§ Order for Second Reading read.
§ 4.9 p.m.
§ The Minister of Health (Mr. Marquand)
I beg to move, "That the Bill be now read a Second time."
The circumstances which have made it necessary to introduce the Bill were described by my right hon. Friend the Chancellor of the Exchequer when he opened his Budget. My right hon. Friend then explained that he was providing for this year an increased expenditure on education, pensions and other social services of nearly £50 million, and that he could provide an increase of £7 million for the health services of Great Britain but no more.
Many who have criticised or commented upon our present proposals have ignored, or maybe misunderstood, the fact that the Government have agreed to increase the total expenditure on the Health Service. The Estimates already presented to the House total £398 million net expenditure. That is £5 million above last year's combined Estimates. Since then the Chancellor of the Exchequer has agreed that maximum expenditure during this year may reach £400 million net. That is—do not let us have any doubt about this—£7 million more than last year's Estimates. It will be even more than that above last year's expenditure. It will be £55 million more than was actually spent in the year 1949–50.
This is hardly the time to discuss whether or not my right hon. Friend the Chancellor of the Exchequer should or could have provided an increase of more than £7 million. We have had several days of discussion on the Budget statement already, and I would only say to some of my hon. Friends that even if there had been more money available it does not follow, as the night the day, that it must necessarily have gone to the National Health Service. Education, war pensions, old age pensions, and child allowances all received increases, but, if still more money was available, these items also, like the National Health Service, would rank high among the claimants for whatever was to be shared out.
233 But when my right hon. Friend the Secretary of State for Scotland and I framed our Estimates for this year we found that if we were to accept the full estimates presented to us by the regional hospital boards we should require not £7 million but £30 million more than last year's Estimates. Why should that be so? Why should the present service require £30 million more than last year? Mainly because of the rise in the cost of the hospital services. The hospital service accounts for roughly 60 per cent. of the total cost of the National Health Service. There have been increases in costs elsewhere in the service. For instance, the influenza epidemic this year and an increase in the cost of drugs, especially imported drugs, have caused increases in expenditure in the pharmaceutical service, but such increases are more or less offset by savings elsewhere.
It is a fair summary to say that the heart and core of the National Health Service—by which I mean the hospital service, the consultant service, and the general practitioner service—when we looked at the accounts, seemed to require £30 million more than the Estimate for last year. I have said that this is mainly due to a rise in hospital costs. Some of that is due to a rise in the price of supplies. Sheets and blankets cost more than they did and surgical dressings are made of imported raw materials which have risen very sharply in price. Rubber gloves, even food, and a thousand essential items, have risen in cost during the year and that has to be taken into account. The biggest single item in the increase comes from improvements in wages and salaries which had already been negotiated during the last year. They have not yet all come into full force. The full weight of that expenditure is only just beginning to be felt, but during this year we must allow for that burden.
Some part of the increase in hospital expenditure arises, of course, from extension of the service. Hon. Members on both sides of the House continually draw my attention and the attention of my right hon. Friend the Secretary of State to long waiting lists and to the need for more beds for chronic sick, gynaecological cases and other deserving groups. We are making some provision for more accommodation and more beds because 234 we hope that the improved conditions will bring forward more staff to run them.
In particular, we are making greater provision for the treatment of tuberculosis. In 1945 there were in England and Wales 24,000 deaths from tuberculosis. In 1949 the figure had fallen to 20,000. The figure for 1950 is not yet known with complete accuracy, but I can provisionally estimate it at 16,000. Not only have the deaths fallen in the last year but for the first time the notifications have also fallen despite the wide use of mass radiography and the detection of unsuspected disease by that means.
Since the start of the National Health Service over 3,500 additional beds have been made available for the treatment of tuberculosis in England and Wales. My aim this year is to provide 2,000 more. A very modest part of that provision will be about 150 beds for England and Wales and the same number for Scotland to be provided in Switzerland. This is provided for, as hon. Members will see, in Clause 3, which empowers us to spend money abroad for this purpose, which at the moment we are not entitled to do. I shall not say much about this just now. I do not want to detain the House too long. My right hon. Friend may be able to say more about it.
We have agreed, each of us, to undertake an experiment of equal size so as to compare results. I do not think any Englishman or Welshman would have expected me to insist on a Goschen formula on this occasion. After all, the incidence of tuberculosis is heavier in Scotland than it is in England and Wales, and in this task of providing additional beds and staff my right hon. Friend, with his smaller responsibility in this field, has not, as it were, the same wide field for manoeuvre that I have. Those are the reasons why we have chosen to take an equal share in this new and somewhat experimental venture.
The figures I have given show that we have achieved good results in our war on this deadly enemy of mankind. We shall continue to make war on tuberculosis with the same resolution as our fathers made war on smallpox or as we ourselves have been making war on diphtheria. So we must maintain and safeguard our hospitals. Indeed, we have to expand them. Even during the next 235 few difficult years there is to be some expansion in the general hospital facilities and a considerable expansion in hospital treatment of tuberculosis.
There must also be some increase in other essential services, for instance, the provision of better facilities for the group practice of medicine by general practitioners. We all know now that it is impossible in this difficult time to pursue, as it was hoped to do when the National Health Service Act was passed, the establishment of large numbers of health centres. We know the reasons for that. We cannot have elaborate health centres and schools and factories and all the other things for which we need building resources.
But here and there through the country I have already discussed and agreed with those concerned—indeed, my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) did this before me; I am not claiming all the credit—the possibility that where facilities are inadequate at the present time for a proper general practitioner service, for example on new housing estates, and where the doctors are willing to engage in group practice, provision may be made for group practice centres.
For all these purposes—I am sorry if I have gone over them so quickly but I am afraid it is necessary this afternoon—we need more money than my right hon. Friend the Chancellor of the Exchequer could see his way to provide. The measure we have taken to get that money has been described in some quarters as an attack on the Health Service or as the first step in dismantling the Service. I am tempted to voice the indignation I felt when I read those words, but I will refrain. Instead, I hope that my hon. Friends will reflect on what I have said this afternoon about the intentions and plans of myself and of my right hon. Friend to expand and develop the hospital and general practitioner service and that they will realise that their criticism is ill-founded.
Let me sum up this portion of my speech. My right hon. Friend and I had before us Estimates requiring £30 million more for the proper maintenance and for some expansion of the essentials of the Service. The Chancellor could provide us with no more than £7 million. Therefore, we must find £23 million from 236 within the Service. The "Manchester Guardian" said the other day that this was a new argument. New? It is the only argument that has been before the Government during the whole course of these discussions. It is the argument which my right hon. Friend and I have been pursuing and exploring between ourselves and with our colleagues ever since the beginning of February. There is no suggestion that anyone can make that we have not explored during that time. It is not a new argument, because it is based on settled Government policy.
In April, 1950, when the Chancellor's difficulties were not so great as they are today, Sir Stafford Cripps said:It is clear that it is not possible in existing circumstances to permit any overall increase in the expenditure on the Health Services. Any expansion in one part of the Service must in future be met by economies or, if necessary, by contraction in others. In exercising this essential control over total expenditure, regard will of course be had to priorities."—[OFFICIAL REPORT, 18th April, 1950; Vol. 474, c. 59.]That was in the Budget speech last year and every Member of the Government at that time was committed to it and I presume accepted it.
§ Mr. Marquand
Because of the doctrine of collective responsibility. This time we had to determine the priorities. Needless to say, it was the duty of my right hon. Friend the Secretary of State for Scotland and myself to guide our colleagues in the ascertainment and determination of those priorities. There was not a sudden bursting out from the blue by the Chancellor of the Exchequer telling us that we had to reduce on teeth and spectacles. Of course not. It was we in discussion with our colleagues who found what we thought was the most suitable point at which to make the charge. We had to preserve the essential expenditure. The general practitioner and hospital services together account for some 75 per cent. of the total expenditure. Out of the remaining 25 per cent.—about £98 million last year—we had to find £23 million. Could we have found £23 million from £98 million by economies without making charges? That question can only be asked by those who have not noticed the economies that have been made.
237 I may mention briefly some of these economies which were instituted by my right hon. Friends the Member for Ebbw Vale and the Secretary of State for Scotland. For example, the Ministers are authorised to pay travelling expenses of patients in any cases of hardship when they have to visit hospitals. Since last September the assessment of hardship has been transferred from hospitals to the Assistance Board. Again, in 1949 there was a 20 per cent. cut in dentists' remuneration, and in May last there was a further 10 per cent. cut. Similarly, there have been two reductions in the remuneration of ophthalmic opticians and ophthalmic medical practitioners. In May, 1950, there were increases in charges for spectacle frames. The institution and extension of central purchasing of materials and appliances have saved £2,800,000 a year as compared with the previous methods which were in use.
As for the chemists, their on-cost allowance for prescribing was reduced on 1st May from 33 per cent. to 16 per cent. That was a provisional figure and may have to be adjusted. In this field of the pharmaceutical service, the Joint Committee on Prescribing has done very valuable work. Some notable reductions in the prices of particular preparations have been achieved as a result, but the full value of its work in recommending types of remedies suitable for prescription has yet to be achieved. That subject is now under discussion with the profession, and I say, in all seriousness, that whatever method anyone can suggest for reducing unnecessary consumption of medicines he must have the co-operation of the medical profession if he is to make it effective.
To conclude this account, we have had close control of the budgets of the hospital authorities with a monthly return of expenditure. My right hon. Friend the Member for Ebbw Vale established teams of experts to review the hospital establishments. The administrative and clerical teams have visited 14 regional boards, 51 management committees and 13 boards of governors. The medical teams have visited 63 groups of hospitals, the nursing teams 57 and the domestic teams 20. Similar activity is going on in Scotland, because we keep closely in step on all these matters. These are substantial and considerable measures of economy and 238 of improvement in the administration without sacrifice to the Service.
§ Mrs. Braddock (Liverpool, Exchange)
Has there been any inquiry into the specialist services and the cost of those services?
§ Mr. Marquand
There are inquiries going on all the time, but I am not aware of any special or particular inquiry apart from what I have said—the visits of these expert teams to each hospital in turn to review the establishments of those hospitals.
Some of the results of these economies were achieved last year. Some of them will produce results only this year, but all of them will go on. After carefully reviewing all these changes and improvements, and looking at this problem of the gap of £23 million, I decided, after long thought, to reduce the hospital estimates which I at first presented to my right hon. Friend the Chancellor of the Exchequer. So did my right hon. Friend the Secretary of State for Scotland.
Between us we cut the estimates by £10 million on the hospital side of the budget, and I would like to express my appreciation of the way in which the regional hospital boards, to whom these decisions have been conveyed in detail, have collaborated in the discussion and the acceptance of those reductions in estimates which were put forward in all good faith. They have done very well indeed. That is a reduction of £10 million in their estimates of their necessary expenditure. It is not a reduction over last year's expenditure, as I shall show in a moment. We thus reduced the gap of £23 million by £10 million to £13 million. We could do no more. It would be self-deception and deception of the House of Commons to pretend that we could.
It was absolutely necessary to obtain money from charges upon some other parts of the Health Service so that we could maintain the essentials. The charges that we now propose are estimated to yield us £13 million in this year. With the aid of that revenue we plan to spend £15 million more on hospitals this year than was estimated for last year. But in a full year we expect to receive £25 million from the charges. Thus, in the next financial year we shall, despite the ceiling of £400 million, have £12 239 million more available to meet essential needs, and possibly rising costs, than we have this year.
§ Mr. S. O. Davies
We are all pleased to hear of the administrative economies which have been effected during last year, but is not my right hon. Friend confusing administrative economies with the violation of the basic principles on which the National Health Service was reared?
§ Mr. Marquand
I intend to answer that question in the course of my speech, if not immediately.
I hope that I have made it clear that the decision to ask for authority to impose charges is not a tax on the Health Service; it is a readjustment within it. [HON. MEMBERS: "Oh."] It is impossible to have listened to me with understanding without realising that that is so. The proposed imposition of a charge for dentures and spectacles need not necessarily be regarded as a permanent feature of the National Health Service. The proposed charges, if agreed by the House, could be revoked or modified by Order in Council on an affirmative resolution.
When we considered where to levy charges, we had four criteria in mind. The first was to provide the income required for the maintenance of the essential parts of the Service. The second was to levy the charge as little as possible on any person who was seriously ill. The third was to avoid a high cost of collection. The last was to have regard to the possible deterrence of abuse.
The prescription charge which was previously considered may satisfy the last requirement, but it does not satisfy the others. When all feasible exemptions on grounds of hardship are made it would yield only £6 million, and even then it would not exempt children. It would be very difficult to collect, and if there were exemptions—and there must be exemptions, especially, of course, the disabled war pensioner, who for 30 years has had his statutory right to free drugs and dressings for his war disability—the charge would inevitably fall, whatever exemptions were made, repeatedly and regularly on the chronic sick and ailing.
We looked also at the so-called "hotel charge" in hospitals. But all patients in hospital are sick and ill and unable to earn. The vast majority have lost their 240 wages and receive only sickness benefit. Even then, if they stay for more then eight weeks that benefit is reduced to allow for home savings. In my judgment, if there has to be a charge the best charge is one on appliances, not one on treatment or services.
There is one group of appliances supplied through the hospitals and largely bought by the Ministry of Pensions. It includes a very wide range of articles—artificial limbs, splints and calipers, invalid carriages, surgical belts, even wigs. The total expenditure on all that is only about £3,500,000, and if a 50 per cent. charge was levied on that it would yield less than £2 million. [An HON. MEMBER: "Who wants to levy it?"] I am explaining that every possible instance of a charge was considered. I am explaining why some of them were rejected. Let us hope that this explanation may prevent anyone in future from wanting to do it.
§ Mr. W. Griffiths (Manchester, Exchange)
The Minister has just made a point which I should like him to clarify. He is saying that the proposal to make a hotel charge and the other proposals examined, were rejected only because they did not measure up to the needs of the economies required. Does not that involve a serious departure in principle?
§ Mr. Marquand
If my hon. Friend reads my words in HANSARD he will see that I rejected every one of them because they would impose repeated charges on people who were sick and ill. That is the principal reason for rejecting them, and if I adduce subsidiary reasons also, it does not mean that I do not believe in the principal reason. Of course I do. I am trying to give the House the fullest possible information so that Members cannot feel that any reasonable economy was excluded.
If, as I said, a levy or a charge were to be imposed on some of these articles, which some people have mistakenly regarded as unnecessary, it would yield a very small income indeed. As for abuse, I hope that hon. Members do not take their ideas of the National Health Service from the music hall. Like all these other appliances, wigs are prescribed only on the authority of a hospital consultant. I do not regard any of these articles as unnecessary. I regard them as urgently 241 necessary for the welfare of sick and ill people who need them to enable them to get to their work and carry on their job.
The only appliances which can reasonably satisfy my four criteria in full are the ones we have chosen—dentures and spectacles. I shall be asked how it can be possible that the small charges proposed in the Bill can raise the estimated sum. I asked that myself. It is easier to understand when one learns that £43 million was paid to dentists in 1949–50, of which 5 per cent. was for examinations, 6 per cent. for extractions, 28 per cent. for conservative work and 61 per cent. for dentures. This heavy demand for dentures has greatly worried the responsible members of the profession. We all know that the school dental service has suffered since the National Health Service started. There are not enough dentists in Britain to cater properly for the whole population. We cannot achieve an ideal solution while that situation remains, as it must remain for some years while more dentists are being trained.
In that situation we must have regard to two main objects in our policy—to safeguard our children's teeth and to encourage conservative work as far as we can. [Interruption.] I am riot speaking in a party sense. Early in March the Standing Dental Advisory Committee of the Central Health Services Council, which is a very important body, passed the following recommendation, which was sent to me:That, since the existing manpower is inadequate to meet the needs of the whole population, in order to increase the availability of dental services the Minister should be asked to consider measures to limit the demand for dentures under the general dental services.They explained that they saw no way of doing this other than by charging. I was bound to attend carefully to advice coming from that quarter. I believe that the institution of the charges will have some effect, as the Committee hoped, in diverting some of the demand from dentures to the more desirable parts of the dental service, and that there will be some beneficial result to the children.
§ Mr. Michael Foot (Plymouth, Devonport)
My right hon. Friend has quoted that authority on the subject Will he say who decides whether dentures are to be put in—the dentist or the patient? Surely it is a criticism of the dentist that 242 too many dentures have been put in? How will the charge prevent that from taking place?
§ Mr. Marquand
It may well be a criticism of some dentists, but it has been made by my Standing Dental Advisory Committee, a sober and responsible body, representative of the most highly qualified and eminent members of the profession. There are to be no charges for dental treatment of any kind, solely for dentures. Hospital in-patients will not pay for them. Children rarely, if ever, need them; if they do, the School Dental Service would provide them free.
§ Mr. Baird (Wolverhampton, North-East)
May I interrupt on one important point? Is it correct that bridgework does not come within the terms of the Bill, but that dentures will have to be paid for?
§ Mr. Marquand
I am not certain about bridges, but I will ask my right hon. Friend to deal with that point when he winds up the debate. The important point, however, is not whether bridges are to be paid for or not. It is that there is to be no charge whatever for treatment, no charge need fall upon children, no charge need fall upon expectant mothers. If the latter require dentures, they can obtain them free through the local authority dental clinic.
In short, the charge is not levied upon the sick and ill or upon children, and it may have valuable effects in steering demand in the right direction. Some hon. Members have suggested that after the Bill becomes law some persons who were insured under National Health Insurance up to 1948 may be at a disadvantage because their approved societies provided dentures. Out of a total insured population of 21 million before July, 1948, fewer than 14 million were entitled to dental benefit. That is about 28 per cent. of the total population. Even so, the vast majority of those entitled to dental benefit received no more than half the cost of dentures and half the cost of dental treatment.
Under the Bill there will be no charge at all for treatment. In any case, this 243 argument is of no value since only one-eleventh of the Health Service is paid for from the Insurance Fund and, of course, the service covers wives, children, pensioners and other non-insured classes and provides an enormously wider service than National Health insurance afforded.
I turn now to spectacles, of which some 20 million pairs have already been supplied by the service. The charges for spectacles at present vary from nothing to 15s. 1d. per pair. Even with these charges, however, there is some evidence of abuse, although I do not want to exaggerate. For example, in the April number of "The Executive Council," published before the Budget, there was a report of a meeting some time before at Kingston-upon-Hull, from which I will quote some remarks of the chairman, Alderman R. E. Smith, who happens to be a member of the Labour Party. He said:Insufficient evidence is available to enable drastic action to be taken, but the Council is aware that persons are not taking due care of the appliances such as dentures and glasses which have been supplied at the cost of public funds. Far too many applications for replacement of and repairs to dentures and glasses are being received by the Council; persons who have been supplied with glasses and are experiencing difficulty with them, instead of returning and explaining their difficulty to the optician who supplied the glasses, are visiting other opticians and incurring a second sight test fee which has to be paid by the Council.
§ Mr. Emrys Hughes (South Ayrshire)
Is my right hon. Friend aware that the Joint Under-Secretary of State for Scotland said only last week that there was no widespread evidence of abuse of the service?
§ Mr. Marquand
I agree entirely with my hon. Friend the Joint Under-Secretary of State. Those are almost precisely the words I used. I said there was some evidence of abuse, but that I did not want to make too much of the point. However, I wanted to indicate that there was some abuse.
Here, again, there is to be no charge for in-patients in hospital, no charge for spectacles in children's frames, no charge whatever to anybody for testing and examination of the eyes. The charge will not fall upon those who are sick and ill. For both sets of charges collection is simple. The customer will hand over the cash to the dentist or optician and will 244 receive a receipt free of stamp duty. The dentist or optician will receive payment at the price already agreed with the Departments minus the amount of the legal charge. There is the minimum of trouble and fuss, the minimum cost of collection, the minimum possibility of evasion.
Finally—and this is important—to safeguard against the imposition of any hardship upon any deserving person, the National Assistance Board is to be empowered to make grants towards meeting these charges to any person who suffers hardship thereby, even though such a person is in work. This may be particularly valuable to lower paid workers who have a number of children. Powers are necessary because at present the Assistance Board are not empowered to make grants for medical supplies. But no wide recourse is likely to be necessary to these arrangements under the Assistance Board because, after all, dentures, unlike medicines, are things which people require comparatively rarely during their lives. There are long intervals during which they can make provision for the eventual payment for these things. It is no great hardship—it can hardly be—to pay two or three or four times in a lifetime for one or other of these things.
In my speech I think I have dealt with all the operative Clauses of the Bill except Clause 2. We have deliberately stated the charges in the Bill instead of providing that they be made by regulation. Clause 2 provides that an affirmative resolution will be necessary to change them. This is because we are asking Parliament to commit itself only to such charges as are appropriate at this present difficult time. The House will have seen from my explanation that we feel certain we shall need this money from dentures and spectacles for the next two years in order to pay for more essential parts of the service.
I have explained that I need £13 million this year and £25 million next year because of the rising cost of the hospitals and because of the reduction of £10 million which I made reluctantly this year. If there has to be any change at the end of that period, or within it, as the result of any wider changes which may occur outside, this Clause provides that the Government must come to Parliament for an affirmative resolution. If there should be a calamitous change of 245 government, and if an anti-social party came to power and wished to increase the charges, it would have to go to both Houses for an affirmative resolution before it could do so.
This is a necessary but modest proposal to fortify the essential parts of the Health Service in an emergency by making a small retrenchment in its less essential features to provide for an expansion in the most important. My right hon. Friend the Member for Ebbw Vale said yesterday that the National Health Service was something of which we were very proud. He need not have used the past tense. I am very proud of it. I acknowledge the great part he played in creating it. I would not stand at this Box today if I thought that the service was being dismantled, and so long as I am entrusted with the task, I shall try to strengthen and sustain it.
§ 4.50 p.m.
§ Sir Hugh Lucas-Tooth (Hendon, South)
I hope the House will forgive me if I start on a rather personal note. I feel like a newly commissioned officer—perhaps I should say a non-commissioned officer—leading his party for the first time on patrol. The intelligence reports which I have received are a little confusing. The civilian population, apparently, are not unfriendly and the enemy forces are not likely to be in very aggressive mood. At all events, they are likely to avoid a major conflict. The trouble is that there are some bandits in the bush——
§ Sir H. Lucas-Tooth
—and we do not at present know quite how many they are or what line they will take. I can tell the Minister right away that I do not regard it as any part of my task to save him from the bandits, who are, after all, deserters largely from his own military headquarters. The bandits are there because he is there, and it makes very little difference to us on this side whether they seek to influence the enemy high command by pressure from inside or from outside. My task this afternoon is to examine the Bill on its merits.
246 The Bill itself is of very narrow scope. If these proposals stood by themselves, I do not think there would be very great interest in them either in the House or in the country. True, they affect every section of the community and sooner or later, unfortunately, every person, but they are not really more widespread than many other imposts which have been inflicted upon our people. The total money involved—£25 million or thereabouts—is really not a large proportion of the present Budget. The importance of the Bill, as the Minister recognised in his opening speech, is its setting in the National Health Service as a whole, and it is that aspect which will call for most attention this afternoon.
The Minister gave some figures in this connection, but I should like to remind the House of the growth of the cost of the service since it began. The two National Health Service Acts—one for England and Wales and one for Scotland—came into force on 5th July, 1948. For the first nine months, to 31st March, 1949, the cost of the service for Great Britain was, in round figures, £208 million. By adding the necessary fraction, it will be seen that the cost per year over the first year of the service was £273 million. In the following year, ending 31st March, 1950, the cost amounted to £358 million—that is to say, an increase of £85 million over the cost of the previous year. I am not now speaking of the increase over the estimated cost, but of the increase in actual cost from one year to the next.
In the following year, ending 31st March, 1951, the cost came to £393 million—that is to say, a further increase of £35 million. The estimate for the current year which the Minister has mentioned is £398 million, making a further increase of some £5 or £6 million, although it should, of course, on the same comparable basis as the other figures I have given, have been £30 million.
That is a picture of absolutely steady growth. I think it would be fair to say that at the early stages of the scheme the growth in the cost of the Service worried hon. Members in all parts of the House. Everybody, I think, felt that the steadily rising cost was something with which we must be concerned. Hon. Members opposite comforted themselves with the assurance, which they received 247 from the then Minister of Health, that this was merely the initial demand making good the neglect of the past. That was the case that was put forward, but that case has been completely belied.
§ Sir H. Lucas-Tooth
I shall deal with that in due course. The Minister has referred to the cuts already made in the service, and they, of course, mean that the real growth has been greater than the figures indicate. Taking the Bill in its setting, the fact remains that there has been a steady growth in the service. It was not merely an initial spurt, but it has been a steady growth in tens of millions of pounds every year.
It is true that over this period of two or three years there has been a steady rise in prices—a fall in the value of money—but that rise in costs has not been in any way comparable with the increase that has taken place in the cost of the Health Service. The right hon. Gentleman did not try to make that case this afternoon. As he pointed out, a number of cuts have already been effected on various parts of the service. There has been a cut in the remuneration of the dentists, the opticians and the chemists, and that, of course, has produced a fall in the Estimates and in the actual expenditure in respect of those parts of the service.
I take the view, and I think it is the view taken by my hon. Friends on this side of the House, that those cuts were, in themselves, very unfortunate. They did no good to the service. It is no good expecting to get a steady inflow of new recruits into the important professions involved if would-be candidates begin by being faced with a series of cuts taking place every year. It has done a lot to prevent the new recruitment to these important professions, and indeed——
The Secretary of State for Scotland (Mr. McNeil)
The hon. Member's argument is very interesting. Is he advocating the restoration of the agreed cuts in dentistry and optics?
§ Sir H. Lucas-Tooth
No, I am not saying that at all. What I am saying is that the Government have felt obliged to make 248 those cuts, one of the consequences of which was very unfortunate. We on this side have not attempted to resist these cuts being made. Prayers have been put down by hon. Members opposite, and we have resisted the temptation of trying to make political capital because we felt that the cuts were right; but, nevertheless, they were unfortunate. Moreover, they cannot be repeated indefinitely. They have effected a reduction in the actual expenditure on the service in the year for which they were made.
§ Mr. Baird rose——
§ Mr. Deputy-Speaker (Colonel Sir Charles MacAndrew)
If the hon. Member for Hendon, South (Sir H. Lucas-Tooth) does not give way, the hon. Member for Wolverhampton, North-East (Mr. Baird) must not remain standing.
§ Sir H. Lucas-Tooth
Those cuts, of course, produced reductions in the increases each year, but, having made the cuts, nothing more can be done to produce a further reduction in the increases in subsequent years and it is that tendency which we have to face at present. The fact is that the cost of the Service has risen, is rising and will continue to rise unless definite action is taken to stop it. In those circumstances, the Chancellor said, in his Budget Speech:We decided that the Health Service estimates must be brought within a total of £400 million, which, for the time being, would have to be a ceiling."—[OFFICIAL REPORT, 10th April, 1951; Vol. 486, c. 851.]Two questions arise from that statement of the Chancellor and they are both vital to the consideration of this Bill. The first is, why have the Government picked on the sum of £400 million as a limit? The second is, assuming that we have such a total amount, whether it is £400 million, or £425 million, or £375 million, or any other figure, are we getting the best value we can from that large sum of money we are spending? I am not at the moment speaking of waste. There is, no doubt, a certain amount of waste in the Health Service; there may be a difference of opinion on either side of the House as to how great it may be, but I am not referring to that. What I am posing is this question: Are we expending such resources as we have on the really essential 249 parts of the Service, or are we perhaps wasting part of our resources by spending them on the less essential parts of the Service?
I would like to say a word or two about the first question, why have the Government taken the total of £400 million as their ceiling? I think I would be out of order if I tried to go in detail into the finances of the Health Service, but it is right that I should state the attitude of the Opposition to the basis of the policy which has been stated by the Chancellor of the Exchequer. Our view on this matter is that the recent Minister of Health was trying to do too much and to do it too fast. What he did was to try to bring in a completely comprehensive and a completely free health service all in one day. No such feat had been attempted since the time of the Book of Genesis.
By taking off all charges over the whole Health Service, with certain negligible exceptions, he took the brake off all demand. There was no limit to the possibility of demand, so far as the patient under the Health Service was concerned, after the entire service had been made free. The Minister did that before there was any possibility of providing adequate supply to meet that demand. That was the trouble and, indeed, in the three years or so since the Health Service has been in existence, very little has been done to increase the necessary supplies.
What we have here is too many patients chasing too few doctors, dentists, hospital beds and all the rest. We have here an inflation within an already inflationary situation.
§ Sir H. Lucas-Tooth
I am posing the problem. The result of that was both serious and damaging to the national finances and was also serious and damaging to the new Health Service itself. Hon. Members below the Gangway opposite do not seem to realise that the potential increase in demand for the Health Service is still completely unexhausted. Hon. Members in all parts of the House know of patients in our constituencies who cannot get into beds, of long queues in outpatient departments and of constituents who complain that they cannot get dental treatment.
§ Sir H. Lucas-Tooth
It is not new. I am saying that this demand is still completely unexhausted.
The right hon. Gentleman himself referred to the need for health centres. In all parts of the House we are most anxious to see these health centres in operation, but the most recent estimate of the cost of building the health centres alone—quite apart from running them—is of the order of £500 million. That is the size of the demand which is still waiting to be met by some sort of supply under this Service; and to meet that demand completely would involve quite unlimited expenditure, something far beyond what any hon. Member in this House could contemplate as being possible at present.
If our sole criterion in the building up of this service is demand, the inevitable result will be that sooner or later the responsible Chancellor of the Exchequer must say that there will be an arbitrary limit set on what we can spend on this service. That was the inevitable result of the policy of the right hon. Member for Ebbw Vale (Mr. Bevan) when he brought in the Health Service and it is not really for him now to complain. May I say, with all the sincerity at my command, that we on this side of the House recognise the importance of the health of the people.
§ Mr. Mikardo (Reading, South)
Is that why the hon. Member's party were fighting the National Health Service Bill?
§ Sir H. Lucas-Tooth
If hon. Members make that kind of accusation, they deserve the fate which is awaiting them. If we are to have a Health Service then that service must be as effective as possible within the financial and other means we can bestow upon it. But the fundamental mistake which the right hon. Member for Ebbw Vale made was in the inception of the scheme; in making the only criterion of its size the need to meet the demand of a free service. I would have preferred to see the service built up by definite stages, first keeping in mind the real priorities at which we were aiming and, secondly, the economic ability of the country to pay for it. We would then have avoided the kind of 251 reversal of policy we have seen only too often in this service, which is doing it so much damage, and we would have had a better service today.
There is one provision in the Bill which is wholly welcome. That is Clause 3. The treatment of tuberculosis is of paramount importance and no one, in any part of the House, will question the rightness of the Government taking these powers. I would like to ask the right hon. Gentleman why the Bill is limited to respiratory tuberculosis. There does not appear to be any reason for so limiting it. If, indeed, that is the more urgent type of case with which he wishes to deal he could put that in the regulations which he will make in due course.
I would ask the right hon. Gentleman what methods he envisages for bringing this Clause into effect. Is it intended that payment should be made direct to the patients concerned; or are the payments to be made through the hospitals, or the local authorities, or in what other way? And how are the patients who are to receive this treatment to be selected? The number is very small indeed, unfortunately——
§ Sir H. Lucas-Tooth
—in relation to the demand, and we would like to know how it is expected that some will be chosen for this treatment. We have never complained of expenditure in this respect. We have always said that this disease was disappointingly intractable to improved methods of diagnosis and improved methods of treatment. As the right hon. Gentleman said, there has been some slight improvement—not great—in the mortality rate. Unfortunately, however, there has, if anything, been a lengthening of the waiting lists for treatment.
I do not want to do the right hon. Gentleman an injustice. The lengthening of the waiting lists, it must be admitted, is due largely to earlier and better means of diagnosis. But what is the good of having better forms of diagnosis if we take no steps to meet the situation disclosed? We have been pressing the Government for fully a year to take exactly the powers contained in this 252 Clause. My right hon. and gallant Friend the Member for Kelvingrove (Lieut.-Colonel Elliot), my hon. Friends the Members for Luton (Dr. Hill) and for Tynemouth (Miss Ward) and other hon. Members, have pressed the Government, by Questions and in Adjournment debates to take just this power. There has been a really appalling delay, which is quite unexplained by the Minister.
§ Mr. Mellish (Bermondsey)
I am sure that the hon. Member wishes to be fair. The Government have given the question of tuberculosis a great deal of attention. Indeed, all the general hospitals were asked, at the request of the Minister, to open a ward wherever possible for the treatment of T.B. patients. Do not let it go out from this House that we have not been bothering about it.
§ Sir H. Lucas-Tooth
Unlike some of his hon. Friends who are sitting behind the hon. Member, I do not throw out allegations which I cannot justify and which I do not believe to be true. I quite recognise that steps have been taken, but I am saying that here is a step which we pointed out a year ago which could and should be taken. Either the Government have been slothful about taking it, or, what I believe to be more probable, this is an illustration of the present muscle-bound inertia of the scheme set up by the right hon. Member for Ebbw Vale.
Regarding the second question which arises upon the statement of the Chancellor of the Exchequer, I must turn to the more controversial parts of the Bill. I wish to ask the Government why they chose false teeth and spectacles particularly for this form of charge. The Minister gave some explanation, but I am not altogether satisfied that that explanation is really valid in the light of what has been said in the House on earlier debates. The House will remember that the Government proposed some two years ago to put a charge on medicines.
I think it would be of interest now to see what was said in the debate in which the Clause empowering such a charge to be imposed was added to the Bill. The right hon. Member for Ebbw Vale, who was then Minister of Health, said this:…we came to the conclusion that if we could in some way reduce the queues at the surgeries and the unnecessary expenditure at the chemists' shops it would be a good thing. 253 It is not correct to say it is only on the side of bottled medicine that some of the abuse has taken place—it is aspirins, bandages and so forth, costing less than 1s., which in a large number of cases could have been purchased by the patient without having to call on the general practitioner, or without making a second call on a doctor for a prescription. That is where the abuse arises. It is no use my hon. Friends telling me that this is not the case, because this proposal has not, in fact, been received with much indignation, as it is generally accepted that there is an awareness of the abuse which has been taking place."—[OFFICIAL REPORT, 9th December, 1949; Vol. 470, c. 2263.]That was the defence which the right hon. Gentleman put up for imposing a charge on medicines two years ago. It is true that he indicated yesterday why it was he did not carry out the policy introduced by that Clause, but, nevertheless, the fact remains that we have a clear statement, which I imagine will be accepted in all parts of the House, that there has been serious abuse of the issue of free medicine; and I do not think it will be denied that nothing at all has been done to remedy that.
§ Mr. Marquand
The hon. Member must remember that I referred to the work done by the Committee on Prescribing which has done, and is doing, a good deal of very valuable work.
§ Sir H. Lucas-Tooth
The medicine bill has continued to rise and the Committee on Prescribing, so far as I know, have done nothing to remedy the type of case referred to by the right hon. Gentleman in the passage which I have just read out. He dealt with such things as aspirins, bandages and excessive queues at doctors' surgeries, and nothing has been done to meet that. That is the point. I would ask the Minister, here and now: Does he say that that abuse has altogether disappeared, or does he not recognise that it still exists?
§ Mr. Marquand
Of course I recognise that some abuse exists. I think I said so. I said that the Committee on Prescribing was examining this, and had already produced a list of remedies that they have recommended that doctors should not prescribe, unless they thought it absolutely essential in the case of some patients. I further added that those recommendations and proposals were being examined by the profession; but I see no means of eliminating fully the abuse unless I have the full co-operation of the medical profession.
§ Sir H. Lucas-Tooth
It does not appear to me that the right hon. Gentleman is facing the real issue. I quite appreciate that action is being taken to eliminate the purchase of expensive types of medicines when cheaper ones would do, but the real abuse is still present and still pressing just as heavily on the medical profession and the public purse as it was two years ago. Indeed, figures show that it is pressing more heavily.
I suggest that the Government have not faced up to this issue in introducing this Bill today. They are seeking quick economies with the minimum of administrative inconvenience. I am not satisfied that that is altogether the best attitude to adopt. Nevertheless, looking at the two proposals, I cannot say that I find myself in very great disagreement with what the right hon. Gentleman has said. The trouble with the dentists is obvious enough. There are not enough dentists to do the job. The real solution to that problem is to provide more dentists, and to provide dentists one must provide the training facilities. It will be a very long time indeed before sufficient new dentists are available.
The case put forward by the right hon. Gentleman is not a new one. It has been perfectly well known to all interested in this matter for a long time. The Coalition Government White Paper "A National Health Service," of February, 1944, says:For a time some aspects of the new service will be less complete than could be wished. A full dental service for the whole population, for instance, including regular conservative treatment, is unquestionably a proper aim in any whole health service, and must be so regarded. But there are not at present, and will not be for some years, enough dentists in the country to provide it. Until the supply can be increased, attention will have to be concentrated on priority needs. These must include the needs of children and young people and of expectant and nursing mothers.That was in 1944. This Government entirely ignored it until this day. We have been telling them that this would happen, that it was happening, and that it must be prevented. It is only today that they have come to the House to put forward some suggestion which may have the effect of deflecting demands on the dentists' time from the important, but less important, provision of dentures, to the vitally important care of the teeth of children, nursing mothers and indeed of the community as a whole. For that 255 reason, I feel that in principle a charge on dentures is acceptable.
But so far as spectacles are concerned the position is different. Here, supply has been able to catch up with demand. The bottle-neck has been the provision of spectacles involving a manufacturing process. In fact, it is easier to expand a manufacturing process than a profession. I believe that the situation now is fairly satisfactory, but I am told that, for every 100 eye tests that are made, over 90 result in the provision of a new pair of spectacles; that there is something like a 90 to 95 per cent. relationship between tests and the provision of spectacles.
I say that if any hon. Member of this House had his eyes tested today he would be told, "Well, it is not strictly necessary, but you might perhaps have a new pair of spectacles with a slight differentiation from the ones you have now." If we had to pay for our spectacles, we should say to ourselves, "The advantage is so slight that I shall not do anything about it." But when there is a completely free service, the position is entirely different. There has been a tendency towards perfectionism in this service, a tendency which is amply proved by this figure of 95 per cent. of spectacles supplied for every 100 tests. If I am not right on that figure, I hope that the right hon. Gentleman will correct me.
There has been no deterrent against perfectionism. More spectacles have been supplied than are warranted by our means at present. Again, on principle I think that a charge can be justified.
§ Sir H. Lucas-Tooth
I do not say anything of the sort. I say that anyone is entitled to have his eyes tested under the National Health Service, but that in most cases, when he has a test made, the optician will tell him that he could do with a new pair of spectacles.
§ Sir H. Lucas-Tooth
It is not the doctor: it is the optician. If the hon. Gentleman were more conversant with the service he would know what I am talking about.
256 There are one or two questions about the Bill itself which I should like to ask the Minister. First, in Clause 1 (1) is it the position that the charges which will be imposed by the regulations to be made are precisely the charges stated in the Schedule? Will there be scope within the regulations for making special exemptions? As the Clause is drafted, I think-that the only purpose of the regulations is to provide the actual machinery under which the charges will be levied.
§ Mr. Marquand
This is a comparatively small point, and perhaps I can answer it now. The purpose of the regulations will be to adjust the charges for frames, as and when there may be changes in the cost of frames, or additions of new frames to the list of those printed.
§ Sir H. Lucas-Tooth
Is that a reference to the regulations in Clause 1 (1) or in Clause 2? Perhaps it is a Committee point, but there is some uncertainty as to how far, without amending the Schedule, it may be possible to alter the scheme imposing the charges. I should also like to ask what is meant by the term "resident," in Clause 1 (2)? Does it mean that anyone who is in hospital for the time being will be eligible to receive free dentures or a free pair of spectacles, or does it refer to someone who is there on a more or less permanent basis? There is some doubt about that. If it includes anyone who happens to be in hospital even if he happens to be a millionaire, then the Clause needs a little justification.
I have indicated that we are not altogether satisfied with the motives which have led the Government to introduce this Bill. We recognise that it was necessary, in view of the policy pursued in the past, to set a limit on expenditure on this Service. We are prepared to agree that, in principle, the provisions of the Bill are not objectionable, though they will have to be considered in Committee. In those circumstances, we would not wish to oppose the Government. If, in fact, there is a Division, if some of the bandits to whom I have referred carry this matter to a Division, I shall advise my right hon. and hon. Friends to go into the Lobby in support of the Second Reading of the Bill.
§ 5.29 p.m.
§ Mr. Grimond (Orkney and Shetland)
I should like to start by joining with the 257 hon. Member for Hendon, South (Sir H. Lucas-Tooth) in congratulating the Government, at least on Clause 3 of this Bill—that being the Clause which allows them to arrange for the treatment abroad of persons suffering from respiratory tuberculosis. The other point of this Bill is to enable the Government to make a charge for certain services rendered under the National Health scheme. We all agree that that is a very serious matter.
We who sit on this bench, at any rate, accept the doctrine that the State must undertake some obligation to look after people who are sick, particularly those who are unable to find the money to get the best medical treatment for themselves. We agree that the State has an obligation to them, just as it has an obligation to the unemployed man, any man who is unable to find work, or to children. Without claiming too much, we might perhaps say that we had some share in founding the Welfare State now existing, and we may even claim, through Lord Beveridge, some slight share in the promotion of the National Health Service itself.
Therefore, it will not be for us to treat this in any way as a light matter, but surely the principle is that, while the State accepts these obligations it can accept them only within the framework of what it is enabled to provide. I think there has been some misunderstanding from the continual statement that this is a free health scheme. Of course, it is not a free scheme, but one provided out of the work, labour and wealth of the country for certain classes of people in the country.
The degree to which we can help the sick depends upon the amount of wealth available for the purpose. We do not even today pretend to supply the old age pensioners with a sufficient income to maintain life, I should say, even at a reasonable standard, or, at any rate, a very high standard. We do not pretend to educate all children up to the university standard. We pretend to do something for them. We agree that the State owes them something, and we do what we can. There seems to be a tendency in some cases to assume that the world stands still, and that we must all stand still with it. Unfortunately, the world has been moving very rapidly in the last year or two, and unfortunately, even within that very short time, we have moved from a time of peace into a time of war.
258 I do not want to cover the same ground as has been touched upon already, or to go into the question whether this scheme was brought in too quickly, whether it was extended too widely or whether it was brought in at a time when the country could not stand it. What I think is unquestionable is that, whatever the situation was a year ago, it is quite different today. I would say to those people who feel that a principle is being breached here that, if a principle is being breached, then several other, and to my mind far more important principles have been breached already.
We have accepted conscription in this country. We have accepted the direction of labour in this country. Why? It is because we are engaged already in fighting a war, and because we are engaged in a rearmament programme which we admit, for the sake of peace, entails that every individual in this country must undertake some restriction of his freedom, which we dislike, and should make some sacrifices for the Commonwealth as a whole. Therefore, we have to look at this Health Service today, not as a matter of principle, but as a question of what we can afford and of how best we can use what we can afford to help the people who most need it. Personally, but reluctantly, I am prepared to accept the limitation inherent in the Budget.
On the particular proposals, the Minister has put up a defence of his reasons for making these charges, as against other suggestions. It may well be, for instance, that administrative economies could be made in the scheme. Whether by administrative economies we could save the amount of money which is needed, I must confess I cannot say at this stage, but whenever a Minister brings forward a proposal for taxation or for a charge, it is very easy—we all do it, I do it myself—to say that, if we need £13 million, it is a very small amount, and we could save it by administrative economies or get it in some other way. That is almost too easy a way out, and if, on other occasions, we may use it, then no doubt Ministers will be able to point out to us that that is an argument which does not carry us very far.
The Minister has further argued, and I think reasonably, that he has taken care that the charges do not fall upon anyone who is not able to work, or on hospital 259 patients, or such people, who are unable to earn. He has pointed out the difficulty of levying a shilling on prescriptions, and I confess that I never very much liked that proposal. I think it would be most likely to fall on a man who is a chronic invalid, and who generally needs the prescription.
There are two points, however, to which I would call the attention of the Minister and invite his consideration. If he is levying this charge—and we accept that he has to do so as a part of the Budget—to raise a specific sum of money, and if we also accept, for the purposes of the argument, that he must have that sum of money, then it is presumably over-optimistic to ask him to make any exceptions which will mean that he raises less money by that charge this year. I feel, however, that the old age pensioner, the man who is in receipt of National Assistance and the unemployed man, do merit consideration.
The Minister has said that that is allowed for, and that the National Assistance Board have power to help, but, of course, there is still a very natural reluctance in this country on the part of people to go to the National Assistance Board. That reluctance we all understand, and I should like to ask the Minister whether, in the course of the next year or so, he should not look at these classes of people—pensioners, unemployed and those in receipt of National Assistance, and there may be other cases of hardship—and then, if he has to consider these charges again, whether he will make some concession for these people.
He may have now made provision for more than one year, but, there again, we should ask him to consider the matter again at the end of the year and see whether it is necessary to continue the charges. No doubt he will do this, and I would also say that, during that year, he would no doubt look at the effects of these proposals on the people affected, because spectacles and teeth are very vital needs today, especially with a bigger meat ration coming along. No doubt, he will have the matter under constant review to see whether this is the best way of curtailing the amount of money which we can spend on these services.
Subject to these qualifications, and while we absolutely accept the need of 260 the State to look after these people, we also accept the overriding present need to defend this country.
§ 5.38 p.m.
§ Dr. Santo Jeger (Holborn and St. Pancras, South)
If there is one thing on which I can congratulate the Minister today, it is upon his extreme modesty. In my five or six years in this House, I have not heard a Minister so anxious to share with any of his Ministerial colleagues the largesse which falls upon him from the Chancellor. So I want to tender to him my congratulations, but I noticed that, in the course of his speech, he said a few things on which I find it rather more difficult to congratulate him.
First of all, he talked about the provisional nature, the temporary nature, of these proposals. I have searched the Bill very carefully—it is a short Bill, and it is not very difficult to search it—and I have found no reference anywhere to the temporary provisions to which he referred. Secondly, he asserted that no demands were being made upon the sick to make any payments. The only reference which I can find to that particular phrase in the Bill is in the Financial Memorandum on page 1, where it is stated that Clause 1 (2) exempts in-patients of hospitals from payment of these charges. In-patients of hospitals are not the only people who are sick; they are not the only people who are incapacitated; but nevertheless that is the only exemption for which the Bill provides.
We are told that it is proposed to obtain £13 million in this year and £25 million in a full year by these proposals. That is not an accurate figure, because when I turn to page 2—again, the Financial Memorandum—I find that the last two lines before the final paragraph read as follows:It is not possible to estimate the cost to the Exchequer of any additional assistance which may be given for this purpose.In other words, the amount of saving will be the £13 million or the £25 million less an amount which will be the cost to the Exchequer—and it is an amount which cannot possibly be estimated. That seems to me to make complete nonsense of the whole of the financial proposals.
The Minister has used a series of arguments in putting forward his case, and I felt they were very similar to the kind 261 of arguments we have been hearing from hon. Members opposite for the last four or five years. I do not suggest that they are the same arguments. They seem to bear the same kind of stamp; they are in the same line of descent, although I could not always say that it is a legitimate descent. They are arguments which one associates with the Tory kind of mind. Among the many claims which have been made by the Tory Party in the course of the last few years, on occasion they have ventured to claim the parentage of the whole of the National Health Services. But they have not liked this child whose parentage they have claimed. They have disliked it and have even made attempts to damage it.
Yet never have I seen the hon. Member for Hendon, South (Sir H. Lucas-Tooth) speak with such a glowing smile on his face as when he rose today to have spiritual communion with the Minister of Health and to approve some of the utterances which the Minister had made. Some of us on this side of the House have always felt——
§ Dr. Jeger
The last time it was raised, the number was far more than the number who have sat on the Benches opposite for a considerable number of years. We, on the other hand, have seriously felt that the time of need was not the time to impose a charge—that the time when a person most needs medical help is not the time to make him pay for it. We regarded that as a vital principle and not as a mere prejudice to be put on or off as a cloak in fine or bad weather.
Acting on this assumption, we have supported a National Health Service in which spectacles have been provided free, in which the waiting lists in the opticians' consulting rooms have been greatly decreased and in which the number of tests for eye defects have been reduced in the proportion of about 100 when the service started to about 16 now. The hon. Member for Hendon, South, has told us that over 90 per cent. of the tests reveal that people need spectacles, but we do not regard that as a condemnation either of the service or of the optician—or even of the patient who has the temerity to go and have his eyes tested.
We felt that people did not usually go to the optician unless they thought they 262 needed optical treatment—and the kind of optical treatment given by an optician is the provision of spectacles. I cannot imagine people wanting to wear spectacles for the love of it or because they felt their noses and their eyes would be better adorned, or perhaps better concealed, by the wearing of horn rims or plastic rims.
Turning to the question of dentures, for many years there has been a great deal of propaganda throughout the country advising people to have their teeth attended to promptly. People have been told a great deal about the fact that defective teeth are the forerunners of many serious illnesses. Any doctor will agree that it is already sufficiently difficult to persuade people who have not been brought up in the right kind of tradition that they need dental treatment.
This new charge is not a money raiser; it is a deterrent, and in many ways it will act as a counterblast to the type of health propaganda to which I have referred. It will force people into a state of dental neglect and, as a consequence, into a condition in which they are suffering from a certain amount of preventable disease. The sort of people who will be affected by that are those who are already being faced with the problems of a rapidly rising cost of living. This fact of a rising cost of living will tend to tip the balance against dental treatment and against what might wrongly be regarded by the patient as an unnecessary expense.
It is true that people can go to the National Assistance Board and ask for help towards the payment for their dentures or spectacles.
§ Mr. Marquand
There is no charge under the Bill for treatment and, therefore, no question of going to the Assistance Board for assistance in the payment for treatment.
§ Dr. Jeger
I regard the provision of spectacles and the provision of dentures as coming within the description of treatment. I am not referring to the operative treatment carried out by a dentist but to the provision of dentures, which I regard as part of the treatment provided by dentists. I thought I had made that clear. We are creating a new class of people who will apply for national assistance. 263 They are people who, as the Minister said, normally may be working people, or may be working part-time, or who may have excessive demands upon their incomes; and if these provisions are passed by the House they will go to the National Assistance Board and will ask for help to meet this new and necessary expense.
Here I would raise the same point as that raised by the hon. Member for Hendon, South: to whom will the money be paid? Will it be paid to the dentists, or to the executive councils who will provide the rest of the payments for the dentists or to the patient himself? We have no information on that point and I think it is the sort of information which we should be given.
In the consulting rooms and the waiting rooms of the opticians and the dentists we shall have three kinds of patient. First of all, there will be the patient who insists on paying everything himself—the man who has stood out righteously against the service and who has refused to take anything from the National Health Service. He is the man who insists on paying his doctor and on paying his optician and on paying his dentist. He will sit there in his righteous isolation. He will be joined by two other classes of people. First, there will be those who receive assistance from the National Health Service. Half their payment will be made by the National Health Service. Then, there will be the third class of patient who will be receiving part payment from the National Health Service and part payment from the National Assistance Board.
It seems to me that that is the kind of thing that we have been trying to remove ever since the idea of a National Health Service was first conceived. We wanted to remove this kind of differentiation between the various classes of patients and we wanted them all to regard themselves as patients on the same level as every other patient who went to receive treatment.
§ Miss Bacon (Leeds, North-East)
Would not my hon. Friend agree that when the Act was under discussion in the House, what some of us considered one of the greatest principles of the National Health Scheme was abandoned in that we gave doctors the right to have both a private and a public practice? Is 264 not that a greater principle than the one to which he now refers?
§ Dr. Jeger
I agree, and I am very much obliged to my hon. Friend for reminding me that in the debate on the National Health Service Bill, in which I spoke on this subject, I raised that point myself and then regarded it as a most important point—as I do now. I am objecting now to differentiation, as I objected then. That intervention helps my case and does not hinder it.
One of the worst aspects of this problem is that we have now put before any future Chancellor of the Exchequer, whatever his political complexion, an opportunity of looking closely into these services for any future sums of money which he may need in order to balance his Budget. I should have regarded these services as being sacred. It is quite true, as the hon. Member for Orkney and Shetland (Mr. Grimond) said, that we live in changing times; the needs of one period are not the needs of another period. But I should have thought that the demands of a population which requires medical or dental treatment or any other of the treatments of modern times, would have remained constant, no matter what may be the circumstances of the period in which we live. We shall always need medical treatment; we shall always need dental treatment; we shall always need optical treatment. These things will not change. They are always with us. We shall always have to deal with them and I suggest, therefore, that we should find a permanent and a just way of dealing with them once and for all.
The Minister said he had been looking for various kinds of economies. I will make a few suggestions to him, though I do not know whether they have occurred to him first. First of all, one economy which I should like to put before him has occurred to me in connection with the optical services. It seems to me that he could save money by insisting that when providing their patients with treatment, opticians should not always regard it as necessary to provide new spectacle frames. The emphasis in the past has been on the provision of new frames and not upon the possibility of using the old frames. Opticians are not always anxious to carry out repairs. They have found it easier to provide entirely new spectacles. I hope 265 the Minister will issue some kind of instruction which will shift the emphasis from the provision of new frames to the utilisation of old frames which can be renovated or repaired.
Secondly, I turn to the provision of medicines. I was one of those who spoke very violently against it in this House when the question of introducing a charge on prescriptions was first mooted. Nevertheless, one of the economies which was not mentioned at that time and which I think could save some money—although not a great deal—is that of asking the patient to provide bottles and containers for medicines and for his various lotions and ointments. A great deal of unnecessary trouble and expense is put upon the chemist who has to provide these things. It is true that the chemist is paid for them but, on the other hand, adjustments could be made in the cost if the patient were encouraged to bring back bottles, possibly with a sort of retaining fee in the way it is used in the off-licence business—if something could be left on the bottle. That would reduce the cost to a certain extent.
The third point is that there is a great ramp in existence in the cost of dental material. A huge monopoly, a huge combine exists about which a good deal of information is already available to official sources. It seems to me that a lot could be done to bring down the costs of dental materials—both the cost to the private individual and the cost to the National Health Service—if steps were taken to deal with this big monopoly.
Fourthly, I think there could be still further readjustments of dental fees. A shilling saved here and a small sum saved there in the amount payable to dentists could make a big difference and would not arouse a great deal of opposition from the dental profession. The same thing applies to fees payable to oculists and also—and here I touch upon my own profession—in the rather inflated sums which are paid to medical specialists by comparison with what is paid to other members of the medical profession. I believe that on those items we could possibly save almost the whole amount which the Minister has been hoping to save by the imposition of these charges.
I turn next to the question of tuberculosis. I do not know whether many hon. 266 Members remember it, but it was only with the passing of the National Health Service Act that local authorities lost the privilege they once had of being able to provide treatment for tuberculosis cases outside this country. For several years I was chairman of the public health committee of a local authority which was responsible for sending quite a number of tuberculosis cases to Switzerland for treatment. I do not know whether that power, which was whittled away from the local authorities when the National Health Service Act was passed, was whittled away deliberately or whether it was done by inadvertence.
I myself, who had operated the powers previously, did not notice that we had lost them until my attention was drawn to the fact by a local government colleague of my acquaintance. He pointed out to me they no longer had the power they once had of being able to deal with these cases in this way. Since then, long before the hon. Member for Hendon, South, and his colleagues thought of it, I and a number of my friends here had been hammering away. We had put down Questions, we had contacted the Minister of Health and had had discussions and correspondence with him and we had made many attempts to have the matter altered.
We were always told it needed fresh legislation. Here we have the fresh legislation and we feel we have a certain amount of responsibility for it. I welcome this particular step. It is a praiseworthy one, and while I do not think tuberculosis is better treated abroad, they have certain climatic advantages abroad over us and certainly rather more of the sun with its healing and beneficent influence than we have been able to have here.
Although I have been somewhat critical of the Government I want to make it quite clear that however critical I am of what is being proposed here, I have no illusions about what hon. Members opposite would do if they had the opportunity. I have heard too many of their condemnations of various aspects of the National Health Service. If they were seated on these benches it would be the greatest calamity the National Health Service could have imposed upon it, and it would be the greatest possible calamity for the nation as a whole. Although I 267 have asked the Government to listen to a good deal of criticism, it is all friendly criticism and I could not do other than promise my wholehearted support.
§ 6.1 p.m.
§ Dr. Hill (Luton)
I hope the hon. Member for Holborn and St. Pancras, South (Dr. Jeger) finds ample compensation in his conscience for the flamboyant remarks at the end of his speech in such criticism as he has felt able to launch at the proposal contained in this Bill. I find myself in substantial agreement with one of his earlier points. It was that we should resist any suggestion to regard teeth merely as cosmetic appliances, as something less than real dental treatment and that we should resist any suggestion to regard spectacles as appliances that are worn to add distinction to otherwise undistinguished countenances. This is a point of some importance, for there has been a tendency to single out the denture for a particular form of ridicule and, to a less extent, that applies to spectacles.
I am not going to follow the rest of what the hon. Member for Holborn and St. Pancras, South, said because I feel he left out of consideration the fundamental issue which is raised by this Bill. It seems to me to be this. Can we, having seen the growth of the expenditure on this service, continue to allow its un-controllability to run riot, its levels of expenditure to rise higher without determining as an act of positive policy what it is we can afford to spend on this service? If—and it is human and tempting to follow it—we take the line of human need, that sickness and its treatment comes before anything else, if we decide there must be the best in personnel, apparatus and equipment of the most up-to-date kind for every person in the community at any cost, such humanitarian motives will lead us bit by bit to a level of expenditure which will spell ruin for other social services and might in the aggregate spell ruin for the budgetary considerations which have been recently advanced.
So I say it serves the purposes of the community best to determine a level, the highest possible level we can reasonably afford, and then, within that level, beneath that ceiling, to determine how best to spend the available resources. 268 Well, as the right hon. Gentleman has told us, a level has been laid at approximately £400 million net expenditure to the Exchequer, and for present purposes I think we must accept that situation. But when we come to determine how best to stay within that limit and how best to impose charges or to seek economies within the various parts of the Service in order to stay within that limit, then there appears a field for examination and discussion.
One thing that emerged from what the right hon. Gentleman said was that hospital expenditure, being approximately two-thirds of the total, was rising. Indeed, it is hospital expenditure which is to exceed the expenditure of the previous year by a substantial amount. A ceiling probably must also be applied within the various parts of the Service or else year after year one may find that the increase in the level of hospital expenditure charges will have to be planted elsewhere in the Service and that such other parts of the Service will have to be cut because of this uncontrollable rise in the cost of the hospital service.
It seems to me that one of the reasons for the present situation is that such has been the financial and administrative structure devised for the hospital part of the Service that there has been insufficient control and insufficient economy within it. I know that over 60 per cent. goes in salaries and wages and that in fact the most economical hospital service could not save a large sum. What I am criticising is a system whereby a budget starts at the hospital management level and then goes up to the regional level and finally reaches the Minister too late for him to make a cut that will not be resented and resisted. We should have an allocation of money at the lowest possible level in the administration and those appointed to administer hospitals and groups of hospitals should feel themselves free to spend within those limits so as to obtain the most efficient possible service.
The issue raised by this Bill is not only whether the charges shall be on dentures and spectacles but whether the charges, the economies, the corresponding sums, could have been raised elsewhere. If we come to the particular items which have been chosen we see again the question of policy versus finance. I feel that one of the criticisms of this Bill is that for financial reasons two rather large and 269 obvious items of expenditure have been selected and it may or may not prove to be the case that this financial policy coincides with what may be the health policy. In the case of the dentures, I admit quite frankly that financial policy to some extent does coincide with the health policy.
The hon. Member for Holborn and St. Pancras, South, spoke about the effect of this payment being to deny people the dental care they need. That of course is nonsense. Dentists will be just as busy after this Bill becomes an Act as before. What the hon. Member did not mention was one of the gravest things of recent years—the decay before our eyes of that important form of health service, the school dental service. Therefore, when I consider the proposed charge in the dental field I ask whether this is part of an effort so to reorganise the dental service as to restore the former efficiency of the school dental service. I know the Minister mentioned—and I am grateful to him—that there are not enough dentists to provide a comprehensive service. We have not faced that fact with sufficient candour. There can never be a comprehensive dental service unless there are sufficient personnel.
If it be true that there are insufficient dentists and if it is our desire to have a complete service for the schools and for mothers and others, to provide that service somehow or other we must place between other citizens and the dentist some barrier or other. It is an unpleasant necessity that we have to face. The barrier might properly be finance. In a sense that has been done by the imposition of this charge. For the life of me I cannot see why it was planted four-square on the dental plate.
The Chancellor might have looked through the service for other charges. I do not see why a man who has three teeth removed and, because of their location does not need a dental plate, gets away with it, whereas the fellow with teeth removed from a place where he will need a dental plate should have to pay the charges. The charges should have been worked out to deter the whole section of the community from rushing for dental care at the expense of the children; and second, worked out in order to encourage conservative dentistry. To that extent this proposal to impose dental charges can be said to effect something.
270 When we come to the spectacles sides of it I want to say to the Minister how much I regret that he did not refer to the fact that this supplementary ophthalmic service is temporary. I shall not weary the House by quoting the White Paper, but it was introduced temporarily. It was known that it was going to be a pretty expensive service from the beginning. But not a word has been said about fulfilling the promise of arranging that this kind of work should be done by and under the aegis of hospitals. Had some progress been made to that end money could have been saved at the same time as the service was being made more efficient.
So it seems to me, although I accept the principle of the ceiling, that it has been forced upon us. Indeed, it is necessary for the preservation of other social services that this one, which makes a peculiar appeal to the generosity and humanitarian instincts of individuals, and which is of particular importance to other social services, is not allowed to steal all the limelight, or to grow, in the generosity of men's hearts, at the expense of other less glamorous social services. I admit the principle of the ceiling, but I say that this service should be examined so that by its growth it does not eat away from other and more important parts of the service and that when charges are imposed they should not be slapped on as this one was.
There cannot have been any careful, conscientious, systematic planning merely to look at charges on dentures. "The costs for dental services? They are to the extent of 61 per cent. for dentures. Charge them half at—well, make it £4 5s." That was the planning that went on in this part of the service. Spectacles? Well, they forgot monacles. It was really only looking for obvious forms of planning to slap on charges on a part, and not to consider a plan in relation to the service as a whole. We are entitled to views about the charges. It is a pity within the field of the spectacles that the nickel spectacle frame has not been retained free. Only 15 per cent. of the spectacles dispensed under the service are the simple nickel frame. At the moment the simple nickel frame is free in the service.
§ Dr. Hill
I have no doubt that the planners will devise some substitute metal for the purpose. I call these spectacles nickel because that is the designation. They are free, but such is the vanity of man that 85 per cent. of the recipients prefer nicer and better frames. I think it might have been left that those content with the most modest form of frame should have it free. [Interruption.] I thought I had achieved a record by making a speech without having any interruption by the hon. Member for Warrington (Dr. Morgan). Inevitably and with sad reluctance we come to the conclusion that these charges are necessary. But amongst the reasons for these charges must be the failure of the Government to retain control of expenditure for the service as a whole. They stood idly by while the costs have been uncontrollably growing to impossible limits.
§ 6.15 p.m.
§ Dr. Morgan (Warrington)
The hon. Member for Luton (Dr. Hill), is in jester mood. He has a very poor memory. In the arguments I have had with him, in the British Medical Association, extending over a period going on for 20 years, I have frequently left him quite alone, and the more juvenile he has been, the more I have left him alone. I wonder what was at the back of his mind when he was making his statement about differentiation in frames—nickel for the poor, tortoise shell for the better off. This is a national service and is based on egalitarian lines—not the sort of thing they are accustomed to in Tavistock Square—and I want it to be understood in this House that men who pose outside as of libertarian minds come here in order to express their antiquarian dialectics for the benefit of a few credulous people who want to listen to such trash.
Let us try to be serious about this. The hon. Gentleman made the observation that these extra services, or these specified services—dentures—should be developed in the hospital line—in a hospital with its rush, in a hospital with its discrimination about whether a case should go to a specialist or whether it should not go to a specialist. They ought to be treated very differently. The hospital services, even now under the best conditions possible, are too crowded with antiquated per- 272 sonalities doing management and making decisions.
One of the failures of the National Health Service has been the personnel who have leaped their way, forced their way, by devious methods and wrong methods, hiding their politics to do it, into the hospital services, and who use the hospital services for purposes for which they were not intended. The hospital services of the country ought not to be used in any way in order to balance politics on one side or the other. After all, there are some things that must rise above political considerations. I have been attached to many of the hospitals and I know exactly what goes on there. I know one hospital which, although a trade union hospital, has no political bias one way or the other.
§ Dr. Morgan
It did—and quite rightly, too. There were good reasons for that—[HON. MEMBERS: "Hear, hear."]—good reasons especially when we came to consider the personnel likely to be appointed, who were not going to be appointed and governed by democratic methods.
§ Dr. Morgan
Yes. Why not? Does the hon. Member think that I always agree with my party? I vote with them because I know their aim is good in the end, but I retain the right to my own individual judgment in things of which I have any knowledge. I am not a bandit—or a baby. [An HON. MEMBER: "Or a vandal."] Or a vandal. There is an attempt here, Sir, to draw me away from the subject of the Bill. Before returning to it, I will just point out that I have been loyal to the Labour Party for between 30 and 40 years, but that I have always retained my right to criticism, and I have always retained my personal individual judgment in things of which I have knowledge. And I intend to go on like that.
Now let us come to the Bill and the dental and ophthalmic services. I heard some leading members of the Government say—I think I can interpret what they said in this way—that it was sometimes useful to impose charges on such things to prevent extravagance. If a prescription is 273 made out, if an eye appliance has to be had, if a consultant's opinion has to be obtained—or an ordinary opinion—it is not the patient's fault. When something is prescribed for a man, is it his fault? Has he any discriminating knowledge by which he can decide and ask for something of a specialist? The specialist can easily say, "No, I am prescribing you the suitable appliance that I think necessary in your case." The poor man does not know whether he wants nickel, gold, silver, uranium or ordinary tortoise-shell spectacles. What he wants is something that will help him in his trouble with his eye defect or eye disease, and in order to distinguish between an ordinary eye defect and an eye disease, he is entitled to ask for specialist opinion first and then to get the best optical measurements for his spectacles.
That is the object of having a specialist examination—to diagnose the disease, or to take early steps to see if it can be prevented, or with an ordinary mechanical defect to get the appropriate measurements for spectacles. It is only right and proper that everyone should be on the same footing for treatment. The eyes are just as valuable to the specialist as they are to the poor workman whose eyes may be destroyed by the nature of his work and exposure to chemicals and noxious dusts.
All sorts of reasons have been given for the cost, necessity and suitability of dentures. I decline to believe that when a patient sits in a dental chair the dentist says to himself, "How much money shall I make out of this patient?" I think that the dentists, like the doctors, want to give good service. If there is a disability, the dentist does his best to relieve his patient, and he treats patients who come to him under the National Health Service in the same way as everybody else, even sometimes without payment. I see hundreds of cases without payment myself. I have done that all my life. But I have had cases in which I felt I was entitled to charge, and by Jove! I did charge. [Laughter.] Well, I have to get something for my work. If a rich man comes to me, perhaps sent by somebody in the British Medical Association who has influence, and who asks me to see the case, why should I not charge him 50 or 60 guineas. I am entitled to do so.
The patient who goes to the dentist is entitled to the very best treatment 274 whether it is for retaining teeth which are sometimes damaged, or for filling them up with different articles—sometimes it is only clay, but at other times it is platinum. The patient is entitled to the best and finest treatment appropriate to his defect, and I think that dentists as a whole have done very well.
Everyone who thought about the subject, every professional man, knew that there was a shortage of dentists, of medical schools and dental schools. There are not sufficient to supply the needs of the population, and sometimes when debating these matters we forget that insufficient men are being trained to give the service the country demands. Everyone who thought about the subject, even the most conservative of men, with the pouting lip and doubtful smile, realised that in the first years there would be a heavy cost, but that as the years went on the cost would level down.
The service will not cost in its twelfth year what it cost in its first. There was a lot of leeway to make up; there were people who needed dental treatment who could not afford to get it at the proper time, and those people naturally went to the dentist when the service was available. That is why in the preliminary years of the service the cost is high. But gradually that will level down; the cost of the dental service and the ophthalmic service will level down.
I tell my colleagues in the Labour Government that the National Health Service Act is a great Act. Good health pays, and in the long run they will find that they have done a finer service for Great Britain than any other political party. It will be costly at first; there will be difficulties and fighting in the face of the enemy who will pretend not to be fighting but will be so very nice, using fine words. I know them well. I have been a member of the B.M.A. for 30 years. For nearly 15 years I was on the Council. I know all the fine fellows there; I like them; they are great arguers; they are great people; they have great words. But they work against anything progressive except what the medical profession thinks it wants. They have not yet got enough medical schools. None of the teaching schools teach the rights and needs of the public. They contemplate more the rights and needs and comfort of the doctor and the professional man—even the most 275 liberal of them, and sometimes even Socialist doctors.
§ Dr. Morgan
Certainly I am in favour of the Bill. I am also in favour of additional benefits being put in, especially some which deal with infantile diseases which affect the bones, and a good many other diseases.
§ Dr. Morgan
I am in favour of the Bill, but not of additional charges for specific items. [Laughter.]
§ Dr. Morgan
I seem to have amused the House, so let me make myself clear. Of course these services cost money, but I should like more spent on preventive and curative services. Health means money, and when the cost of it has to be met I am in favour of it being met out of the public purse. Everybody contributes according to his means. When certain diseases are selected for special treatment, the question arises whether one is justified in taking a certain benefit or a certain failure of the human frame for special treatment. [Laughter.] I must stop now, because I am very sensitive to ridicule.
When my opponents, and even some of my hon. Friends, start to laugh at me there must be something wrong either with my argument or my expression. I have heard more, shall I say, "tripe" used in this debate than I have heard for a long time. I have heard it especially from the opposite side of the House, but on occasions from this side of the House also. I say that this Bill is a fine Bill. This Bill has possibilities——
§ Dr. Morgan
I am speaking generally of the National Health Service Act. I know that there is another Bill, and I say that in the primary years the service will cost more, because so much disease has to be treated, than it will in subsequent years.
276 I am sorry that I have been so disjointed in my remarks. Much of that is due to the jeering of my opponents, but I thank you, Mr. Speaker, for the courtesy of calling me after such distinguished speakers. I am going to vote for this Bill in spite of the difficulties——
§ Dr. Morgan
Yes. What a stupid remark to make. Of course, I am going to vote for the Bill on the general principle and because the Government want it. I am not going to vote for this Bill wholeheartedly but with reservations. All these things are gradually coming into the general scope of the National Health Service Act and everyone will be entitled to have benefits, and great benefits will be felt, especially relating to diagnosis and early treatment, and everyone should have the opportunity of receiving the best treatment.
§ 6.31 p.m.
§ Sir Austin Hudson (Lewisham, North)
I hope that the hon. Member for Warrington (Dr. Morgan) will excuse me if I do not follow him in his argument. I think that a great number of us were not laughing at him but laughing with him. I am very pleased to have had the opportunity of catching your eye, Mr. Speaker, on the Second Reading of this Bill. I want to make only a few points, and I hope to make them very briefly. The first, I think, can only be made on Second Reading, because I am making an appeal to the Minister to make an alteration in Clause 3—which deals with tuberculosis. It seems to me that to make the alteration I want we shall have to have an Amendment, not only of the short Title of the Bill and of the Clause itself, but also of the Financial Resolution.
I am not a doctor—in this debate I seem to have been fortunate to follow three medical men—but I have some experience of the scourge of tuberculosis, because for many years I have been the honorary treasurer of the National Association of the Prevention of Tuberculosis, a body which is entirely non-political, and which has Members on both sides of the House on its council. I would like to say to the hon. Member for Warrington that there is absolutely no politics in any of our discussions, and that we are all the 277 greatest of friends. This also applies to the hospital boards.
We welcome Clause 3 of the Bill in that it makes a small contribution to lessening the waiting list, which I have had put to me as some 12,000. I think that there are 300 beds in England and Scotland. There are many of us on both sides of this House who serve voluntarily on hospital management committees, and who know the efforts which are being made by the Government to get additional nurses so that more beds may be opened in this country. We hope to do that, and to train the nurses at the earliest possible moment.
The Bill, unfortunately, makes very frequent reference to the word "respiratory." I have written to the Minister, and he has replied to me that he is unwilling to take out that word because he does not wish to open the door too wide to the many types of tuberculosis which there are. But there is one particularly sad case which we have brought before us in N.A.P.T., and it is that of ocular tuberculosis. At the moment, the only place where people who are suffering from ocular tuberculosis can get treatment is Switzerland.
During the last few years, these people have had, if they are to get the treatment, to go to Switzerland, and if they are poor they have been supported by voluntary contributions. Obviously, any association has limits to its funds. We have been able to send nine cases to Switzerland, which has cost some £970, and other voluntary bodies have assisted. But that is not satisfactory, and the Ministry is in process of setting up a small nursing home, or small hospital, at Swanley in Kent to deal with these cases.
I am told that that hospital will have only 22 beds, whereas the number of cases—it is not a very prevalent disease I am glad to say—is some 50 or more a year. I would urge the Minister not to close the door to helping these people to go to Switzerland even when the hospital at Swanley is open, because the experience which can be gained there would be valuable, and we may find that there are more cases of this ocular tuberculosis than can be treated at the new Swanley home which, I believe, is to be opened in May. I hope that the Minister will look upon this as a special case, because if the treat- 278 ment cannot be taken early, and the worst happens, the unfortunate patient goes blind. I know from personal experience how important it is to deal with these cases, and owing to the fact that, unless the Minister can give an affirmative answer today, it may be difficult during the future stages of the Bill to move suitable Amendments, I hope that he will consider what I have said.
There is one other subject with which I want to deal briefly, and that is the question of the dental service. I think that one is always rather tempted if, like I and some other hon. Members, we were out of the last Parliament but had been in before, to think that we would have been much cleverer than some of our colleagues and would have done things differently. I try to avoid that temptation if I can. However, it has always seemed to me, since the passing of the National Health Act, that the Health Service has suffered from the delusion that the more money we spend the better the service we get. I remember serving in one of our big voluntary hospitals under an extremely able chairman who, when someone brought up something which was very expensive, used to say, "It is very easy to spend money, but it is very difficult to spend it wisely and well." The mere pushing out of more and more money on the Health Service has prevented people from examining in detail the way in which the money is being spent.
If, as we have heard from the Minister, the charge for dentures will have the result of cutting non-essential work of the dentists and allow them more time to deal with priority cases, we should welcome the Bill whole-heartedly. In my constituency of North Lewisham, which, I imagine, is not very different in this respect from the constituencies of other Members, there was no school dentist when first I came to the House, in this Parliament, with the result that the children were not getting the treatment that they should. I was asked to inquire into the school dental service, and the last report, in February, was that there was one full-time dentist for the whole of Lewisham, and that the average waiting time for a child was 12 months. All will agree that that is too long. Although the children can get emergency treatment, it is not satisfactory. If, as a result of the Bill, the dental service can give more 279 attention to priority cases I am sure that we shall be wise to pass it.
There is one point of detail I should like to raise, and that is in connection with the word "resident." Surely that cannot be someone who has gone into hospital temporarily; otherwise, we shall have the position that if a patient goes into hospital or nursing home to have teeth removed he gets his dentures free, but that if the teeth are pulled out by a dentist at the chair he has to pay. I cannot believe that this is correct. I believe it must apply to people who have been long resident, as my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth), has said. Perhaps the Minister will look into that point.
Generally speaking, I agree with the other Members who have spoken from this side of the House. We are by no means delighted that these charges have to be made, but we believe that when we are spending £400 million on the Health Service economies have to be made. We want to see that the money is spent in the best possible way for the recipients, and that waste is cut out. For that reason we intend to support the Bill.
§ 6.45 p.m.
§ Mrs. Jean Mann (Coatbridge and Airdrie)
I am glad to have this chance to take part in the debate, because while I deplore some of the aspects of the Bill, I feel that the voice of Scotland ought to be heard on one very important feature which will bring hope and relief to many people. I refer, of course, to Clause 3 and the provisions it contains in regard to tuberculosis. The sum of £200,000 for the first year seems very small, but I am encouraged by the thought that the stone we heard about yesterday which, when released down the hill may gather momentum, will give more promise next year for the patients in Scotland who suffer from respiratory and pulmonary tuberculosis.
Members opposite have expressed disappointment that some other forms of tuberculosis are not provided for in the Bill. Our great anxiety in Scotland is about the pulmonary type of tuberculosis, which is a type that requires long care extending over many months and even years. This provision has given great hope to those of us who have been concerned with this scourge, which is a 280 blot on the name of Glasgow. It has given us great hope that something of this courageous nature has been accomplished. I hope that the patients will be drawn from the dismal tenements in Glasgow. These people will know for the first time that they will receive specialist attention in that delectable country of Switzerland, irrespective of whether they are rich or poor. The door is now open to them; they need not be the sons and daughters of the rich.
The provisions of Clause 3 compensate us for some of the more disappointing Clauses in the Bill. I am very glad that care has been exercised on these disappointing clauses to fix a price for dentures. It would have been so easy to say that half the cost will be paid and then to leave it to the patients and the dentists. It would then have been found that some dentists, perhaps more scrupulous than others, would have had different prices. This care to protect patients against overcharging is something that recommends the Bill to us. I think that the price in 1938 for spectacles, including testing of the eyes, was £4. The testing will be on the Health Service. These are both items which give some warning. A person knows that teeth have to be replaced and can set aside some small provision until such time as the gums harden and the half-price is forthcoming.
There is one criticism I would make on the entire service and it is not peculiar to this Bill. One hears a great deal of criticism about the Health Service and its extravagances. Of all our services this one has been the most criticised for having loopholes and undue incentive to sabotage, whereas it ought to be everyone's service and everyone's care. Doctors are worried because patients now come and give the doctor the prescription. Prior to the service the doctors prescribed, but since the service the attitude has changed and the patient approaches the doctor with the prescription. Doctors ought to be protected against this sort of thing.
A woman who believes that there are tablets for slimming goes to the doctor and asks for slimming tablets. The doctor knows that there are no tablets for slimming, that the tablets merely slim because they are a drug, which curbs the appetite of the woman, and if she could be persuaded to curb her appetite the effect would be the same as the taking of patent 281 slimming tablets. These patients read about slimming tablets. In spite of the alleged shortage of newsprint it is still amazing the number of patent remedies that are advertised.
The patient goes along with her own pet patent remedy and asks the doctor to prescribe. If the doctor refuses, however diplomatically and gently, he can be told that she is going off to somebody else who will. I can remember when doctors had a letter sent to them when they were over-prescribing or needlessly prescribing, but apparently since the inception of this service the sky is the limit. Something ought to be done to protect the doctor and the service from this form of sabotage.
I heard someone say that this Bill would operate unfairly against the man who was in employment, because he could not go to the National Assistance Board and ask for consideration in regard to payment for spectacles or dentistry. I notice the Bill introduces the new principle whereby a man in full employment—and we all know lots of men in full employment who have very great liabilities and who require some assistance for dentistry or spectacles—may not have any charge to pay at all where it is found necessary to excuse the charge. These items in the Bill show that the Minister has been found trying to temper the wind to the shorn lamb, and we must pay tribute to the Front Bench for what they have done to make available for Scots people the hills and the sanatoria of Switzerland.
§ 6.55 p.m.
§ Mr. Gerald Williams (Tonbridge)
I do not intend to quarrel with the hon. Lady the Member for Coatbridge and Airdrie (Mrs. Mann), because I agree with almost everything she said. It must be a great day for her, because Scotland has been treated so very generously. According to the population of Scotland I reckon it has probably got about seven times more than its share of the money provided for the treatment of tuberculosis abroad, but I am not going to be ungenerous. I know that the Scots have been more enterprising over this affair than we have been. The Secretary of State for Scotland, was, in fact, the first person to send out scouts to Switzerland to see if the idea of sending patients there could be adopted.
I do not pretend that occasionally there is not a little tussle between Scotsmen and Ministers, but in this case my right hon. Friend has been very generous. He has pointed out that this experiment is not conducted on a population basis, but has agreed that since the incidence of tuberculosis is so much worse in Scotland, this is a fair way of tackling it.
§ Mr. Williams
I am very glad that the Scots are satisfied, and I was congratulating them on bringing about this result. I myself am delighted that Clause 3 is included in the Bill because, while not suggesting that it is entirely a Conservative proposal, it has been pressed from this side of the House for a considerable time. Now that we have got it, I believe it will prevent a great deal of suffering, and that eventually it will increase production in the country, which is so sorely needed and which is being hindered by the incidence of tuberculosis.
Why did the Government suggest that we could not get this treatment in Switzerland? When we suggested it in the past there was always a categorical denial from the Government. They told us that they had no power to treat and our reply was that it was very easy to obtain the power. In fact, they have done that now though they would not do it before and always told us that it was quite impossible to carry out. There is, of course, some difference between this Parliament and the last. We ask Questions and raise matters on the Adjournment. We get some attention to what we say, whereas in the last Parliament we were apt to be ridden over rough-shod. Having said that, I want to thank the Minister for what has been done in this direction.
In the winding-up speech tonight I hope we shall hear a little more, because the Minister of Health, in opening the debate, told us very little about how the arrangements with Switzerland were to work. I do not know whether the Ministry have already booked up the beds and whether they have applied for reduced terms on condition that they will keep 250 or 300 beds filled continuously throughout the year. I do not know whether they have ascertained whether the accommodation is available.
On my own working, if it takes, on the average, ten weeks to cure a patient—I 283 know that nobody can tell how long it will take—and it costs £16 per week, that would give £160 per patient, which would cover about 1,250 patients a year. That would mean 250 beds kept going all the time. The Minister, who has better knowledge that I have, suggested 300 beds would be kept going, but in making these calculations did he take into consideration that special treatment would be required, such as radiography, medicines, investigations and even operations? Of course, if those have not been allowed for it will mean that fewer patients will be able to be treated.
I want to express my personal opinion—I think it is shared by a great many on all sides of the House—that the amount of money which is mentioned is not nearly enough, because there are over 12,000 people waiting to be treated for tuberculosis at present. Far be it from me to advocate any further expenditure at present, but I would point out that a little spent on curing tuberculosis now will save millions in the future because there will be less infection and, therefore, less disease. I do not believe that anyone can accuse me of asking for unnecessary expenditure because, in the long run, there is bound to be a saving. Moreover, in this country it costs £10 to £12 a week to keep a patient, whereas we can send him to Switzerland and treat him there for only about £3 a week more, including the fare, if my calculations are correct.
Clause 3 mentions that people can be treated outside Great Britain. Many of us have come to imagine that that means Switzerland, but I hope the Government will bear in mind that there are such places as France and Scandinavia, where we might get cheaper terms and just as good treatment. Even more important, the currency arrangements in the case of France, for example, may be easier than those with Switzerland. I hope that the Government will make inquiry elsewhere before sending people to Montana or Davos or wherever else they are thinking of sending tuberculosis patients.
An hon. Member pointed out that diagnosis has been very complete lately and that that has accounted for more cases having been discovered. As we have discovered this it would be making a mockery of the matter if we did not do something about it. Anyone who 284 knows that he has tuberculosis will have it on his mind until he is treated. Therefore, for humanitarian reasons alone we should spend more now and save it in the future. That is also an economic reason for doing it. If we can catch people when they have only just contracted the disease it is very much easier to cure it. That is known, and that is why some of the worse cases are at present left untreated.
It is a tragedy to see those people who are affected very badly almost condemned to die in their own homes because they know that our hospitals will not admit them. I believe that if we spent, say, £1 million instead of the £200,000 we should be able to treat 6,000 of the 12,000 who are waiting and that would be a very great achievement. Instead of spreading the disease among other people, which is happening all the time, we should know that they were being looked after and would eventually be cured and become capable of doing a day's work. I am certain that this money would not be an extravagance, but would be well spent. Even within one year it would help industry and help our defence programme, and it would save millions of pounds for our country in the future.
§ 7.5 p.m.
§ Mr. W. Griffiths (Manchester, Exchange)
I shall not follow the hon. Member for Tonbridge (Mr. G. Williams) except to join him in welcoming Clause 3, as I am sure the whole House does. We hope that this will be the commencement of a scheme for the overseas treatment of T.B. cases which will flourish. I certainly support that part of the Bill.
It is customary for hon. Members to disclose their interests. As many of my hon. Friends know, I am by profession a consulting ophthalmic optician, and have been so for a good many years, apart from the intervals of war service and attention to Parliamentary duties. I commiserate with my right hon. Friend on the melancholy task he has had to perform today in introducing a Bill which marks the departure from a principle. It cannot be pleasant for him, because he was a member of the last Parliament, a Parliament with a big Labour majority, whose finest achievement was the intro- 285 duction of the National Health Service Act.
Whatever may be the present position of my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) and whatever may be his fortunes in the future, for ever his name will be associated with that great Act. I always thought that that Act had the most Socialist content of anything that we did. Enshrined in it was the cardinal Socialist principle of "to each according to his need." It was not based on any insurance qualification, a fact which many members of the public do not seem to appreciate even to this day and of which apparently some hon. Members were unaware until recently. Since July, 1948, it has brought relief and comfort to millions of our fellow countrymen during sickness, without involving them in financial worry.
In his Budget speech, the Chancellor of the Exchequer was a little ungenerous in making not even a passing reference to the colossal achievements of the National Health Service. And now it is proposed to depart from the principle of a National Health Service available on the sole basis of need, and charges are proposed for dentures and spectacles. There is no doubt about it that these services have been immensely popular, and from the evidence which I see before me from time to time the ophthalmic service has been used by hon. Members on both sides of the House who have sported new spectacles since the service was inaugurated. A great many people have benefited from the services which have been made available. It was a pity that the inevitable delays while the arrears of the years of neglect were being cleared up were made the subject of Opposition Press abuse, misrepresentation and adverse comment. For two or three years we were subjected to derision in regard to these matters by hon. Gentlemen opposite and by their Press representatives outside.
When people talk about an abuse of the services and when, like the hon. Member for Luton (Dr. Hill), they wonder whether even now the limit of the demand has been reached, my mind goes back to my pre-war experience in practice in a working class area where the majority of my patients were all too often 286 entirely denied the privileges which have now been made available to them under the National Health Service. They either went without proper spectacles or came to practitioners like myself and suggested that they might pay 6d. a week towards the cost, or they went to Woolworth's. Apart from the fact that my own personal position has been improved financially as a result of the National Health Service—I admit that at once, and I am sure a number of other practitioners would say the same—it has been a great pleasure to give of one's best in the service to people without asking them what they have in their pockets.
§ Mr. Osborne (Louth)
Is the hon. Gentleman suggesting that because of this Bill, any of those unfortunate people whom he has had the pleasure of serving will be denied what they need?
§ Mr. Griffiths
If the hon. Gentleman will allow me, I will come to that point later on. I claim that they will be so affected and I hope to show how. On this question of abuse, of course there has been an enormous demand and there has been some abuse. As this Labour Government goes forward it is attempting to change society, but it inherits the psychology of the society which it is trying to change. The psychology of a capitalist society is that we have selfish acquisitive motives running rampant throughout all sections of the community. Some have a conception that we must get something for nothing, and we are trying to operate a national service, as I have tried to show in the House before, with the profit motive present, and always being a strong temptation to professional men to depart from the highest ethical standards of conduct.
On this question of abuse I say that the responsibility must be put definitely where it rightly belongs. If there are greedy members of the public who want to get more spectacles than they need, it is up to the professional men to resist this pressure. The responsibility is their's to say yes or no. If they live up to the ethics which they claim their profession upholds, they will have the guts to resist the demands which are made upon them. The abuses must be laid at the door of the professions, including my own. I think the number of people who have practised these abuses are relatively few and, while we condemn abuse, we must never forget 287 the great amount of good work that has been done by doctors, opticians, dentists and so forth in the National Health Service along the lines which I have tried to illustrate from my own personal experience.
I am sorry that a fundamental principle is being departed from in this Bill. Apart from that, I would also say that there is a case for saying that the timing of its introduction is extremely bad. I have spoken earlier of the psychology of getting something for nothing, and I have said that we were bound to inherit that as the National Health Service was introduced, but we are getting over that now. People who at the beginning of the scheme rushed to get the various benefits, are now treating the Service as a commonplace in their ordinary lives, and the services are, in fact, being used with increasing discretion. Even the most greedy people do not go rushing off to have their teeth pulled out every day. As I once said in the House, if they are anything like me they are terrified of going to the dentist; I am terrified at the thought even of going to my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird). It is not common sense to believe that ordinary men and women go rushing off to these places every day.
It was always anticipated that there would be a very great demand, and the reasons were the great need to which I have referred and the novelty of the situation. I claim that it is now being increasingly regarded as a commonplace in our day-to-day lives. For evidence of that, let us turn to the Civil Estimates in which are set down on page 17 the Estimates for two of the services for last year and for the forthcoming year. Under the general dental service the figure for last year was £35,790,000, and there is a decrease of £5,775,000 this year. In the supplementary ophthalmic service the estimate for this year is £17,560,000—a reduction of £8 million compared with last year.
§ Mr. Griffiths
Even so, there is evidence of a considerable decrease in the demand. Let me tell the House what is the present position in my own county of Lancashire. The position at the moment—I have informed myself of the 288 position—is that the number of sight tests per week per practitioner is about 10 on the average. There is no evidence there of great demand. Of course, the number is increasing at the moment because people want to get in before this Bill becomes law. That is human. As a matter of fact, precisely the same thing happened just before the General Election. The demand now has just reached the same level which it reached in January and February just before the General Election. When I saw that demand increasing I regarded it as a very good electoral omen. My constituents were terrified lest the Tories were going to get back and do what a Labour Minister is doing today.
Many economists in the Ophthalmic Service have been made. Reference has been made to the administrative economies. They are very considerable. Considerable savings have been made, and rightly so, by a reduction in the cost of frames and lenses. But apparently this is not enough. May I here refer to the interjection of the hon. Member for Louth (Mr. Osborne)? I should like to examine the effect of the proposed charges. What we have to recognise at once is that so far as the ophthalmic service is concerned, when this Bill becomes law a good many people in Great Britain will be much worse off than they were before the National Health Service was introduced.
Under the old National Health Insurance Acts, although a comparative few of the population were affected, it is a fact that additional benefits were available for members of approved societies and friendly societies whereby even if they were members of not a very generous friendly society which had few funds available for additional benefits, they were at least able to get free the appliances to which the hon. Member for Luton referred—a plain nickel frame and the flat form of lenses. Under the proposals in this Bill they cannot get such appliances for less than 23s. They have to pay 10s. for each lens and the cost of the nickel frame is about 3s. Therefore, they are very considerably worse off.
It is true that assistance may be sought from the National Assistance Board under the provisions of Clause 4 (2), and I hope that when we get to the Committee stage we shall seek a little enlightenment on how this will work, because it is a means 289 test and I suspect that it will be extremely difficult to operate, in particular in its application to workers in full-time employment. Some kind of scales will presumably be determined. If a worker goes to the dentist or optician in a week when he is working short time the National Assistance Board may pay for his appliance. If he goes the next week when he has had a full week and done overtime, he will presumably be outside the provisions of National Assistance. That is a most untidy way of dealing with this matter. It is a Committee point, and no doubt the House will wish to go into it further on the Committee stage.
I am sorry that the Government have had to introduce this thoroughly miserable Bill, miserable with the exception of that gilding of the pill in the shape of the Clause about tuberculosis patients, which was apparently included in the Bill to make it more palatable. [HON. MEMBERS: "Nonsense."] I may be a very simple chap or I may be reading evil into the motives of my right hon. Friend, but that is just my opinion.
§ Mr. Marquand
May I assure my hon. Friend? I pointed out that I intended to spend £15 million more on hospitals this year than last year, and that included within that was a very small amount—I never pretended that it was more than a very small amount—for the treatment of tuberculosis. That is why that provision is in the Bill.
§ Mr. Griffiths
I am perfectly certain that my right hon. Friend is not an evilly disposed person, and I accept his assurance on that point.
I conclude by saying it is a miserable Bill because it marks the first departure from a Socialist principle unique among all the legislation which we passed in the last House. It is a miserable Bill because it will produce insignificant savings, compared with the deprivations which it will inflict on certain sections of the community; because it is badly timed; and, above all, because I share the view contained in the general observations expressed yesterday by my right hon. Friend the Member for Ebbw Vale and my right hon. Friend the former President of the Board of Trade today. I think it is completely unnecessary, and I suspect that there are some of my right hon. Friends, there may even be some 290 hon. Members on this side of the House, who are not enthusiastic about a completely free National Health Service.
§ 7.23 p.m.
§ Mr. Osborne (Louth)
I cannot understand how the hon. Member for Manchester, Exchange (Mr. W. Griffiths) can describe this Bill, as he did on so many occasions, as a thoroughly miserable Bill.
§ Mr. Osborne
I will accept that. The hon. Gentleman went on to say that he commiserated with the Minister on having had to bring in this "miserable little Bill" because it was, the hon. Member said, a breach of a great Socialist principle. He proceeded to put before us the old ideal: "To each according to his needs." That is a fine ideal, whether in respect of health, work, clothes or food. I would beg hon. Members opposite to believe that there are many on this side of the House who believe in that ideal as deeply as they do.
But what the hon. Member forgets, and the point I wish to emphasise, is that the first part of that ideal is utterly unattainable unless one attaches to it the second part, "From each according to his ability." What is wrong with the country today is that we are all emphasising "To each according to his needs," and drawing upon our humanitarianism, and no one is having the courage, because—I say this with great respect to the hon. Member—it may involve losing votes, to say to the strong that "To each according to his needs" is utterly impossible, unless the strong are prepared to do that extra bit that will make that possible.
§ Mr. W. Griffiths
I entirely agree. I should think that if we had had from each of the people employed in the Health Service the best that he or she was able to give, a good many of the abuses that have occurred would never have occurred.
§ Mr. Osborne
But it applies not only to the people employed in the Health Service; it applies throughout the nation as a whole.
In the last six years, it is fair to say, we have been emphasising too much the 291 one side of this wonderful ideal. It is high time that someone had the courage to say that it is only possible if from each, from the strong, especially the young, an extra bit is put into the common pool of life so that the unfortunate can get more than they are able to put in.
§ Mr. Manuel
Would the hon. Member clear up one point about the ideal which he is now enunciating? Do I take it that he agrees that we are getting the equity about which he is speaking if a man with £2,000 or £3,000 a year income is to pay half the cost of his dentures and spectacles, when a man with £5 a week has to pay the same? There does not seem much equity there.
§ Mr. Osborne
I agree that there is not complete equity. I will come to that point.
The former President of the Board of Trade said today, in his very moderate and wise statement, that the principle of the free Health Service has been breached. He also said that he had fears that there would later be other breaches. I cannot see that there has been any breach at all of any Socialist principle, for if I understand the Bill aright, the underlying motive is that those who can afford to pay something towards the cost of the optical and dental services will have to pay, but that those who cannot afford to pay will still receive what they require without payment. I should have thought that that would have appealed to hon. Members opposite as being true Socialism.
When I challenged the hon. Member for Manchester, Exchange, to say, out of his practical experience in relation to the poor people whom he serves, whether, under the Bill, anyone would be denied the services which he says they need, he said that they would, but he did not prove it. I believe that he is quite wrong. If I understand the Bill correctly, no poor person, because of poverty will be denied the glasses or dentures that the specialist says he or she needs.
§ Mr. W. Griffiths
The person who is in employment and is just able to get by each week with a small margin will be denied because he cannot afford, in the case of the service in which I work—the supplementary ophthalmic service—the 292 23s. which will be the minimum charge for the cheapest spectacles. If that person does not come within the low level of Assistance Board standards, if he is just above that level by being a moderate wage earner, he cannot afford the appliances.
§ Mr. Osborne
Under Clause 4 it will be for the Assistance Board to decide. Unless the hon. Member is saying that the Assistance Board will not decide fairly and equitably he cannot deny that those in need, who cannot afford to pay for the appliances, will still have their needs met.
I wish briefly to make three points about the Bill. The Bill seems to me to be necessary because the Government have accepted the position that there must be a ceiling on the expenditure on the Health Service. That ceiling has been accepted because we must have a re-armament programme, and the re-armament programme has been accepted because we believe that no social service of any kind can last unless we have peace through strength. Unless hon. Members say, "We will not re-arm," they must accept the ceiling. Curiously, the ceiling of £400 million a year for this service has been fixed at the same figure as the ceiling for the food subsidies——
§ Mr. Mikardo
If the ceiling had been fixed at the same figure as the food subsidies, this Bill would not have been necessary because we should not have needed the £13 million.
§ Mr. Osborne
Approximately £400 million has been agreed for the food subsidies.
I want to put the following point to hon. Members opposite. For two or three years, since Sir Stafford Cripps fixed the limit of £400 million as a ceiling for food subsidies, they have accepted it without protest. They did not say it was a breach of Socialist principles. If they accept the ceiling of £400 million for food subsidies, why do they object to a ceiling of the same amount for the Health Service? It seems to me as important to get food for people to eat as to give them free false teeth to eat nothing with.
293 I do not think there is any special social virtue in an absolutely free social service. I see no justice in taxing the meagre luxuries of the lower-paid worker to provide a free medical service for the wealthy who can afford to pay for it themselves. Let me illustrate that by the old age pensioner with his few shillings a week. It does not seem right to tax his odd "Woodbine," in order to provide false teeth for the millionaire who goes to the Savoy to buy his cigar, so that he may hold it more tightly in his mouth. The idea of free service to everybody seems to me wrong and anti-social.
When hon. Members opposite object to a partial payment for the service, may I point out that the very idea of a free service of any kind is a misnomer. It is misleading and it gives people a false impression, both of our prosperity and of our ability to provide something for nothing. There cannot be an absolutely free service for everybody. Somebody has to pay. To say that everybody can have what they want for nothing, is just nonsense. We are misleading our people by it. In the provision of glasses, for instance, there is material, skill and labour, all of which have to be paid for. The idea that manna will rain from heaven is quite wrong. If hon. Members opposite object to partial payment, if they insist on the Health Service being free, why not free food, why not free clothes, why not free coal, and why not free rent?
§ Mr. Mikardo
Can I, in reverse, put this point to the hon. Gentleman? If he says we ought to have partial payment, and thinks it unfair to have a free service, is he in favour of partial payment for education, partial payment for having our refuse collected, partial payment for going into Hyde Park? Obviously, we cannot have that.
§ Mr. Osborne
I agree that there are some things—[HON. MEMBERS: "Ah!"] If hon. Members will allow me to reply, since I have been asked a question——
§ Mr. Osborne
There are certain things that the State must provide free. I am saying that to widen that scope, and to give the people of this country the idea that more and more can be provided free without more effort from anyone, will lead us into trouble.
294 I believe that things which are free tend to be misused, undervalued, wasted, and tend to extravagance. If hon. Members are fair to themselves and to their own experience they will agree that is undeniable. Some 30 years ago I used to run a boys' club in an industrial town. It was agreed by men who ran similar clubs that it was a wrong principle to give the boys the club for nothing. If they only paid a ½d. or a 1d. a week they valued their club more, they looked after the equipment better; in fact, they were more careful with things because they helped to pay for them.
This Bill has been forced upon the Government owing to re-armament. To say that it makes such a breach that two of His Majesty's leading Ministers must resign, is stretching a point monstrously far. I say that this step was inevitable and I shall, therefore, support the Bill.
§ 7.38 p.m.
§ Dr. Broughton (Batley and Morley)
My chief purpose in speaking tonight is to try to correct what I regard as a false impression which has arisen spontaneously in the minds of some people and has, I suggest, been deliberately planted in the minds of some others by people who are strongly opposed to this Bill. I think it unfortunate that the first mention of these charges for dentures and spectacles should have come from the Chancellor of the Exchequer. I regret that he used these words, because I think they have misled many people. My right hon. Friend said:…what is really essential is to find some other source of revenue."—[OFFICIAL REPORT, 10th April, 1951; Vol. 486, c. 851–2.]There is now a belief in some quarters that these charges are a tax, to be collected by the Chancellor, possibly to be stored for a time in the Treasury, and then to be expended on re-armament. There is an impression that these charges are a direct contribution to re-armament. The "Tribune," in its issue of 20th April, fosters this fallacy. It contains this statement:Mr. Gaitskell's argument for the health charge is based on general revenue raising grounds.I should like to examine the facts. The National Health Service is to cost more this year than it has cost before. So we cannot say that re-armament is causing less expenditure than formerly. A figure of approximately £400 million has been 295 decided upon as the limit of expenditure for this year and I think this huge amount should be regarded as reasonable in present circumstances. Of this vast sum of money the Chancellor will contribute the greater part. The remainder, that is, £13 million, has to be subscribed by some patients making a comparatively small contribution towards the cost of certain appliances, namely, dentures and spectacles. The money is to be paid by the patients direct to the dentist or to the optician, and it is a payment towards the cost of those articles.
There are other ways in which this £13 million could have been obtained from patients using the Health Service. From the point of view of Parliament, the simplest method would have been to impose the 1s. charge on prescriptions, because no legislation would have been necessary. The necessary power has already been given to the Minister of Health, and no more than an order from him is needed for its implementation.
Hon. Members who were in the last Parliament will remember my right hon. Friend the Member for Ebbw Vale (Mr. Bevan), then Minister of Health, carrying through legislation for that purpose in the face of opposition. They will remember that on 9th December, 1949, my right hon. Friend mustered his forces and marched a majority of Members into the Lobby to carry the vote for the "bob on the prescription," as he himself described it. Yesterday, my right hon. Friend told us that he allowed himself to be responsible for that legislation only because he knew it would not be brought into effect. In other words, he led us into the Lobby to vote for an unpopular measure, and in doing that he was leading us "up the garden path."
Another measure which might conceivably have been adopted to obtain the necessary £13 million, would have been a charge upon hospital patients as a contribution towards the cost of their food. I agree with my right hon. Friend the Minister in his objection to both these suggestions, because the charge would fall on many people at the very time when they could least afford it, when they were ill and unable to earn. The proposed charges for dentures and spectacles which we are now considering fall on people who, generally speaking, are not ill. If 296 they are ill in hospital and in need of dentures, the dentures are to be provided free of cost. If they are too young, too old, or for other reasons unable to earn, they are exempted from payment. Children can have free spectacles through the schools service. Retired persons and others unable to afford the cost of the dentures and spectacles can have them paid for by the National Assistance Board. Every effort is being made to be fair and reasonable.
A point which I now wish to examine is the suggestion of abuse of the Health Service. It has been said that these charges which are contemplated are to be imposed to prevent abuse. The Chancellor of the Exchequer may have been responsible for creating this impression, because he said of the charges for dentures and spectacles:They apply where there is least danger of hardship and perhaps more danger of abuse than anywhere else in the Health Service."—[OFFICIAL REPORT, 10th April, 1951; Vol. 486, c. 852.]I wish to confine my remarks to that branch of the service which deals with optical treatment, because I know more about that and because I do not wish to take up too much of the time of the House. It is regrettable that there should have been some abuse. There have been cases where people have had spectacles on order from two opticians at the same time, but these cases come to light eventually and are few in number. Let us make an inquiry into the procedure. A patient going to an optician must first take a certificate from a doctor stating that his sight requires to be tested. People such as harassed housewives, anxious students, and craftsmen who have been engaged upon close work, may suffer from headaches or some other symptom which leads them to fear that their eyesight is defective, and so they consult their doctor. Because this practice is by no means uncommon, it should not be assumed that people are abusing the service. Many people, at one time or another, have doubts and fears about the cuity of their vision, and their only approach to the optician is via the doctor.
What happens when the patient enters the doctor's consulting room and asks for permission to go to an optician? The doctor may quickly learn, by asking a few 297 questions and by applying a few simple tests, that a careful examination of the sight is desirable. But supposing he is not sure. Is he to refuse the patient the necessary certificate? Is the doctor expected to devote half an hour or more of his valuable time, in the middle of a busy surgery hour, to try to decide whether the patient should have his sight tested by an optician? It is far from easy for the doctor to withhold a certificate.
§ Dr. Broughton
No, he is not paid for giving it.
Let me try to explain by means of an analogy. If I enter a meadow and within a few minutes find a lark's nest, I can speedily certify that there is a lark's nest in that meadow, but it may take me more than a week to examine every portion of another field before I am in a position to state definitely that there is no nest in that field. Even then, I should be reluctant to express a decided opinion, because my search may have been imperfect and I may have overlooked something. The same applies in the field of optical examination, a sphere in which the majority of general practitioners make no claim to be specialists. Every doctor knows that it is his professional duty, whenever there is a question of doubt, to give the benefit to the patient. From the doctor's point of view, he would rather send 100 patients with perfect vision to the optician for eye testing than withhold optical treatment from one person in need of it.
Hon. Members may now understand why it is not difficult, as a rule, for patients to obtain certificates for optical treatment from doctors. No question of abuse arises. There is the genuine concern about his vision by the patient, and there is the genuine desire to do his best for his patient by the conscientious doctor, who frankly admits that he is not a specialist in that particular subject. From the administrative aspect, the approach to the optician being through the doctor's surgery is of very little value.
Let us now see what the optician does. He tests the sight with care and skill and is paid for that examination. If he then orders spectacles he will make a profit on them. Is not that inviting opticians to prescribe lenses for some cases in which they are not really necessary? It is, and 298 my right hon. friend the Member for Ebbw Vale, when he was Minister of Health, knew it. What he said, in effect, was that there would be free spectacles for all, that arrangements had been made which were foolish because they opened the door to abuse by opticians, and that, therefore, he would place an imposition upon the doctors; use them as sorters and burden them with another form.
The opticians, generally speaking, have shown a really high standard of professional conduct. My right hon. Friend the Member for Ebbw Vale admitted that as long ago as July, 1949, when he accepted an Amendment of mine giving statutory recognition to local optical committees. But I suggest that the time has come for doctors to be relieved from the necessity of filling in the form of recommendation for sight testing. If the Minister of Health would like to make a note of that under the heading of "For immediate action" it might be helpful for him to know that the green faced imposition I have in my hand has the official number of O.S.C. 1. I admit that there has been extensive use, that there has been extravagant use of the service but I have tried to show that the amount of real abuse is far, far less than is imagined.
In concluding, I turn for a moment to a consideration of the principles involved in the application of these charges for dentures and spectacles. A recent issue of the "Tribune" said that this policy sought:To strike a fundamental blow at the essential principle of the Health Service.I would like to know whether it is a fact that when the National Health Service Bill passed through Parliament there was a clear understanding by the majority of hon. Members that the service would be in all respects always free for all. I ask that because I was not here when the Bill was passed, but I can say that there was no such understanding in the country. I well remember people telling me—and some of them were ardent supporters of the Labour Party—that free for all dental and optical treatment was much more than they had expected, that it was more than was necessary and that it was over-generous and extravagant. I suggest that the fault with this Bill is that it is being presented to Parliament now. I believe that the measures it contains should have been incorporated in 299 the original Act. If some hon. Members hold a belief that everything in the Health Service should be free for all I sympathise with them in their disappointment——
§ Mr. Mikardo
I do not know why my hon. Friend should be so surprised about this or why he is now seeking information. The fact that the service was to be free for all was contained in the programme explicitly stated on which the Labour Party fought the General Election of 1945. I do not know how long my hon. Friend has been a member of the Labour Party, but he was not very clear about its policy in 1945.
§ Dr. Broughton
When the Act came into operation it was not free for all in all its aspects. There were quite a number of services which had to be paid for, for example, home helps. Since the Labour Government have been in power we have legislated for a 1s. charge on prescriptions and a charge on people not normally resident in this country using the Health Service.
I gather that there are some, perhaps many, of my hon. Friends who consider the Health Service should be free for all but, personally, I am satisfied that this Bill does not violate a fundamental principle of Socialism. If a charge were to be made on all dentures and spectacles it would violate a principle of Socialism, but concessions are to be granted where needed. I do not believe that Socialism teaches us that goods and services should be free for all. I believe that essential goods and services should be available for all. This Bill respects that principle and I hope the House will give it a Second Reading.
§ 7.56 p.m.
§ Mr. Iain MacLeod (Enfield, West)
The hon. Member for Batley and Morley (Dr. Broughton) has a very deep personal interest in these services, but I cannot help feeling that in his defence of the Chancellor he rather over-stated his case—if I may use such an aggressive term to describe his speech—because I think we have heard a great deal too much about the £13 million and a great deal too little about the principle involved. I disagree flatly with the hon. Member when he says that these charges are comparatively small. They are of very great 300 significance, in many cases, to the people who will be called upon to meet them.
§ Dr. Broughton
When I said that they would be comparatively small, I was referring to the fact that the charges to the patients would not cover the full cost of the articles, but only a proportion of the cost.
§ Mr. MacLeod
I had appreciated that they are only about 50 per cent. Most of us had. It is probably a pity that this matter inevitably has been surrounded with a good deal of speculation and some tension, because those who have discerned that these charges are the most important charges in the Budget are, in my view, quite right. This is more than a new tax and more than a new rate of tax. It is genuinely a new principle and if one wishes to support it one must justify support of the principle as a whole. I disagree very strongly with something which was said this morning in "The Times" leading article:It is entirely a matter of administrative and financial convenience whether a public social service is provided at its full cost (with remissions to avoid hardship), or part cost (again with remissions), or free.I think that is a very incorrect judgment of the situation that this Bill presents to us.
We have these charges—or rather, and it is an important distinction—we have these proposals. We had proposals before for the 1s. per prescription and it is at least possible that once again, if I may muddle the metaphor, post-natal difficulties may result in stillbirth. If anyone says that it is clinically impossible, it will not prevent the right hon. Member for Ebbw Vale (Mr. Bevan) having a very good try. It may be also that the political pressure of events will stifle the Bill.
It is quite true that the 1944 White Paper did suggest charges on appliances. It is quite true that many of my right hon. Friends—the right hon. Member for Warwick and Leamington (Mr. Eden), the right hon. Member for Saffron Walden (Mr. R. A. Butler), the right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) and many others—have proposed at one time or another charges not dissimilar to these. It is quite true also, if I may come down with a bump from those levels, that I, as a 301 Member of Parliament and before I was a Member, have, in writing and in speeches, counselled such charges.
So, on the face of it, it may appear that I should welcome this Bill. Yet I do not welcome it. Frankly, I do not trust it, although I am bound to admit that I am more reconciled to it since I heard the speech of the Minister of Health this afternoon. I disagreed with only one thing in the speech of my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth). He said that if the Bill went to a Division he would support the Government. If there is a Division tonight—I am speaking entirely for myself—I will take no part in it. I can neither oppose a Bill which is fumbling towards the truth as I see it, nor can I support a Bill which, in my view, shows very little understanding of the real problems involved.
We know that in the Government two views are clashing on this matter of principle. There is the view, to adopt the phrase used by the hon. Member for Batley and Morley, which is the "Tribune" view, and there is the Wykehamist view. I wish to put a line of thought to the House which I think important and which. I know, is fundamentally different from both. I would quote, first of all, on the subject of dental charges, from something which was written in the middle of last year by some of my hon. Friends and myself. In considering the dental service we said:The School Dental Service is disastrously understaffed. To restore priority to this service is our first aim.A little later we said:There are too few dentists for a full free service for all. Someone must go short, and it must not be the maternity and child welfare services. We would, then, impose a charge for dental appliances.The House will see that we reached the same conclusion. But the premises are very different, and the argument is very different indeed. Later, talking about the eye service we said:It is essential to establish priorities, to ensure that the most urgent needs are met in good time. We believe that the imposition of a small charge would effectively damp down unnecessary demands.Tuberculosis proposals are also contained in that same book. I do not underrate the financial importance of these proposals. Indeed, as I will show in a 302 moment, I am quite prepared to go further. I think that we had from the Minister of Health this afternoon the most realistic speech on health matters that the House has heard since 1945. I do not want—I concede that it might be necessary—for the sake of doing it to put a charge on dentures. But if by putting a charge on dentures, in conjunction with other matters, I can help to get priority to the School Dental Service I am fully prepared to make such a charge. I do not want to put a charge on glasses, but if, by doing so, we can push further up in the queue those to whom glasses are a necessity, and not put an amenity of life, then I would readily face a charge on glasses.
There is an immense problem facing us, not only in the Health Service, but in every single one of the social services and in their relation to each other. The right hon. Member for Ebbw Vale yesterday touched on this point. Briefly, if we are to have a ceiling of £400 million—and I accept that there are those who would not agree to that—then the fact that we are an ageing population, with rising costs, rising wages and rising salaries, inevitably, year by year, will cut the value of the Health Service. That is inevitable, and it is the central dilemma which faces us now. If that is the problem, how do we try to find the answer? It is, I am sure in a system of priorities, as has been mentioned.
Let me take two examples, one very small, and one much more important. A comparatively small amount of money is being spent on research. I am sure that the Secretary of State for Scotland will agree that one of the most encouraging pictures in the report of his Department of Health for 1950 was that of the results which are beginning to come from the money being spent on research in Scotland. But everybody who has studied the problem will agree that too little money is being spent on research in Scotland and in England. If we need more money, where is it to come from?
Let us take the much bigger problem of tuberculosis—and whatever our views may be on the first two Clauses of this Bill everybody gives a whole-hearted welcome to the third. We have had rather better figures—much better figures—lately for tuberculosis, particularly in Scotland, where, as the Secretary of State will agree, 303 a year or two ago the situation was most grave. When a disease like this begins to yield to treatment it is precisely then that we should get in behind and shove. That is precisely the moment for an all-out assault. If we are to find the money for this assault, if we are to find the money, apart from treatment abroad, for such things as the provision of night sanitoria for infected workers, we must face the possibility of charges in the Health Service. There is nowhere else from where this money can come.
Taxes or charges on appliances, as the Bill proposes, are, in my view, acceptable with those social and humane needs in view. A tax on prescriptions is acceptable for the same reason. In my view, however, a tax should not be made, as I know has been suggested, on visits to a doctor's surgery or from him. The idea of the family consultation is the best thing which has come out of the Health Service. The family consultation used to be the prerogative of the wealthy, but, before long, it will become the ordinary accepted method of medical treatment in this country.
I am prepared to face charges, if they are necessary, on a far wider range than this, so that first things may come first. I am prepared to face charges so that the vital parts of the Health Service will not founder. That, as I understand it, is the theme which was summed up in the vivid phrase of my right hon. Friend the Member for Warwick and Leamington when he spoke of the strong helping the weak. That is the way we should approach, not only these specific problems, but the whole of the problems of the social services.
Let me indicate two matters of some detail. First of all in Clause 2 it is true that by Order in Council these charges can be varied, subject to affirmative resolution. I believe that that power to vary by Order in Council should be exercised only to reduce the charges. There are constitutional reasons for that as well which I will not go into, but it seems clear that if these charges are to be increased the Minister of Health, of whatever party, should come to the House with a Bill and plead the case again. I hope that the Committee may be able to consider inserting the simple 304 word "lesser" in line 40 of page 2, which will give effect to what I have suggested.
The next matter is one of considerable importance and is a trend of thought which has been suggested to me by some of my hon. Friends. The hon. Member for Orkney and Shetland (Mr. Grimond) first brought out the question of a National Assistance Board. Every speech has dealt, always with some anxiety, with this problem. If we agree, and I am sure we do, that whatever happens, cases of real hardship must not be penalised, that means a test of means, but I do not see that it follows that the National Assistance Board must carry out that test.
It is distressing to most people to find how many of our countrymen and women, for one reason or another, are dependent on the National Assistance Board. Even allowing for higher standards and larger population, it is disturbing to find that, at this moment, more people are receiving National Assistance than were receiving Poor Law benefit at the beginning of this century. It is the most sombre mark of our failure in this field that, from the days of the Beveridge Report up to 1946, when these Bills were passed, every party went forward with the aim of establishing a national minimum through National Insurance, and the measure of our failure is how quickly that national minimum became the National Assistance level. That gap widens month by month and year by year, and I have no doubt that, when we come to discuss another Bill on Thursday it will widen, and rightly so, again.
Can we find anything to put in the place of the National Assistance Board? I think we can. I think we have the example under the Education Act. By Section 52 of that Act, local education authorities can recover charges from parents for a wide variety of uniforms and school meals and other services provided.
§ Mr. Mikardo
I am grateful to the hon. Member for giving way, and also for his reasoned analysis of this problem. Surely, on this question with which he is now dealing, the real problem is not who shall make the test, but whether it is ever worth while to make that test for a single payment which could be as low as 25s. The 305 Education Act one went on for several years, and the National Assistance one may go on for a long time. Is it worth while to have these tests for a payment of such small value?
§ Mr. MacLeod
I appreciate that point very much, and I will say something on it, although I accept the general principle of charges, in my summing-up later.
I do not see why this sort of machinery cannot be applied through Executive Councils to this sort of charge. I am not seeking an answer tonight, because this is a matter which we can discuss in Committee. There is, however, a precedent in the National Health Service Act itself. Hon. Members know that, by Section 29, charges can be made for a home help. I have some experience of this matter, and my first personal experience of the National Health Service Act was in connection with this particular section.
As happens sometimes where there are small children, we had a recurrent series of crises; both my children had measles and my wife was ill at the same time. We had no help of any sort, and I asked whether it was possible to obtain a home help for a week or so. Incidentally, I was sent a most competent one, and my application was treated very courteously. I was told that if I was not prepared to pay, which I was in this case, I should fill up one additional part of a small form. It seems to me that the same method could well be applied to the provisions of this Bill, and I hope it may be possible in Committee to draft something for the hospital provisions and those in Part IV of the Act which will take care of that matter.
Let me sum up in this way. As I see it, there are three distinct viewpoints. There is the point of view called the "Tribune" point of view, and that, as I understand it, is that there shall be no ceiling to these matters unless and until every other reasonable source of revenue has been tapped. It is an outlook which is Socialist and which I can understand, but with which, frankly, I must disagree. There can be no social security unless there be national security first. They cannot be separated from each other, and I quite agree that no field should be left ungleaned, provided that the national interest and national security are involved.
Secondly, we have the official Government view, which demands that we must 306 glean all the fields, and, so far, I agree, but the contributions that are prposed in the Bill relate, in my view, far too closely to finance and far too little to health. They are exercises in arithmetic, and not in social policy. Fundamentally, I believe that these should not be treated as financial proposals with repercussions on the fields of employment and health; they are fundamentally human and social proposals with repercussions on the financial field.
There is, in my view, a third approach, and it is that we should be absolutely clear in the priorities that we put forward, that we should be absolutely ruthless in putting first things first, and that we should never put forward Health Service proposals unless the service of those in the greatest need is the consideration most in our minds.
§ 8.17 p.m.
§ Mr. Shurmer (Birmingham, Sparkbrook)
It is not my intention to take up the time of the House for long, as I know there are many other hon. Members who want to speak, but there have been quite a number of speeches from professional gentlemen—opticians, dentists and doctors.
My purpose is to deal with Clause 3, but I think I ought to make my protest against the charges for dentures and spectacles. I am sorry that this has to be brought about, because I believe that there will be much play made with regard to abuses. There was obviously a rush in the early stages of the National Health Service, because we know—and many of us on this side of the House know probably more than hon. Members opposite—the need for dentures and spectacles among the ordinary working class mothers especially, and even among the menfolk who were not eligible under their approved societies because of their inability to pay.
I can remember the time when our womenfolk had to go tramping the streets or the roads of the better-class districts, knocking at doors asking servants if their mistresses subscribed to certain hospitals and collecting so many notes. I know that very well from my experiences as a young councillor from the '20's onwards, and I remember how often they came to ask me if I could tell them where they could get these hospital notes in order to get their dentures. It was true to say that there were certain abuses, but is there 307 anything that comes along that does not have some abuse attached to it?
We know now that we have definitely passed the peak in the demand for dentures and spectacles. What we do not know about is the case of the ordinary lower-paid worker who has a large family, to whom £2 10s. will be an enormous amount. Hon. Members opposite often wonder why we make our protests and then go into the Lobby in favour of the Government. Obviously, we are right to make our protests and make known our wishes. I cannot see anything wrong in it. I agree that there are minority and majority reports, but, on the other hand, I protest against it, because I do not like it.
I am sorry to see this inroad being made into the Health Service, and I should like to avoid the necessity for the ordinary working man in need having to go to the National Assistance Board. I should like to see an arrangement whereby a man or woman who needed dentures or glasses, for which they were unable to pay, could fill in a form giving the full particulars of their income which the dentist or optician could send on to the National Assistance Board in order to see if they were eligible for the grant, instead of having to go personally to the Assistance Board offices. Many people do not like going to the Assistance Board, although one can say that our Assistance Board officials today are very different from the old board of guardians officials.
Very little has so far been said about Clause 3. I suppose it is true to say that one of the most urgent health problems in Great Britain is the lack of institutional facilities for the treatment of tuberculosis. It is not the shortage of accommodation in our sanatoria, but the shortage of nurses which is the cause of this disturbing state of affairs. Therefore, I welcome this Bill which will provide treatment for tuberculosis cases in Switzerland. Hon. Members know that we have something like 10,000 to 12,000 tuberculosis cases in this country waiting for admission to sanatoria.
But how many people can afford to pay anything from eight to 16 guineas a week for sanatoria treatment in Switzerland? Very few of the cases on the waiting list can afford that amount of money. I have 308 been able to recommend one or two cases for treatment in Switzerland, but they were fortunate enough to have someone in the family who could pay for them. Had they stayed in this country, the probability was that they would have petered out altogether, and the treatment they received in Switzerland restored them to health. I know of two cases in particular where the people concerned are now back at work in this country quite restored to health, but who, had they not gone to Switzerland, would certainly not have lived.
This is no new venture because in 1939 there was a steady stream of tuberculosis cases from this country to Switzerland. This was made possible by grants from local authorities, and the patients were able to stay in Switzerland for six months or longer. In one sanatorium, at Leysin, one-third of the patients were British; at the Davos sanatorium, three-quarters were British, and at Montana there was a sanatorium entirely devoted to British patients. Whereas before the war there were several hundred patients at Leysin sanatorium, after the war this number was reduced to something like 100. Then there is a sanatorium in Switzerland subsidised by the Americans. If any hon. Member would like the address of that sanatorium I shall be pleased to give it. It is possible to get a patient to this sanatorium for a charge of six guineas a week owing to the fact that it is subsidised by the Americans.
There are very few patients at Montana, although there are altogether some 1,000 vacant beds for tuberculosis cases. Not a moment should be lost in taking advantage of these beds which are vacant just because many tuberculosis sufferers in this country are unable to pay the fee. I do not want to cross swords with the people in Switzerland, but, in many instances, the sanatoria are run on a commercial basis. In some cases, they are charging extortionate fees, and therefore I hope the Minister will watch this matter.
In a few days' time I hope to be able to let him have some information concerning the sanatoria which hope to cash in on this. Sanatoria in different parts of Switzerland are competing against one another for the treatment of cases from this country, and I think it will be possible to bring down the charge to less than £1 a day. I am not sure what the charge is 309 in this country, but £7 a week would be very cheap, even though there would be the cost of transport. I cannot see why patients could not be transported from this country to Switzerland by air. Surely, it ought to be possible to make such an arrangement with the Civil Aviation Department.
While these beds in Switzerland remain empty, many of the sufferers in this country are spreading the disease to a great degree. I should like to see, not £200,000 being spent on this scheme, but £1 million. Why not send out 2,000 cases a year, which would mean giving 1,000 cases six months' treatment each? If that were done we should soon eradicate the waiting list, which would be money well spent.
§ Mr. Mellish
While agreeing with my hon. Friend that more money should be spent on sending people to tuberculosis sanatoria, would he say whether he thinks it would not be better to charge more for dentures and spectacles in order to provide the money for sending these cases to sanatoria?
§ Mr. Shurmer
I would not agree to that.
Holland, Belgium and Germany have their own sanatoria in Switzerland. I do not know whether any hon. Members have seen the big Juliana sanatorium in Davos, and the big German, Belgian, and Jewish sanatoria in Switzerland. It is amazing how other countries have been able to send their patients to Switzerland for treatment, and with such wonderful results. It has been my good fortune to go through these sanatoria because I happen to be interested in a scheme for sending patients to Switzerland.
Soon after I came to this House, I fought the Treasury on the matter of sending young children from Birmingham to Switzerland. This was done through the generosity of a big chocolate merchant in this country, Mr. Kunzle, who is still a Swiss national, and who has a chateau in Switzerland. A great many of the children are still out there. It has been a wonderful scheme. When those children return to this country, 98 per cent. of them, instead of going to special schools, are so restored in health through their stay in the wonderful climate of Switzerland, that they are able to go 310 back home and lead a normal life. Strange to say, the great Kunzle organisation send some of their employees there for five or six weeks when they get a little chesty to do a few chores for the children and I understand from that organisation that they have less absenteeism than any other works in the city of Birmingham. Whilst I was in Davos it was my pleasure to see those sanatoria.
It has already been mentioned that for a long time now X-ray units have been doing a wonderful job up and down the country. It has been possible to find out cases in the early stages which of course is a great step forward towards early treatment. If beds were available for those patients it would save them a long spell in sanatoria. I saw a report that 30,000 men, women and children in the Rhondda Valley undergo this X-ray examination. The Queen Elizabeth Hospital in Birmingham, one of the greatest hospitals in the Midland region, has decided that every patient admitted shall be tested for tuberculosis. But what is the use of all this if cases needing treatment are found and they cannot be provided with beds in sanatoria? It is a waste of time and money and it makes the patients more worried.
I am well aware that everything possible has been done and is being done in this country to stamp out this disease. I want to pay tribute to the doctors and nurses in our sanatoria. If I may say so respectfully and with all humility, it has been my pleasure never to miss spending the whole of my Christmas mornings for the last 30 years in one of the biggest sanatoria in Birmingham. I was so impressed when I first went there that no matter who else invites me away for Christmas, I would not accept the invitation. I know the devotion of the nurses and how they lay themselves open to infection.
§ Mr. Linstead (Putney)
If the hon. Member will forgive me, I think he has made a statement upon which he might want to reflect. Surely it is true to say that staffs in sanatoria, by reason of the precautions which are their every-day lot, are really less liable to infection than many nursing staffs in other types of hospitals. I am sure he would not like his statement to go out uncorrected.
§ Mr. Shurmer
I thank the hon. Member. Not being a medical man I am probably not right in saying they are laying themselves open to infection, but nevertheless I want to pay tribute to their wonderful work. I am vice-chairman of a mental hospital. I know how difficult it is to get staff for that hospital and I think wonderful work is done by the doctors and nurses in sanatoria. I ask the Minister to do all in his power to increase the number of patients sent to Switzerland as quickly as possible. If it is only possible to deal with about 300 now I hope it will not be long before we can increase that average. No bed in a sanatorium there should remain empty, while we cannot find places for the patients in this country. Desperate situations need desperate remedies.
Much has been said about the charge for dentures and spectacles and that it is all wrapped up with the problem of the great re-armament programme. We are going to spend millions not to destroy life, we are told, but to prevent the destruction of life, limb and property and to prevent misery and devastation in the future. I hope that will be the result, but why cannot we spend £1 million on this project? Compared with the amount we are going to spend on re-arming it is a small sum to spend on preventing and fighting disease and restoring people to good health to become an asset to the nation instead of a liability. I have not the slightest doubt that for every pound we spend on these cases in their early stages, we shall save thousands of pounds in the future, because these cases will become a liability to the country if they are left untreated.
I welcome Clause 3 of the Bill. I am glad the Minister and his associate the Secretary of State for Scotland have taken this step. I know it will be a success and I hope it will be received with open arms in the country. I hope, too, that it will give a little hope to many of those who so often are waiting for admission to sanatoria. Indeed, I wish the scheme all success.
§ 8.35 p.m.
§ Mr. J. Enoch Powell (Wolverhampton, South-West)
The speeches which have been made in this debate can be classified into two categories. There have been those which sought to show that the Bill 312 is of comparatively minor importance and that it introduces nothing which is really new or fundamental. On the other hand, there have been speeches which have argued that the Bill brings with it what is really a change of principle and that it should be viewed in that light. I emphatically adhere to the second view. I believe that what this Bill does represents a turning point in the history of the development of the social services in this century, and that it is of very great importance indeed in what context we view the action which this Bill seeks to take.
As we have them at present, the social services are organised in different ways. There is one class of social service which is applied under a means test and always has been so applied. I refer to the social services administered by the National Assistance Board—not only the payments but also the allowances of all kinds for which the National Assistance Board are responsible. In that case there has always been a means test. On the other hand, we find other social services which are either unconditionally free or which unconditionally attract a subsidy and to which no means test at all is applid. It may be that it is inaccurate to include the food subsidies in that class; but at any rate the class includes primary and secondary education and it includes the service of subsidised houses, where the tests applied are tests of physical need and not tests of financial need.
We have then, these two methods running side by side in the social services—the provision of a service subject to a means test and, on the other hand, the provision of a service unconditionally free on the ground that the game is not worth the candle to attempt to apply a means test which would cost more in trouble than what we could get by applying it.
There is a third category, which is a mixture of the two—where a service is partly subject to a means test. Into this class fall some aspects of the domiciliary health service provided by local authorities to which my hon. Friend the Member for Enfield, West (Mr. Iain MacLeod) has referred, and also those ancillary parts of the education service which are dealt with by the education welfare departments of the local education authorities. There we have a service in which certain elements are subjected to a means test.
313 What this Bill does is to take the Health Service out of the class of unconditionally free social services and put it into the category to which a means test is partially applicable and indeed increasingly so; for, as hon. Members who have taken part in the debate have in many cases argued, there is no logical boundary which says that thus far and no further shall go the principle of the means test; there is no logical boundary which one can set by which a charge can be imposed on one sort of appliance but not on another.
So we embark upon a transformation of this social service from one sort of social service into another by the application of charges linked with a means test. It is all the more important, when we take what may be an historically decisive step, that the manner in which the means test is to be applied should receive the most anxious consideration of the House. I must say that I am very worried about the form which the means test takes in the present Bill. That form, briefly, is that a person called upon to make a payment under the Bill may apply to the National Assistance Board to be reimbursed in respect of part or the whole of what he has had to pay. He is enabled to do so even though he is in full-time employment and would not in other circumstances and on other grounds be a suitable recipient for National Assistance payments.
I believe that that method is wrong, and I believe that it is going to lead to grave difficulties. It will present the National Assistance Board with quite a new type of problem. It will present them with an able bodied, fully employed, self-respecting, self-supporting citizen who, nevertheless, being met with one of these charges, goes to them and says, "Are you going to pay part of this charge or not?" In order to answer that question they will have to work out an entirely new system of assessing needs.
Entirely new principles will have to be worked out, and that is a very serious task to superimpose upon the National Assistance Board at the present time. It is really, one may say, the introduction of the Speenhamland system once again into our Poor Law administration, and there is a twofold danger that it brings with it.
314 There is a danger from the point of view of the service and there is a danger from the point of view of the recipient. From the point of view of the service there is this danger. No one who has dealings with the National Assistance Board—and I imagine all hon. Members in their constituencies owe a great deal to the co-operation of the local managers as I certainly do in Wolverhampton—can doubt that it is administered with the greatest sympathy, humanity and care. If we go overloading the Board with all sorts of miscellaneous means tests and assessments, then, sooner or later, almost inevitably, it will become rigid and bureaucratic, and will tend towards inhumanity. I do not believe that the favourable features which the National Assistance administration has at present will stand up to the strain of these excessive demands which are going to be placed upon it.
Now from the point of view of the potential recipient, the people who are not going to be helped, who are not going to pass this means test, are precisely, in many cases, the most deserving. They are the people, the old-age pensioners, people just on a living wage, who are going to say, "This is a pretty stiff sum I have got to pay, but I will be dashed if I am going to the National Assistance Board to argue the case about it." Those are the people who are going to suffer most from these charges, if we leave this method of assessment in the Bill.
So I suggest that if this new principle which we are introducing—and I think it is a new principle—is to be healthful and not harmful, if it is to assist the re-creation of priorities in the social services, we should envisage a wholly new approach, quite separate from the National Assistance Board, in the determination and administration of the means test. I would also add that we are making these difficulties all the severer for ourselves by what I believe is the mistake of having concentrated this principle upon two particular elements in the Health Service instead of taking a broad survey and making the same total saving over a much wider field.
§ 8.44 p.m.
§ Mr. Mellish (Bermondsey)
First, let me say to the hon. Member for Wolverhampton, South-West (Mr. Powell) that he has made a very thoughtful contribu- 315 tion to this debate. I commend his remarks to the Secretary of State for Scotland who is to reply to the debate, because I think that this is one problem which this Bill shows up—the question of the many people who would, perhaps, qualify for help at a National Assistance office, but who, for one reason or another, would dislike very much going to such a place because—and here I do not want to raise a political point—there is still some legacy left of the Poor Law and the way in which it used to deal out assistance in the past.
I find myself in this position. Like many hon. Gentlemen on this side of the House I am faced with this problem: if I make a speech in favour of the Government I am likely to be regarded in certain sections of the House as a Right Wing "stooge." While an hon. Member on this side of the House who makes a speech against the Government, is regarded by other sections as a Left-Wing intellectual. If I may say so with very great respect, I am neither. I am happy to be just a good, ordinary, member of the Labour Party who happens to think a great deal of his party, who thinks that it is more important than right hon. and hon. Gentlemen opposite think their party is, and who regards his party as part of his faith and creed.
I support the Bill because, as I see it, my right hon. Friend the Minister of Health had no alternative but to introduce it in view of the fact that the Chancellor had made it perfectly clear that there had to be a "ceiling" on the Health Service. There are some of my hon. Friends who say—and they are entitled to their points of view—that there should never at any time be a "ceiling" on what they call this free health scheme of ours. I can understand that point of view, but I not only believe in this scheme but also try to work for it by serving on a regional board, on a hospital management committee, and even on a board of governors and all the various sub-committees that go with it.
I think it was inevitable that, as the rate of expenditure on the scheme was increasing year by year there had to be a "ceiling" placed on it at some time. Let us be fair to our own Labour Party. The Chancellor has given £7 million more on the Estimates for the Health Service 316 than he gave last year, when the Estimates were much higher than the year before. Today, we have reached the astronomical figure of £400 million for the Health Service. Many wild charges are made about how easy it would be to save this, that and the other on the administrative side of the hospital service. As I have already said, I have some close contact with that, and if we were to say that one clerk shall do the work of two clerks in future, and prove all that type of thing, as so many critics argue, the saving would be negligible; and in the long run we should not save anything because of the inefficiency that would be created.
The Minister, having to face the fact that the "ceiling" has now been reached, has produced what I believe to be the most satisfactory solution of this problem, and I will tell the House why. Let hon. Members on this side of the House be honest about the charge for spectacles, because 90 per cent. of the people who purchase spectacles already pay for the frames. That figure has been given to me, not by the Minister but by those who manufacture the spectacles. People do not want nickel frames; this Government have so improved the standards of our people that we have gone beyond the stage when any old spectacles will do; they want the better frames. Under the Act as it stands, 90 per cent. of the people are paying 4s. 9d. for frames which, under the Bill, will cost them 7s. 3d.
§ Mr. Mellish
I agree that they could have the nickel frames, if they wanted them, for nothing. I accept that; but 90 per cent. refused to have the nickel frames. That is a fact, not theory. The 10 per cent. who are having the nickel frames—and this is merely surmise; I cannot prove it—are, I suggest, what I would call the old-age pensioner type who, for one reason or another, do not care so much about that sort of thing, or could not afford to pay for better frames. It is a fundamental principle of our party to protect the weakest, and that is what we are doing. The Minister has made it perfectly clear that the only people who will pay under this scheme will be people at work, although I accept the argument of the hon. Member for Wolverhampton, 317 South-West, that we ought to devise ways and means to make sure that those people get assistance if necessary.
I want to finish on this note. My hon. Friend the Member for Sparkbrook (Mr. Shurmer) did not understand the interruption I made in his speech. I will put my point to him again, because it is important that he should understand the position.
Tuberculosis is a matter in which I am very interested. I warn the Minister of Health to be careful about the application of any scheme for sending patients to Switzerland. First, we shall have the job of saying who is to go to Switzerland; and if that is the case I am going to see that I get a fair quota of my constituents going to Switzerland. Apart from the problem of who is to go to Switzerland, I hope that it will never go out from this House that merely by going to Switzerland people can be cured of tuberculosis. That is an appalling idea. The right way to deal with tuberculosis is to improve our own sanitoria, have more nurses and give them the finest conditions in the world. We do not have to go to Switzerland for cures when we have places like Wales to go to. We are doing a great job here, and I welcome the Switzerland idea as a gesture of what the Government intend to do.
I support this Bill with confidence, and I am going into the country to tell the people why I have done so. The Labour Government are maintaining a great principle, so do not let us deal with this matter in any spirit of vindictiveness and, by expressing our spleen, destroy the life and soul of the party. Let us do it in such a way that the whole of the party throughout the country may understand exactly what we have in mind.
§ 8.52 p.m.
§ Mr. Butcher (Holland with Boston)
The hon. Member for Bermondsey (Mr. Mellish) is always listened to in the House with the greatest interest. May I say to him, however, that Bermondsey and South Wales are not going to divide up all the beds in the sanitoria between them. I think that one of the most interesting observations in this debate was that of the hon. Member for Wolverhampton, Southwest (Mr. Powell), in which he pointed out quite clearly that this Bill was a definite departure in the approach to many of our health services.
318 The hon. Member for Sparkbrook (Mr. Shurmer) said that he desired to see £1 million spent on sanatoria and the cure of tuberculosis in Switzerland. We would all like to see that. Equally, there are others in the House who take a keen interest in other maladies, such as infantile paralysis and cancer, who desire to see substantial expenditure in those particular directions.
We have been brought back by the Minister of Health's speech this afternoon to the fact that in all this social service—and I believe that it is the forerunner of other services—there must be some ceiling on the amount of assistance that it can receive from the national Exchequer, and that it is within that ceiling that this Government, or any other Government, must work. I think that the right hon. Gentleman put his case moderately and fairly, and explained admirably the steps that he had taken to avoid making these charges, which are not liked by many hon. Gentlemen opposite. For my part, I do not object to charges being made, provided that they fall upon the people who are able to pay them. What I dislike very much is this introduction of Clause 4 of the Bill, by which we bring an ordinary man in regular employment before the Assistance Board for perhaps only one visit in his life. The Board's officers, however sympathetic they may be, have no opportunity of assessing his need and he himself is merely a transient visitor. I believe that something better could be done.
The right hon. Member for Ebbw Vale (Mr. Bevan) suggested yesterday that this was a breach in the social services. I do not believe that that is the right way of viewing it. I believe that this should be regarded as a review of the social services by a new and perhaps more moderate Minister of that Department. The first breach, and let us be quite clear on this, in the Health Service was made by the previous Minister of Labour, when Minister of Health, when he stopped the payment of travelling expenses to hospital. He consented to a second breach, which would have taken place had it been administratively workable, which was the payment of 1s. on prescriptions.
The present Minister of Health is to be praised for the courage and candour with which he has introduced this scheme to the House. Let us bear in mind that we are seeing a departure in this Bill from 319 the principle of free social services irrespective of means. The means test—and it is a return of the means test—is wholly objectionable to many of us on both sides.
On the other hand, with the urgent need for increased sanatoria treatment, increased research and increased developments in many fields, has not the time come to review the whole field of these social services and to say that those who can without detriment to their families, make a contribution for the assistance they receive shall do so, not only in respect of dentures and spectacles, but also in respect of other treatment they receive?
§ 8.57 p.m.
§ Mr. Baird (Wolverhampton, North-East)
I have listened to most of the speeches in the debate, and I must say that it seems to me that my right hon. Friend has some strange bed fellows tonight. It is obvious that the majority of the Tory Party are with him on this matter. It also seems that my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) has done a bit of conversion on the other side, because the hon. Member for Enfield, West (Mr. Iain MacLeod), and the hon. Member for Holland with Boston (Mr. Butcher) have a certain sympathy for his point of view. [HON. MEMBERS: "No."] I may be wrong.
I do not want to deal with the principles tonight, because I made a short speech on the Budget in which I stated my views. Given the fact that we have to raise money by this means, the Minister has argued that the charge for dentures and spectacles is the best way of getting the money out the Health Service because it would cause less hardship than any other charge, because he thought it would help to attract dentists from the general health service into the school dental service, and because it would stop any abuses there may be. I wish to direct my remarks to those three points.
I agree entirely with the Minister that if a charge has to be made for the Health Service, it will create less hardship by being a charge on dentures and spectacles than a charge for entry into hospital or for consultation with a doctor. What I object to, as I said earlier in another speech, is the fact that this may be only the beginning. The Minister has told us 320 tonight that the way the Bill is drafted makes it impossible to tack on any further charges. I most gratefully welcome that statement.
But that is not enough. We have to envisage the time when Members opposite may be in power. It would be fairly easy for them to pass another Bill imposing further charges. We could oppose it, but once we have passed this Bill, we can no longer effectively argue against another Bill imposing charges for hospital treatment or consultations. Furthermore, while there may be less hardship with these charges, there will be a considerable amount of hardship. I am entirely with the hon. Member for Wolverhampton, South-West, perhaps for the first time, in the matter of people in work having to go to the National Assistance Board.
I want to deal at some length with the second argument. The argument has been used by the hon. Member for Luton (Dr. Hill), and the hon. Member for Enfield, West, that by making a charge for dentures, dentists will be encouraged to leave the general dental service and go to the school dental service. That is a very important argument, because we all know that the school dental service has been decaying and withering away during the last few years. Personally, I do not believe that what those hon. Gentleman said was true. It is rubbish to stand up and say it without analysing the position—to argue that by making a charge for dentures, we are going to provide a solution of the problem of the school dental service.
The remuneration in private practice is very much higher than the remuneration in the school dental service, and we would have to prove that that remuneration in private practice was falling so fast while the remuneration in the school service was going up so fast, that the gap between the two would be closed, and the flow of dentists would start going the other way. As a matter of fact, what is happening in the Health Service, at present is that the private dentists receive a smaller percentage of profit for dentures than for other work. Indeed, many dentists, while accepting patients for filling and other conservative work, are refusing to accept patients for dentures. Therefore, I do not think there is any possibility of this gap between the two services being closed. There is still a 321 tremendous demand for dentists, and even when this charge is imposed the dentists available will still be fully employed, making it as difficult as ever to procure dentists for the school dental service.
Listening to the speeches of the hon. Members for Luton and Enfield, West, one would have thought that before the Labour Party came into power there was a flourishing school dental service. There never has been a flourishing and efficient school dental service in this country. It has always been the poor relation of the Health Service, and before the war, dentists in the school dental service were paid very low salaries and the conditions under which they worked were disgraceful. The service was never efficient and it could never do good work in the country. I regret that we have not been able to do much about it, but I hope that in the near future we will face up to it. In the present set-up it is not a problem for the Government but for the local authorities, and if they cannot find the money then the best people will not be drawn to the service.
The third point the Minister suggested was that these charges might help to stop abuses. I am sorry that a Labour Minister of Health put forward this argument, because, personally, I do not believe that there has been any considerable abuse of the Health Service by the patient. I should have declared my interest in the matter, because I am a practising dentist. For every patient who comes into my surgery and asks for dentures I have to sign a form stating that I consider that the patient requires the dentures to make him or her dentally healthy. The onus, therefore, is on the dentist every time to show that the patient requires the dentures. A great majority in the profession have on numerous occasions turned patients away when they considered they did not require this treatment. If there are any abuses it is not the patient who is to blame, but the dentist.
The hon. Member for Hendon, South (Sir H. Lucas-Tooth), whom I should like to congratulate on his promotion to the Opposition Front Bench, spoke about inflation in the Health Service, and said that too many patients were chasing too few dentists. That may be true, but what is the solution? Time and time again the hon. Member has advocated 322 for the dental profession what the dentists call a "grant in aid." That has been the solution of the Tory Party in the past. There have been too few dentists for too many patients and the Tories have suggested that the number of patients should be cut down, and that the way to do that was for the Government to make a contribution to dental treatment and allow the dentists to charge on top of that. The result would be that only the people who could afford the extra charge would get the treatment and those who wanted the free treatment would have to take a place at the back of the queue. Their solution is the solution which the dentists want.
The right hon. Gentleman quoted from the Dental Advisory Committee of the Central Health Services Council, saying that they were in favour of this charge because it would help to encourage dentists into the school dental service. I would tell him that the dentists are in favour of a charge because they think it is the thin edge of the wedge and that they will be able to impose the grant in aid which they have always advocated, but not because they expect dentists to go back into the school dental service.
There is an important argument which we have to face. I believe that this charge was completely unnecessary because money could fairly easily have been found by other means within the Health Service. Every hon. Member has today received a circular sent out by an organisation called the Incorporated Dental Technicians' Association, pointing out where £9 million could be saved by cutting dentists' fees for dentures. I want to elaborate that point and I also want to debunk the circular.
I am very sorry to see that the "Daily Telegraph" this morning had a large article on it and the B.B.C., in their one o'clock news, gave a considerable amount of publicity to the fact that an association of dental technicians was pointing out how a considerable amount of money could be saved by cutting dental fees in this way. This organisation is a "phoney" organisation, representing men who have no place in the dental profession. The arguments they use are "phoney," and the figures they give are also "phoney." It is an organisation which has been disowned by the British 323 Dental Association and also by the bona fide trade unions who represent the workers in the industry. It is an organisation which has used sweated labour, made high charges and brought discredit on the dental profession, and I am sorry that the B.B.C. should take this up without inquiry into the bona fides of the organisation.
But there are ways in which we can save some money. I have advocated time and time again that there is a considerable wastage because there is not sufficient check on the type of work which dentists are doing. A small proportion of dentists are not playing the game, because the Treasury have refused to allow the Ministry of Health to increase the salaries of the regional dental officers who supervise dentists' work. The establishment of regional dental officers is 36 and only 22 are employed because the Treasury will not permit an increase to bring the salaries of such men up to the level of dentists in private practice. If we could fill the establishment of 36 we could have a considerable amount of supervision of the dentists, and find out who are the shoddy dentists and the amount they are "skimming off."
I should like the Minister to answer this point. Was the Dental Estimates Board, which is responsible for the organisation of the National Health Service dental work, ever consulted before the charges were proposed? Was it asked to put forward other ways of raising the money required? I am told that it was not. I am told by responsible people closely associated with the Dental Estimates Board that £7 million or £8 million could be saved by cutting out luxury treatment.
At present dentists are allowed to fit temporary dentures and, therefore, almost every dentist is fitting temporary as well as permanent dentures for each patient and is also allowed to reline them twice, and this has meant that instead of getting £8 for fitting dentures the dentist gets £24. This is happening throughout the dental profession. We could save a considerable amount of money by cutting out this luxury treatment. The Dental Estimates Board could have put forward other ways of saving this money, I believe; there are other ways, also. The consultants could be 324 cut considerably. They are being paid much more than they are worth.
I support the Bill, although I do so reluctantly, and I appeal to the Minister to look at this matter again. The Bill will go through, but let us see to it that from now on we, on this side of the House at least, are determined that this is the last step in that direction we shall take. Let us see that from now on our efforts will be turned, not to making further cuts in the social services but, at the first opportunity, to ridding the Health Service of what I believe to be a stigma.
§ 9.11 p.m.
§ Lieut.-Colonel Elliot (Glasgow, Kelvingrove)
We have had a long debate, but not too long considering the importance of the subject we are discussing. I think it is true to say that the non-technical Members of the House have contributed more than the technical Members to the discussion which has gone on this evening. We are dealing with a very wide subject, and it cannot be discussed on the basis—if I may say so to a fellow-Glasgow man—of an argument between one set of professional men and those whom they regard as members of phoney institutions.
This is indeed a very big subject. The Minister broached it with admirable candour and explained his position to the House. The Debate has been carried on since by speeches such as that of my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth), speaking for the first time from this Box, and by my hon. Friends on the back bench such as the hon. Member for Enfield, West (Mr. Iain MacLeod), and the hon. Member for Wolverhampton, South-West (Mr. Powell). I think it is the opinion of all the House that they made valuable contributions to what is, I do not think we can deny, a parting of the ways.
As my hon. Friend the Member for Wolverhampton. West, said, this is the moment at which we transfer the Health Service from the principle of an almost entirely free service to the principle of a service in which a charge is instituted. It is certainly not the first time that this has been suggested. The underlying principle was conceded by the late Minister of Health, the right hon. Member for Ebbw Vale (Mr. Bevan). In speaking on 17th February, 1949, he said:As the hon. Member for Chippenham said, inevitably there is only a limited amount of 325 money to be spent at any time on all our social services."—[OFFICIAL REPORT, 17th February, 1949; Vol. 461, c. 1461.]That envisaged the principle of the ceiling, and it was conceded by the then Minister of Health.
As for the other great question which has been broached this evening, the question of the charge, that also was conceded by the right hon. Gentleman the Member for Ebbw Vale. We have had quoted already his remark about the amendments—oddly enough, coming from the House of Lords—which empowered a shilling charge to be made. Indeed, the hon. Member for Sowerby (Mr. Houghton) commented rather acridly on that remark of the right hon. Member—that he had, in fact, led his followers up the garden path by getting them into the Lobby in support of a proposal which he himself did not consider to be practicable.
§ Mr. Douglas Houghton (Sowerby)
Is not the right hon. and gallant Gentleman confusing me with my hon. Friend the Member for Batley and Morley (Dr. Broughton)?
§ Lieut.-Colonel Elliot
Yes, I beg his pardon. I had jotted it down wrong. I apologise to the hon. Member.
That was not the only statement of the then position. It was prefaced by a statement from the head of the Government—from the Prime Minister—who, speaking on 24th October, 1949, said:We propose to make a charge of not more than 1s. for each prescription under the National Health Service. The purpose is to reduce excessive and, in some cases, unnecessary resort to doctors and chemists, of which there is evidence which has for some time troubled my right hon. Friends the Minister of Health and the Secretary of State for Scotland. The resultant saving will contribute about £10 million…"—[OFFICIAL REPORT, 24th October, 1949; Vol. 468, c. 1019.]Indeed, the Prime Minister later had the authority of the right hon. Member for Ebbw Vale for that, for, speaking on 15th November, the right hon. Member said:I shudder to think of the ceaseless cascade of medicine which is pouring down British throats at the present time.It is true that, speaking in the House yesterday, the right hon. Member said:The prescription charge I knew would never be made because it was impracticable…. I had to manoeuvre, and I did manoeuvre and 326 saved the 25,000 houses and the prescription charge."—[OFFICIAL REPORT, 23rd April, 1951; Vol. 487, c. 43.]The trouble of the right hon. Member's mind seems to have been not quite so much the argument of the prescriptions, which was bothering the Prime Minister, as the particular manoeuvre upon which he should embark at any given time. I find it a little difficult to reconcile those two statements.
§ Lieut.-Colonel Elliot
Then the troubling of the right hon. Member's mind must have gone on from that day to this—…there is evidence"—said the Prime Minister—which has for some time troubled my right hon. Friends the Minister of Health and the Secretary of State for Scotland. The resultant saving will contribute about £10 million, although this is not the primary purpose of the charge.As I say, if the charge has never been applied it means that the right hon. Member's mind has been unnecessarily troubled for an unnecessary length of time. The Minister, however, comes forward to rescue him from that, but he comes forward with another proposal. We have heard nothing of the proposal which was to deal with the floods of medicine "pouring down British throats," or to reduce theexcessive and, in some cases, unnecessary resort to doctors and chemists, of which there is evidence,or even the abuses to which the right hon. Member referred on three separate occasions when recommending that proposal to the House—the abuse has taken place…. That is where the abuse arises…it is generally accepted that there is an awareness of the abuse which has been taking place."—[OFFICIAL REPORT, 9th December, 1949; Vol. 470, c. 2263.]What are we to say now? We trust that the new Minister of Health is not manoeuvring upon this occasion, but he must understand that the statement of his right hon. Friend the Member for Ebbw Vale has sown a certain distrust, or, at any rate, has called for a close scrutiny of any proposals which are brought forward lest they again prove to be some kind of a manoeuvre. We trust that that will not be so on this occasion.
327 The Bill brings forward a ceiling, a charge, and quite another set of proposals, the proposals for restoring to the authorities of this country a power of which they have been deprived: the power of paying for tuberculous patients' treatment outside the bounds of this country. The hon. Member for Sparkbrook (Mr. Shurmer) spoke most eloquently in support of this proposal, and I am sure that it will find support from all quarters of the House. I do not need to remind either the Secretary of State for Scotland or the Joint Under-Secretary of the numerous occasions upon which it has been pressed from this side of the House. I think it is fair to say that it has also been pressed from the other side of the House.
The hon. Member for Batley and Morley, if I am not misquoting him, seemed to think this had been brought in to gild the other somewhat unpopular proposals. He was told this was not so, and accepted the position. It was merely a coincidence that this ram was found caught in the thicket at the time the patriarch uplifted his knife to slay his son. But the Minister was more ruthless than the patriarch and the ram has been slain as a sacrifice and the son has had his throat cut as well.
The hon. Member for Bermondsey (Mr. Mellish) most eloquently advanced the claims of Rotherhithe for a sanatorium as a place suitable for treatment of tuberculous patients; and with that singular power he has of giving a side kick against people who have no quarrel with him at all he landed a kick at the Rhondda Valley. I saw no reason for that as I see no reason why the Rhondda should not treat tuberculosis cases—[Interruption.] The hon. Member of the Hyacinthian name knows very well that the difficulty is not getting a bed, but getting staff. There are beds in this country, as everyone knows—thousands of beds—closed because we cannot get staff to staff them. The difference between a bed here and a bed in Switzerland is not that Switzerland is a mountainous country and ours is a flatter country, but that there are nurses to attend the tuberculous patients in Switzerland and we cannot get them for the beds here.
That is the reason why anything and everything we can do to bring down the 328 waiting list is of the very greatest importance because this is an infectious disease. It is a disease which can be communicated from the patient suffering from it to others. We all have in our constituencies the most distressing cases of people on waiting lists sharing quarters with other members of the family who will almost inevitably infect those other members of the family unless segregation can take place. This is an occasion on which to do it and I am sure everyone of us welcomes that provision from the bottom of his heart.
I would say to the Secretary of State for Scotland that I trust he will not be too rigid about confining this provision to the respiratory cases. I have here a number of quotations, with which I shall not trouble him, of occasions when he, or the hon. Lady the Joint Under-Secretary of State, or other Ministers have refused this proposal because they said they had no legislative power to do it. Here is the legislation. Opportunities for such legislation do not occur so often and frequently as we could wish, but this is an opportunity. Do not let these proposals be placed on the Statute Book in such a way that they cannot be changed without the authority of the King, the Lords and the Commons, to allow a person suffering from other than respiratory tuberculosis to be so treated. That was not so in the past, and I do not see why the National Health Service should have such powers withheld from them.
This is a proposal which evokes universal consent. The other two do not. It is true that we have not heard tonight the voice of the "Tribune," or any of its supporters.
§ Lieut.-Colonel Elliot
It may be so, but we are unable to discuss their proposition because it has not been put forward except in columns of journals outside this House. But it is true that there is indeed uneasiness, and uneasiness which is not confirmed to one school of thought, or to one side of the House. It has been faced by my hon. Friends and it is faced by us all. Here is a departure which is taking place, and certain aspects of it are difficult to stomach.
For instance, the proposal that treatment should be given under a certificate of means from the National Assistance Board has been commented on by several 329 hon. Members. I do not think it is as great a breach in our social life as hon. Members opposite seem to think. They seem to have forgotten their own Legal Aid Bill, when, in the teeth of much opposition from many of us, the principle of bringing in the Assistance Board to determine the need for a particular kind of social treatment, namely, legal advice, was written into the Statute Book of this country; and written in when there was a great Socialist majority with no question of narrow or wavering support. There it is in the Statute Book today. For all that, I think it was a mistake and I and my right hon. and hon. Friends opposed it then. I look upon it still with the greatest uneasiness.
The human sympathy of the Assistance Board depends, like all human sympathy, on not being exhausted by over-pressure of applicants. Those of us who sit taking "cases" know that towards the end of a very long morning our patience—I will not say, like the patience of Mr. Hitler, is exhausted—but we tend to give more perfunctory consideration to the final applicant than to the earlier one. It is time which is the essence of good social work, and unless we can give individual attention to cases, they will not get that human sympathy which they need. I dread the over-loading of a board which is doing very valuable work just now and which I think is likely to be injured if too great a burden is placed upon it.
However, the charges to be made must be determined somehow. I should have thought if it was necessary to find some organisation to investigate the affairs of our much investigated race the Board of Inland Revenue which knows every detail and item of my own personal circumstances could be considered. I cannot think of anything about myself that any snooper, however pertinacious, could find out and communicate to the Board of Inland Revenue that they do not already know; in any case, I should have thought that it would have been possible to use some simpler machinery than the machinery of the Assistance Board.
Apart from all that, is the charge justified? Has a ceiling to be imposed? I think the case made out by the Chancellor of the Exchequer and by the Minister, for the imposition of a ceiling was inescapable. But that ceiling must not have coming up to it the rising floor 330 of prices. It would crush the virtue out of the system just as the man in Poe's terrible story was crushed by the descending ceiling. If one is between the upper and nether millstones it does not matter which is the moving one. This proposal makes it absolutely inescapable that we should bend every effort to resist inflation and the rise in the cost of living, which month by month is eroding and gnawing away the very benefits which this House is voting.
As for the charge, the point on that has been made by my hon. Friends, and I agree with them that our imposition of a charge should be rather to direct than to tax. It should be to direct the resources available to cure the errors which are arising, as, for example, in the dental services. The hon. Member for Wolverhampton, North-East (Mr. Baird) said the school dental service had not been of very much good. I was sorry to hear that and I thought that was an exaggeration. I am sure that the place for conservative treatment in dentistry, as in politics, begins with the young, and I should certainly hope that if the school dental service was poor it should be fortified and strengthened.
It was my own view when, several years ago, I took the first step to provide school milk, that the first step in an improvement in the teeth of the children was to provide adequate supplies of lime to growing children. For that reason, we introduced milk in schools, and, although many accusations have been made against us of lack of interest in the social services or even of positive hostility to them, I will say that that was introduced by a Tory Government, and, although I do not wish to raise a discordant note at this stage, I will add that the chief speaker against it was Sir Stafford Cripps, and that, in the Division against the Bill, the present Prime Minister followed him into the Lobby. I regret that, but we all come to fall from time to time. [Interruption.] There was going to be school milk if the Bill went through; if it was defeated, as the hon. Lady and others know very well, there was not. A vote against the Bill was therefore a vote against school milk. Let there be no mistakes about that. I do say that the principle of a charge or contribution was involved, and to say that they were justified in rejecting a Bill be- 331 cause of the principle of a contribution in the case of school milk conies badly from——
§ Lieut.-Colonel Elliot
To criticise it, may be, but not to vote against the Second Reading of the Bill. The hon. Lady herself, a highly educated specimen of Scottish womanhood, will be well aware of the French proverb that the best is the enemy of the good, or to put it in more homely language. "Half a loaf is better than no bread."
§ Lieut.-Colonel Elliot
The hon. Lady's knowledge of our common tongue is at fault. It is "An auld horse for a feal dyke" and "A stout heart for a stey brae." But let us not interchange the vernacular across the Floor of the House in the presence of the brethren, or the debate will move into other spheres altogether. I have already encroached on the time of the Secretary of State by three minutes.
I say that these proposals seem to us proposals to which, although with reluctance, we must concede a Second Reading. But they do involve great problems, both of detail and principle, which will require further close examination, as will the Bill itself, in the Committee Stage. Meanwhile, it is an absolute sine qua non of the working of this or any other such Measure that the rise in the cost of living must be halted. Otherwise all the provisions which we are bringing forward here are going to be of no avail to remedy the difficulties and the problems which have caused these particular proposals to be introduced.
§ 9.35 p.m.
The Secretary of State for Scotland (Mr. McNeil)
It was very good of the right hon. and gallant Gentleman the Member for Kelvingrove (Lieut.-Colonel Elliot) to apologise, although I assure him that there was no need to do so. I am always entertained by these battles in the vernacular, and it was part of the general pattern of this debate that there 332 should be such a friendly interchange at the end.
I think I would be lacking both in courtesy and perhaps a little in my duty if I did not say, on behalf of the Government, that this has been a most helpful debate. I would also confess that we were not very sure that that would be the general character of the debate. I am bound to say that most helpful speeches have come from some of my hon. Friends on this side who do not completely agree with me. We had, for example, a most studied and moderate speech from my hon. Friend the Member for Manchester, Exchange (Mr. W. Griffiths). We had, I should also confess, a very helpful speech from the hon. Member for Enfield, West (Mr. Iain MacLeod). I did not quite follow the praise which was offered to the hon. Member for Wolverhampton, Southwest (Mr. Powell), but I will come to that in a second or two.
Information has been asked for about various aspects of the Bill, to which I shall now try to address myself. A good many questions were asked about the details of the proposal embodied in Clause 3, inquiries which were usually accompanied by approval of the Government's intention in this respect. It may be quite true that from hon. Members opposite we have had questions from time to time. That is delightful, but from this side we are having action.
I was asked in a most helpful speech by the hon. Member for Lewisham, North (Sir Austin Hudson), if we could agree to extend the scope of Clause 3 to cover tuberculosis other than respiratory conditions. He particularly asked that we should consider ocular tuberculosis. I hope we shall not be thought unsympathetic if I say that, at any rate at this stage, I can hold out no hope that we shall so extend it. It would be very difficult to choose between one type of surgical case and another. In any event, I am assured that there would be slight risks of the attitude of the surgical side of the profession differing a little from one country to another. In the beginning, at any rate, we want to try to play safe in this respect. The real reason why it is proposed to confine the matter to respiratory tuberculosis is the one given by the right hon. and gallant Member for Glasgow, Kelvingrove. We must tackle the infectious side of the disease, and that, of course, means the respiratory cases.
333 I was asked by several hon. Members how the patients will be chosen, and I duly noted the claim offered to my right hon. Friend by my hon. Friend the Member for Bermondsey (Mr. Mellish). I should think there would be several competitions of the kind he indicated, and I propose to try very hard to keep clear of them. He, along with other hon. Members, asked how patients would be chosen. I would say that while I anticipate difficulties, we shall, of course, try to choose cases primarily upon medical advice as to their suitability for treatment.
One hon. Member suggested that we might try to deal with the matter by selecting the case which would benefit from a short stay. I think, at any rate at this stage, that that would be injudicious, and we shall, subject to medical advice, try to aim at the case where the normal expectation of treatment is about six months. One other qualification I should make is that the choice will be guided against cases where there is any expectation of surgical intervention, certainly of a major kind.
Hon. Gentlemen asked how the money aspect of the subject would be handled. The patient will not come into that part of the business at all. It will be a contract between the National Health Service and the sanatorium chosen, and the payment will be made direct. We were encouraged to extend. There is at present only a limited number of suitable beds. There are administrative difficulties and we should not take any undue administrative risks at this stage. We are dealing with sick people who will be far from home.
Moreover, I should like to join in the plea made by my hon. Friend the Member for Bermondsey who told my hon. Friend the Member for Sparkbrook (Mr. Shurmer) that we ought to temper our enthusiasm. Do not let us assume that the only places where respiratory tuberculosis can be treated are in Switzerland; do not allow people to imagine that they have no hope of getting well unless they go there. The Minister, in introducing the Bill, pointed out that we hope in the very near future to extend our capacity for treatment of tuberculosis at home by something like over 2,000 beds. If we can overcome our subsequent staff difficulties we shall extend that further.
334 The Swiss experiment should be helpful at a time when a substantial improvement is being shown in our tuberculosis figures. In Scotland, we have seen a reduction in the death rate by as much as 20 per cent. in one year—a quite startling figure. We have also seen, to our relief, a reduction in the notifications, despite the extension of better diagnostic facilities. While we have this great problem on the move we as a Government want to use any reasonable methods, and I know the whole House wants us to do so. This is one on which, at any rate, we can start.
I now turn to another aspect of the Bill about which a good deal of information was asked. I refer, of course, to the employment of the National Assistance Board and how that will be applied to the patient. Here, I must say quite frankly I did not find the speech of the hon. Member for Wolverhampton, South-West, at all helpful. Despite its apparent analytical approach I thought it was an attempt at political mischief. It is nonsense to pretend that the Assistance Board has not already been employed in this service. It is also nonsense to pretend that there has been no question of charges before in this service.
There have been charges from the beginning, charges for a great range of services. The hon. Member for Enfield, West, drew our attention to a charge which has been inherent in the Act from the beginning. More legitimate anxiety was expressed by hon. and right hon. Gentlemen about why the Assistance Board should be employed, and Members asked if there were not alternative methods.
The right hon. and gallant Member for Kelvingrove suggested that the Board of Inland Revenue might come into it. Most of us will have had more experience of the Board of Inland Revenue than of the National Assistance Board, and I would not think that was at all a good suggestion. It is not just a case of looking at a column of figures and making a decision. This is a very complex matter. It is a subject in which the Assistance Board have produced a great many specialists and a great many people who have not only the technique but have a sympathetic approach in the handling of this kind of problem.
335 One hon. Member asked whether dentists would know that the Assistance Board had come into it. Not at all. There will not be, as he suggested, two races of people in the dentist's surgery. The Assistance Board will make the inquiry and the assessment, and the subject will lie between the Board and the applicant; the dentist will not come into it at all. One of my hon. Friends suggested that we might allow either the dentists or the opticians to make the assessment. I am sure that was meant sympathetically, but, here again, I think it is not a practical point for consideration. I do not imagine that either the dentist or the optician has any kind of facility for this business.
Another point upon which I should like to comment here relates to the advice offered by my hon. Friend the Member for Wolverhampton, North-East (Mr. Baird), who asserted that the introduction of charges could make no contribution towards filling the deficiencies in our dental educational system. My right hon. Friends and I find that very difficult to accept. There is a very good reason why we should have difficulty in accepting it. Before the Health Service Act came into operation there were in Great Britain about 50 per cent. more dentists in the dental educational system than there are at present. There have not been fewer dentists trained in the interval. The drain off has taken place almost exclusively to the National Health Service.
We have made cuts—cuts which I think were completely justified and which, of course, arose from impartial examinations; still, we did not fill the gap in that service. Today, we have some 800 in the service. We could quite easily employ twice that number and, if circumstances were suitable, we might even be able to employ efficiently three times that number in the educational dental service. I make no apology for saying that I believe that this is the most important part of our dental practice; this is the only place where we bring preventive medicine to the dental practice. The child at school, regularly examined, treated carefully, builds up a series of good habits which not only are of subsequent benefit to the nation but which are of great benefit to the individual in terms of good health.
336 It was also suggested that our figures on the dental side were now running down. That is not so. My right hon. Friend drew to our attention the appallingly high proportion of our expenditure in terms of dentistry, and my hon. Friend the Member for Wolverhampton, North-East, did not disagree, but it was suggested that the figures are going down. That is not at all definite. It is a misconception.
I will quote the Scottish figures, but I have no reason to believe that they differ in any substantial degree from the national pattern. I should say that for the first quarter of this year, from January to March, we ran up to 126,000. That does not mean much in isolation so I should say, perhaps, that for the first quarter of 1951 that figure represented the highest on our records. There has been newspaper comment and investigation which does not belie that picture.
I have admitted that that is for Scotland, but I have no reason to believe that the Scottish picture differs very substantially from the English and Welsh pictures. I should want to concede that on the optical side we do seem to have run down to a figure which looks like representing a steady maintenance and replacement rate.
I should like to join with my hon. Friend the Member for Coatbridge (Mrs. Mann) and the right hon. and gallant Gentleman and others who diverged a little to talk about the abuses in prescriptions. It is a large subject which I am not anxious to pursue at this moment, but it is common sense that we all have an obligation, by the use of any influence we have, to pull people away from those wretched habits. I am not going to go back into old history of who provided the milk and at what price in the schools, but we all agree that one bottle of good milk is much better medicine than 10 bottles of medicine.
§ Dr. Morgan
I did not quite hear. Did my right hon. Friend say that one bottle of milk was as good as 20 bottles of medicine?
I said that one bottle of milk was worth 10 bottles of medicine—I am prepared to say 100 bottles of medicine.
It is quite obvious that my hon. Friend should declare his interest in this subject.
We have, as the House knows, made a decided movement towards the control, or, at any rate, the better control, of prescribing, mainly by the recommendations of the joint committee, which is now usually referred to as the Cohen Committee.
Several Committee points were made during the debate, mainly on the Assistance Board, upon which we shall be glad, naturally, to afford opportunities for discussion and, perhaps, further information. [Interruption.] I said "naturally," but I meant that at this stage they were Committee points—for instance, exactly how the Assistance Board would operate a scale—that are not a subject I would attempt to discuss on the Second Reading of the Bill. I was merely indicating that if I was not answering these points it was because I thought they were Committee points.
Several of my hon. Friends have indicated their dislike of, or even their repugnance to, the Bill. That we quite clearly understand. My hon. Friends, particularly, who have a close acquaintance with the hardships and privations of the working class are always worried, most understandably and most properly, lest further hardship should be visited upon them. We have attempted to take care of that in the Bill. The Minister of Health and the Chancellor of the Exchequer have explained the context in which we have taken this decision. It is not a breach of the Health Service. It is not the creation of a new principle. It is a principle which the House has accepted, and it is a conception that was inherent in the Act from the beginning. I make it quite plain that we would not have taken it had there not been these overriding economic necessities.
We are all, or almost all, committed to support of the defence programme, and, as the hon. Member for Orkney and Shetland (Mr. Grimond) said, in effect, we cannot have a defence programme without tears, so let us face up to it. But I suggest that these are minor tears. These do not represent the only cuts that have taken place, the only economies that have been effected in the social services.
338 Moreover, my hon. Friends who find this unattractive are not the only people in the House with claims. There are people who are worried that we are not able to find more for education, to find more for pensions, or to find more for other sectors of the National Health Service. If there were no restraint upon us would any of us argue that we should disregard the demand for more tuberculosis accommodation anywhere we could find it?
If there were no competition would anyone deny that we should extend ourselves to find more obstetrical facilities? I am not competent to enter into the argument as to where confinement best takes place, but, undoubtedly, there is a great desire among our womenfolk to be guaranteed the facilities and the appearance of safety that many of them associate with institutional confinement. These are claims which I should not apologise for putting against these comparative restrictions which we embody in the Bill.
My right hon. Friend said that the basic principle of the National Health Service Act—that is, that these services and essentials should be made available to a man, woman or child whenever they are sick—is still safeguarded; there is no suspicion that that should be prejudiced in any way. These very modest charges are charges—and no one has sought to deny this—which are put on the very periphery of the National Health Service; they are charges which will not normally be applied to a man or woman while sick, or while they are out of work in consequence of being sick. The Bill expressly provides that where these things are necessary to in-patients there is no charge; it provides that such dental facilities as are necessary for pregnant or nursing women are available without charge.
I therefore suggest that we have acted judiciously and wisely, that the charges have to be made, and that this is the place where the charges can be made without threat to the principle of the Act, and with comparatively little hardship to anyone affected. The need for dentures or spectacles is not a frequently recurring need, and it is not a need that normally descends suddenly upon anyone.
§ Question put, and agreed to.
§ Bill accordingly read a Second time.
§ Committed to a Committee of the whole House for Tomorrow.