NATIONAL HEALTH SERVICE BILL

HC Deb 27 March 1952 vol 498 cc841-80

Order for Second Reading read.

4.5 p.m.

The Minister of Health (Mr. Harry Crookshank)

I beg to move, "That the Bill be now read a Second Time."

The Bill extends the power to make and recover certain charges for the National Health Service. The general reasons for that were explained during the debate on the financial and economic situation in January, and they were then accepted by a majority of the House. But, of course, the Opposition then made, and I dare say will go on making, an attack upon the Government for touching this service at all. I think it may well be that many people who are not themselves engaged in political battles will, in their heart of hearts, be surprised, if a general saving of public expenditure is to be made—and "is to be made" is the key consideration—to find that this field should be automatically put out of bounds. It is one which should at least be explored.

We are not concerned today with a purely financial attempt at retrenchment at all costs. Far from it. When the Government were seeing whether any savings could be made in the Health Service the considerations they had constantly in mind were: are there any obvious abuses to be rectified? Can we sooner or better reach what is the ultimate objective of us all, improving the public health, by pruning or re-arranging some of the present services or, indeed, by getting the emphasis altered in the right direction? By this Bill we can make some such improvements while, at the same time, restraining the expenditure.

There are two general points to be remembered on the financial side of the Health Service. It is important to remind hon. Members and people outside this House that this service is paid for as to 90 per cent. out of taxation. It is not an insurance system in any sense of the word. Let me remind hon. Members that the employed man's card, on which the stamps are put each week, represents 9s. 5d., or 113 pennies. The employed man himself pays 5s. 1d., that is, 61 pennies out of the 113 pennies. But out of the 113 pennies the total contribution which goes towards the Health Service is only 10d., which is a minute contribution towards the £400 million that it costs. That is what we in this House would call a grant in aid, and it is neither an insurance premium nor a payment for services to be received. It is just a contribution.

This was very much in the mind of Sir Stafford Cripps when Chancellor of the Exchequer, because I remember that in April, 1949, he was saying that there was a good argument for a special charge or tax in connection with the Health Service to help to finance it and—this is the important point—so that people generally should remember that the service had to be paid for out of taxation. To impose a charge is, therefore, not breaking faith with anybody. The fact that right hon. Gentlemen opposite have done it before emphasises that point.

The second general financial point is this: it was the right hon. Gentleman the Member for Leeds, South (Mr. Gaitskell), who, last year, put a ceiling of £400 million on to the service and to keep public expenditure below that ceiling he recommended the House to put charges both on dentures and on spectacles. He did not put any charge on prescriptions, but it was he and his colleagues who two years before had taken power to do it. They took the power, but when the time came in 1951 they did something else. They put on charges, and they accepted the principle that a ceiling of £400 million sterling was reasonable for this service.

All that we are doing in the Bill is to work to exactly the same ceiling as did the Labour Government last year, and because costs have risen we are doing exactly the same thing as they did; that is to say, we, too, are putting on charges. When I say that we are making it possible to put on a charge I really mean a charge, and I do not mean the sort of thing which the right hon. Gentleman the Member for Ebbw Vale (Mr. A. Bevan) meant in 1949 when an Amendment was moved and accepted to give the Government of the day power to do it then. What the right hon. Gentleman said was: We are, in fact, confining the power to make Regulations to withhold free sales up to a certain amount—not to impose a charge. That is not a power to impose a charge. This is to restrict the free service on the pharmaceutical side up to 1s."—[OFFICIAL REPORT, 9th December, 1949; Vol. 470, c. 2261.] When is a charge not a charge? When proposed by the right hon. Member for Ebbw Vale.

As a matter of fact, we are in some difficulty over this whole matter, upon a procedural matter. I know that hon. Members will be wanting to discuss many implications of the proposed charge on doctors' prescriptions, which is to make up most of the charge with which we are dealing. The Bill does not deal with that at all, but I hope that sufficient latitude may be given by the Chair for that ground to be covered.

The Bill deals with a very small part of that problem. Regulations will be laid under the Act of 1949, the Labour Government's Act. We have had to introduce a Bill to tidy up the power of making Regulations. We are making no new decisions. The Labour Government, in 1949, took the decision that it was a proper thing to put a charge on doctors' prescriptions. We do not need any Act to carry that out. We are merely putting life into the Labour Act and we shall make Regulations to impose a 1s. charge, which, in itself, may well save the Exchequer something like £12 million sterling. They made the plan, and we are taking the action. It is a shared business.

There was one small gap in the Act of 1949. The Labour Government took power only to issue Regulations covering prescriptions and appliances prescribed by doctors. I do not know whether it was an oversight or by intention—and it is immaterial which it was—but they did not take similar power in the case of prescriptions and appliances provided in the outpatient departments of hospitals. If we are to ask the generality of people to pay a charge for prescriptions it seems only right that the fact that the particular person gets his medicine or appliance from an outpatient department of a hospital should not be of tremendous advantage to him. Clause 1 deals with that aspect of the matter. It is only to that extent that the matter arises technically in the Bill. It does not deal with in-patients. They continue to get everything free. There is no power to impose a charge upon them.

As regards outpatients, if there is a dispensary for them in the hospital there will be no charge to the recipients of National Assistance or to war pensioners who are being treated for accepted war injuries. They will continue to get the issue free. If there is no dispensary, those people and the other outpatients will have to go, like everybody else, to a chemist and get their prescriptions made up. They will fall within the same group of provisions as were published by the Labour Government in 1949, dealing with prescriptions.

I will say what is generally proposed; we are still having conversations with doctors and chemists about the practical difficulties arising, particularly in rural areas. The proposals are that persons having prescriptions made up by chemists must pay not more than 1s. Persons who get their medicine from dispensing doctors pay 1s. when the medicine is dispensed. It is very often the case that more than one item is prescribed on a form, but the proposal is that the shilling will be paid per form and not per item on the form. There will be no exemptions. Everybody will pay, in the first instance. Those in receipt of National Assistance grants will claim, presumably, their refund, and they will get it from the office where they draw their assistance when they next go there to get it.

They will produce for that purpose a special receipt which the chemist or the dispensing doctor will have given them. It is a perfectly simple procedure. [HON. MEMBERS: "Form filling."] Form filling? It is only a receipt given by the chemist. They take it to the place where they receive their payment in the normal way, and they will get the money paid back to them. The same applies to war pensioners in respect of the charge incurred by reason of their accepted war disability.

Mr. H. A. Marquand (Middlesbrough, East)

I should like to be clear about what is in the mind of the right hon. Gentleman. He says that these people will have their shilling refunded when they get their payments in the normal way. They get their payments in the normal way at a post office by means of a book in which the sum due is printed. Have they to wait until special books have been printed? How long have they to wait?

Mr. Crookshank

I am sorry if I am not making the position clear.

They will get their receipts, worth 1s. or 2s., and when they go with their books they will hand over these receipts and get the corresponding number of shillings. They will not need new books at all. As to its being done at the post office, I did not put in "at the post office" because I am advised that there are cases where the money is not obtained at the post office and in which the recipients get the money by post or by some other means. The normal place is the post office and the normal procedure will be that they will hand in their books and these receipts, and get the corresponding number of shillings. Nothing could be simpler than that.

I have a lot to say. Perhaps it would be more convenient if I ran through the Bill. Cases of hardship will be dealt with in exactly the same way as was proposed by the right hon. Gentleman last year in the Act of 1951. That is on the prescription point.

In regard to appliances, Clause 1 takes power to charge when the appliances are provided by hospitals. This principle was conceded by the Labour Government in the Act of 1949 because it allowed charges to be made for appliances provided by doctors but not by hospitals. The Bill brings in hospital out-patients, but only for a very small range of appliances.

Mr. Aneurin Bevan (Ebbw Vale)

rose—

Mr. Crookshank

I hope that the right hon. Gentleman will let me make some way with my speech.

Mr. Bevan

I only wanted to say that I hope the right hon. Gentleman will not twist the use of the term "appliance" as used by doctors. It was put into the Act in a technical way, to cover bandages.

Mr. Crookshank

I thing that the right hon. Gentleman's recollection is at fault.

A great many rumours and exaggerations have got about on the subject of the appliances with which we intend to deal. We do not propose to touch artificial legs or arms. There is a very short list, and if it is for the convenience of the House perhaps I might be allowed to give it. [HON. MEMBERS: "Hear, hear."] First is the surgical boot. Hon. Gentlemen will realise that people who have surgical boots prescribed for them ipso facto do not require ordinary boots. [An HON. MEMBER: "Oh!"] They do not. It is quite reasonable to make a charge for this appliance. The proposed charge will be £3 a pair, and there will be a charge for repair, in the case of women from 6s. to 13s. 6d. and of men from 8s. to 13s. 6d.

The second group is surgical abdominal supports, and we propose a charge of £1 each on them. The right hon. Member for Ebbw Vale probably knows that there have been a good many cases of alleged abuse reported, of prescribing what was not much more than a reinforced corset. The third item is elastic hosiery, charged at 5s. to 10s., according to its character. The fourth on the list is wigs, charged at £2 10s. each.

It had been suggested at one time that hearing aids should also be charged for as being analogous to the spectacles and the teeth. However, when it was realised how big a backlog in hearing aids there is still, and that it would have been unfair to many who have been on the list for so long that, just by a fortuitous act on the part of the House they should be made to pay when their next door neighbour did not, these were not put on the list. So the list is surgical boots and repairs, surgical abdominal supports, elastic hosiery and wigs. This is expected to bring in about £250,000.

There will be no charge for hospital appliances in the case of children under 16 or in full-time attendance at school, persons in receipt of National Assistance or their dependants or war pensioners in respect of "accepted" disability. And, as in the case of the Act of last year, hardship can be dealt with by the Assistance Board.

Mr. Frederick Elwyn Jones (West Ham, South)

Can the right hon. Gentleman say what proportion of the cost of these items is represented by these charges?

Mr. Crookshank

It is roughly about half, as was the case with the other charges put in by the right hon. Gentleman and his hon. Friends.

Now I will pass to Clause 2, which deals with the big subject of this Bill, namely, dental charges. This provides for a charge of £1 or less for the actual fee for dental treatment, though it sets a maximum possible charge, where dentures are provided, of £4 5s. The estimated saving is of the order of £7½ million. We suggest two exemptions in Clause 2 (3)—school children, and mothers who are either expectant or who have borne a child within 12 months, are to have completely free treatment.

All that those persons will have to do who come within the exemptions will be to sign a declaration when they visit the dentist and satisfy him of their identity. Probably the reasonable way to do that is by showing the ration book. There is no question of any doctor's certificate or other document. We trust entirely in the honesty of these people and I am sure that it will not be misplaced. However, in case free treatment may be given to people who might come forward when they are not really entitled to it, there must be an ultimate sanction.

That is in Clause 5, which is common form in cases of this kind. It says that where it is afterwards discovered that knowingly false statements were made, a prosecution can follow against the person who has tried to get the benefit. Otherwise there is no formality short of signing the declaration that they come within the exempted classes and of identifying themselves.

Mr. John Baird (Wolverhampton, North-East)

rose—

Mr. Crookshank

Can I not finish the dental Clause? I may be going to deal with the very point which the hon. Gentleman has in mind, and, anyway, he cannot be certain that I shall not.

These proposals have led to a great deal of argument as to whether we have chosen the right exemption age. It is suggested that instead of it being the school-leaving age, as it is in the Bill, it would be better to continue the exemption up to the age of 21, from the point of view of the future dental health of the nation, and having also in mind that men who are called up will, during their term of National Service, get free treatment. It is argued that it is rather unfair that young women should not get the advantage which the other sex gets owing to the call-up.

If we were to do anything of that kind, we should, naturally, reduce the amount we hope to recover by these charges; I must warn the House that it would be a reduction of the order of £1 million. However, I said at the beginning of my speech that money was not the sole criterion and that we also wanted to get the emphasis right. Therefore, after further examining this point, the Government are prepared to accept the suggestion of raising that exemption age from the school-leaving one to 21—that is, under this Clause. I emphasise that it is under this Clause because there is no reason why, if dentures are provided, the recipient should not pay the normal charges under the Act of the Labour Government.

Mr. Marquand

From 16 to 21?

Mr. Crookshank

Yes. Should there be cases of hardship they will be treated in the same way as the Labour Government showed us. I admit that the £1 charge is a rough and ready way of dealing with this, but the Government recommends it largely to keep the free treatment more or less to the priority classes; that is to say, young people up to 21 and expectant and nursing mothers.

It is a sad result of the recent system that the school dental service has gone rather into a decline. We hope that these changes may encourage more dentists to enter into contracts with local authorities to work in that service, possibly on a part-time salaried basis. If that happens it will, in the long run, be very much to the advantage of the health of the nation, because the more care that can be given to the teeth of children and expectant and nursing mothers, the better, as I am sure the House will agree.

As for the £1 charge, arguments have been put to me by friends of mine in the House and outside and by correspondence with hon. Members in different quarters of the House, to the effect that a £1 charge put on in this way will reduce real conservation work for the adult population. I am not fully persuaded that a maximum charge of £1 need necessarily do this, and to describe it as "rotting the miners' teeth" as did the right hon. Gentleman, is the wildest of exaggerations—

Mr. Baird

The right hon. Gentleman does not know what he is talking about.

Mr. Crookshank

I know that the right hon. Member for Ebbw Vale is always assumed to be the only person who knows what he is talking about, but I claim that this was an exaggeration. However, there is a case to be made that it would be a good idea under the Act that all examinations should be free of cost, and that the charge should begin only after the mouth has been examined. If we allowed the clinical examination to be free I think we should be quite within the principle of the Act. And in so far as it was a mistake in judgment to provide otherwise when we first made these proposals, I am quite prepared to stand in a white sheet and say so. I am also prepared, on behalf of the Government, to move the necessary Amendment so that this can be discussed and, I hope, put into the Bill.

There is one other point on teeth in Clause 4, about bridges. I mention it because it was of interest to my two predecessors when they were administering the service. In Clause 4 we make it clear that a bridge comes within the scope of the charge for dentures. Apparently there was some doubt about it. Bridges, generally speaking, are more expensive than dentures, but people who have had them put in instead of dentures have been getting away without any charge. That is obviously an unfairness as between citizen and citizen and we propose to alter that in Clause 4.

The other point of Clause 4 is that it extends the power which local authorities already have to make charges at day nurseries. At present they can make certain charges, but only for meals and particular articles and residential accommodation. This will enable them, if they so wish—it is a local government option, not a Government decree—in appropriate cases to make charges. It may interest the House to know that there are at present something like 45,000 places in day nurseries and that they cost about £5,250,000, of which the taxpayer finds half and the ratepayer half.

The average cost per place is about 45s. a week and of this some of the authorities recover only 7s. 6d. We feel that in many cases no hardship would follow if further charges were made, recovering either the whole or part of the cost, but it is left to the local authorities to decide whether they put them on and what kind of arrangements they will make. This is only an enabling Clause but it may, possibly, save the Exchequer up to £500,000.

I have already referred to Clause 5, which deals with evasions. I do not think there is anything very much else in the other Clauses, which are mostly machinery, except, perhaps, to point out on Clause 6 that it is for the National Assistance Board to determine whether a person should be exempted from the charge, or part of the charge, on grounds of hardship and that they can grant assistance to persons for the purpose of meeting any of these charges even if they are in full employment. This will be entirely for the Board to decide and, of course, if they feel that their general discretion is insufficient, they can always come back to the Government and to Parliament.

Mr. Bevan

There is a form of words which puzzles me, and perhaps the right hon. Gentleman would enlighten the House about them. Apparently the National Assistance Board can give assistance to persons receiving dental treatment outside the National Health Service. What is the meaning of that? It is referred to in the Explanatory Memorandum, which states that Clause 6 (2) empowers the National Assistance Board … [HON. MEMBERS: "Where does it say that?"] There are only two pages of the Explanatory Memorandum. It is in paragraph 9, which refers to Clause 6 (2).

Dr. Edith Summerskill (Fulham, West)

Can I help the right hon. Gentleman? It probably means that the Assistance Board will be able to help those people who incur expenses subsequent to advice and treatment being given by a dentist outside the Assistance Board.

Mr. Bevan

No.

Mr. Crookshank

The right hon. Gentleman is obviously not satisfied with that explanation.

Mr. Bevan

What is the Minister's explanation?

Mr. Crookshank

I will see that the right hon. Gentleman gets one later.

Mr. Bevan

The Minister does not know.

Mr. Crookshank

Quite frankly, offhand I cannot say. I apologise to the House—I might as well be quite honest about it. I think that the Clause is meant to cover all the points which were covered in the provisions about the National Assistance relief in respect of the charges of last year. I will inform myself further, and I offer my humble apologies to the right hon. Gentleman and to anybody else who feels deeply on this matter. I am very much obliged to the right hon. Lady for her explanation, but we will leave it at that for the moment.

Dr. Summerskill

If the right hon. Gentleman suggests that my explanation is not the right one, does that mean that if a poor patient is in an area which is not serviced by a dentist who was serving the present scheme that patient would be unable to have a refund of his or her expenses?

Mr. Baird

This is an important point, but it is quite simple. All emergency dental treatment up to £1 would be carried out by the dentist outside the Health Service; he would be able to charge anything up to £1. Will the Assistance Board pay anything up to £1 which the dentist wants to charge?

Mr. Crookshank

I dare say that the right hon. Lady's explanation is the correct one but, as I have said, I will look into it. I am not a dentist, like the hon. Member for Wolverhampton. North-East (Mr. Baird), and this is a very technical point—

Mr. Bevan

It is the right hon. Gentleman's Bill.

Mr. Crookshank

Dealing with bridges is quite complicated enough without getting into this difficulty. A reply will be given to the right hon. Gentleman, but I was under the impression that the Clause was merely carrying out the same arrangements as the previous Act had done; but if I am wrong I am sorry. I was saying that if the Board are not satisfied with their discretion, they can always come back to Government and to Parliament.

Those are the general provisions. I said the other day, and I repeat now, that it is not any pleasure for the Government to ask for the imposition of these charges, but we still have to view these matters in the light of our perilous economic situation. Because of that, we have no alternative, and so long as the real hardships can be guarded against we hope that these economies will not be crippling to anybody.

Mr. Spencer Summers (Aylesbury)

rose—

Mr. Crookshank

I wish I could get on.

Mr. Summers

Before he leaves the matter of hardship, will my right hon. Friend allude to the question of prescription forms, with particular reference to the chronic sick? In other words, will it be permissible to prescribe well ahead in order to deal with these cases?

Mr. Crookshank

In the presence of so many distinguished members of the medical profession in the House, I am sure they would agree that I should be the last person to lay down anything in this field for doctors to do. I am quite sure that the doctors are just as much seized of these difficulties as anybody else. I am not going to lay down the law here and now as to how doctors are to do their prescribing.

Mr. Hector McNeil (Greenock)

This is not a point for medicals; it is a very important point for the House. There are people whose illness is of a kind which necessitates that periodically—perhaps, weekly—they must have a supply of certain drugs.

The Prime Minister (Mr. Winston Churchill)

Why cannot that be put in the debate?

Mr. McNeil

Because we are at this point in the Bill, and it was raised by an hon. Member on the Prime Minister's side. It is not an unreasonable question. I am sorry if I upset the Prime Minister, but this is a point which has arisen at this stage of the debate and I intend to put it. Will the Minister tell us: Where there is chronic illness and a predictable amount of drug is needed—perhaps, every week—will practitioners be permitted under the Bill to make allocation ahead, so that the patient does not come every week to pay 1s.?

Mr. Crookshank

As I understand, that is more or less the practice now. Doctors know about that quite well and do, in fact, prescribe quite a bit ahead of time. All I am saying is that I do not think that the lay authorities ought to lay down in black and white to a profession like the medical one, exactly how they should prescribe in any particular case. [HON. MEMBERS: "Hear, hear."] I am glad at last to have assent to something I have said.

We all know that doctors frequently prescribe in chronic cases for a considerable period, and I shall do nothing in the Bill which would stop that. I am not going to interfere with their professional ways of doing their business. But all this, of course, will come up under the Regulations; it has nothing to do with the Bill. That shows the wisdom of allowing a fairly wide debate on this matter.

I was saying that it is no pleasure to have to introduce this sort of Bill, but that the background all the time is the economic situation, which hon. Members from time to time lose sight of, as do people outside. These administrative provisions will have to be covered by Regulations, and it will be open to the House to debate those Regulations when they come along. They will not come until after the passage of the Bill.

I want to be quite fair to the House. Although I have full power, and have had ever since we came into office, as did hon. and right hon. Gentlemen opposite, to impose the major charges under the 1949 Act, it is much more decent and proper, in the Parliamentary sense, so long as we are making amendments and extensions, to wait until the Bill has received the Royal assent, if so that be.

I see the right hon. Gentleman agreeing with that and I hope he will agree with me in this. I think it is only fair now for hospitals to warn people who attend to have appliances prescribed for them and to say, "This Bill is before Parliament and if it is passed you will have to pay a certain amount towards these appliances if you do not get them before the Bill is enacted." I think that that warning should be given and I hope the House will not think it improper. As there is no dissent, I hope the House will think it fair to do that as quickly as possible. There are no exemptions under the hardship provisions of the Bill except those I have mentioned.

The fact remains that the cost of prescriptions this year is expected to be more than £50 million. If charges are introduced the assumption is that the estimate will go down; we estimate by about £12,500,000.

Hon. Members opposite, or at any rate their leaders, have accepted that there is a case for reducing this vast bill for medicines. The former Prime Minister, in 1949, said in the House that there was excessive and, in some cases, unnecessary resort to doctors and chemists."—[OFFICIAL REPORT, 24th October, 1949; Vol. 468, c. 1019.] and there was an occasion when the right hon. Member for Ebbw Vale himself shuddered at what he called the ceaseless cascade of medicine which is pouring down British throats. That was in November, 1949, when the cost of the pharmaceutical service was £35 million. Now it is £50 million. If £35 million was a cascade, it is a Niagara today.

Mr. Frederick Messer (Tottenham)

There are increased costs.

Mr. Crookshank

Oh, no, the increased costs do not cover anything like that; it is the increased number of prescriptions.

There have been requests for exemptions for old-age pensioners, Service men, and various other categories, but the Government do not feel that it would be right to give any of these groups exemption as such, although we have considered the problem in all its aspects. I have just said that persons in receipt of National Assistance benefit will, of course, receive repayment of the charge, just because they are on Assistance. Out of the old age pensioners that covers, I am sorry to say, something like 750,000. They would be immediately exempt and of the other four million old age pensioners if there are cases of hardship they will be able to make their case.

Part of our plan, as outlined in the Budget, is to increase the pension rates. [HON. MEMBERS: "Not enough."] It is more than hon. Members opposite were able to achieve. [HON. MEMBERS: "No."] The war-disabled who need medicine because of their war disability will be automatically repaid, but that is as far as we can go in that field. We examined the question of the industrially injured people, who have a special scheme of their own, but it has not been found possible to bring them in. I am not sure whether it would be justifiable.

Then there have been criticisms about the dental scheme to the effect that we were retarding the much desired improvement in dental health, but we think that by the re-arrangements made in the Bill and which I have mentioned today this will be altered. The real trouble there is that we have only 10,000 dentists. If we had more than that things would be easier and the teeth of the nation would be better. To try to do as much as we can seems to be the answer.

Mr. Baird

If the dentists are shifted from the School Dental Service they still have to be paid; how will that save the £25 million?

Mr. Crookshank

I think it would work out.

I want to say a word before I close on something which is very much in the mind of hon. Members in all parts of the House: that is the relationship to this Bill and to the £400 million ceiling of the effect of the Danckwerts judgment. Perhaps I may be allowed a brief reference to that. I explained on Tuesday that the effect of the adjudication was broadly to increase the remuneration of general practitioners in the basic year of 1950–51 by £9,750,000. But the total bill that would fall in course of payment next year as a result of increases in previous and subsequent years might be of the order of £40 million although, of the £40 million, only £10 million would, in fact be attributable to the increased cost of their remuneration in the next financial year. That is to say, the £10 million is next year's part and the other £30 million, in rough figures, is the backlog for other years.

For next year the estimates, excluding Civil Defence, have left a little headroom below the ceiling and I am estimating that if no other great changes occur, no major catastrophes, and the charges in this Bill have the effect we assume, the ceiling will be exceeded but not by very much—by comparatively little. That is on the assumption that the £30 million payable next year is taken out of this account altogether. That is the assumption I made; it is not to be counted against the ceiling.

The conclusion is that it is not the intention of the Government, as a result of the Danckwerts award, to increase any of the charges I have mentioned in connection with this Bill and that if, as a result of this award and the £10 million or so next year, the figure of £400 million is surpassed in 1952–53, that is a situation which we shall all have to accept. The ceiling will have gone up pro tanto and that is that because it is a situation which could not have been fully foreseen by anyone. I hope that clears up the doubts of the right hon. Member for Ebbw Vale.

In the last debate he said that we were trying to destroy the National Health Service because we always hated it.

Mr. Bevan

The free National Health Service.

Mr. Crookshank

Nothing could be further from the truth. We have not always hated it and are not trying to destroy it. I only have to remind the House and the nation that it was a Conservative Minister who, in war-time, took the first step along this road under Lord Woolton, as Minister of Reconstruction, and under the Prime Minister in command. There is no reason for us either to want to destroy it or to hate it. [An HON. MEMBER: "You voted against it."] The fact remains that unless we restore our present precarious situation, unless we can restore confidence in sterling and stop the drain on our reserves it is not the National Health Service which will be destroyed but the very foundations of our economy which will be shaken—that is the danger we have to face—and much that all of us together have created and enjoyed would disappear in the twilight of national bankruptcy.

Those are the grim facts which, fundamentally, are the justification for the financial parts of the Bill. The other portion, which tries to turn the emphasis into a slightly better direction than it has been in the last few years, is the more constructive portion of the Bill which I now commend to the House.

4.49 p.m.

Dr. Edith Summerskill (Fulham, West)

I have seen the right hon. Gentleman perform at the Dispatch Box on many occasions, but never have I seen him so uneasy, so unsure of himself and so ignorant of his facts as this afternoon—and I am not surprised. He has this afternoon come to this House and done something which I believe is without precedent. He has presented a Bill on its Second Reading, a Bill so manifestly unjust in certain respects that he has had to come and promise to amend it because, I take it, his followers refused to allow him to wait until Committee stage.

I am very sorry for the Minister to find he has been deserted this afternoon by the one whom I regard as the architect of the Bill, the Chancellor of the Exchequer. I feel that the Chancellor might at least have given the Minister a little more support during the next few hours.

What the Minister has announced must be eleventh hour changes, because I recall last week, when my right hon. Friend the Member for Lewisham, South (Mr. H. Morrison) pressed him to tell the House what he proposed to do, the Minister was a little coy, and refused to disclose what the changes were to be. So, therefore, I say that they must be eleventh hour changes.

I am not surprised. My right hon. and hon. Friends have gone up and down the country during the last few weeks protesting against this mean Measure. Furthermore, I feel there have been other forces at work. I see the hon. Member for Enfield sitting opposite, and I recall that in the old days, when I was Minister of National Insurance, he used to make most constructive suggestions, for which I was grateful.

Mr. J. Enoch Powell (Wolverhampton, South-West)

Yes, but I sit for Wolverhampton.

Dr. Summerskill

I beg the hon. Member's pardon. My memory for the faces of hon. Members opposite is greater than my memory for their constituencies. I am sure that the hon. Gentleman will agree I am right in saying that he has on occasions taken particular interest in matters of social welfare. I cannot believe that hon. Members like himself, and his hon. Friends, have allowed the Minister during the weeks which have elapsed—and there has been a great deal of procrastination—to come to this House with this Bill without insisting that there should be some amendment to it.

After all, I think it must have been a little difficult for the Government to make hon. Gentlemen sitting on the back benches opposite forget that in the Tory Election Manifesto of October, 1951, it was said: … in health some of the most crying needs are not being met.

Hon. Members

Hear, hear.

Dr. Summerskill

Hon. Gentlemen opposite say "Hear, hear," yet they are prepared this afternoon to come to this House and listen to the right hon. Gentleman expounding a Bill which is emasculating the Health Service of this country. They have been asked to forget the health provisions in the Tory Election Manifesto just a few weeks after they were asked to erase from their memories the section about food in the same Manifesto, which read: Food subsidies cannot be radically changed in the present circumstances. … I suspect also there are other forces at work. The right hon. Gentleman is in charge of a very large Department and I believe he employs many distinguished doctors, both full-time and part-time. I think that if any one of those people had been consulted before this Bill was even printed they could have told him that the degree of dental caries is greater among the adolescent groups than among any other age group.

These changes, quite major changes in the dental charges, have been made today and I think that is some evidence that this Bill was hastily conceived by the Chancellor of the Exchequer and thrust upon a bewildered Minister of Health who, quite understandably was not familiar with a Department, which is highly complex and technical. He has shown this afternoon, and I have every sympathy with him, that it has been quite impossible for him to grasp all the technical details of his Department. But it seems that these advisers of his have been brought into the picture only very recently and that, I say, is another example of the mismanagement of the business of Government.

The right hon. Gentleman made a point in his early remarks of reminding the House that my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) was responsible in the first place, for introducing some of these provisions. Let us look at the whole picture. I recall the Chancellor of the Exchequer making a certain remark with regard to this Bill which struck me as being a little curious. This was shortly after the present Government was returned. He said: Our predecessors, in the shape of the present Opposition, have conveniently left behind them legislation, out of which I do not propose to be manoeuvred, enabling a charge to be imposed on prescriptions."—[OFFICIAL REPORT, 29th January, 1952; Vol. 495, c. 54.] I think that this afternoon the Minister of Health showed, by his hesitant manner, why that legislation had been left behind. I think the whole House will agree with me that it is a very unstatesmanlike approach for any Chancellor of the Exchequer to make to a piece of legislation left over in the pigeonholes of Whitehall. The very fact that the previous Government, after a most exhaustive discussion, had not thought fit to charge for treatment along the lines proposed in this Bill should be the very reason for at least delaying it, and not rushing in at the first opportunity, which is what the Government have done.

The Chancellor of the Exchequer said he was not going to be out-manœuvred. The Bill was printed and remained in the Vote Office for many, many weeks. Meanwhile the Minister of Health was compelled to do what his predecessors had to do, but too late. He showed this afternoon that he has found himself in a great difficulty. He has been apologetic with regard to the other provisions to which I am now coming, and I will show him just how difficult it will be to administer this Bill. I am rather sorry that he did try to ride away on the Regulations. But there are some things this House must be told about in detail this afternoon of how these provisions are to be administered, because they are of the utmost importance to the poor sick of this country.

I say that we on this side of the House have no desire to out-manœuvre the right hon. Gentleman. I even tried to help him myself. All that we on these benches wish to do is to put the case for the sick and the poor. If this Bill is proceeded with, I believe I shall be able to prove that it is one of the most heartless pieces of legislation ever introduced by a Tory Government. The only excuse which I can find for the right hon. Gentleman and his hon. Friends is that their ears have been so deafened by the raucous voices of the brewers in the last few months that they have been unable to hear the protests of the poor and the sick.

One excuse offered by the right hon. Gentleman—we are so tired of hearing this in this House—is that the reason right hon. Gentlemen opposite do things is that they are guided by the previous Government. The excuse offered, which he felt justified this charge, was that the previous Government had made a charge for dentures and spectacles. I say there is no comparison between what is a once-for-all-time charge, and borne in the main by healthy people, and a charge for treatment for sickness which may continue for weeks; and for life, in the case of a chronically sick person.

No argument which the right hon. Gentleman has advanced this afternoon disguises the fact that the Government now propose to erect a financial barrier between the doctor and the poorest in the community. I thought I understood the Chancellor of the Exchequer when he addressed himself to this proposal many weeks ago. I thought he said that where there was hardship help will be given.

I ask the Minister who is to reply to the debate to define to this House what is meant by the word "hardship." Every old person in the lowest income groups, whether he is on National Assistance or not, will suffer hardship; and so will all small pensioners, the widows, the blind persons, the orphans, the chronic sick, the epileptics, the diabetics and the tuberculous.

It was the chronic sick who were in the mind of my right hon. Friend when he pressed the Minister to say whether a doctor would be able to prescribe heavily. The point of his question was whether a doctor could give, say, insulin for a diabetic to cover several months on one prescription at a charge of 1s., or whether he could give treatment for an epileptic to cover several months on one prescription.

The right hon. Gentleman, who said that there is no intention of interfering with the treatment of doctors, must realise that there is an ethical side to this business. No doctor, however warm- warmhearted he may be, can say to a chronic sick person—and these people have to have continuous treatment for the rest of their lives—"I will give you a prescription to cover three months treatment," and then wash his hands of the treatment. Of course, the doctor bears a very heavy responsibility. These people will be called upon to pay 1s. for each prescription every time they see the doctor, which will be very often.

The right hon. Gentleman is placing this heavy burden on the aged and the widows with dependent children. I will take those two groups to begin with. Does the House realise that if the Minister does this he will deny adequate medical care to the old people and the dependent children of widows? We all deplored the fact that the coalminers made a violent protest when this Bill was printed. The responsible leaders of the trade unions asked the coalminers not to do what they had threatened to do, which was to withdraw their labour on Saturdays.

But does the House realise what was in the minds of the coalminers? They were not necessarily thinking of their own wives having to pay 1s. for treatment. They were thinking of the thousands of men disabled through pneumoconiosis, which is another chronic disease. There are thousands of them in the South Wales coalmining area who will be called upon to pay shillings for prescriptions for the rest of their lives. I think that it was my right hon. Friend the Member for Llanelly (Mr. J. Griffiths) who said, either to me privately or in the House in the eloquent way he has of expressing himself, "Are these men to be denied for the rest of their lives a little relief in the morning when their disablement is at its height?"

This is the reason why the coalminers made a protest. It is not as many hon. and right hon. Gentlemen opposite thought. It is not, as they thought, that there is a Communist element which sees this as a way of attacking the Government. It is because they know the position from bitter experience among the men with whom they work. That is the defect of the Government. They are so remote from the lives of the workers that they can frame this legislation, and only at the last moment do they realise that it will bear so heavily on the poorest in the community.

While I am on this point, I should like to ask the Minister to explain Clause 6, which makes a provision for those in full employment who are unable to meet these charges. Will the right hon. Gentleman tell us the wage limit below which a worker can apply for repayment?

Now I come to prescribing. I am very pleased that the right hon. Gentleman mentioned the question. If he will read the debate which took place in another place yesterday, he will see that a distinguished doctor addressed himself to this subject and made some recommendation. I always like to be constructive on these matters, and I have given a good deal of thought to this question. I propose to suggest a remedy. I propose to suggest to the Minister exactly what I should do if I was in his place. I do this after having given a great deal of thought to the matter and after having discussed it with many doctors.

Has the Minister considered this factor? Here he is imposing this charge of 1s. on prescriptions which, there is no doubt about it, will bear heavily on thousands of poor families, when he knows that the most flagrant abuse of the scheme exists in the field of prescribing. I say this deliberately. It is an abuse, in the main, by the better-off section of the community at the expense of the worse-off.

He knows, because he addressed the Lincolnshire Division of the B.M.A. I can tell from the speech that he made that he had been informed by his advisers what the position was. He said: The drug bill has, in fact, got out of control, and it is for this reason that the Government proposed a 1s. charge on prescriptions."— he did not talk about balancing the Budget then— The wider question raised by what has happened is whether all this prescribing is really necessary. … There may be pressure by the patient convinced that he cannot get better without a 'bottle,' or high-powered salesmanship by the travelling representatives of the drug manufacturers, or the difficulties today experienced by the doctor in ascertaining the cost of prescribing. I would not deny that the drug bill of £50 million a year is too high. It is one-eighth of the total expenditure on the Health Service. But the Minister must know that it was never out of control before 1946, when only the lowest-paid workers were entitled to treatment. It is out of proportion today because, as the right hon. Gentleman has learned, high-powered salesmen on behalf of the drug manufacturers are persuading doctors to prescribe expensive proprietary drugs for their more well-to-do patients.

As most hon. Gentlemen know, every doctor is supplied with a national formulary by the Ministry of Health. It contains economical and adequate prescriptions suitable for most of the complaints with which a doctor is called upon to deal. Today doctors are departing from the national formulary and prescribing unnecessary and expensive drugs. [An HON. MEMBER: "Oh."] The hon. Gentleman need not say "Oh." I never make this kind of statement—and a distinguished doctor in another place said something similar—without knowing that my facts are absolutely true.

Dr. H. Morgan (Warrington)

Sorry, but they are not.

Dr. Summerskill

Perhaps my hon. Friend, who always disagrees with all his medical colleagues over everything—

Dr. Morgan

That is not true. I am on the Council of the B.M.A. and take part in their discussions on these matters—simple or intricate. I am elected not by British doctors, whom I frequently oppose politically, but by my medical friends in the West Indies.

Dr. Summerskill

Perhaps my hon. Friend will listen to these figures. I leave it to the House to decide. Incidentally, behind me are other hon. Members who are doctors, and perhaps they will address themselves to this point. According to a Ministry of Health report the approximate proportion of proprietary prescriptions under the National Health Insurance Scheme before the war was 3 per cent. This rose to 7 per cent. in 1947 and to 12 per cent. in 1948. By the end of 1949 it was 21 per cent., and today I believe it is over 30 per cent.

Who are consuming the expensive drugs? I should like to remind the right hon. Gentleman that he told the House, quite rightly, that 90 per cent. of the cost of the Health Service came out of the pockets of the taxpayers. I should like to quote from the memorandum of the Birmingham Executive Committee of the Health Service, which was set up by the right hon. Gentleman's Department. It is apparent that in those areas, where, prior to 5th July, 1948, the greater proportion of the population were panel patients, the prescription cost was considerably lower than in the better residential areas, where the majority of persons were formerly private patients. This is attributed to the fact that doctors in the more densely populated areas, who were formerly prescribing national formulary preparations, continue to do so, and the remedy is to encourage doctors in the other areas to prescribe these preparations more. I want to give the evidence, because this is most important. The average cost for a prescription for the whole country is 3s. 8d., and a little inquiry shows that, district for district, there are astonishing variations. Recently, a number of pharmacists practising in seven districts of one large area of Greater London compared the cost of their prescriptions over the last 12 months, and the pharmacists, of course, are only too happy to give the Minister this information, if he wants it, although I know that he does not, because he has already got the information.

In one of these suburban areas of high rateable value, the cost of a prescription was as high as 7s. 6d.; in a favourite residential area on the borders of Middlesex it was 6s.; in a large and varied urban district, it ranged from 2s. 10d. to 4s., while, in a crowded industrial borough, it was as low as 2s. 3d.

Furthermore, may I draw the attention of the Minister to an article in the "British Medical Journal" of 9th February, and I am inclined to think that this article was published for the Minister's benefit. It is on prescribing, and it makes most depressing reading. It constitutes the report of a survey of 17,000 prescriptions on Form E.C.10, which the Minister has mentioned, conducted by the Department of Therapeutics in Edinburgh University by Dr. Dunlop, who was responsible for the review.

It discloses that one prescription alone for Vitamin E cost £14 and that many more cost about £5. His conclusion was the right one. After criticising the position in the country today, due to over-prescribing, he said that good prescribing was often economical prescribing.

It is so easy for hon. Gentlemen opposite to say "You knew all about this: why did not you do something about it?" I have a good answer. We knew the trend, and we recognised that it was a serious trend, and, if the Minister searches those pigeon-holes again, he will find out what we did. We prohibited the prescribing of proprietary drugs publicly advertised, which, therefore, encourage patients to take them, although they had no great therapeutic value, but it was impossible then to anticipate the means which would be adopted by the drug manufacturers to circumvent us. I think I am right in saying that, during last year, since we introduced that prohibition, the position has considerably worsened.

This over-prescribing is well known. I am sorry that the Chancellor of the Exchequer is not here, because I would have said that, while he was busying himself looking for legislation which the previous Government had discarded for good and proper reasons, he was being out-manoeuvred to the extent of millions of pounds in the wealthy areas of this country. Clearly, the source of the Minister's saving should not be the pockets of the sick poor but the millions of pounds spent on expensive drugs consumed by the better-off people.

I have said that I would conclude this portion of my speech by telling the Minister what to do. I want to give him some good ideas. First, I would revise the national formulary more often, and, if necessary, amplify and modify it. Next, I would instruct chemists not to dispense proprietary drugs unless the doctor indicated that there was no equivalent in the national formulary. Not for one moment do I want to penalise one sick person, whatever the income of that person may be, but if there is an equivalent in the national formulary, then it is gross extravagance to prescribe a prescription costing £14 or even £5, which has to be paid for by the taxpayers of this country.

I have only one more question on prescriptions. The right hon. Gentleman has said that a charge of a shilling will be imposed on every prescription. It is possible for a conscientious doctor to prescribe a few tablets or some ear drops, the cost of which will be under a shilling, but, in order to prescribe that, of course, he must have a consultation with the patient. I want to know whether, in that case, the patient will be allowed to pay less than a shilling. It is a very important matter to the very poor in the community. The Minister may well say, "I will consider that; it is a very good suggestion," but now I want to show him some of the difficulties he will run into.

If a conscientious doctor has prescribed a few ear drops costing less than a shilling, when the patient goes to pay for the prescription, it will be disclosed for the first time that the cost of the treatment is less than a shilling, and the doctor who gave the prescription will not be very happy at this disclosure, having regard to the fact that he is being paid on a capitation basis. Whether we like it or not, the doctor—and this is one reason why there is heavy prescribing—likes to be persona grata with his patients.

The Minister may say that it would not be fair to the doctor to reveal this, and that, therefore, the shilling must be paid, irrespective of the value of the prescription. In that case, it will not be surprising if the number of prescriptions valued at under a shilling and there are many—disappear altogether, with a consequent loss of money to the Revenue.

There is another point, and this concerns the question of heavy prescribing. While many people will be deterred from going to the doctor, there are others who will not. I can see old age pensioners saying to the doctor, "Do not give me a prescription for an 8 oz. bottle, which is what you always do. Give me a 10 oz. or 12 oz. bottle, or, possibly, even prescribe a 16 oz. bottle." Two 8 oz. bottles would last a week, and, therefore, the cost of prescribing on that basis would be 2s.; but, if the doctor could be persuaded to prescribe one 16 oz. bottle, the cost would only be 1s. But the result would be waste.

I would say that, in this House, there is not a single hon. Member who has not in his bathroom a bottle of tablets, lotion, medicine, ointment or a few bandages unused. No wonder the charge for prescriptions is £50 million a year, and, although the Minister thinks he is making this economical approach and—I am telling him now what our exhaustive inquiries have led up to—although he thinks he is approaching this matter wisely, all he is going to do is to encourage people to have more medicine, lotions and tablets than they need, and that these will go to clutter up the cupboards of the country.

I cannot believe that the Government have really considered the effect of this mean Measure on the children of the country. During the last few years, the infantile mortality rate in this country has dropped considerably. Last year, we were all proud of the fact that our vital statistics are quoted in other countries, and, only on Friday, a Norwegian journalist came and discussed our vital statistics with me, and I was proud to tell him how good Britain's were.

Infantile mortality has dropped to such an extent that in three quarters last year we established three new low records. I am among the first to recognise the relationship between a low infantile mortality rate and better feeding of our children, but do not let us ignore the fact that since the free National Health Service was introduced no mother in this country has been deterred from a consultation with a doctor on grounds of expense.

To the ordinary housewife every penny counts. As for the gentlemen in the Cabinet who decided this—and this had to be decided at a very high level—I do not believe they realise that a poor housewife in this country has to think not in terms of shillings but in terms of pennies. This charge, of course, will mean she will wait before she summons a doctor, and that means a return to the old method of self-medication, with the inevitable results. I will go as far as to say that if this charge continues this Tory policy will be reflected inevitably in our vital statistics in the years to come.

I come now to National Assistance. I understand that all those on National Assistance will be exempt and certain others will be allowed to claim from the National Assistance Board repayment on presentation of a receipt. Now at least the Minister knew that the procedure was of great importance to this House. He knew he would be asked by his hon. Friends what the procedure would be.

It will be recalled that when I was Minister of National Insurance I was at great pains to assure those people who were entitled to National Assistance that they could apply for that assistance without their need being disclosed. We made a special provision for this because it was discovered that many people in dire need were not seeking assistance because their pride forbade it. This Bill will expose a person's poverty once more to her neighbours.

The Minister outlined the procedure and I want to know from him if I am absolutely correct in my understanding of it. Perhaps he will say whether I am right or wrong. I hope I am wrong. As I understand it, a poor person will visit a doctor and then a chemist, whom she will inform that she desires a receipt, thereby disclosing her circumstances to the other customers and the staff.

It may be the Minister will devise something to obviate this, but then she may have to visit the Post Office. She may have a book but if she has not a book she may come within the category of a hardship case. Then she goes to the Post Office with a receipt for 1s. or 2s. to claim a refund and once more she will receive unwelcome publicity. [HON. MEMBERS: "They go there anyhow."] Hon. Gentlemen opposite are so removed from the lives of the poor—

Mr. Ian MacLeod (Enfield, West)

rose—

Dr. Summerskill

If the hon. Member listens, I will explain. It shocks me to realise how ignorant hon. Members opposite are. They say these people go there anyhow. They certainly go there with a book if they are entitled to assistance, but this Bill makes provision—

Mr. MacLeod

So did the 1951 Bill.

Dr. Summerskill

There is provision in the Bill to cover people who are in full employment. We are now dealing with a Bill which will impose a shilling charge for the first time.

Mr. MacLeod

No.

Dr. Summerskill

We are imposing a charge of a shilling on every prescription. It is no good the hon. Member saying that has happened. Never before has a shilling charge been imposed, and now it is to be imposed. The hon. Member will see from Clause 6 of the Bill that people in receipt of a full wage can obtain repayment.

Let us take the case of a widow in receipt of a full wage. When infectious disease affects two or three of her children she is faced with prescription charges of maybe 3s., 4s. or 6s. a week. She obtains a receipt and she is forced to go to the Post Office or to the Assistance Board, and she reveals to her neighbours what her position is in order to receive repayment. I want to know from the Minister whether that is the provision and whether the policy which the Labour Government adopted, a policy which allows needy people to obtain help without their need being disclosed to a third person, is to be reversed.

Mr. MacLeod

I am grateful to the right hon. Lady for giving way. Surely she must realise that these provisions for National Assistance, that these restrictions on the 1947 Act, and that this power to recover a shilling are taken word for word from the Act passed by the Socialists.

Dr. Summerskill

I am glad of that intervention and I am grateful for the attention of the House. I am also glad to see that the Chancellor of the Exchequer has returned.

The Chancellor of the Exchequer (Mr. R. A. Butler)

I heard a report of what the right hon. Lady had said. In my present position, I have to receive distinguished visitors, and I had an appointment at 5 o'clock. I kept the appointment very briefly and then came at once to the House.

Dr. Summerskill

I thank the right hon. Gentleman, and as I would not wish to say anything behind his back I repeat that I said he was the guilty man and that he should be sitting holding the hand of his right hon. Friend the Minister of Health. [Laughter.] The right hon. Gentlemen may laugh, but if they only came to me I would advise them. The mistake is that the Minister of Health has not a woman to advise him.

This all arises out of the intervention of the hon. Member for Enfield, West (Mr. Iain MacLeod). He has shown the House better than I can what I meant when I said that the Chancellor of the Exchequer conceived this Bill too hastily. I said that it was then thrust on the Minister of Health. What I am saying does not stem from any swotting I have done during the last week. It comes from the knowledge I acquired through the last few years when I investigated what would happen if the shilling charge were imposed.

The hon. Member for Enfield, West, intervened to say that we introduced the legislation. We did not. We examined the matter very carefully and for all these reasons we rejected it. As the Minister has not intervened to say that the procedure I have outlined is wrong, I presume it is right. On consideration he must realise the heartlessness of this Measure.

Furthermore, has he considered the effort involved for a sick person? Unfortunately, poverty and loneliness too often go together. He is now proposing that a sick person shall go to a doctor once and go to a chemist twice. He no doubt knows what happens in every chemist's shop. The first time the sick person leaves a prescription. At the same time he will ask for a receipt so he returns a second time for a bottle of medicine and a receipt.

Those are two visits that an old sick person has to make. Then there is a third visit to another office for repayment of the charge. Does the Minister understand that old sick people, contemplating these different visits, and knowing what the charge on buses and trams is, will be deterred from attending to obtain treatment?

Mr. G. Lindgren (Wellingborough)

That does not worry the Tories.

Dr. Summerskill

This is Tory legislation at its worst. In its heartlessness it savours of the old Poor Law, and the underlying principle of the Poor Law, I would remind the House, was to make the application for help in cases of need such an unpleasant process that the aged sick and the needy would rather suffer than seek assistance. Here we are, back to the 19th century, back to the same methods adopted in those times by the Tories.

Mr. Lindgren

Back to the Poor Law.

Dr. Summerskill

If I cannot reach the hearts of the Chancellor of the Exchequer and the Minister of Health, may I remind them of this? I know this will appeal to them. Not only will this transaction prove a burden on the poor patient; it will absorb the valuable time of the chemists. The chemists will have another form to fill in, and the Minister of Health will soon receive representations from the chemists of this country asking for a higher prescription charge.

I asked a London chemist what he considered was the average number of prescriptions dispensed by him. He said about 75. For a high proportion of prescriptions in the poor areas a receipt will be requested. I am afraid the Chancellor of the Exchequer will have to face the fact that there will be a bigger administrative cost. Furthermore, not only will the chemists be asking for higher pay, but there will be the loss of time of the officials in the Post Office and the National Assistance Board refunding shillings.

Now I turn to day nurseries. The Minister dismissed this subject in about a couple of sentences. Does he realise the true position? He dismissed it because he believed, as so many hon. Members opposite believe, that day nurseries are used by lazy women. They feel that the day nursery is a place where women can park their children while they earn high wages. Has he examined the facts? I am sure he has not, because he has not had time.

Let me give well documented facts of what the real position is. The Minister who is to wind up may well say that the previous Government reduced the accommodation in day nurseries on grounds of expense. But when we did this we recognised that there were certain mothers and children who should have acess to day nurseries.

Let me illustrate the point. Since the advent of the present Government and their policy of cuts in the social services, the Kent County Council proposed to close all its day nurseries, and the result was that the women who were using the day nurseries in Kent demonstrated in the streets. Let us see what kind of family Kent caters for. I trust the Minister will listen to this, and if he likes he can have all these documents.

In a nursery in Kent likely to be closed—the decision has been postponed until May—of the 42 children attending the nursery, the mothers of three were dead; the parents of 21 were divorced or separated; the mothers of two were widows; 14 of the children had unmarried mothers and two of the mothers were crippled. Those were the reasons why those children were admitted.

Let us look at other nurseries under the London County Council. This is typical of them all. In 5 per cent. of the cases the mother was in hospital, in 6 per cent. the father was in the Forces, in 6 per cent. the father was in prison, in 9 per cent. the mother was a widow, in 14 per cent. there was an inadequate joint income, in 15 per cent. the father was disabled, in 17 per cent. the child had an unmarried mother, and in 28 per cent. the child had been deserted by the father.

Can the Minister justify penalising this tragic little army of mothers and children? This is not economy. This is a short-sighted policy. These are the children who, if neglected now, will fill our Borstal institutions and prisons. This is a time when the Minister and the Chancellor must recognise that this service is a good investment.

Where will the children of the unmarried mothers go if we do not undertake some responsibility for them? Unfortunate young women with a stigma placed upon them will go to find minders. These are the children for whom the Chancellor of the Exchequer should have responsibility. [Laughter.] I apologise to the Chancellor of the Exchequer. It would have been worse if I had said the Minister of Health.

I apologise for keeping the House, but I must say something about surgical appliances. The Minister of Health cast an eye upon me and said—I was longing to support him on this, but I could not—that women were having abdominal belts which were not necessary. That is absurd. Women do not wear abdominal belts or surgical boots unless they are necessary. Furthermore, they do not try to get them because they want to get the maximum from the Health Service. The right hon. Gentleman has forgotten that equipment of this nature is ordered by a specialist for the patient, and it is a burden to be endured, not sought.

By the way, when the Minister told the House that surgical boots would be charged for and that this was only fair because people have to wear boots anyhow, he had apparently not been reminded—I am told this is a fact—that surgical boots need more frequent repairing than ordinary ones. I should like later to be given the evidence to prove that this part of the service is abused.

I now come to the Dental Service, with which I believe my right hon. Friend will be dealing at some length later. Let me say something about these cuts. It is proposed to charge up to £1 for dental treatment. Who will be most affected by this charge? Certainly not the better off. The most serious consequences will be that people who hitherto during the last year or two have gone for a regular inspection will not go in the future. They will have second thoughts about going when they realise that it will cost them £1.

Furthermore, has the Minister considered that it will pay people, in terms of hard cash, to delay treatment, for while three fillings done on three different occasions will cost £3, three arising out of one examination will cost only £1. I am sure he has not thought of that. In fact, the right hon. Gentleman has put a premium on neglect. We are all glad, of course, that the adolescent has been exempted. I have already said what I think about that. If the right hon. Gentleman had taken advice earlier from his experts, any doctor in his Department could have told him that they should not have been included.

My hon. Friend the Member for Wolverhampton, North-East (Mr. Baird) asked about school dentists. I suppose it is very attractive to some people when they are told that if this Bill is introduced the number of patients will decline, as of course they will, and the dentists will be forced into the School Dental Service. I understand that the rates of pay in the school medical service are £800 to £1,200, whereas the average figure of gross earnings of dentists is about £220 a month. Therefore, there must be a time lag before this transference takes place, and, meanwhile, irreparable harm will be done.

I will conclude by saying that during the whole of this century, the enlightened section of the medical profession, the social workers of the country, the people who worked in voluntary organisations at the beginning of the century and Government Departments also, have emphasised the need to approach disease from the preventive angle and have instanced the importance of dental treatment. Today, the Conservative Government have taken a retrograde step calculated to destroy a social service which is an indispensable part of a healthy community.

5.41 p.m.

Mr. Philip Bell (Bolton, East)

It is a great comfort to me in my highly nervous state to reflect that at any rate in a few minutes' time I shall be able to give one answer to one question, though it is rather a personal one. I shall be able to answer those constituents who with irritating frequency keep coming to a new Member and asking, "Have you spoken yet?" I am advised that a new Member exercising his privilege on these occasions must be very careful not to say anything controversial.

Many hon. Members present here today do, I am sure, look back already on many powerful speeches and regard them in a regal way from their safe and large majorities. But they do, perhaps, remember how very naked and defenceless they felt when they were in my shoes. They could not fill up the gaps in rhetoric and oratory by a little bit of prejudice or abuse. They could not resent the fact that other hon. Members were not paying attention by leaning forward and saying with a great lack of self-consciousness, "You baboons." They could not win the headlines—sometimes I believe the principal object of a speech—by rounding on their own Front Bench and describing their own right hon. Friends in that historic phrase as "squalid Tammany Hall bosses." All these things are denied to me on this occasion, and I appreciate that my contribution is only a cup of cold water which will be dashed into the fiery furnace of this debate.

Let me now say something—for I am afraid I must since it is expected of me—about the topic which we are discussing today. I have three things to say about this Bill. I daresay none of them is very novel, but I do not believe that is necessarily objectionable. The first is that the Bill itself is not a novel Bill. One has only to read the first few lines of it to realise that it extends "the existing powers." In my submission, it is a Bill which should not excite controversy over its principle, but only over its details. Whether in fact the details are wise or not is, of course, a matter for full discussion.

My second point is that this Bill is not to be a shackle on the National Health Service for ever. It is clear from Clause 3 that, to a large extent, it is experimental. Clause 3 says that the Minister shall have power to vary the amount to be charged under this Measure or under any other regulations, and that he may direct that it shall cease to be payable. It is therefore a Bill which explores methods of making the National Health Service even better than it is today and assures its solvency.

The third thing about it is that when I look at the National Health Service Estimates—I have no experience of these matters—although I see that there is to be a decrease under heading D of the General Medical heading, it is counterbalanced by the other payments which are, in fact, being made to the credit and thus there is in the end a credit. It is an interesting comment on Parliamentary discussion that the total figures are so rarely brought into operation.

That leaves me to say only this. I do not suppose that anybody in this House really thinks that the last word has been said about the administration of the social services, and, in particular, of the National Health Service. We know—and it is idle to pretend that it is always the other side that makes mistakes—great advances were made in the National Health Service as conducted under the leadership of hon. Members opposite. Of course, they made a great contribution. I do not believe they are so vain as not to know that there are some things that could be adjusted and improved. We are all trying to improve the service, and, as has already been said, get value for our money. In that, surely, we are all together.

The right hon. Lady the Member for Fulham, West (Dr. Summerskill)—I was rather jealous that she should have taken my point—dealt with the question of expensive drugs. I have been told by medical practitioners in my constituency that there is the great danger that an ordinary drug which can be paid for under an ordinary prescription is not being prescribed, and that instead an expensive proprietary drug is prescribed. Ordinary general practitioners have said that there is a great leakage there. I believe that matter has already been mentioned by some of my hon. Friends, and it was certainly mentioned in another place. It is something that has to be done as part of the scheme. It is another experiment or progression to be made.

In the same way I am told by the surgeons and medical practitioners I meet that in Manchester there are instances of over-staffing and of duplication, and that great savings could be made in the hospital services in that respect. Quite frankly, I am personally uneasy about the charges in respect to old age pensioners. I know it has been said that it is administratively impossible to exclude them. I am puzzled by this because I am told that it is done in Northern Ireland. A different coloured prescription form is used. One is free and the other is not. Therefore, I am not wholly satisfied as yet that it is administratively impossible to exclude old age pensioners. Whether there are other reasons for not doing so is, of course, another matter and should perhaps have to be taken into account in the whole picture.

In many countries some charge is made. In New Zealand, in Denmark, and even in the Isle of Man a charge is made, and according to the best information I have received there has not, as yet, been any increased mortality in the Isle of Man on that account.

The truth of course is, as the right hon. Lady said, that there are bound to be some cases of hardship in human affairs There is unfairness, there is hardship, there is loss of dignity at times—of course there is. It is a thing to be avoided, but in my submission it is not a thing upon which to base the economy of the country today because, as I see it, we are fighting a very stern battle today. We are, not tomorrow or next year, but today, under the black shadow of financial disaster.

Hon. Members will remember, or at least some of them will, that in the old days that great Commoner, William Pitt, just before he died, was told of the result of the Battle of Austerlitz, and he turned to his secretary and said, "Roll up the map of Europe, it will not be required these 20 years." If we fail this year to stave off financial disaster we can roll up our National Health Service Act, because it will not be wanted for 20 years; we should have no money, only chaos and disaster.

That is a right way, surely, in which we should meet this problem. It is not for me, perhaps, as a new Member, to say anything about the functions of the House, but personally I feel that our functions in this battle are rather limited, though we can help in a small way. The battle is to be won in the fields and the factories and the homes and the churches. We can set a standard here: we can give a lead; we can do no more. We can say, "Shall we talk reasonably, shall we be patient, shall we be fair?"; and if we do that, the country will pay attention to what we say. But if we sit here and discuss these matters viciously and with cleverness, with hate and and with spite, what do we expect from the country?

Hon. Members, who have been very patient with me, and indeed I am grateful, will excuse me if I make what is probably an awful mistake for a young Member to make, and that is to refer to Shakespeare. Perhaps other Members have done so on these occasions. I want to refer to those fine lines in "King John": This England never did, nor never shall Lie at the proud foot of a conqueror. We all remember that. Do we remember the next line? But when it first did help to wound itself. It is a grave responsibility for us this year, under this financial crisis. It is we who must see that we do not give way to too much irritation, prejudice and passion, and it is we who must make sure that the Commons of England are not the first to wound our country.

5.53 p.m.

Mr. Aneurin Bevan (Ebbw Vale)

May I, on behalf of the whole House, congratulate the hon. Member for Bolton, East (Mr. Philip Bell) upon his most entertaining and instructive speech? He spoke with such ease and with such confidence that I am quite sure that all his friends must be delighted with him. We look forward to hearing him on some other occasions when the rules of combat will enable us to hit back.

The House will perhaps forgive me—indeed they will probably be relieved to know it—when I say that I shall not be able to address them at any length today because the medical profession have not assisted me very greatly in the last week. It is, therefore, perhaps appropriate that we should be talking about the National Health Service Bill this afternoon.

At the beginning I want to make one reference to a subject with which the Minister closed his speech, because it seems to me to be one which overshadows the whole of this debate—and it is the recent arbitration award which gave the general practitioners £10 million a year more and £40 million altogether in back money. I do not want to reflect upon the arbitrator because it is not his responsibility, but I believe that that award has shocked the majority of people in Great Britain.

Something has gone wrong with the sense of values in this country when we can confer £40 million upon one branch of the medical profession and at the same time propose to impose charges on old age pensioners. I am sorry that the Chancellor of the Exchequer is not here, because my quarrel in this matter is very largely with the Treasury. It is not with the Minister of Health, because innocence and ignorance exempts him from attack, but I have a quarrel with the Treasury because I consider that this year, last year and the year before, the Treasury, and the Treasury alone, have been responsible for this violation of one of the chief pieces of architecture of the Welfare State.

That is not because of the fact that the Treasury is safeguarding the national finances, because that is the Treasury's job, but because the Treasury is so ignorantly manned that it has not adjusted its conventions and its principles to the extent to which the State has now intervened in so many practical fields. In the old days, it was quite easy for the Treasury to be sagacious, because all it need do was to increase or reduce a few taxes. Therefore, all we required at the Treasury were arithmeticians who could add or deduct.

Unfortunately, that is all we have got there now, but with this difference—and I beg right hon. and hon. Gentlemen in all parts of the House to try to seize the significance of this, because I have put it over and over and over again—that to the extent to which the State intervenes in practical fields of administration, physical factors must be taken into account in adding up the sums.

That is why I resisted in Committee, as the right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) knows, against the right hon. and gallant Gentleman and some of his hon. Friends, a proposal to put compulsory arbitration into the National Health Service scheme. I objected on two grounds. In the first instance, it was because every trade unionist knows that there is nothing so ruinous of conciliation machinery as a compulsory arbitration clause. Once that is there, negotiating skill is no longer necessary. Each party refuses to budge, knowing that finally the compulsory arbitration clause can be made operative, and all negotiations end.

That is the first point, and, as hon. Gentlemen know, I resisted that all along the line, although I was exposed then, as now, to the most malicious misrepresentation in the Press. Although letters were being written by eminent members of the medical profession demanding that this tyrannous power of the Minister to make regulations should not be permitted; although we had all that agitation, nevertheless I refused to do so because I thought it would destroy the Whitley machinery, I thought it would ruin relationships between the Government and the medical profession and secondly—and this is the most important reason of all, of which the Treasury ought to take note—because it puts the Budget outside the House. We have just been told today that the sacred ceiling has now gone. It was so sacred last year. I am very anxious, naturally, not to make an attack on the ex-Chancellor of the Exchequer, because he also had been at the Treasury for so short a time that he had not been able to acquire sufficient control over it, and he bought the idea of a ceiling.

What does a ceiling mean? A ceiling means a figure that must last more than two Estimates. That is the meaning of it—that a spending Department must suit its behaviour to the fact that not only in that particular year but for a number of years that is the figure it must not exceed. I am glad that the Chancellor is in his seat. Does he mean that by ceiling? I should like to know—[HON. MEMBERS: "He does not know."]— because his ceiling has already been busted—and it has not been done by the House of Commons. It has been done by somebody outside. Really, this is not good enough. This really is crazy nonsense, that the House of Commons should be outside this control so—

6.2 p.m.