HC Deb 29 January 1952 vol 495 cc145-58

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

9.21 p.m.

Mr. Malcolm MacPherson (Stirling and Falkirk Burghs)

I wish to draw the attention of the House to the question of tuberculosis in Scotland. It is pleasant to find that we have a little more elbow room for this discussion than normally falls to the lot of a speaker on the Motion for the Adjournment, and I hope that Scottish energies have not been exhausted by the debate earlier this evening on another Scottish topic.

The question of tuberculosis in Scotland, as I think the Joint Under-Secretary of State will agree, has been a somewhat melodramatic question of the course of the last few years. Some surprising things, and some still unexplained things, have happened, and the whole matter has been attended by not only a good deal of publicity but, I think one might also say, notoriety. In the post-war years, there has been a very considerable increase in the incidence of tuberculosis in Scotland from causes which, as far as I know, are still not understood, at a time when, in other countries, the incidence of tuberculosis was falling. In the last 2½ years or thereabouts, there has been a sharp decline in notifications, in deaths, and in the whole incidence of tuberculosis in Scotland. I am not sure whether the reasons behind that fact are fully or even partly understood either.

The right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot), on one occasion, described this rather curious episode—the rise in incidence; he was not then talking about the fall—as "a detective story, half read." The experts in the matter could not understand what were the causes producing these results, and, of course, the detective in that detective story must be the expert—the doctor. The general public cannot find out the villain; the detective must be the expert.

With that situation in the background, I think it is desirable that the Government, on this early occasion after taking office, should explain to us what their policy is. I do not think that, since the report on the subject in December, 1950, published some months later, by the Scottish National Health Service Committee, there has been anything like a detailed Government statement. Although there are some illnesses and some pathological states which perhaps can be cured by the simple intervention of the doctor with the patient, in the case of tuberculosis it is abundantly clear to all of us that Government policy lies at the base of any real advance. The major factors in the situation are factors which Government decisions will strongly affect, and will, perhaps, one might also say, either put there or take away, so that Government policy is something which, it seems to me, should be continually made clear.

I should like to ask the hon. and gallant Gentleman whether it is the intention of the Government to maintain in operation all those factors, policies and methods which may have contributed to the decline in the incidence of tuberculosis over the last 2½ years. There used to be a maxim in the Army that you should reinforce success. It is not to meet failure that one throws in reinforcements, but when one is getting ahead; and I would suggest to the hon. and gallant Gentleman that Government policy just now should be based on the proposition that we should take the opportunity of reinforcing the present good trend.

I want to draw attention to one or two specific matters in the very wide range of matters concerned with the prevention of increased incidence of tuberculosis. First of all, in connection with prevention, which, presumably, is the first step in general measures for protecting society against the heavy incidence of tuberculosis, I hope that the resistance of the Scottish community can be built up —is being built up and is growing up—and that the rise in incidence in the years immediately after the war does not mean that there is any permanent decrease in resistance to tubercular infection.

There is one specific method that has been used to extend our protection against infection, and that is, of course, the use of B.C.G. In the past two years that has been used in connection with nurses, with medical students, and with contacts with people who have had tuberculosis. The question is now a reasonable one: Should the use of B.C.G. not be extended? We were, after all, extremely conservative in introducing B.C.G. as late as we did, after other countries had had long experience of its use.

If there is a case—and that is a technical question on which a layman cannot express a very emphatic opinion—from the medical point of view, for extension of the use of B.C.G.—for example, to children in leaving classes at school, or even more widely than that—does the hon. and gallant Gentleman contemplate that that extension will take place? There is one other question about the B.C.G. programme, and that is in connection with local schemes. Is the hon. and gallant Gentleman satisfied with the extent and effectiveness of the local schemes for B.C.G. just now?

In connection with B.C.G. I think it is possible to turn back to the detective story. One cannot, of course, as I suggested earlier, make a very certain detection, but in the movement of decline from the high and alarming peak of about 1948 both the death rate and the notification rate declined at what, to the layman, seemed to be roughly about the same time. Presumably, from the point of view again of the ordinary, uninstructed layman, if there were one single cause operating there would have been a fairly considerable time lag between any decline in the death rate and a decline in the notification rate; and one is inclined to wonder if there are not two separate causes operating and whether one of them—the decline in the notifications—may not be due to the extended use so far of B.C.G.

I do not know whether the hon. and gallant Gentleman's medical advisers have been able to give him any information concerned with that question, but it seems to me a relevant question to ask. In that case, one might, I think, ask whether the decline in the death rate has not been due—or has been possibly due—at least in some part, to the use of mass radiography—to pass on now from prevention to diagnosis. To the layman, in recent years the most interesting development in diagnosis has been the use of mass radiography, which enables diagnosis to take place much earlier in the course of the disease. With early diagnosis, treatment can be more effective, and one wonders whether the decline in the death-rate is due particularly to the increased use of mass radiography.

The amount of mass radiography undertaken so far has been fairly considerable. The last statement of the numbers undergoing mass radiography in Scotland shows a rate of 150,000 a year—a fairly considerable proportion of the Scottish population. I do not know that that could not be increased, but when we remember that it applies largely to adults rather than children, and that already about a quarter of a million have been examined, it will be appreciated that a considerable amount has been achieved in mass radiography.

Even so, it is relevant to ask whether its use could not be extended. I believe that there is a certain psychological barrier to extending it to 100 per cent. examination; people do not like to be discovered having any signs of T.B., and one can understand that sort of fear. One can understand also that in this kind of problem the psychology of the approach is in some ways as useful as ordinary medical treatment.

In treatment the big problem has, of course, been the provision of staffed beds in sanatoria, or in other institutions in substitution for sanatoria. The big difficulty has been in recruiting nurses to nurse tuberculosis patients. In recent years there has been a fairly steady increase in the number of staffed beds and in the nursing staff, both full-time and part-time, and I should like to learn from the Under-Secretary whether that trend still continues, whether we are still getting more and more beds brought into use and still getting more and more nurses. Even if the progression is comparatively slight, it is better to have a progression than a decline.

I should like to know, also, what is the situation respecting the nurses' health. Again, there has been a psychological barrier here in the fear that nurses nursing tubercular patients might themselves contract T.B. I understand that that fear is without foundation, but I am wondering whether the hon. and gallant Gentleman and his advisers find that that fear is now being dissipated. I ask specifically also about part-time nurses and how successful that scheme has been, and whether there is any real possibility of increasing the numbers engaged part-time very sizably.

The Swiss project is a fair indication of the spirited and determined way in which the last Government tackled this problem, and I hope that the present Government will continue with it, although we should like the home situation to be so improved that the Swiss project could be dropped, since the reason for it was the lack of nursing staff—of staffed beds really—at home. If it were possible to provide all our own treatment here without the necessity of having treatment abroad we would have advanced very considerably.

I should like to ask the hon. and gallant Gentleman about treatment in the home. It is not so long ago since a well-known public health authority—I cannot remember which it was at the moment—described home treatment as "an idea born of despair"; but in the last couple of years or so, it seems to me, the authorities have been inclined to take a rather different view of it, and that, I understand, is very largely due to the use of new drugs which have proved, so far as one can understand, very effective with certain types of tubercular patients.

If that is so, and if home treatment is now not a treatment of despair but a treatment that can be considered reasonable, then one is inclined to ask the hon. and gallant Gentleman what developments in it are planned. Is it intended that home treatment shall become a really big part of the treatment of tuberculosis, and, in that case, what organisation is planned in order to develop it? The organisation will, presumably, be local, and one imagines that if there was any further considerable development there would need to be a certain amount of local re-organisation or additional organisation.

A further topic in connection with treatment generally is that of after-care and rehabilitation. This is a particular phase of treatment of tuberculosis which does not, it seems to me, get very much publicity; if, in fact, there is very much activity to publicise. One is always aware, in dealing with a subject of this sort, that underneath the ideas that one can grasp as an ordinary layman there are the technical and medical activities which one may not know about, and of which one may not perhaps be able to assess the importance.

I would certainly put it to the hon. and gallant Gentleman that if there is very, much rehabilitation and after-care work done in Scotland, then it has not come very prominently to the notice of the Scottish public; and yet it does seem to be a fairly important element in preventing cases that are already cured from slipping back into a renewed attack of the disease.

May I draw his attention to one or two general questions, not concerned specifically with treatment, on which he might perhaps be able to give the House some information? It is always useful for the figures in a matter of this sort to be kept up to date. It is not always convenient perhaps to give long lists of figures in debates; it does not altogether enhance the liveliness of debate; but if the hon. Gentleman feels that he can bring many of the key figures up to date to the end of 1951, I think that the House would welcome it, because we have a little more elbow room in the matter of time than we might normally have expected.

I should like to ask him about a recommendation in the report of December, 1950, in connection with inquiries into research. Most of them are a little outside my range. I can understand one of them, which was an inquiry into environmental factors. I can understand what that means from ordinary ability to read English, but I am not too sure that I can understand the implications of all the others; but I should like to ask him whether that particular section of the report is to be carried into effect, or is, in fact, being put into effect, under the auspices of the Government?

Finally, it did not seem to me from what the Chancellor of the Exchequer said earlier today that there was any threat in his remarks of a curtailment of expenditure on the treatment of tuberculosis. I hope that the opposite may be the case and that since the incidence of the disease is now moving downwards that will be taken, as I suggested earlier, as a sign to the Government that this is the time to put more and more resources into it, in order that success may be reinforced. I hope that the hon. and gallant Gentleman will be able to reassure the House that he intends to carry on a progressive and, in that way, a reinforcing policy in this matter over the next few years.

9.40 p.m.

The Joint Under-Secretary of State for Scotland (Commander T. D. Galbraith)

I should like first of all to thank the hon. Member for Stirling and Falkirk Burghs (Mr. M. MacPherson) for his courtesy in giving me notice that he intended to raise this subject, and also of the particular points which were causing him a certain amount of concern. It is perfectly true, as the hon. Member said, that the course which the disease followed in Scotland, particularly during the post-war years, differed from that in other parts of the United Kingdom, and I personally have been unable to find any very satisfactory explanation of that, but I am glad to assure the House that the improvement which began some two or three years ago continues, and that the death rate continues to decline.

The hon. Member asked me to give him certain figures in the course of my reply, and I am afraid it may be that I shall give too many figures. I shall try, however, to be moderate in their use. The variations in the death rate from 1938 to the present day have been rather extraordinary. In 1938 deaths per 100,000 of the population amounted to 52, and that figure increased during the war years until we reached a peak in the years 1948 and 1947. The record of deaths then amounted to 66 per 100,000 of the population. The figure started to fall after that and it fell to 60 in 1949 and 47 in 1950. I regret that the figures for the full year 1951 are not yet available, but the figures for the first nine months can be compared with a similar period in the previous year.

In the first nine months of 1951, the deaths recorded were equivalent to an annual rate of 37 per 100,000, compared with 47 for the previous year. So what has happened in the last three years is that the death rate has fallen—if we can accept 37 for the first nine months of 1951 to be the likely figure for the full year—from 66 to 37 in the period of three years per 100,000 of the population.

Notifications are also showing a steady decline, and that in spite of improved means for detecting the disease in the early stages being used much more widely in recent years. That, in fact, in part accounts for the increase in the notifications between 1938 and 1949, which so startled everyone interested in this matter. The year 1949 was the peak year for notification, when 8,653 were recorded as against 4,793 in 1938. Since 1949 the number has decreased by about 800, and the provisional figure for 1951 is 7,875. These are somewhat impressive and re-assuring figures, but on the other hand they give us no cause whatsoever for complacency. They are the outcome of a continuous and continuing struggle in the scientific research field and also in the preventive and curative fields.

In the research field work is proceeding throughout the whole of the United Kingdom, under the auspices of the Medical Research Council, on scientific and medical problems underlying the treatment of prevention of tuberculosis. In Scotland there is the report of the Tuberculosis Committee of the Scottish Health Service Council. That report has been considered by the Advisory Committee on Medical Research in Scotland. A field survey under Professor Charles Cameron is being arranged. It is intended that that survey shall cover the environmental factors alluded to by the hon. Gentleman, including size and structure of the family, analysis of income, dietary conditions, and the effect of re-housing.

I turn to the preventive side. The most notable method recently introduced has been B.C.G. vaccination. That vaccine has been made available in cases where there was a chance of special risk being incurred, such as in the case of nurses and medical students, and others who are known to have been exposed to infection. While presumptive evidence of the value of that vaccine is provided by experience gained in other countries, and particularly in Scandinavia, its value has not been scientifically established, and tests towards that end are presently in progress.

The hon. Gentleman asked me about the policy of the Department in connection with the extension of the use of this vaccine. In the meantime, the policy is that there shall be no general extension of these vaccination arrangements. B.C.G. vaccination is a supplementary provision and is not in any way an alternative to the existing preventive methods of local health authorities. It might interest the House to know how many people have recently been vaccinated. During 1950, 23,735 persons were tested with a view to vaccination and 4,500 of them were successfully vaccinated. That is continuing on an increasing scale.

Mr. MacPherson

Before the hon. and gallant Gentleman leaves the subject of B.C.G. vaccination, can he tell us what reason the Government have for not extending it?

Commander Galbraith

Yes, Sir. The hon. Gentleman will have noted that I said that the value of this vaccine has not yet been satisfactorily scientifically established. We would rather wait, before continuing with an extension, to ascertain exactly what the true scientific value may be.

The hon. Gentleman spoke of the need for early diagnosis. That is of the utmost importance, as treatment in the early stages greatly increases the hope of complete cure. Mass radiography plays a very important part in this respect. The history of this service is interesting. The House will remember that it started in Scotland in 1944 with two static units in Edinburgh and Glasgow. Since then, four mobile units have been added. Another two are shortly to be in operation, one in the western region and one in the north and north-east of Scotland. Still another two are in contemplation, one probably to be centred on Dundee and another on Paisley.

Figures of the numbers of persons examined in 1951 are not yet available, but we can offer a comparison of figures for the first six months of 1950 and the same period of 1951, to show how very greatly the work of those units has been expanded. In the first six months of 1950, 78,060 persons were examined: in the same period of 1951 the number was 114,287. Further expansion of this service depends upon the availability of additional skilled medical staff, which is not too easily obtained at the present time. There is one further figure relating to mass-radiography which may be of interest to the House, and that is the percentage figure of active tuberculosis discovered in the course of these examinations. The figure for 1950 was 6 per cent. of those examined and the figure for 1951 was 4 per cent.

I have dealt briefly with the matter of prevention and detection, and I want to say a few words about the curative side, in answer to the hon. Member. Cure naturally depends on treatment, which, in general, can only be given in hospitals or sanatoria. Therefore, the number of beds that can be made available is a matter of great importance, and this in turn naturally depends on the number of nurses which can be obtained. In the last three years great advances have been made in both directions.

An additional 1,173 beds have been provided, which brings the total tuberculosis beds at 31st December last to 5,967, and all but 286 of these beds are now fully staffed. The increase in the staffed beds is reflected in the waiting lists for admission to hospital, and these have been reduced from 2,877 at the end of 1949 to 1,700 at the end of 1951. The downward trend in the waiting lists is not solely due to the additional beds which have been provided but is, I feel, a measure of the success of the work which has been undertaken by all the health authorities during recent years.

The hon. Gentleman has stated that, in addition to the beds which have been provided here at home, beds to the number of 180 have been provided in sanatoria in Switzerland. That innovation commenced in June, 1951, when the first 36 patients were flown out, and they have been succeeded by other groups in subsequent months. The first group is due to return to this country in March of this year, and I understand that the great majority of them will be fit to be discharged to their own homes. I wish to say about the treatment in Switzerland that the medical advisers of the Department of Health are fully satisfied with both the treatment and the care which these patients have received and the progress that they have made.

I indicated while I was in process of giving the increase in the number of staffed beds that recruitment of tuberculosis nurses has been fairly successful. The increase last year was 138, and the total number of tuberculosis nurses that we now have is 1,587. However, I want to warn the House that in future there may be some difficulty in maintaining that level, for we are given to understand that during the next 10 years the number of women between 18 and 30 years of age will decline very considerably, and that means that there will be fewer young women to take up nursing. That emphasises the importance of endeavouring to recruit tuberculosis nurses from the general hospitals, where the staffing position is somewhat better. The regional hospital boards have been invited to encourage the secondment of such nurses, and I am glad to say that some have already volunteered.

The hon. Gentleman asked about the fear of infection. I should like to reiterate what has been said in previous debates on this subject. The Department of Health believe that nurses working in sanatoria, under suitable precautions, suffer no greater risks than nurses working in general hospitals.

The hon. Gentleman also referred to the matter of after-care. It may be that this is a matter which has not received very great publicity, but the local authorities are required to make provision, after discharge from hospital, for the care of tuberculosis patients, including visitation and the provision of extra nourishment and comfort where these are necessary. The authorities also have the duty of keeping in touch with the officers of the Ministry of Labour in relation to questions both of resettlement and of training for new occupations. I most heartily agree with the hon. Member when he stresses the great importance of these two matters.

Mr. James McInnes (Glasgow, Central)

I appreciate the desire of the hon. and gallant Gentleman to encourage this campaign in every way, but why have regional hospital boards been encouraged to put a complete embargo upon the building of outdoor clinics for T.B. patients?

Commander Galbraith

The question of outdoor clinics is a technical one, on which I am not at the moment informed, but as the hon. Member will see, the number of beds is greatly increasing and more accommodation is being provided in that way.

I was asked also to say something about treatment in the homes. New drugs, such as streptomycin, have opened up the possibilities of treating patients in their homes—that is to say, where conditions are suitable. These patients would come under the active domiciliary scheme. Many would receive treatment during a short stay in hospital and thereafter would return home, attending a clinic from time to time. That scheme, of course, calls for the very closest co-operation between the tuberculosis physicians, the general practitioners and the local health authority, the latter being responsible for home nursing, the home help service, and the health visiting services.

The hon. Member asked about the possibility of the extension of home treatment. At present, the manner and the place in which streptomycin injections are given varies throughout Scotland. Some are given in the home of the patient, either by a general practitioner or by a qualified nurse. Some are given in clinics where there is a specialist staff. Some local authorities prefer meantime to employ the latter method, believing that it ensures better supervision and enables, at the present stage of development, more patients to be treated.

Mr. MacPherson

Before the hon. and gallant Gentleman leaves the subject of home treatment, can he give any approximate indication of the number of cases being treated in that way? How does it compare with, for instance, the number being treated in sanatoria and hospitals?

Commander Galbraith

I have not got information on that point available to me, but certainly in Glasgow, as the hon. Member may know, a great many cases are being treated in clinics, more so, I think, than in patients' own homes. Indeed, as I understand it, the health authority in Glasgow believe that at present it is better to treat their patients in clinics.

New and improved methods of treatment have given T.B. patients an opportunity of recovery which has never before been possible. The discovery of streptomycin and its use in conjunction with other drugs, and, if necessary, in conjunction with accepted forms of surgical intervention, has radically improved the effectiveness of treatment, and never has the outlook of the patient been so favourable as it is today. Nevertheless, I should make this clear: that the contribution of the public health work of the local health authorities plays a most vital part in defeating tuberculosis.

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

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

Commander Galbraith

The final eradication of the disease is very greatly a matter of better nutrition, better environmental hygiene, better housing and more health education. Tuberculosis is still the major health problem in Scotland and, although the last three years have produced evidence of great progress in every field, we must press forward and continue to do so with every weapon that is available to us until the disease, which is said to be preventible, has been eradicated. While we have every reason to be hopeful, there is no room for complacency. It is the intention of the Government to do everything possible to speed the improvement which has recently been obtained.

Question put, and agreed to.

Adjourned accordingly at One Minute past Ten o'Clock.