed under the regulations concerning an Act which touches most intimately and vitally people in every household in the land. It is rather an affront to the House that the right hon. Gentleman is not here to deal with these matters. That is no reflection on the hon. Gentleman the Parliamentary Secretary, whom I much admire and whose talents we all respect, but he is not the Minister and has not the same responsibility.

The Minister may say, as he has said in answering Questions in the House, that at the present time he is negotiating with the British Medical Association and other interested bodies such as the opticians and the dental surgeons. It is right that these negotiations should take place, but this House has the responsibility and is entitled to know what is going on. I remember that on one occasion, in the later stages of the war, a most virulent attack was delivered from this side of the House by the present Minister of Health upon one of his own leaders in the Coalition Government at that time, the present Foreign Secretary, because he did not take the House of Commons into his confidence and was negotiating with the T.U.C. behind the back of Parliament in regard to matters about which Parliament ought to know.

The cost of the Health Service is enormous. I understand it is now something like £30 million over the estimate and responsible authorities say it may go even to £100 million above the estimate over the next year or two. The House and the people of the country are entitled to know that they are getting value for their money when such immense expenditure by the State is involved. During the Recess I have made further acquaintance with some of the problems involved in more than one part of the country—in industrial areas. London and residential areas—and have talked with medical men, dental surgeons, opticians and nurses. It was only right that I should do so before raising these points today.

I think we can say, in referring to certain anomalies and injustices arising under the Act, that, as the Minister anticipated, the birth pangs of an Act such as this were bound to be somewhat severe. In one speech in the country just before the Act came into force he said, I think, that he would expect overwhelming numbers of letters and complaints from all parts, which indicated the severe teething troubles being experienced. I do not doubt that the Health Service has had its teething troubles and is still getting them. Many a promising infant has lost its life during its teething troubles. I do not suggest the Act will do that; I think it will survive such troubles. It is up to the House, however, to inquire where it is touching most severely and where we can secure redress within the regulations without initiating further Acts of Parliament.

I make no apology, therefore, for touching upon the main pivot of the Act in so far as it deals with the first intimate contact with the Act by the doctor—that is, by the general medical practitioner of this country. There is no doubt that large numbers of medical men are extremely unhappy and very purturbed about their present position and the working of the Act. Their work has unquestionably increased in all areas, far more in some areas than in others. On the subject of remuneration I think that in large industrial areas medical men have, on the whole, gained somewhat, in some areas fairly substantially perhaps by as much as 25 to 30 per cent. But they are the only areas in which the incomes of medical men have risen. In all other areas—residential, rural and seaside resorts—they have gone down, in some instances so seriously as definitely to affect the morale and working power of the general practitioner.

Dr. Haden Guest (Islington, North)

Would the hon. Gentleman define exactly what he means by "residential areas"?

Sir H. Morris-Jones

I would put the residential areas into two classes: areas like the dormitories of London—the Home Counties, Kent, Surrey and Sussex, for instance. We can include resorts, both inland and seaside——

Dr. Guest

Colwyn Bay?

Sir H. Morris-Jones

Yes, Colwyn Bay, Bath, Brighton, Bournemouth, and many other places. Then, of course, there are the rural areas.

I quote a letter from a firm of reputable practitioners of whom I know, in what we term a residential area, in this case a seaside resort. There is a feeling that seaside resorts are not very popular with the Minister. In his remarks during the passage of the Act, in his somewhat sarcastic and general way, he did not seem to be very much in sympathy with the medical fraternity in those resorts. At all events they are a very responsible section of our people and many people go to these places for their health.

This firm, of three medical men, say that they have 4,000 patients on their panel at 16s. a head, which gives them a gross income of £3,200 a year and that practice expenses for the current year amount to £1,950. leaving a net balance of 1,250; that is to say, £416 for each of the three partners. No doubt they have some amount of private practice in addition, but that is the amount of their income from the State panel—not their net income after tax, but after deduction of practice and daily expenses. They say: What do we do for this remuneration? An accurate record of consultations and visits is kept and averages 90 per day for the last six months—the quieter half of the year. The gross pay per attendance is 1s. 10d. and "— after practice expenses are deducted— the net pay is 9d. The figure of 90 per day does not include consultations by telephone (estimated at 20 a day) and innumerable people dealt with by the receptionists—repeat prescriptions, certificates and forms which just require our supervision and signatures.… Under the stress of increased work and reduced income one's work loses interest; financial worry adds to the strain. My political bias"— this letter is from the senior partner— is towards Socialism. I think the Health Service is necessary, and I voted in favour of joining it at the Plebiscite. … So the Health Service in this area is being soured at the point of contact between patient and doctor. A medical man may work for reasonable remuneration and give good service. He may work for nothing and give good work, but he cannot work for 9d. a service and do good work.

I am very glad that in the rural areas the Minister has made a concession, a fairly substantial concession, I think. Some of these rural practitioners were undoubtedly very hard hit. We must remember that a man working in a rural area, with a panel of 1,000 is often harder worked than a man in an industrial area with a panel of 4,000. I know of one medical man in my constituency who spent three-quarters of a whole day in seeing one patient. He had to walk eight miles from a point where, owing to the snow, he could not use his car. The patient had a fractured leg and could not be admitted to a hospital. The best part of one day was spent in visiting this one patient—on a capitation grant of 16s. per head per annum plus a certain mileage. Many of them are threatened with financial ruin at the present time; they cannot meet their commitments.

I hope that the concession which the Minister has made will, to a certain extent, mitigate that position in the rural areas. I am sure that the Government do not wish to have sweated labour under this Act. It may seem a peculiar thing to say at a time when enormous expenditure is involved under the Act that there is room for further concessions. But this is the very foundation of the Act, and if we cannot give good service under this head, the whole Act fails. The whole basis of remuneration should be reconsidered.

In my judgment, there is much to be said for payment per attendance, with power by the State to make a grant in aid. I see that a Commission in New Zealand has recently reported in favour of that suggestion in view of the enormous demands made by the public under the State scheme in that country. I believe that, on the whole, our people have behaved very well, and have been most patriotic in all ways. I am not talking only of the voluntary bodies which were removed by the Act, many of which had given service for a considerable time; I believe that all the people have behaved with great circumspection. However, we must face the fact that in any State scheme of this character there is bound to be a greater demand on the service, and, therefore, more demand on those who have to give it. There is very grave danger that we may find discontent among those who give the service, which would have very severe repercussions.

As to the basic salary, this arrangement is working very badly; indeed, it is really not working at all. In one area the doctors get it, and in an adjoining area they do not. Liverpool has granted it, but other large cities in Lancashire have not. In North Wales, Llandudno has granted it, but Colwyn Bay, a town in another county five miles away, has refused it. In the County of Caernarvon they pay the basic salary, but in Denbighshire only three out of 32 doctors who have applied for it have been granted the basic salary.

Mr. Messer (Tottenham, South)

Will the hon. Gentleman explain who are "they" to whom he alludes?

Sir H. Morris-Jones

It is done at the instigation, or on the authority, of the executive committee. I am only pointing out to the House the result. Parliament intended the basic salary to be paid; much was made of it at the time, but it is completely anomalous in the way it works.

Dr. Santo Jeger (St. Pancras, South-East)

Is the hon. Gentleman now asking for the basic salary which at one time he was concerned with rejecting?

Sir H. Morris-Jones

I am afraid I did not get the hon. Gentleman's point; I do not want to be long because other hon. Members wish to speak, and I have one or two observations yet to make.

I come now to the question of the distribution of medical men. The Minister throughout his many speeches on the Act made great play of the maldistribution of medical men. Assuming there is such maldistribution, it is a natural one, and one dependent on economic circumstances, the desires of the medical men and their wives and families to go where they wish, and the demands and amenities of the areas chosen. That is something which is to be expected in a free country. What is the position about distribution today? It is undoubtedly worse than it ever was. I say that because medical men and women are now "frozen" in their areas—they cannot leave those areas.

Take, for example, a town such as I mentioned just now. Suppose that in a seaside resort such as Brighton, Bournemouth, Colwyn Bay or Llandudno, a certain number of medical men are now finding that their income is reduced, or they do not want to spend their lives attending a lot of nervous and elderly people, or that they find that their commitments are heavy and wish to go elsewhere. They cannot do so. If they apply to go to an industrial area the Executive Council will say "We have all the medical men we want here we do not want any more." So maldistribution, of which the Minister made so much in the terms of the Act and in his speeches in this House, is intensified at present and may become more serious from the point of view of a properly functioning health service.

There is one place in North Wales, Deganwy, which lies between Llandudno and Colwyn Bay, where there is no medical man at the present time. The people of Deganwy have been refused a medical man by the Executive Council. There has been a medical man practising there for 70 years from the time it was a fishing village to the time when it has grown to be a place of a thousand or 1,200 people. If it could support a medical man for 70 years why should the people there be deprived of that opportunity at the whim of some executive council? I do not think it is right that the people of that area should be deprived of their own doctor; they are entitled to one. What has been the custom for so many years has established the need for that. Why should they have to go two miles away, where there is only one evening surgery, and where many of them have to wait all day to see a practitioner?

It was stated that distribution would help young medical men to start in new areas. What has happened in that respect? They are not allowed to start in new areas in many cases. They make an inquiry, having thought they would like to begin to practise in a certain area, and they are told: "Have you any accommodation there? We cannot give you any sanction to settle there unless you have accommodation." They then have to make sure of getting accommodation. The House will realise, the housing problem being so difficult, the difficulty which they have in securing that accommodation. Having done so they are not even sure that they will even then be allowed to settle there. The purpose of the Act of enabling young men to settle in some area is being frustrated. I wish the House to note that under these conditions the Act is not functioning at present as it should.

I turn to the question of the facilities given to foreign visitors in this country to have free treatment under this Act. I do not object to a foreigner in this country who has been living here for some years, say for two or three years, participating in the facilities of the Act, but why should a temporary visitor coming to this country be allowed all the facilities of the scheme under every heading he likes—to get for nothing the treatment and the equipment which he can get under this Act? I will give an example which may be stretching the matter rather far but from the possibility point of view there is no objection today to, say, a wealthy Belgian coming here—I am only referring to Belgium because it happens to be a non-sterling area—and yet we cannot visit their country, but under the terms of the Act a wealthy Belgian can come to this country today and get medical treatment. Most expensive prescriptions can be obtained which will cost £1 or 25s. in some vitamin tablets. He can get a chit and go to the optician and be provided with spectacles. Without any medical advice or authority of any kind he can go to a dental surgeon in London or any other part of the country and get an upper and lower denture——

Mr. Walkden (Doncaster)

If he waits long enough.

Sir H. Morris-Jones

—and in this cold weather, if he likes, he can have a hot-water bottle to take away with him.

Dr. Guest

Would the hon. Member mention the hearing aid which he can also get?

Colonel Stoddart-Scott (Pudsey and Otley)

And the wig?

Sir H. Morris-Jones

I have mentioned some of the things he can get and there may be others. But there is no reciprocity at all for a Britisher visiting Belgium. He is not allowed anything of that kind. Surely this country, under Marshall Aid, and with a deficit of £300 million a year, is not going to make itself the laughing stock of the world by throwing out things like that which we cannot afford.

Dr. Segal (Preston)

Is it not likely to encourage the tourist traffic in this country, which would be a very desirable thing?

Sir H. Morris-Jones

I should think it would have a very beneficial effect in that direction, in the sense that they will go away with far more than they have spent.

The Parliamentary Secretary to the Ministry of Health (Mr. John Edwards)

Would the hon. Gentleman tell me whether, when he says he wishes to prevent foreigners from enjoying these facilities, he includes Canadians, Australians and other British people from overseas?

Sir H. Morris-Jones

I do not for one moment suggest that members of the Commonwealth should be excluded. After all we are one family and I would not suggest that.

The question of specialists needs reviewing generally and I hope that other hon. Members will deal with the point. The services of a large number of specialists in this country are not being utilised. Many specialists are finding that their incomes have been drastically reduced. An orthopaedic surgeon in the provinces tells me that he was making thousands a year and his income has been reduced to £1,200 a year as an allowance from the State for his hospital work. Practically the whole of his private practice has gone. Out of that he has to pay his car allowance, and he is making very little himself. He is considering very seriously whether he can carry on in his profession or whether he should get another job, or go abroad, or do something like that. It is a very great deprivation to the country when there are men of that sort who have been established for years, eminent men who are capable of making large incomes, whose services are appreciated and who are now reduced to a salary which, after tax has been taken from it. is a pittance.

There are directions in which economies could be exercised. I see that there is present an hon. Gentleman who is the chairman of the Health Services Central Council. He must see a good deal of waste going on in many directions. The House would be interested to know, if I had time to read the letter, of what is going on in some hospitals in London today. Administrative blocks are being built up at great expense in hospitals where nothing is being done about the actual equipment. In some hospitals the boilers and other fittings are in a disgraceful state, yet money is being spent on the building of blocks for administrative purposes and not for the doctors and nurses. I have a letter from a working man giving some startling facts.

I hope that the Minister and the Parliamentary Secretary will take note of some of the points I have made. We must get the hearty co-operation of the general practitioners in the working of this Act. If we have their hearty co-operation, this Measure has a wonderful future. It has a great future capable of development. The whole world is watching how we are proceeding. But if the doctors are to be put in a state of financial anxiety, wear and worry, their interest in their work may go. The Act will suffer and the health of the people will suffer in consequence.

3.17 p.m.

Mr. Messer (Tottenham, South)

We have listened to a speech which, if it were dealt with in isolation, might have some effect in almost giving the impression that the new Health Service is a complete failure. I want to be careful in what I say. There is a danger of being misreported, not by HANSARD but by certain organs of the Press. I want to take the opportunity, therefore, of saying that, in the day to day experience of the administration of this service, I have found complete co-operation from every section of the medical profession. It is necessary to say that because, if everything else were wrong, the one thing which the hon. Member for Denbigh (Sir H. Morris-Jones) has said which is undoubtedly true is that this service stands or falls on the co-operation of the medical profession. We know that the doctor is not the only factor. We know that there are many factors in the service which must be considered, but we cannot ignore the supreme fact that the centre of the service is the doctor. I rather think that the hon. Member was a little unfair to the Minister in saying that he should have been here for this important Debate. My view is that for the Minister to be present would have given an importance to certain features of the service which perhaps would have put the whole matter out of perspective.

The one consideration which has not been realised is the tremendous task of pulling together the small units and making a comprehensive, unified service of what was a lot of scraps and pieces. Out of this mass of contradictions, in some places, and certainly anomalies, in others, we have had to form a pattern from a jig-saw the pieces of which did not fit. That has not been an easy job. Six months is no time in which to test it. We are going through a period of experimentation when we are compelled to experiment with compromises which, very likely, have made the service much more difficult than otherwise would have been the case.

I will deal with the major point raised in reference to the general practitioner. As a supporter of the service, I support the hon. Gentleman in saying that great hardship is being experienced by many general practitioners at present. Those general practitioners who had a big private practice and a small panel practice have been unable to attract the requisite number of patients to their lists to enable them to approach anything like what was their income before 5th July. Do not let us attempt to hide the facts of the situation. I happen to be fortunate in that I am a member of every level of administration in this service—the Executive Council, the local health authority, the regional hospital board and the Central Health Services Council. At a meeting of the Executive. Council of which I am a member, we had some really serious instances brought to our notice where doctors' incomes had been reduced from a range of £2,000 to £1,500 a year. We have a medical committee of that Executive Council, and we entrust to that committee—that is, the doctors themselves—the distribution of the basic salary. When the report was submitted by the medical committee I asked "Do you then want a basic salary?" and the answer was "No."

I suggest that the negotiations that preceded the Act in which compromise had to be reached, are responsible for much of the difficulty that exists. I leave the point there because clearly everybody knows that the situation cannot remain as it is. For me to say anything more as to what considerations are proceeding at the moment, would be to say too much and would involve divulging confidences which I am not entitled to do. It is true that we have a service the very nature of which has meant that the doctors themselves are compelled to work very much harder than they did before. Very much more treatment is being given. That is not a weakness of the service. It is a recognition of the fact that the wives of insured men who previously could not get treatment are now getting it; that the children of insured men who were not getting treatment are now getting it at the hands of general practitioners; that there are now claimants for beds in hospitals who were previously deterred because they either had to pay some contribution towards the cost of maintenance while in hospital, or had to belong to some association which could arrange for a bed. All these factors are indicative of what we were lacking before the service started. They are not weakness of the service.

Let us look at the administration to which the hon. Gentleman referred when he said that in certain hospital groups there is an administrative block which is wasteful and extravagant in expenditure. Again we have to face the facts, which are these: we have had to join together two entirely different forms of administration of the hospital service—the voluntary hospital and the municipal hospital. The danger of the municipal service was in over-centralisation. The weakness of the voluntary hospital system was in ultra-fragmentation. We had small cottage hospitals of 25 or 30 beds which had their separate administrative set-up. We have had to join together two entirely different forms of organisation.

We have had to do away with that over-centralisation because we cannot give to regional boards the responsibility of the day-to-day management of a hospital. Nor can we continue to allow the small unit, the cottage hospital, the small general practitioner hospital, to continue as an individual unit. In joining them together it was necessary that we should set up an administrative machine which would ensure that the work would be done and in my view, because it was so important that the work should be done, there was inevitably a danger that we might exaggerate the number of staff required. I feel that that, too, will have to be investigated with a view to seeing whether and where there is redundancy so that we may avoid redundancy in the future. I suggest, and this view can be heard in the country, that we should let this scheme have a fairer chance than that given by six months. The joining together of parts which were so different was a difficult process and it is inevitable that in that process the machine should reveal some creaking cogs. But there is room in the administration for those weakened parts to receive attention when they are seen.

I am certain that when we look at the financial aspect of this scheme we must not be content to say that this is just an enormous expenditure without having regard to where the expenditure is going. All those who are now receiving free treatment are, in point of fact, receiving an addition to their income. Every working man whose wife goes to hospital is no longer in law the legally liable representative who must maintain her while she is there. She is entitled to that treatment. Every working man who occupies a hospital bed is entitled not only to free treatment and maintenance whilst he is there but also to 26s. a week sickness benefit for a period.

The cost of the service is high. It was bound to be high. Nobody could see within millions how high it would be, for nobody could know the extent to which the service would be used. I am of the opinion that six months' experience is by no means sufficient to give us an indication of what major changes should be made. What we do know is that the greatest experiment in social service has been launched. There is every indication that, with the co-operation of all who are concerned with it, we shall forget some of the difficulties.

I am aware of the difficulties of the specialists, which have been mentioned, but the Spens Report is out and we are waiting to know what action is to be taken on that Report. The doctors themselves have a voice in all these things. There is a difficulty about specialists because we have not enough of them. The hon. Member for Denbigh (Sir H. Morris-Jones) mentioned orthopaedic specialists. He knows that there has never been an organised orthopaedic service in this country. When we can get down to the organisation of that service we shall provide the service so that the specialist will have the maximum amount of his time in the place where it is most required. What had we prior to the Act? Specialists going from different parts crossing each other's paths, to do jobs in hospitals when there were other hospitals closer to their own places of abode. When we can get down to the organisation required, which is a tremendous job, we shall find that we have indeed launched a service which is probably the finest monument to the ability of the people of this country to meet the needs of the people of this country.

3.30 p.m.

Mr. Linstead (Putney)

I have never been one of those who have felt that the Act of 1946 is as good an Act as it might have been. I have always felt that it attempted to go too fast and too far. A number of the anomalies of which we are all conscious today in the working of the Act could have been avoided, I believe, if the attempt had been made to go by evolution rather than by revolution. However, now that it is the law of the land there are many thousands of people, the paid staffs and the voluntary workers, who are trying to make this social reform work satisfactorily. I would very much agree with the hon. Member for South Tottenham (Mr. Messer) that it is on the rails and moving; but it is creaking and groaning, and I think that one of the most useful things we can do in the short time we have today is to draw the attention of the Minister to some of the more immediate anomalies which, by fairly rapid action in the Ministry can be ameliorated to help the thing to run more smoothly.

There is a much more substantial reckoning I suspect in waiting for the Minister. He has obviously to come to this House to ask for more money. No doubt, that will be the occasion when there will be a full-dress Debate, when the whole development of the Health Service can be discussed here. There is, of course, a number of very important matters—for example, the dental situation, which seems to have got completely out of hand; there is the secrecy which still surrounds the remuneration of specialists, for although I know, what the hon. Member for South Tottenham has said, that the Spens Report is out, only a very limited number of people have seen it, and specialists do not know where they are. Then there has been long delay in the payment of chemists' accounts, due to the fact that the machine has become completely overloaded. However, these are matters, I think, for a future time.

The only points to which I want to refer today are, perhaps, more detailed, but if the Parliamentary Secretary will indicate the policy of his Department in regard to them he will be doing a good service to those who are anxious to make the best they can of the Act. One question about which I hope he will be able to give us some information is: When is the amending Bill to be produced? A considerable number of unsettled matters, particularly about medical partnerships, are causing friction and anxiety, which cannot be settled until the Bill is produced. I think it is overdue, and if the hon. Gentleman can give us some indication of when the Bill may be expected he will be able in doing so to help a good many people.

I hope that as soon as possible the Ministry, in its dealings with the hospitals, will be able to give some indication of its long-term policy over capital projects. It is impossible to plan hospital development, in regard to capital expansion, on a year-to-year basis. A hospital may have had its outpatients' department bombed. To put it into proper working order again may cost £50,000. They may be prepared to wait a couple of years if they know that the project is to be sanctioned; if, on the other hand, they know they have to wait seven years they may be justified in spending £3,000 or £4,000 upon some temporary prefabricated building for the time being. If they are put off from year to year, not knowing a year ahead when that particular project is to be sanctioned, they are placed in a very difficult position. I hope that it will be possible to work the capital side of hospital finances on the same lines as university finances, at least for quinquennial periods, so that the hospital committees may know a little more clearly where they stand.

There are two points upon which I hope the Parliamentary Secretary can give us some information. Section 9 (8) of the Act gave to the Minister power to make regulations for determining by arbitration in cases of doubt whether a particular institution was or was not a hospital. I know of four institutions which have claimed to be homes and not Hospitals—there are probably a very large number of others—and they are at the moment waiting in a state of suspense; they do not know whether they should have been taken over on the appointed day or whether they are still free to carry on their own affairs in their own way. Now that is a very embarrassing position for these large institutions; it is bad for the patients and bad for the staff. I have not been able to find that the Minister has yet made arbitration regulations. There is such a mass of regulations that they may be tucked away somewhere, but I have not myself found them. Perhaps the Parliamentary Secretary could tell us whether those regulations have been made; how many applications for arbitration have been made; how many, if any, have been heard, and what the results have been.

I draw his attention particularly to the position of the staffs of those institutions which are suspended in doubt. If they had come into the service they could have chosen whether to carry on under their old conditions or under the new National Health Service conditions. Because they are still in suspense, the day for choice has passed, and if any of those institutions are found to have been taken over by the Minister the staffs should, I think, be given another date by which to make the choice whether to accept the new or the old terms.

The only remaining point to which I wish to refer is the great difficulty in which hospital management committees are at the moment being put through the activities of nursing agencies, commonly known as the "co-ops." In normal times the nursing agencies have a real place to fill in a health organisation. They cater for the nurse who does not want to be attached to a particular institution, but who wants to be available for private nursing, or for holiday or locum tenens work in hospitals. They worked on the basis that the nurse had no superannuation; she was probably paid substantially more than she would have got under Rushcliffe, and the hospital paid the agency for the nurse for the period of weeks for which they used her. What happens now is that, owing to the short- age, nurses, on qualifying, are joining the agencies and getting paid in some cases twice as much as they would receive under Rushcliffe.

Mr. Somerville Hastings (Barking)

More.

Mr. Linstead

I know of cases of midwives who are getting paid three times as much, but certainly some nurses are getting twice as much from the agencies as they would get under Rushcliffe. The hospitals are having to pay twice as much as they would pay if the nurses were permanently on their staffs, and the agencies take their 12½ per cent. That reaches its absurdity when a newly-qualified nurse walks out of her hospital, joins an agency, walks back into the hopsital next day and stays as a full-time resident nurse at that hospital, at twice the negotiated salary, for perhaps a year, as is the case at at least one hospital I know, the agency collecting its 12½ per cent. every week for doing nothing at all. That is an abuse of what might be a useful service, and creates a great deal of anxiety, trouble and difficulty for the hospital; it creates a strain among nurses who want to be loyal to their hospital rather than to go out for extra money. I very much hope that the Parliamentary Secretary can tell us that urgent attention is being given to this question by the Minister, because unless national action is taken fairly quickly there will be substantial difficulty and abuse.

3.40 p.m.

Dr. Haden Guest (Islington, North)

The hon. Member for Denbigh (Sir Henry Morris-Jones) who opened this Debate mentioned a number of points. I should like to address myself to that part of his speech in which he spoke of the abnormal cost of the National Health Service. He did so without referring to what I think he would agree is the enormous saving which will inevitably accrue to the nation in a very short time, if indeed it has not already begun to accrue—I think it has—in actual cash saving, through the improvement of the health of the people. I am sure that the hon. Gentleman knows quite well that it has been estimated that the loss in time, in production and in other ways, to the nation has been of the order of £300 millions a year, a very formidable sum. It is to be expected that the National Health Service will largely diminish that great loss.

The hon. Member mentioned that the remuneration of general practitioners in large industrial areas is regarded as satisfactory by them because it has increased. That is quite correct, but it is fair to mention that that category includes the larger part of the general practitioners of the country. Therefore we can say that the larger number of general practitioners are enjoying improved conditions. That applies to areas around London like Mitcham, which are not commonly regarded as industrial but where people are under the income limit which enabled them, before the new Act came into operation, to be panel patients under National Health Insurance.

The difference that the Act has made in many millions of homes is that the wives and families of insured persons get free treatment. That is of enormous benefit to them, as the hon. Gentleman knows. He has been in practice for many years in Colwyn Bay. He will remember an occasion when I brought in an aunt of mine to consult him about her condition, and when he gave her kind and efficient treatment. He knows quite well that one of the defects of the panel system was that women whose husbands were insured were not themselves insured and could not get treatment without paying for it. Therefore they did not go to the doctors for women's illnesses, but suffered from them all their lives, sometimes very seriously indeed. One of the great benefits which the National Health Service will confer upon the population is that many thousands of women, the whole population of women, will have the opportunity of being treated for the ailments to which they are especially subject and which are exactly the kind that disable them frequently. While the panel system was in operation they usually, in working class circles, did not have them attended to because they could not afford the doctor's bill at the end of the month. The same applies to the treatment of children. In those two ways the benefits of the Act will be very large indeed.

While the hon. Member for Denbigh was speaking, I interrupted him to ask him to define what he meant by residential areas. He suggested such places as Colwyn Bay and Llandudno and subsequently mentioned Brighton and the dormitory areas around London. He might have added such places on the coast as Worthing. Those are precisely the places which were over-doctored in proportion to the population.

Sir H. Morris-Jones

What is to be done about it?

Dr. Guest

That is a matter which will not adjust itself all at once. Some of the doctors who settled there were at the retiring age or near the retiring age and they wanted to make not a large income but a certain amount to supplement the income they already had. This was particularly true in the south-west of England. In the early part of the war we had great difficulty in getting doctors from that area to do certain kinds of national service because they did not want to leave their little niches. Some of them were earning £400 or £500 a year. I can quite understand that in those circumstances the abolition of fee-paying practices puts many of those people in very serious difficulties. It is admitted on all hands that this matter must be looked after. It is by no means a matter which is not capable of being well looked after and I think a solution will be found, but it will be a complicated solution in which the same treatment will not be applied to all areas. It is an individual problem for the local organisations.

In regard to rural areas, the hon. Member for Denbigh welcomed the concession made by the Minister. He was quite right. The Minister has made a substantial concession which will no doubt be to the advantage of the rural areas. However, the hon. Member will no doubt agree that in certain rural areas many doctors had too many patients on their panel. I could give him—though not across the Floor of the House—the names of areas where doctors in the past took on a great many more people than they could properly attend. The condition is now correspondingly wórse. As for his instance of the doctor who had to spend three-quarters of a day—I presume in Wales—going to see a man who had broken his leg, I wonder whether the hon. Member himself has not occasionally spent a very large part of one day attending one man. I have sat up all night attending one patient and not being paid anything for it, and my father, who was a doctor, did the same. Every doctor has had that kind of experience.

We cannot calculate our fees on the amount of time we give to patients; we must average them out. That kind of experience must be rare even in Wales, a country which I happen to know fairly well. I do not think that the people there so continuously break their legs in inaccessible places that the doctors are constantly spending three-quarters of a day and walking eight miles in order to repair them. With respect to the hon. Member, I think that was a rather exaggerated instance. I do not want to take up too many of the instances which the hon. Member mentioned, but I feel tempted to do so because I happen to know that country very well. Take Deganwy for instance. Surely that is so near to Conway and Llandudno—forgive me for my pronunciation—that it can hardly lay claim to a separate doctor. There is at present a shortage of doctors. I was not very much impressed by the hon. Member's diatribe about the treatment of foreigners. His picture of the wealthy Belgian—I happen to know a good many wealthy Belgians—coming over here for the purpose of spending his time getting spectacles, dentures and vitamin preparations when he might have been spending it much more pleasantly in other ways, for instance at the Savoy or the Ritz, is not very probable. I do not think the Exchequer will lose a large amount on that account, and if the Belgians were excepted, how would we deal with citizens of the Commonwealth? Would we give them stamped identity cards? The amount involved is not a serious one, even if some extreme crank came over to get spectacles, dentures, hearing aids, expensive vitamin tablets, and the other things which he could get. Indeed, we might get so much advertisement in the Press and the tourist agencies that the outlay would be almost worth while. However, I cannot think anybody would be so foolish as to do that to any extent. What is actually involved is a sudden illness or indisposition and the necessity for somebody receiving medical treatment. Are we to provide an elaborate separate arrangement for that, or a fee-paying arrangement? I think there will have to be some extension of the present system of free treatment.

With regard to specialists, the hon. Member for South Tottenham (Mr. Messer), who holds a responsible position in the medical service of this country, and I myself who happen to be Chairman of the Medical Priority Committee—whose chief headache at the present moment is the provision of specialists—know that there are not enough specialists in the country. It is calculated that an increase of about 50 per cent. of specialists is required to staff the hospitals properly. It is only in the large centres, such as London, Birmingham, Glasgow and so on, that there are specialists. Does the hon. Member realise that the town of Bristol, at the time when the hospital survey was made of those four southern counties, was the only town which had a hospital in it with a full and complete specialist service for that vast area? There is a deficiency of specialists in the eastern counties of England, as well as in many other places, and also in the Armed Forces. It may be quite true—I have no doubt it is—that the orthopaedic surgeon whose case was brought to the notice of the House today by the hon. Gentleman may be in a serious condition, but that is a temporary matter which can be solved when the Spens Committee Report is applied, as it will be.

One hon. Member opposite dealt with the nursing agencies and the co-operative nursing associations. I agree that the position is ridiculous when nurses, after training and qualification at a comparatively small remuneration, join the "coop" and go straight back to the hospital where they were trained at twice or more than twice the salary they were receiving. In view of the fact that the shortage of nurses is seriously holding up medical treatment, I suggest that the Government will have to consider the nationalisation of the "co-op"; that is to say, putting out the people who are running these businesses on a substantial and even generous scale and having these nurses in a nursing service. That is beyond the scope of the present Debate, but it will be valuable to think of it for the future, and I hope the Government will consider whether the co-operative nursing associations ought not to be brought within the scope of a National Service.

Mr. Messer

Before the hon. Gentleman sits down, will he explain that the "co-ops" to which he referred are not Co-operative societies, but are only employment agencies?

Dr. Guest

Yes, they are only employment agencies.

3.55 p.m.

Mr. Assheton (City of London)

I am glad that the hon. Member for North Islington (Dr. Guest) was protected by his hon. Friend the Member for South Tottenham (Mr. Messer) in the interesting suggestion he just made about nationalising "co-ops," which at first sounded to many hon. Members on this side the most attractive part of his speech. I am very glad that the hon. Member for Denbigh (Sir H. Morris-Jones) raised this Debate this afternoon. We have had a number of interesting speeches from both sides of the House, and I was particularly interested in the remarks made by my hon. Friend the Member for Putney (Mr. Linstead). As the House knows, we on this side believe in a comprehensive Health Service, and I am very fully aware of the great advantages to which the hon. Member for North Islington referred, particularly the benefit given to the womenfolk and children of men whose dependents were not catered for under the previous insurance arrangements.

Everybody must be aware of the enormous difficulties created by the introduction of this new scheme. Although we on this side of the House genuinely believe that a number of those difficulties could have been avoided if things had been arranged differently, none the less, we appreciate that there are bound to be great difficulties when such a scheme is first put into operation. This is not the appropriate time for a full dress Debate on the subject—I have no doubt there will be opportunities in the course of the next month or two for raising the question of the working of the service in general—but there are one or two questions I wish to address to the Parliamentary Secretary who, I understand, is going to reply to this Debate.

The most important question I wish to put to him is whether, at the present moment, the medical profession is not finding itself very much overworked, and, consequently, has insufficient time to give to serious illness. That is an entirely nonparty and non-controversial question, but I should like the Parliamentary Secretary to pay some attention to it in his reply. Germane to that question is the question whether the people who really need them most are getting the beds in the hospitals. These are, perhaps, two different aspects of the same problem on which I should like to have the Parliamentary Secretary's views. I appreciate that it is an extremely difficult problem, but I should like to know what ideas the Government have for dealing with it.

I should also like to ask whether there is any possibility of avoiding some of the great delays which patients suffer in getting hospital accommodation. I can quite believe that, in some cases, it is almost impossible to avoid such delays, but one comes across numerous instances which make one very anxious.

Early in October a friend of mine was taken ill. His doctor immediately decided that he should see a specialist, but he was unable to obtain the services of a specialist until the second week of December. The specialist said that my friend should go into hospital for an operation, but it appears unlikely that he will get into hospital for several months yet. That is only one illustration, and I have no doubt that hon. Members could easily give many more. That sort of thing makes one feel anxious to know whether anything could possibly be done to establish a system for dealing with such cases.

Dr. Guest

Was that tuberculosis?

Mr. Assheton

No, Sir, it was not tuberculosis. Then, again, the queues in surgeries have grown enormously, and, possibly, for inevitable reasons. But, on the other hand, is it not possible to give the doctors more help in dealing with some of the work which is not strictly medical work? An enormous amount of their time is taken up with form filling, giving certificates and so on.

It being Four o'Clock the Motion for the Adjournment of the House lapsed. without Question put.

Motion made, and Question proposed, "That this House do now adjourn."—[Mr. Snow.]

Mr. Assheton

A great deal of their time is bound to be taken up with form filling and other non-medical work. I should have thought that some means could be found to relieve them of part of that work and free them for more of the work for which they have been trained. I wish to put a question to the Parliamentary Secretary about hospital costs. I understand that as late as 16th December last the Minister said in reply to a Question that he had received statements of probable expenditure for the current financial year but none had yet been approved. I should like to ask if that is still the situation, because unquestionably it must be leading to great difficulties.

More than one hon. Member has referred to the remuneration of doctors. I have no doubt that there is a great deal of evidence that a large number of doctors, at any rate, are worse off than they were before, and there is also a feeling that the doctors are worse off than any other class of professional men or women in this scheme. That, I think, is probably brought to notice very much by the question of the remuneration of dentists which raises great problems in itself and which, no doubt, will come to be discussed on a subsequent occasion. I am anxious, as the Minister and the Parliamentary Secretary must be, as to how the posts are to be filled in the county dental services. I had put into my hand today a copy of the "British Dental Journal" which has a large number of advertisements for posts in the various county services at a remuneration which, of course, is low compared with that offered in other columns for posts for dentists in ordinary practice. That matter must be giving great anxiety to the Minister. No doubt in due course he will tell us how he proposes to deal with it.

My hon. Friend the Member for Denbigh raised the question of the payment of consultants and specialists and asked whether that problem has yet been solved. Perhaps the Parliamentary Secretary may be able to say something on that subject. I should also like to ask whether it is possible for private patients who have not become part of the Health Service to obtain drugs in the same way as those who belong to the scheme. It seems rather unfair that private patients, who do not take up any of the time of the medical profession who belong to the Health Service, should be deprived of the opportunity to obtain such drugs as are necessary for them which other citizens are granted.

I am afraid that a large number of points have been raised. I know that the Minister requires a considerable time in which to answer them. I hope that he will appreciate that I have deliberately refrained from raising a great many matters which are in the minds of hon. Members on this side of the House and many questions which are agitating the minds of doctors and dentists throughout the country. We have had an opportunity to ask a few questions, and I wish to give the Parliamentary Secretary sufficient time to answer.

4.4 p.m.

The Parliamentary Secretary to the Ministry of Health (Mr. John Edwards)

We have had an interesting discussion and I will do my best in the time available to deal with the fairly considerable number of questions that have been raised. The hon. Member for Denbigh (Sir H. Morris-Jones), I thought rather strangely, took exception to the absence of my right hon. Friend. I know that there are views about the usefulness of Parliamentary Secretaries, but I had always assumed that the one job the Parliamentary Secretary was expected to do was to deal with the sort of administrative reviews that we have from time to time in the House on the Motion for the Adjournment. In any case, I assure the hon. Gentleman that, although no doubt the terminology that I shall use will be different from that which my right hon. Friend uses, I think that my views will be very much the same as his. The hon. Gentleman said it was important that we should be sure that people were getting value for their money, but he spent a good deal of his time asking, as I understood him, for more public money to be spent. That raises fairly considerable issues, some of which were answered by my hon. Friend the Member for South Tottenham (Mr. Messer).

It would be convenient if we considered at the outset some of the difficulties with which the service has had to contend. It has been functioning for just over six months, which for a scheme of this kind is a relatively short period. There is no longer any doubt that it has been welcomed by all classes of the general public to an extent beyond expectations. We knew that the need was great but how great we completely underestimated, and the figures themselves, a few of which I should like to give for purposes of record, bear this out. Taking the family practitioners' services the need is borne out by the fact that about 40 million people have placed their names on doctors' lists. One cannot be precisely sure, but the percentage of the total population who will he in this scheme will be of the order of 95 to 98 per cent.

Sir Hugh Lucas-Tooth (Hendon, South)

Is that taking into account possible duplications?

Mr. Edwards

Yes. There is a margin of error of 3 per cent. which one cannot be sure about, but I am certain that the total will be 95 per cent., and it may be 98 per cent.

Sir H. Morris-Jones

In order that we may be accurate about this percentage might I ask what is the estimated population of this country at present? I have seen it put as high as 50 million by some authority. If we could have that figure it would give us a picture of the proportion.

Mr. Edwards

I am sorry but I have not got that figure. It is obviously of the order of 42 million.

Sir H. Morris-Jones

Surely it is much more.

Mr. Edwards

I am talking about England and Wales but not Scotland.

To take the position as to doctors, 18,165 general practitioners out of an estimated total of about 21,000 have conic into the scheme. Those doctors have already prescribed 75 million medicines or appliances since the service began. If we take the dentists, out of 10,000 in general practice 8,988, which is the last figure I have got, have now come into the service. They have treated 2,200,000 patients and 1,200,000 are under treatment at present. It looks as though the initial peak in the demand for dentists' services has been passed, but even now the demand is running at the rate of about 130,000 a week. More than two-and-a-half million people have had their sight tested under the supplementary ophthalmic service while over three million pairs of glasses have been supplied or are on order.

I have given those figures because wish the House to appreciate something of the magnitude of the whole operation and the fact that, as I said at the start, we had completely underestimated the need. The pent-up demand for these things is much greater than we had anticipated. Now that the Service has been running for about six months, and as the rush is, in some quarters, beginning to subside a little, we are naturally taking steps at the Ministry of Health to review every side of the Service.

Among the things we are considering are of course those remuneration points to which the hon. Member for Denbigh referred. I will say a few words about remuneration, since that is perhaps the most important point that has been raised. I wish to make it plain that we have negotiated with the representatives of the profession at every stage, and that the kind of arrangements which we have made have in many cases not been those which we in the first instance thought to be the right ones, but arrangements which we have adopted at the request of or following representations from the profession.

In the beginning, the remuneration of practitioners for private general medical services under the Act was agreed with the negotiating committee of the British Medical Association. The arrangement by which the bulk of the fee was to be paid in the form of so much per person on the doctor's list was at the request of the profession. While I have no time to give all the details of the remuneration, it is interesting that altogether, taking everything into account, the payments to doctors under the G.P. part of the scheme, from the appointed day to the 31st March of this current year, are estimated to amount to £32,500,000.

In addition, there are Exchequer superannuation contributions which amount to £1,600,000 extra. I believe that that amount overall will be ample to secure that doctors will be remunerated in accordance with the Spens recommendations. I know and I accept the view that distribution has been uneven, but I would remind the House that payments so far have been on a provisional basis, partly because of the administrative difficulties and partly because of a certain amount of inflation of doctors' lists, for one reason or another which I need not go into. We do hope, however, that we shall have eliminated this element of inflation in the doctor's list, and will really get down to firm figures so that final payment can be made, at the end of March, 1949, when all the necessary adjustments will be brought into account.

I recognise that the position of the rural doctor is particularly difficult. Before the appointed day the mileage allowances under the old National Health Insurance scheme helped the rural doctor to meet the extra, costs of travelling, and so on. He was also able, if he was so minded, to charge higher fees to his private patients in the rural areas to meet the extra cost of covering the distances. With the introduction of the new Act, it is no longer possible for the rural doctor to cover his extra heavy expenses out of his private fees. Therefore some time ago we did agree with the profession that we would increase the mileage payments, which are the extra payments to be made to cover ineffective time spent on travelling in the case of the rural doctors, to £1,300,000.

It is quite clear that that amount will not be sufficient to meet the needs of the rural doctors. Therefore the Government have agreed to provide a further sum of £500,000 a year for the purpose. We have also agreed with representatives of the profession that we shall divert £200,000 from the inducement money which is in the Bill, and that will give us a total mileage fund for Great Britain of £2 million a year. That is more than three times the amount available under the old National Health arrangement. I hope it will be used in a way that will bring benefit to the rural doctors.

There are one or two other things which have not yet been brought into line. Broadly speaking, maternity medical fees do not become payable until about two months after the date of the confinement. At this stage, therefore, the full effect of maternity fees has not shown itself in doctors' remuneration. I say to the House quite seriously that when the final payments for the period 5th July last to 31st March, 1949, have been made we shall then be able to see whether the remuneration of general practitioners does, in fact, accord with the Spens recommendations. If it does not, the arrangements will be reviewed to see what adjustments are necessary to give effect to those recommendations.

Reference was made particularly to the question of basic salary. I do not agree about the difficulties which the hon. Gentleman says are arising. Various changes have taken place in the attitude to basic salary. The original intention was that basic salary should form a substantial part of a doctor's remuneration. Then the medical profession said that they did not like that method and the Minister agreed that it should form only a minor part of a doctor's remuneration. Later on the Minister, following representations, said, "Very well, we will give basic salary to new entrants to the profession for a period of three years and to certain others on certain conditions." Finally, the profession still was not satisfied and the Minister agreed with it that the decision whether a basic salary should be given or not should be left to the local executive council after consultation with the local medical committee, with the right of appeal by the doctor to the Minister.

The British Medical Association wanted a different kind of treatment, but the essential arrangements for basic salary and the conditions under which it was paid are wholly to be held to come from the negotiating committee. Here, the Minister did precisely what the profession wanted him to do. There were people who criticised him for doing so. If anything is wrong, however, I suggest that it is for the doctors themselves to go to their own Association rather than to tell us that they have begun to alter their minds. We cannot take the responsibility in circumstances where we have gone about the thing in the way the profession asked. In fact, although I have no detailed information about the number of basic salaries granted by local executive councils, we had the figure some time ago of a thousand cases in which it had actually been granted.

Moreover, we have given advice to executive councils on this subject. We have advised them to give consideration to applications for the basic salary where there is reasonable justification and we have given them examples which include, for instance, a doctor starting a new practice or working a small practice; a doctor who, on account of ill-health or age, is unable to do as much as he would otherwise do; and doctors whose incomes have dropped substantially as a result of the new service. While I do not seek to deny that there may be difficulties here and there, I think they are difficulties inherent in the system which we have adopted at the request of the profession. In so far as we can remove the difficulty by advice to the executive councils, we shall be happy to do so.

The hon. Gentleman referred to the difficulties of the distribution of doctors and quoted particularly a case from Deganwy in his area. It is interesting to note in passing, although not as a matter of principle, that in that case the central medical practices committee have indicated that they would sympathetically consider an application from a doctor to live and practise there but that, in fact, no application has been received. It may well be that because the practice would be small this village will have to be served by neighbouring places, which are not, after all, very far away.

Sir H. Morris-Jones

Is the hon. Gentleman aware that there has been a doctor there for 70 years, and he has made a living quite satisfactorily?

Mr. Edwards

People's notions of what constitute a living have altered as the years have gone by. It would be wrong to say that nothing has been done about the maldistribution of doctors. I have with me a few figures which might be interesting to the House. Since the appointed day 530 general practitioners have died or resigned from the medical list and 532 new doctors have been admitted to the list. Of these 530 vacancies, 230 were filled by a partner, an assistant or a person who seemed to be the logical successor. In 238 cases no successor was thought necessary because the outgoing doctor had only a small list, and in 62 cases the vacancy was advertised and a selection made from applicants. Of course, I do not deny that the filling of a vacancy takes time. To advertise and to give people a fair chance to compete for a vacant post takes time; normally it takes from 2½ to 3 months to fill a vacancy.

Mr. Hastings

Can my hon. Friend say whether consideration is only given to people who already have a house and are living in the area concerned?

Mr. Edwards

No. That is not the case. As my hon. Friend knows, consideration is always given by the committee to what I call the logical successors, but after that if a vacancy is advertised, it is then open to anyone to apply.

Mr. Hastings

Even though an applicant is not living in the area?

Mr. Edwards

Yes, so I understand.

Mr. Hastings

I understand not.

Mr. Edwards

So far, we have only closed up completely two areas, and those areas are Chester and Hastings, although there are some places where small parts of districts have been closed up. I think very soon now the Medical Practices Committee will be able to give a better indication of the under-doctored areas. They are studying reports from all the executive councils which had to be in by the end of December, and when those reports have been considered I am hopeful that much more help and advice can be given.

I do not want to spend time dealing with foreign visitors except to say that I do not know of any way, short of introducing an elaborate new administrative technique, by which we can separate the foreigner from the British visitor from overseas. I believe that to do what the hon. Gentleman wanted, even if it were desirable, would need a new control which would involve an awful lot of time, money, trouble and vexation to all our own people.

In the few minutes which are left to me, may I turn rapidly to some of the other points that have been put to me? I am sorry that I cannot tell the hon. Member for Putney (Mr. Linstead) when the amending Bill is going to be introduced. We have it in preparation at the present time. Nor can I in the time remaining begin to elaborate on the capital side of hospital finance, but I can just give a little information about the apportionment and transfer regulations in which the hon. Gentleman was interested. They were in fact made on 1st May, 1948; they appear in S.I. No. 888. The panel of arbitrators has been set up by the Lord Chancellor under the chairmanship of Mr. Christie, K.C. There are six requests to go to arbitration; five of them were received round about the appointed day, and one was received only last week. The five are carrying on as before pending the arbitration. In the case of the sixth, whose application only came in last week, we have got some difficulties in determining the right course to take. We have been at great pains to try to evolve a procedure which will be fair to those who wish to go to arbitration. I think we have now settled a number of legal points which arose, and I am hopeful we shall be able to refer the first case to the panel next week. I think that tells the hon. Member what he wants to know.

As to the co-operative nursing agencies, I agree entirely that here is a problem which requires very careful consideration. We have already given some consideration to it at the Ministry of Health. It is bound up, I think, with the discussions going on in the Whitley Council concerning the whole field of nurses' remuneration but I assure the hon. Member and others who are interested in the matter that we are giving it our attention.

Finally, I turn to the points raised by the right hon. Member for the City of London (Mr. Assheton). I shall not say anything about local government dental officers, because I cannot add to what I said in the Adjournment Debate just before the Recess. I must reiterate the view expressed by my right hon. Friend that it is impossible for us to agree that the private patient who goes to a doctor should be permitted to obtain drugs through the service. We cannot accept the view that doctors who are outside the service, to whom we cannot apply the principle of public accountability in any way, should be able to prescribe drugs for their private patients. I am sorry, but that is the position as stated by my right hon. Friend from which I cannot depart at all.

Turning to the question of estimates of hospital expenditure, the position is as on the 16th December last—that is to say, estimates have not been approved but, of course, they do not apply until the beginning of April and we must have time to co-ordinate this whole business if we are to keep our National accounts in proper order and in the sort of state which would appeal to those who scrutinise them so carefully.

There was a point of real substance in what the right hon. Gentleman said about the use of hospital beds. I know of cases where there are delays—long delays. I do not think there is anything new about that. I think it was so before the appointed day. Those delays are due either to actual lack of accommodation or to lack of staff to look after the beds which exist. Although we have more nurses than ever we had, and although we have as many nurses coming forward as ever we had, we are still dreadfully short. Having said that, however, I assert that it ought to be the rule throughout the country that beds are allocated in accordance with medical need. If it should happen that any hon. Members come across cases where they think that rule is not being observed, I should be grateful if they would let me know. There should be no way in which the genuine medically urgent case can be by-passed by less urgent cases in any block of accommodation, whether a private, paid block or anything else.

In conclusion, there can be no doubt that there are some sections of the medical profession which are very much overworked at the present time. I wish it were possible to give them some help. I have never thought any other than that, try as we might to plan, much as we might rely on the regional boards and management committees, in the end the scheme would be a success or a failure in accordance with the degree to which we obtained the skill and devotion of the people who work in it. I have been pleased by the co-operation we have had up to date and I look forward, as time goes on, to our improving this scheme, which is young yet, and in which, no doubt, there are still a number of anomalies.

Question put, and agreed to.

Adjourned accordingly al Twenty-Nine Minutes past Four o'Clock.