§ 3.41 p.m.
§ Mr. Aneurin Bevan (Ebbw Vale)
The reason we have sought to raise this matter today is that we take the gravest view of the statement made by the Minister of Health, immediately before the Easter Recess, in which he said that he was appointing a Committe of inquiry into the National Health Service. To refresh the minds of hon. Members, I will read what the right hon. Gentleman said upon that occasion. He informed the House that he was going to appoint a CommitteeTo review the present and prospective cost of the National Health Service; to suggest means, whether by modifications in organisation or otherwise, of ensuring the most effective control and efficient use of such Exchequer funds as may be made available; to advise how, in view of the burdens on the Exchequer, a rising charge upon it can be avoided, while providing for the maintenance of an adequate Service; and to make recommendations."— [OFFICIAL REPORT, 1st April, 1953; Vol. 513, c. 1229.]I should like to make it quite clear at the outset that, as far as I know, no one on this side of the Committee objects to an inquiry into the organisation and administration of the National Health 1704 Service. In fact, it would be quite reasonable for such an inquiry to take place in view of the number of years which have elapsed since this unique Service started. We are, however, apprehensive because of the language used in the terms of reference and also because that language follows upon certain actions of the Government which lead many of us to believe that the Government are not particularly enthusiastic about the defence of a free Health Service—to put it with my usual Parliamentary myosis.
What we cannot understand is why the right hon. Gentleman has not made use of the machinery that is available to him. I have been taunted by him on at least one occasion that I always appeared to fear that whenever any inquiry was made into the National Health Service itself, it was an attack upon me. Let me say at once that the right hon. Gentleman should acquaint himself with the origins of the Service, and then he would not make such a charge.
I have before me a book that was sent to me by a gentleman called Dr. Charles Hill—
§ Mr. Bevan
—written in 1949. In this book he outlines, in his description of the Health Service as a whole, the Central Health Services Council. When the Act was being framed, it was agreed between all of us—that is to say, between the Ministry of Health at that time and the representatives of the local authorities and the various bodies of the medical profession—that there should be a Central Advisory Council whose purpose would be to keep the Service under continual review.
There are 41 members of the Council, including the Presidents of the Royal Colleges of Physicians, of Surgeons, and of Obstetricians and Gynaecologists, the Chairman of the Council of the British Medical Association, the President of the General Medical Association and the Chairman of the Council of the Society of Medical Officers of Health. There are also 35 members, 15 of them general practitioners, two of them selected for their knowledge of mental illness, five experienced in hospital management, five with experience in local government, two 1705 dentists, two persons with experience in mental health, two registered nurses, one certified midwife and two registered pharmacists.
That is the body which was established for the purpose of advising the Minister, not only of any changes that might be necessary in the Health Service, but also of the defects which might be thrown up from time to time in the experience of the administration of that Service. In order to make it quite clear that at that time it was the Government's anxiety that this Service should be renovated and refreshed, this organisation can come into action not only upon the initiative of the Minister but upon its own initiative. In fact, this machinery is unique. I know of no single Act of Parliament which provides for a more continuous review of the administration than is the case with the National Health Service.
This is a body which has a pool of knowledge unsurpassed about the National Health Service. Immediately it was established, I appointed a number of special committees, so that not only should there be the general review of the administration, but that the review should be particular and detailed. I appointed medical, maternity, midwifery, cancer, radiotherapy, mental health, tuberculosis, ophthalmic, pharmaceutical and nursing advisory committees. There is, therefore, in this body not only a pool of all the knowledge that can be got in the daily administration of the Service itself, but also machinery for keeping the various parts of it under continual review.
I want, therefore, to ask this question. Why has the Minister not used this body? He could have done it at any time. If he believed that there were certain parts of the Service that ought to be inquired into, it was there for him to use. If these ladies and gentlemen in the profession felt that there were some major defects in the Service, they could call the Minister's attention to them. Why has he not inspired them to action, and if something is seriously wrong, why have they not themselves advised him?
The Committee are entitled to have from the Minister an answer to that plain question. We shall not get men of this eminence, persons of this knowledge and reputation, to serve on bodies of this sort if they are to be set summarily upon 1706 one side when a Minister wishes to have an investigation. They will feel hurt, as many of them, in fact, feel hurt already, and think that the Minister—I will not put it too strongly—has acted inadvisedly in not asking them to advise him on this matter.
When we come to the actual terms of reference, it begins to be clear why the Minister has not used the Council. The reason is that it would not be possible for the Council, under its own terms of reference, to advise the Minister for a limitation of the National Health Service. It would be possible for the Council to advise him only of any defect in the administration and any changes which would have to be made to repair those defects. Obviously, what the Council could not do would be to advise the Minister to curtail the Service. So the first explanation of why the Minister is setting up an independent Committee of inquiry is that he is not anxious to improve the administration of the Health Service. What the Minister is anxious to do is to obtain an alibi in order to cut the Health Service. He says:to suggest means, whether by modifications in organisation or otherwise"—it could not be wider than that—of ensuring the most effective control and efficient use of such Exchequer funds as may be made available."—[OFFICIAL REPORT, 1st April, 1953; Vol. 513, c. 1229.]What we have here is the assumption that the Exchequer will make a sum of money available to the Minister of Health for the whole of the Service, say, £420 million or £430 million, or any sum. How that is to be arrived at I do not know, but that is the assumption. Then the Committee are to advise the Minister how that sum should be apportioned. Surely that is the function of the House of Commons, not of an independent Committee.
How can such a Committee come to a conclusion, for example, that it is in the best interests of the country that there should be a reduction in the expenditure on the pharmaceutical side of the Service or an increase on the dental side? That is not a matter for specialist knowledge. Priorities of expenditure within the Health Service itself are a matter of political opinion and judgment. As to whether we ought to reduce this or increase that is not a professional question at all. Indeed, if it is a professional issue this is 1707 not the body to advise upon it. If it is a professional issue and if we are to seek the consequences and the therapeutical value of spending money on this or that, it is a professional question; but if we are to decide who is to be the beneficiary, whether it is a person who wants dental care or a person who wants hospital care, that is not a professional question at all but a question of social priorities.
It does not seem to me that this Committee will be useful in advising Members of the House of Commons on who should be the recipient of expenditure from the National Health Service fund. I should have thought that the case was quite clear and that, if we are to discuss priorities within the figure allowed by the Exchequer, priorities are a matter of political judgment and not of expert opinion, and that, if it be expert opinion, this is not the body. If, however, we are to consider priorities, not within the Health Service expenditure itself, but priorities within the Exchequer funds, then an entirely different issue arises.
People have talked about the National Health Service as though it is liable to a grave shortcoming and that the grave shortcoming is intrinsic in its original conception—that is, that it is a free Health Service and that the Exchequer is required to provide whatever money is needed to keep it free and keep up efficiency. Therefore, critics of the Service have said, "this is an open-ended service—open at both ends; there is no limit to the amount of money the National Health Service can attract from the Exchequer; but there ought to be a limit and there ought to be an inquiry into what the limit shall be." That has been the argument, and I want to look at our experience of the National Health Service to see what validity there is in that argument.
I think it would be agreed on all sides that the two services where the patient initiates expenditure—that is to say, where the initiative does not lie with the Minister or with the physician, but with the patient, the consumer of the Service— the two services where money is attracted from the Exchequer by the initiative of the patient are, mainly, the dental and ophthalmic services. Quite often the patient will go to an ophthalmic optician 1708 merely on the advice of his doctor, or sometimes he is not advised and he will go to the dentist even though his doctor has not advised him to go. Let us look at those two items of expenditure, because it has always been the case made against a Socialist experiment of this sort—and I say it advisedly—that, being free, it would be abused; that, being free there would be no control over the expenditure, and that, being free, the Chancellor of the Exchequer would never know how much money he had to find.
If we look at the expenditure on these two services, the dental service and the ophthalmic service, a curious picture, completely contradicting that fear, is shown. In 1949–50 the expenditure on the general dental service for England and Wales was £42,628,000. In 1950–51 —that is, after there had been one full year's experience—the expenditure was. £40,337,000. After the back-log had been worn off, when the neglect had been made good and when people were using the dental service normally, the expenditure had begun to fall. That is a very important point to consider. The same is even more true of the supplementary ophthalmic service for England and Wales, where the expenditure in 1949–50 was £21¾ million and in 1950–51 was £19,572,000.
I confess to hon. Members in all parts of the Committee that when I was watching the expenditure on those services I was extremely anxious because the graph showed a precipitate rise in the demand of the public. This was particularly marked in the matter of spectacles. As the months went by and the graph went up and up and showed no signs of declining, I am bound to tell the Committee that I was full of anxiety about what might be the behaviour pattern of the British public. But if we look at those two figures, we see that where the initiative lies mainly with the patient his demands upon the services had already begun to decline before charges were put on. In other words, here we have in practical experience a demonstration of the fact that making a service free to the public does not face the Chancellor of the Exchequer with unknown anxieties.
It was therefore possible for me in 1950–51 to put estimates to the Chancellor which were not exceeded. The Minister smiles, but I should have thought that 1709 anyone would have been proud of the fact that, when the people of Great Britain had been able to demonstrate one full year's use of the National Health Service, it was possible for the Minister to put in estimates that were not exceeded at all. In fact, in 1950–51 expenditure was under the estimate.
Turning to the pharmaceutical side, the picture is slightly different. Here is where the initiative in expenditure lies mainly with the doctor—I should like the Committee to remember that—not with the patient. It may be that the patient makes demands on the doctor, but it is the doctor himself who advises the prescription and attracts money from the Exchequer on the pharmaceutical side. On that side, expenditure has been going up, and I believe is still going up, despite the shilling prescription charge.
Here, however disciplinary action is open to the Minister. There are administrative pressures which he can bring to bear which might be increased more severely than they have been. It is surely a reflection on the medical profession that we spent £400,000 on dexedrine last year though in point of fact the equivalent on the official formulary would cost only about £158,000. That is a reflection on the doctor. What is required here is not to penalise the patient, who in this case is not responsible for the increase, but to make an investigation into the profits made by the big drug houses, and to stiffen more severely the discipline over the general practitioner, because we are told by chemists in different parts of the country that doctors are still prescribing far too liberally. Indeed the figure given by the right hon. Gentleman a few months ago illustrated that.
While I was at the Ministry of Health, because I was anxious about this increase in the drug bill, and because I believed that the increase in the drug bill could be to some extent avoided—not entirely, because new and more expensive drugs are coming on the market all the time— I asked Sir Henry Cohen to preside over a committee for the purpose of informing general practitioners of what prescriptions could be found in the official formulary which would provide the same advantages as proprietary medicines—or, may I say, the same disadvantages as proprietary medicines?—because there is a very great difference indeed between 1710 the price of a proprietary medicine and its equivalent in the general formulary. That investigation was proceeding; in fact, I think that several reports have been issued, but it is not yet clear that the general practitioners have themselves been as prudent and as co-operative as they should be. I am certain that the position is improving, but it can be improved even more.
All I am trying to point out at this stage is that in the first two instances the patient has behaved properly, and that in the third instance, where the cost has been going up, administrative measures are available to the Minister, without putting disabilities on the patient; and that these administrative measures ought to be taken before the patient is penalised.
Turning to the hospital services, the expenditure on them is entirely within the Minister's control. In fact, as the right hon. Gentleman knows, they have been severely controlled. So here we have a Service which cannot be said to be one which presents the Chancellor of the Exchequer with unpredictability; here is a Service in respect of which the Chancellor of the Exchequer will know, with a degree of certitude far exceeding that in the case of the Defence Services, how much money he can be expected to find.
§ The Minister of Health (Mr. Iain Macleod)
It is important to add one qualification, which the right hon. Gentleman knows. Sixty-six per cent. of the cost of the hospitals is covered by nationally-negotiated or other agreements over which one has no control. Therefore, to that extent we cannot prophesy exactly what will happen.
§ Mr. Bevan
That is not the case with the National Health Service only; it is the case with education—with every service. I am dealing at the moment with the special case of the National Health Service, and I am dealing with the argument, which has been advanced in newspapers and by hon. Members in some parts of the House, that one of the defects of the National Health Service is that the degree of expenditure is unpredictable. I am addressing myself to the case that this is not, in fact, the experience that we have had, that it is predictable, and 1711 that, therefore, the amount of money which we want to spend on it is within our power. "The Times" today, in a leading article of exceptional obtuseness—
§ Mr. Bevan
The right hon. Gentleman says that that means that I do not agree with it. We will see whether he agrees with it. I am bound to tell him that he comes under the lash, as I do. This is strictly relevant to what I was saying about the relationship between the Exchequer and the right hon. Gentleman, because he is now being accused of the same faults as it found in me. "The Times" said:How long is Mr. Macleod going to continue Mr. Bevan's penny-wise pound-foolish policy of starving the hospitals of resources for building and labour-saving equipment?Of course, "The Times" has not heard, and if it has not we had better let it know, that in February and March this year there was an argument between the Minister of Health and the Chancellor of the Exchequer. It is not an unusual argument. I can tell the House a secret: it is an argument in which I used to be engaged myself. It is also an argument in which every spending Department has to engage. What was the argument about? It was how much the Minister of Health was to have this year for hospitals. It was not how much he was to have for the dental and ophthalmic services, and not even particularly for the pharmaceutical services, because that graph is now predictable. It was how much more money, if any, he should be allowed to spend on the hospitals.
That is the argument, but it is not an unusual one. This is not a special feature of the National Health Service. It is an argument which takes place about education, about the Armed Services, about every spending Department; it is not a peculiar defect of the National Health Service. Yet it has been represented by many hon. Members as though it is. That is what they meant by calling it an open-ended service. It is an argument which goes on in every Government about priorities. It is a difficult argument to resolve.
1712 In some respects the right hon. Gentleman lost the argument; so did the President of the Board of Trade; so did the Minister of Supply, and so did the Minister of Education because the Minister of Housing and Local Government said to them, "Look here, boys, you stand back a bit; I am advancing here." That is exactly what has happened, and they have all stood back and he has gone on a bit. [HON. MEMBERS: "Hear, hear."] Yes, there are more houses, but fewer schools, fewer hospitals and fewer factories. That is an argument in the direction of which I cannot go very far. I merely use it as an illustration. Ail I am saying is that there is always an argument about priorities. Hon. Members may have been right: I am not arguing that. They may have been right in saying that that was the priority they proposed to have; but they could not have the other things as well.
But there was another argument as to whether this year the right hon. Gentleman should spend more money on hospitals or whether the Chancellor of the Exchequer should reduce Income Tax. The Chancellor of the Exchequer decided that his priority was a reduction in Income Tax. That is what happened this year. Therefore, where we have the argument taking place between spending Ministers and the Chancellor of the Exchequer, the argument is resolved in terms of the moral standards of the Ministers discussing it. Their moral standards were so low that the hospitals lost and the Income Tax people won. That is the argument about priorities this year, and this is indeed the difficulty that the Conservative Party are in. They are anxious, therefore, to find some device by which this painful annual argument about priorities should be resolved.
Can they produce some artificial formula by which the National Health Service shall be limited in its expenditure? What is it to be related to? I have heard some people say that it should be related to the total national revenue. If that be the case, then the right hon. Gentleman is entitled to more money. Even if we removed all the charges on the Health Service, if the whole service were free, it would still cost a smaller proportion of the national income than it did in 1950–51. If we take the national income as a formula, we are not doing too badly; but why that formula? Why this idea 1713 of an iron law of health payments remimiscent of the iron law of wages? The amount of money that the Government want to spend upon the health of the nation will depend very largely upon what importance they attach to it as against other demands upon national funds. It will depend upon the morality of the Administration engaged in making the assessment. That is why it seems to us that there was something wrong about the morality of a decision which put Super Tax payers ahead of the treatment of old people in hospitals—something wrong entirely.
All I am pointing out is that this is an argument about priorities. Will hon. Members opposite tell me how an independent Committee can advise about that? How can a Committee outside the House of Commons advise the House as to how much should be spent on health as against other forms of public expenditure? That is a political decision. It is not a piece of expertise as to whether we should reduce the Armed Forces and increase the Health Service, or increase education at the expense of both. All those things are matters of priorities which indeed involve not the assessment only of the material resources of the community but the morality of the people engaged in deciding it. So it seems to us that there was no occasion at all for the appointment of this Committee, and we are bound to treat it with the utmost suspicion.
In "The Times" leading article today, there was a further mistake. I mention it not because I wish to discuss "The Times" too much, but because I want to call attention to another very grave fault. "The Times" says that it is to be doubted —I am paraphrasing—whether we ought to have a free dental service at all—they have not heard that it is not free now— because the Teviot Committee, during the war, advised that we should require 800 more dentists in order to have a free universal dental service and we had not got enough.
Surely, the fact is that, as a consequence of charges on the dental service, the demands upon the dentists have declined very seriously indeed. A cut of one-third is expected in total dental earnings and of 55 per cent. in State payments compared with 1950–51. Why was there a shortage of 800 dentists in Great Britain before the war? It was because the standards of the British 1714 people were so low that they did not provide a living for more dentists. What is done now by continuing the charges on the dental service is to perpetuate a low standard of dental health for the people of Great Britain.
No one would deny that good dentistry is one of the most valuable preventive services. Therefore, if we save immediately, if we make the budgetary saving on dentistry, we shall ultimately have to pay more in hospitals bills. It is a bad saving. It is not a saving at all. It is not an economy. It is in fact merely buying larger headaches in the future for immediate relief. Therefore, "The Times" has got hold of the wrong end of the stick entirely.
For example, there is the question of provision for the chronic sick in our hospitals. That is a very serious problem indeed—the most serious problem of all —and it has nothing to do with parties. It is because the age of our population is growing. More and more people have to be looked after in the hospitals. The hospital organisation ought to be looked at narrowly from the point of view of seeing whether the treatment of the chronic sick cannot be so conducted as to reduce the charges on some of the hospitals. That is a matter for investigation; but, there again, I say that it is a matter for expert professional investigation and not for a body of this sort at all.
Therefore, we come to this conclusion. The right hon. Gentleman has set up a Committee of a sort that fills us with fear. I was in the House of Commons in 1931 when the May Committee was appointed. It went through. I do not think that it was divided on, if I remember correctly. It just slipped through, and then we had a Report which had serious consequences for Great Britain. That Committee made recommendations which were seized hold of by the Government for the purpose of making reductions in social services, reductions which, if they had to be made at all, ought to have been made on the initiative of politicians and not on the initiative of civil servants or so-called independent persons.
We suggest that the right hon. Gentleman should alter the terms of reference. It may be that he will say that the Central 1715 Health Services Council is so deeply involved in the administration that it is not able to take an objective view of it and that therefore the Council ought to be asked to give advice to this body but ought not to advise him itself. There is something to be said for that— not very much—but there is nothing to be said for asking advice about what our opinion should be. We are an opinion-making body. We are an opinion-creating body. Therefore, it is nonsense to ask four or five ladies and gentlemen outside, "What do you think our opinion ought to be about this?"
That is why I said—and I stick to my words—that it was cowardice to set up the Committee. If the Government want to cut the Health Service, why should not they say so? Why do not they face up to their responsibilities instead of calling into existence a Committee and hoping to be able to hide behind it?
§ Mr. Bevan
I would rather manoeuvre to save the Health Service than manoeuvre to destroy it, which is what we are having at present—a cheap calculated manoeuvre against the welfare of the Health Service. I do not believe that the right hon. Gentleman is entirely responsible for it. If he is, I am sorry, because every Minister, after he has been in a Department for some time, no matter what his views were before, and if he is a human being at all, develops a certain proprietary jealousy for its welfare. He feels that he would like to be able to say to the hospital authorities of Great Britain that he is able to find a little more money for them, and he should be able to feel that he can stand up to the Chancellor of the Exchequer sometimes. If he has not got that sense of craftsmanship, he will never be a Minister, but will only remain crafty. What these terms of reference show is not a sense of jealousy for the Health Service at all, but a subtly-laid plot to provide the Administration with an excuse for a further attack on the Service itself.
May I say, in conclusion, speaking for myself and, I believe, for many of my hon. Friends on this side of the Com- 1716 mittee, that we are deeply sorry that this. step is being taken. I have been told in different parts of the world, and by hon. Members of all parties, that the one feature of post-war Britain of which practically the whole British people were proud was the British National Health Service. Even the Tories, when they go abroad—most of them, not all—say it is a very fine thing that we did. Why cannot we afford in 1953 what we could afford in 1950–51? Everywhere there is evidence of relaxation and tensions are easier. Why should we spend substantially less on a free Health Service this year than we did in that year?
It seems to us that this is retrogression. It may be that at the moment the nation is not fully aware of what is happening, but it will become aware and if it becomes clear to the nation as a whole that the British Government are plotting against the future of the British National Health Service, we shall not see many repetitions of the scene that we had this afternoon; and I would say that, even if it happened that a series of such scenes occurred and coincided with the decline of the British National Health Service, I should regard it as the decline of Great Britain itself.
§ 4.23 p.m.
§ The Minister of Health (Mr. Iain Macleod)
I think it is an excellent thing that we should have this opportunity of a full day to discuss the National Health Service, because, although the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan) linked most of his points with the Guillebaud Committee, the Motion before the Committee does not limit us in any way in our discussion of the National Health Service, both in England and Scotland.
Before I come to some matters which I should like to put before the Committee, it would only be courteous if I made some immediate response to one or two points made by the right hon. Gentleman. I am bound to say that I found his speech singularly disappointing. He has been making the most vicious personal attacks on me in the Left-wing Press, where I cannot reply, and in elections at which I was not present. I thought he might have repeated some of these charges in the House of Commons 1717 this afternoon, but we found him—[An HON. MEMBER: "Is the right hon. Gentleman disappointed?"] Indeed I am disappointed. We find him roaring like any sucking dove.
How does a dove suck?
§ Mr. Macleod
It is a quotation from "A Midsummer Night's Dream."
I want to take up the right hon. Gentleman on something which he said about the National Health Service in the Sunderland by-election, to which he just referred. An article in the "Daily Express" is headed "Says Bevan, 'If I'm not right, I'll resign.'" We know that the right hon. Gentleman is a man of his word, and, if he is wrong, he will, of course, resign. The article continues:It is perfectly true that in 1951 certain charges were put on the National Health Service. But not by me.That was done by the rest of the Socialist Party.And it was the Tories who made the charges permanent and introduced another Bill making charges on dentistry and spectacles and hospital gadgets.The charges on spectacles, of course, come from the 1951 Socialist Act, and not from the 1952 Measure. [An HON. MEMBER: "And they were not permanent."] The permanency of them is irrelevant. The article says:It was the Tories who made the charges permanent"—and I quite agree—and introduced another Bill making charges on dentistry and spectacles and hospital gadgets.That is quite wrong.
§ Mr. Hugh Delargy (Thurrock)
The whole point, and the great difference between us, is that the party opposite say their charges should always be permanent, while we say that ours should not.
§ Mr. Macleod
I am sure that the right hon. Gentleman the Member for Ebbw Vale will be grateful for that assistance, but I should like to deal with that point later on. I want to come straight to the question of the Guillebaud Committee.
§ Mr. Bevan
I was hoping actually to get this debate into a little more objective fashion than the other one, but if the right hon. Gentleman makes challenges of that sort, then I want to meet him at 1718 once. What I said in the height of the Election I stick to, and it was not in connection with that that I said that I would resign. I said that the right hon. Gentleman the Minister of Health did not believe in a free Health Service and had said so. Does the right hon. Gentleman deny that? In fact, he said to the House of Commons, and I have here a quotation from the speech in which he qualified for his present office:It remains the belief of this party, apart from economic circumstances, that there should be charges in the Health Service.And he went on a little later to say:It seems to me quite absurd that, when the economic reasons reinforce the social and ethical ones, we should not support them."— [OFFICIAL REPORT, 27th March, 1952; Vol. 498, c. 966–7.]So here is the Minister saying that there are moral and ethical reasons for charges in the Health Service, and it is on that that I make my challenge. Does he deny that?
§ Mr. Macleod
Certainly not, but I will refer later in my speech to how some of these charges have worked out and justify precisely what was said a year ago on that point.
The Guillebaud Committee, to which the right hon. Gentleman made some reference, was greeted first of all with almost unanimous approval by the Press. It is true that the "Daily Worker" headed their story "Tories' Bid to Kill Health Services." In that, they were completely in line with the "Daily Herald," which said "Health Service in Danger of New Cuts." Let us now look at the other side. "The Times" had a leader headed "A Wise Move," and it said this:If the remaining members have minds as fresh and independent as his,"—that is, Mr. Guillebaud—if they are not tied to a rigid timetable or precluded from promoting necessary inquiries, nothing but good is to be expected from this new investigation.The "Manchester Guardian" said:It is hard to see why Mr. Bevan made such a fuss about the forthcoming appointment of a small non-political committee to review the costs of the National Health Service…. In fact, there is an excellent case for a review now.I cannot resist also quoting from the "Daily Mirror" leader:Mr. Bevan was making a frantic fuss the other day because there is to be an independent inquiry into the administration and cost 1719 of the National Health Service. Why? What is wrong with finding out if it is properly organised? Why should we not look to see if we are getting value for money in the Welfare State? Mr. Bevan is blowing his fog horn before the Health Service is in danger.Those comments show accurately enough what was ordinary opinion in this country on the appointment of this Committee, and I think it is significant that the form of this debate has been widened as much as it has and that it is not narrow, for as I understand it we were once threatened with a Motion of censure on this issue.
I believe there are two questions in relation to this Committee. I am sure the House agrees with this: that we must decide, first of all, is there anything to inquire into; and, secondly, if there is, what sort of body should make the inquiry? I appreciate that there is much more disagreement about the second question than about the first, but I should like to indicate some of the matters which, in my view, are in the arena of dispute in the Health Service at the moment—matters on which I should like advice, although I entirely agree that the decisions on them can be taken only here, in the House of Commons.
First of all, there is the question of the block grant. There are those who say— and in a sense I think the right hon. Gentleman is one of them—that the financial system, the central accounting system, of this country was never designed to take upon its shoulders the sort of burden which the Health Service has had to put upon it and that it was never designed to look after a great number of hospital management committees and several thousand hospitals.
There are those who say that the fact that money has to be returned at the end of the financial year is a disincentive to wise spending in the last months of the financial year, and there are those who say that there would be great economies if it were possible to allow the hospitals to plan three or five years ahead. That, roughly, is the case for the block grant.
On the other side there is the question that two-thirds of the cost of the hospitals is related to salaries and is therefore not absolutely within the control of the Minister, nor would it be within the 1720 control of the hospital authorities; and it is difficult to envisage a block grant system working in that way. There is also the point that if a block grant is to be effective, we must be reasonably certain of stable prices for some time ahead, otherwise the system itself clearly would break down. What the final answer may be is a matter for the House of Commons, but it is one matter on which I believe the Guillebaud Committee will be able to advise us.
Take the question of the ambulance service. It is a hospital service in Scotland and a local authority and hospital service in this country. It is extremely expensive. There are many people who hold the view that we can never get true economy in the ambulance service until the body which orders the ambulances also pays for them.
§ Mr. Macleod
I am glad to have the hon. Gentleman's view. I should like to have the opinion of this sort of Committee on whether the Scottish system is or is not an improvement. There is also the immensely difficult problem of fitting national wage negotiations into such an intensely human and personal and individual service as the hospital service. Above everything else, there is this point —and I will return to this theme at the end of my speech: we must find a way in which we can relate savings to efficiency so that if it is possible to isolate efficiency as a reason for saving, the hospital can get some benefit from it in the succeeding year.
Of course the difficulty is that underspending is not necessarily due to efficiency. It may, in fact, be due directly to inefficiency. It may be due to overestimating. It may be because some of the things for which plans were made are not available, or it can be due to changes of policy or, indeed, to a dozen other things, but if we can find a method —and the Select Committee on Estimates said something about this a year or two ago—of isolating savings which are due to efficiency and rewarding the hospital for them, it would be of immense value to the service.
I do not think we are satisfied that the local authorities have yet found exactly their right role in the Health Service, and 1721 although I shall deal with this point separately in view of what the right hon. Gentleman said, I doubt whether we have yet reached anything like finality in our answer to the question of the pharmaceutical service.
There is, then, little doubt that there is a good case, particularly after the expiry of five years, for some sort of an investigation, and we come, therefore, to the question of which body should do it. The right hon. Gentleman has suggested that the Central Health Services Council is the right body, and it has also been suggested that the Public Accounts Committee and the Select Committee on Estimates might have the task. Perhaps we can first dispose of the last two, because there is a stronger case in what the right hon. Gentleman put for the Central Health Services Council.
The difficulty, in so far as the Public Accounts Committee and the Select Committee on Estimates are concerned, is that these Parliamentary Committees are concerned, in the first place, with expenditure, after it has happened—that is, the Public Accounts Committee—and, in the second place, with current Estimates but within the framework of existing policy. Quite clearly, neither of those bodies fits the sort of case that I am putting, because the Estimates framework for this year is already laid before the House and the Guillebaud Committee is not concerned with that.
I turn then to the serious case which has been put for the Central Health Services Council. I thought myself that, in part, the right hon. Gentleman answered his own case. He answered it, first of all, by relating who was on the Central Health Services Council. Nothing I say is to be taken as detraction of them in anything. They are a most excellent body and I have received full assistance from them, as have all previous Ministers.
§ Mr. Macleod
First of all, there are 41 members on the Central Health Services Council in England and Wales. I think that alone is a most convincing reason against putting this case to them. Secondly, the right hon. Gentleman has said that it would not be possible for them to carry out the terms of reference as they have been agreed—and these terms of 1722 reference are what the Government wish to keep. Thirdly—and perhaps this is most important—it is because the Central Health Services Council has members of all the interests in the service that I simply do not think it is the right body for this sort of inquiry. I genuinely believe we shall get what we want, on which we can make our decisions, if the body is an independent one, which certainly the members appointed indicate, and is not tied in any way either to a political party or to any service within the Health Service.
§ Mr. Manuel
Is the right hon. Gentleman now telling the Committee quite bluntly that, although these people are very good and have an excellent character in their profession, whatever branch of it they may adorn, they would be influenced in any report they made to him because of the particular section of the profession to which they belong in the Health Service and would not make a true report?
§ Mr. Macleod
There is no question of that. Take one particular example, the block grant. I know the views of the hospital authorities on the block grant. They all want it. There are many other examples. I know roughly the views of the local authorities on many of the matters to which I have referred. What I want is an independent view from independent-minded people who are not tied either to the professions or to the political parties. That is what I seek to achieve by the Guillebaud Committee, and although I shall keep referring to them I am going to leave them for a moment.
I think that the case that there is something to be inquired into is un-answerable. I agree that there may be room for argument on the second case as to who should inquire. I hold the view, both for the reasons I put forward and because I am encouraged by the reception they have had in the country, that we have found the best method in this particular field.
§ Mr. Macleod
I am sorry but I disagree with the right hon. Gentleman in that 1723 matter. I shall return to the various matters affecting the Guillebaud Committee. It is right that on this occasion, which is the only one we have in the year to review the Health Service, I should also review fairly quickly some other matters, and first of all the question of manpower policy, which has been again bitterly criticised from the other side.
Here there is no essential difference between us in aim at all but difference only on method. We cannot possibly control expenditure in the Health Service field unless we control that. The salaries and wages, as we have said, come to two-third the cost of the hospitals and the hospitals themselves nearly two-thirds the cost of the scheme. At the end of 1951, there were 328,000 full-time and 90,000 part-time staff in the hospitals. That is an increase of full-time staff of 15 per cent. over the end of 1948, and of part-time staff of no less than 33 per cent. It is important that we should try to relate the numbers that we employ to the services that we obtain.
It is agreed on both sides of the House that we want a national manpower policy in the hospital field; indeed, the first steps were taken by the two right hon. Gentlemen in the Socialist Government. What is the clash? It is that they set up review teams and intended them to fix establishments for the different hospitals, after which the procedure which I have initiated now of a prior permission would come into force. The difficulty of their scheme is that it would take far too long. It would have been very many years before the review teams had completed their reviews of hospitals, so I decided at the end of last year—I wanted to bring this into effect before I presented my Estimates as part of my Estimates— on more drastic methods. I decided that we would take the establishment on one particular day as the establishment of the hospital and that we would ask the hospital to see if they could, by different methods but not by reducing essential services, do something to contain the level of staff.
There are a number of results already in. I do not want to go into them in too much detail except to say—I put it no higher—that I hope that as a result of 1724 this policy we shall be able to get staff into the hospitals, and into sanatoria and mental hospitals particularly where they are most in need of staff. If we can limit to some extent those who are already up to general staffing ratio, it may make it possible to help those which are less satisfactory. I shall turn now to the cost of the drug service.
§ Mr. James H. Hoy (Leith)
Before the Minister leaves that part of his speech may I ask whether this is not a departure from the assurances that his Department gave to the Public Accounts Committee of last year when it was intimated that these teams were going to inquire into the Service. Is it not a fact that in the preliminary investigations they found that they could not apply a general rule to the hospitals, which would have to be taken in order, one at a time, because of the differences between different hospitals?
§ Mr. Macleod
Some of the reviews are going on. The hon. Member is quite right when he says that this is a new policy, in the extent of its amplification at the end of last year to existing hospitals. That is certainly true.
The cost of the pharmaceutical service I know interests hon. Members, and particularly what has happened as a result of the 1s. charge. The Government view the present cost of the pharmaceutical service, as their predecessors did, with the very gravest concern. It is indeed the only part of the National Health Service that I cannot claim is under financial control at the present time. There has been a steady increase in the number of prescriptions, which are now running at the rate of 241 million a year. I should point out that throughout my speech I am speaking, unless I say otherwise, about Great Britain, including Scotland as well.
The average cost of prescriptions has climbed from 38d. in 1949–50, to 405d. in 1950–51, 47d. in 1951–52 and 50.5d. in 1952–53; and we have taken a figure of 52.5d. for each prescription for the Estimates this year. This increase is due to the general rise in ingredient costs, although that is now flattening out, and to the increasing use of new, valuable and expensive drugs; and finally to the remarkable increase in the proportion of proprietaries.
1725 Before I leave the average cost of prescriptions, let me say that it is not true that the increase of 3½. last year per prescription is wholly or mainly due to larger quantities being prescribed, although that conceivably can be an element in it, as it went up 6½d. the year before. Before the National Health Service came in, the proportion of proprietaries was 7 per cent. In 1949 it was 15 per cent. and it is now 25 per cent. That 25 per cent accounts for about half the whole drug bill, which, if we take the hospitals in, is something in the neighbourhood of £60 million.
The right hon. Gentleman referred helpfully in his speech to the Cohen Committee. Perhaps I can say a word on the present position there. It is this: I am going to notify doctors in a month or so, when the final arrangements are made —they are practically complete—of the two schedules laid down by Sir Henry Cohen's Committee which refer to drugs not of proved therapeutic value, and I am going to ask the doctors not to prescribe them. I am sure that I will have the help of the medical profession. The biggest problem of all is that no fewer than 4,000 preparations come into the category which the Cohen Committee advised me ought to be prescribable, although they are not superior to standard preparations—subject to satisfactory price arrangements being made.
The problem that confronts us is what we are to do here. It is not a new problem. The House of Commons was recommended to take action over proprietaries first in 1914. The first Bill came before the House in 1920. Many other efforts have foundered in the past. There is a genuine difficulty here, which was outlined in a leading article in "The Times" a short time ago. This is a very big industry indeed and its annual product is something like £90 million, divided almost exactly into three parts. Roughly a third goes to export, roughly a third goes to the National Health Service and roughly a third is taken over the counter without prescription.
There is therefore a most important export element present, and of course I have been closely in touch with the President of the Board of Trade on it. There is also truth in the argument that they advance that much of the research that they have done has to be paid for by their proprietaries, although I am bound 1726 to add ruefully that if I have a ceiling it is a little hard that I should have to pay for part of their research. There is a genuine case, therefore, for many of these firms. But the trouble is that there are firms who are merely wrapping up standard preparations in pretty packages and forcing them on the notice of doctors by salesmanship. The difficulty that I have is to distinguish between the two, so as not to harm the export industry and not to damage research which has brought splendid advances in chemo-therapy, but to try to get rid of those firms who batten —and that is the right word—on the Health Service.
There are various possible approaches, but the Government have decided in the last few days that we will start a number of investigations—as many as we can undertake—into the cost of manufacture of certain of these proprietaries which seem at first sight to be specially expensive. I hope that this will yield substantial savings and in due course I intend to circulate again to doctors the names of those preparations concerning which we are unable to reach satisfactory agreements on prices. I merely add that the action we are taking now is not to be taken as the end of the story, and I do not rule out more drastic measures if that fails.
§ Mr. A. Woodburn (Clackmannan and East Stirlingshire)
Does not the right hon. Gentleman agree that one of the essential differences between the cost of the standard article and of the proprietary medicine is the huge sums spent in advertising, and that if this kind of article is wrapped in a package and heavily advertised it will sell and be accepted more readily than the standard article?
§ Mr. Macleod
There is a great deal of truth in that, but it is fair to say that many proprietary articles are hardly, if at all, more expensive than the standard equivalent. The difficulty here is to separate the sheep from the goats.
§ Mr. Bevan
I do not want to interrupt the right hon. Gentleman unduly, and I intervene now merely for the purpose of reinforcing the points which he is making. It is not only the fact that the National Health Service is itself to some extent financing research in the pharmaceutical industry for which the National Health 1727 Service should have credit, but it is also the fact that bulk purchase arrangements made probably by the right hon. Gentleman, and made by me, have buttressed the export industry. Streptomycin is an example where we began to earn dollars within one year of the National Health Service giving a blanket order to several firms. Therefore, the ceiling of the Health Service is concealing a subsidy for the export industry.
§ Mr. Macleod
Yes, I do not dissent from what the right hon. Gentleman has just said.
I want to tell the House what has been the result of the 1s. charge. There was a 14 per cent. drop in the first month and that came down and down until in September the deterrent effect was a quarter of 1 per cent. Then we had three months at the turn of the year, December, January and February. In those months the number of prescriptions dispensed ran at about 12 per cent. above the year before, even though the 1s. charge was on. But, of course, all hon. Members will see the difficulty; because there was fog, there was flood, and there was 'flu.
So it is quite impossible to make any valid comparison from year to year unless at the same time one looks at the sickness figures of the Ministry of National Insurance. Therefore, in the past year it has genuinely been almost impossible to draw conclusions. Those three months have upset things so badly that all I can tell hon. Members is that I have put down in calculating my estimates a deterrent figure of 6 per cent. against 1951–52 for the coming year. Whether that is right or not I cannot say. It depends whether it will be an epidemic year or not.
§ Dr. Barnett Stross (Stoke-on-Trent, Central)
Has the right hon. Gentleman an estimate of the increased amount of quantities on each individual form, on the average on E.C.10's?
§ Mr. Macleod
I have not the information before me, but I am certain that the figures are of this order: before charge there were 1.59 prescriptions per form, and the figure now is 1.71. I may be a fraction out.
Turning to the general dental service, we can make a most fascinating comparison between what has happened 1728 under the two Acts. Here I justify what I said a year ago—that what we needed was a switch in resources and that there were social and medical reasons for charges in the health scheme. First of all, the effect of the 1951 Socialist Act was that in the last full year before the introduction of charges for dentures, over 3 million applications were made for dental treatment requiring prior approval, that is mainly dentures. In the first full year after the introduction of charges, the number of applications was not much greater than 1,500,000; in other words there was a deterrent effect of 50 per cent. in that particular field.
§ Mr. Macleod
Now let us turn to what has happened under the 1952 Act. Under that Act the charges for adults have led to a very slight fall indeed in the real volume of conservative dental treatment of adults, and as many of the courses of treatment costing less than £1 have been provided for obvious reasons under private arrangement, I doubt if there has been any real fall in the number of treatments that have taken place. But, within that, a change of most profound social importance has taken place. The number of children's courses under the Service for the last quarter of 1952 was 350,000 as against 170,000 in 1950. They comprised 22 per cent. of the courses under the Service in 1952 as compared with 9 per cent. in 1950. I am talking, of course, of children treated under the general dental service.
In 1950–51, 63 per cent. of the total Exchequer expenditure on dental service was attributable to dentures and as a consequence 44 per cent. of the total cost of the Service in 1950–51 was in respect of persons aged 45 and over. At the other extreme, the proportion attributable to children and adolescents, leaving out school dental services, amounted to 9 per cent. By the second half of 1952, when the charges which we imposed a year ago were in operation, the proportion of total Exchequer expenditure on dental service in respect of those aged 45 and over had fallen to 20 per cent., whilst for the treatment of children and adolescents it had risen from 9 per cent. to 27 per cent.
§ Mr. Macleod
I thought that I had given that. In the last quarter of 1950 the figure was 350,000 and in the last quarter of 1952 it was 170,000. The last quarter of 1951, to which the right hon. Gentleman refers, was before the introduction of the charges under the 1952 Act and therefore for the moment is irrelevant to the point which I am making.
§ Mr. Macleod
Let me add to that the figures of dentists and their full-time equivalent under the School Dental Service. The figure of over 1,000 in January, 1948, went down and down until it reached 812 in January, 1951, and then let us see what happened: January, 1952, up to 837; October, 1952, up to 958; January, 1953, up to 998, and the figure now, I have no doubt, is well over 1,000, and we are back, having repaired all the damage that was done to the School Dental Service.
For the first time, therefore—and those figures show the position correctly—since the Act came into force in 1946 there is now a genuine measure of priority for the priority classes. I tell hon. Members opposite that if they remove the charges on the dental scheme before there is an adequate number of dentists they will destroy all the progress that has been made towards securing that priority for the children.
The basic problem that confronts us is set out well by "The Times" in the leader to which I have already referred. It is this:Since there is no discernible limit to the amount that might be spent on medical care, but since in practice a limit must always be imposed the Government have the unenviable task of having to estimate how much of what is spent or demanded 'ought' to be spent on public account for health care.Perhaps I can illustrate this from a meeting that I had with my Newcastle Regional Hospital Board a short time ago. They told me that, in their view, they needed £29 million of capital expenditure in their region alone on the mental and mental deficiency services. 1730 Even if we take into account that they are good advocates and that they were probably bidding a bit high, and even if we take into account that Newcastle is one of the worst served regions, as it is, in that particular respect, that seems to show that one could spend something like £250 million on capital expenditure in the mental field.
If one adds to that the question of new hospitals—none have been built since before the war—or the problems of the old, of health centres and perhaps of outpatients, I could probably justify to the House of Commons, if medical need alone were the criterion, a capital programme of something like £1,000 million. But so, no doubt, could many other Ministers. Therefore, we have this dreadful dilemma which hon. Members have always been in, the dilemma of priorities. The struggle to keep within a given limit has dominated arguments about the Health Service ever since Sir Stafford Cripps' 1950 Budget.
The main problem, therefore, is how to meet the thrusting needs of the hospital service. The right hon. Member for Ebbw Vale twitted me with not having stood up enough to the Chancellor for money for the hospitals. But I do not think that suggestion can be repeated when I have given the figures to the House. That dilemma brought in consecutive years two different charges. This year there is no additional charge put on the National Health Service, and it is important to study how that has been achieved. The right hon. Gentleman in his 1951 Measure said that it was self-deception and deception of the House of Commons to pretend that that could be done without a system of charges. I am certain that that argument could have been fairly used by the Leader of the House, the then Minister of Health, because when he came into office the Estimates for the forthcoming year were already in Savile Row.
Perhaps we can consider the figures for hospital running costs. Taking the first full year of the service, the out-turn, which of course is the important figure here—not the estimate—went up from 1949 to 1950 from £228 million to £241 million, to £258 million and then to £272 million last year, and the estimate for this year is £287 million. 1731 The first point to explain is how the hospitals last year underspent by £14 million. That was partly in response to the request and the pressure put on them by the Lord Privy Seal, which I have continued, by personal letters to all the hospital authorities drawing their attention in particular to the danger of overspending in the last few months of the year.
But there are other matters. The amount of money that was put aside to meet rises in the cost of living was in large measure not required, and I am one of the biggest benefactors from the fact that this Government have for so many months held the cost of living virtually steady. As a direct result, moreover, linked to the last point, the amount that was put aside for wage increases was not by any means up to the extent of about £3½ million fully required.
§ Mr. Macleod
Let me turn to the question of the estimates. We have provided as against the out-turn for last year £15¼ million extra for hospitals. But it does not stop there. I have looked at the stocks that hospitals were carrying. In England and Wales they have gone up from £11½ million in March, 1949 to £21 million in March, 1952, and I decided1 that those could be reduced by £3 million, and therefore that amount is additionally available to hosptals for the coming year.
I looked at the question of cash balances, the amounts that are available for the first nine days of the month to tide them over until the full monthly payments come on. I saw that those totals amounted in March, 1952, to £8 million, and I came to the conclusion, on advice, that those could be reduced to £6½ million. If we put those on to the £15¼ million it will be seen that the Health Ministers—I am now talking of Scotland as well—have provided more than £20 million over the out-turn for last year for the hospitals, and, in view of that, no one could say that there has been any lack of co-operation between the Chancellor and myself in finding that money.
I particularly wish to draw the attention of the Committee to the fact that that has been achieved without a charges 1732 measure on the precedent that the right hon. Gentleman set two years ago. With £20 million I can, therefore, maintain the service. I can bring into full use the developments that have been finished recently and I can provide for modest future development. Added to that are the effects of the manpower policy which I outlined earlier, the new costing method which is coming into operation all the time, and a most important development —the abolition of individual ceilings for building maintenance—because we have got away altogether from the conception of a separate ceiling there, and it is now possible for hospitals within their total to spend as much as they like on building maintenance.
Having dealt with the estimates for the current year, I wish to turn to the future. It seems to me—it is always proverbial for politicians to have three choices—that there are three roads that we can travel now. The first one is the Socialist road. That, as I understand, is to say that charges in the Health Service are immoral and anti-social, and that includes the charges brought in by the Socialist Ministers in 1949 and 1951. But that does not apply to the original charges in 1946. So the Socialist policy now is to abandon as soon as possible all charges in the Health Service and, in order to do that, they will slow up and hinder the development of the Service. [An HON. MEMBER: "That is not true."] Very well. Perhaps I may quote from a Labour Party publication which has a foreword by Mr. Morgan Phillips. This publication was issued in September, 1952, and it says:We are pledged on regaining power to remove charges under the 1949, 1951 and 1952 Acts as soon as is practicable. This means that the development and expansion of some parts of the Service may slow up. But we consider that free treatment is more important both from a moral and economic standpoint.
§ Dr. Santo Jeger (Holborn and St. Pancras, South)
May I ask whether the sub-heading on the outer cover of that pamphlet indicates that it is merely a discussion pamphlet?
§ Mr. Macleod
Do I understand that the Labour Party only have discussion pamphlets on things in which they do not believe? I would ask the right hon. Gentleman a question—and this is a most important point, to which I hope the party opposite will address themselves. 1733 Suppose we have a vast trading surplus; suppose all the things we want to see come true in fact come true, and suppose the Chancellor approaches the Minister of Health and says, "You can have another £40 million for the Health Service." It costs that to get rid of the charges. Is this really the first use to which a Minister of Health ought to put that sum? I know where I should look if I had that sum, or one tenth of it. I should not look to free dentures and free medicines but to the mental health of this country.
It is a strange system of priorities that puts free dentures and free medicines before the care of the mentally ill. I certainly agree that there is a moral issue here. It divides the two sides of the Committee, but I deny altogether that the moral issue is whether or not parts of the Health Service should be free. In my view the moral issue is whether, given a limited expenditure on health, one is prepared to put first things first.
I should like the right hon. Gentleman to amplify what he said a year ago. Is he prepared to find £40 million to put back charges, £20 million for the ordinary expansion of the hospital service and an unknown number of millions for policies like the medical staffing policy which I put into operation and which has been rejected? If he is prepared to find £65 million in the first year, is he prepared to find £90 million in the second year— as he will have to do? What happens to the various policies with regard to recruiting, health centres and other matters? I should be glad if he would answer that. Perhaps he should consult with the right hon. Member for Leeds, South (Mr. Gaitskell) before he replies.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
As the right hon. Gentleman has raised this point of priorities, does he mean he is prepared to accept the policy of his Government and to give concessions to wealthy people in priority to any increased care of the mentally sick or the aged sick?
§ Mr. Macleod
That is largely irrelevant. As far as I recall, no one from the Opposition Front Bench said that in place of some of the concessions in the Budget they would have restored all the charges imposed by successive Governments.
1734 This is a most important issue. Individual Members have mental homes in their constituencies and know their problems. I do not want to make a party point of this, but are hon. Members opposite really saying that the first £40 million of free money, if it comes—and I should love to see it come—should be spent on making the Health Service free again? It will be free only in the technical sense, because there will still be charges as imposed under the original 1946 Act, and, indeed, for the ambulance service.
§ Dr. Edith Summerskill (Fulham, West)
This is not a party point. Does the right hon. Gentleman say that his medical advisers are of the opinion that one can put the welfare of the mentally abnormal before the welfare of the mentally normal?
§ Mr. Macleod
That is a very considerable over-simplification of the issue. An immense amount has been done for the mentally normal. The problem of the mentally abnormal is crowding on us all the time. It is the problem that gives me the greatest concern at the moment, and in my view it has the first claim for more money.
The second course available was the course pursued in 1951, of totting up the sum available and the sum needed, shrugging one's shoulders and saying, "We will fill the gap by charges." If any of the things which have been said by hon. Members opposite about me were true, surely that is the route I should have taken this year, instead of struggling to avoid charges—and with some success.
The difficulty about a policy of successive charges is that in time it must destroy the Health Service. It is like the fable of the man whose donkey was eating too much hay. He reduced its hay day by day until he got it just to the point where he could afford the hay and then, unfortunately, the donkey died. That is what would happen to the Health Service if we went on in that way. We have shunned a further step down that road.
Hon. Members opposite made a number of charges in their speeches in the country, one of which was that we were considering hotel charges this year. That question was never discussed at any level by myself or my colleagues. It may be 1735 that we are at the end of charges in the National Health Service. I do not know; but at least we have called a halt.
If we reject the first approach—because I believe it to be muddle-headed, however sincerely the Opposition put it forward—and if we reject the second, because it is self-destroying, is there a possibility that we can find a third path for the National Health Service? I hope we can. As I have shown in my Estimates this year, I have tried to hold the line, but many of the things I have done cannot be repeated from year to year. What we want to achieve is a system whereby the Service itself has an interest in economy which is as natural and rewarding as is its interest in medical efficiency.
That is the essence of the problem which the Guillebaud Committee are trying to solve. Now that the Estimates for this current year are behind me, that is also the problem which I am trying to solve. I am not offering a final solution today; it is much too early, but I hope to be able to find an answer that does not follow either of the previous solutions.
I have made a long speech, partly because I have given way on a great number of occasions. I have not given details of progress in nursing, recruitment and the provision of beds, nor even the trend of the vitally important statistics in maternal and infant mortality and tuberculosis My right hon. and gallant Friend the Member for Glasgow, Pollock (Commander Galbraith) will give some of those figures in his reply. It is enough for me to say that the Committee will see from these figures that 1952 was a splendid year of steady and at times spectacular progress in these most important fields.
I claim that the finances of the Service now, from the account I have been able to present to the Committee today, are far more soundly based than they have ever been before. I claim, as a result of that, that we are right at this point to review the Service. I claim that the Guillebaud Committee are the best body to carry out the investigation we require, and I am certain that the Health Ministers are entitled to ask for the support and confidence of the House.
§ 5.20 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I am sure the Committee have listened to both the opening speeches with a great deal of interest, and that we are grateful at least for the fact that we have gained some information from the speech of the Minister which is of undoubted value, although we must try to obtain some further details from him before we draw any too easy conclusions. When discussing the effect of the charges proposed, it is, of course, of the greatest importance that we should be given a comparison with the earlier period before the charges were introduced. I am not at all clear as to how those figures will be made available, but I hope that whoever winds up this debate will be able to give us some extra information regarding the earlier figures, particularly in respect of dental treatment, which is of undoubted interest to everyone in the Committee.
We are grateful to the right hon. Gentleman for so clearly declaring the difference between his approach to this problem and that of hon. Members on this side of the Committee. He has made it clear that he does not regard the question of a free and comprehensive service either as a matter of moral or of economic concern in the development of the Health Service. We missed the wider sweep of approach to this problem which we think is needed in order to tackle the serious problems with which we are faced at the present time.
It should be made clear at the outset that we on this side of the Committee have been concerned with the introduction and development of a free and comprehensive Health Service available to everyone. We take the view that health, like education, is a service of the greatest concern to the community as a whole as well as to the individual recipient of any benefits which may be made available. This is not a matter in regard to which we can rely on individual initiative. It is a matter of supreme importance to the community as a whole and essential for its economy that the standards of the Health Service should not merely be maintained, but should be developed.
We failed to get that approach from the Minister this afternoon. He was concerned with the financial economies 1737 he could obtain by juggling first with one side of the Service and then with the other. But that form of juggling, as he himself admitted, is not one which can be continued, and therefore he is still faced with the problem of how to find the extra finance needed in order to provide a Health Service which the community is entitled to expect.
It is clear from what the Minister said today and from what he has written in the past that, in his view, there are, as it were, two sections of the community, the one which might reasonably be expected to pay charges and the other which might be expected to receive the benefits. The right hon. Gentleman and his hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) have said that the social services, in the true sense, exist only for a portion of the population. It follows from that, according to his ideas, that for the richer section of the community social services do not exist because, although they may use them, they pay more in rates and taxes than the benefits they derive are worth. That is what was stated in the pamphlet written by the right hon. Gentleman and the hon. Member for Wolverhampton, South-West a little while ago.
This is a sort of paternal view as to what should be done with our social services; that it is the responsibility of the rich, in so far as they are willing and able, to make some extra provision out of their resources in order to provide benefits for the poor. It seems to us that it is this paternal approach which is bedevilling the Service at the present time. It takes no account of the interdependence of all sections of the community today. It is quite impossible to segregate one section of the community and to say that they shall receive benefits from the Health Service, but that another section shall not. Today the whole community shares in the Health Service, and, indeed, in the education service, and it is of vital economic significance that they should. Therefore, the idea that one section of the community should pay for the benefits enjoyed by another section is no approach to this problem of charges.
We look at the matter from a different point of view. We are not concerned 1738 with personal incomes, because we believe that the Service should be paid for out of general taxation. By imposing charges, we are asking straight away that the whole provision of our social services shall be directed to one section of the community which, it is assumed, cannot afford to pay for the benefits they receive. The Minister today, as on previous occasions, welcomed the concept of charges, even though he may take a different view concerning where they should fall.
The Minister has posed the question, as, of course, he is entitled to do, as to the priorities that we would place on different sections of the Service. But he is posing a false question, because the way was open this year for the Government to withdraw the charges that had already been imposed and to enable a proper development of the Health Service to take place. If, instead of making extra revenue available to those who are already well enough off as it is, those resources had been made available for a proper development of the Health Service, it would unquestionably have been of infinitely greater value to the community as a whole. Indeed, it might very well have been a greater incentive to the trade union movement with regard to the economic problems in the country with which the Chancellor of the Exchequer ought to have been concerned.
If we look at the attitude that the right hon. Gentleman adopts of, as it were, dividing the community between those who can be asked to pay charges and those who are, as it were the recipients— the attempt to sectionalise the community —we can understand why he has been prepared to accept the maintenance of a financial ceiling which by this time has become utterly unreasonable, because, although he has told us with some pride that the hospital authorities have been able to save large sums from their estimates over last year, many of us know from our own experience the serious effect of the savings. They are not savings in which the Minister ought to take any pride, because they are savings at the cost of the proper running of the service.
I think he would himself be the first to admit that many schemes have been held back that ought certainly to have gone forward. Had it been possible to include them in the last financial year it 1739 would not have been a question of savings; it would have been a question of over-spending. It seems perfectly clear that, by attempting to maintain this financial ceiling, he is forcing on himself a problem which he need not have faced today. He could very well out of the resources available to the Government have ensured that modicum of increase in spending power that the hospital authorities need.
§ Mr. Iain Macleod
The hon. Gentleman said that many schemes were held up and that I was taking credit for the fact that there had been a considerable saving in cost of the hospital maintenance expenditure. It might have been inferred from what he said that there was a saving in capital expenditure. I over-spent in capital expenditure, though not by very much.
§ Mr. Blenkinsop
The total sum involved in capital expenditure is so small that it hardly enters the issue. The Minister made some play a little while earlier about its now being possible for the hospital authorities to use capital funds for maintenance expenditure. That will not help them very much either, with the vast problems they face in respect of capital and maintenance expenditure, considering the sums being made available to them. I am astonished to hear the right hon. Gentleman say that he takes pride in savings on the care and maintenance side. I thought that one thing of which he was convinced was the appalling state in which some hospitals have been placed by excessive cuts in repair and maintenance.
§ Mr. Macleod
Not repair and maintenance. I used the term "repair and maintenance" in the ordinary accepted sense of running costs.
§ Mr. Blenkinsop
The right hon. Gentleman will agree, if he is now referring to the total which comes under that heading in the Estimates and in the final accounts, that one of the most important sums in that figure is the sum made available for actual repair and maintenance of buildings and plant in the hospital buildings. The argument has been put forward in the House on many occasions by myself and others, including the hon. Gentleman the Member for Kidderminster (Mr. Nabarro), that one of the most false 1740 forms of economy is to continue this very severe restriction on repair and maintenance expenditure on plant. It is possible to do this in one year, or perhaps even two years, at the most; but if we attempt to maintain buildings with restrictive cuts on this field of expenditure, we are certainly piling up much heavier expenditure in later years. I should have thought that the right hon. Gentleman would have agreed at least to that.
We have to face the problem touched on by my right hon. Friend today. He pointed out that this ceiling of expenditure is being maintained at a time when not only is our total population rising but the form of that population, the make-up of the population, is changing. We have more old people at risk today than before. A very strong argument was developed by Professor Titmuss in a very interesting paper at the Sociological Conference that extra provision of beds and other accommodation in hospitals would be required to provide for the natural growth in population and the change in the age distribution of the population.
Of course, no provision for that has been made at all, nor for the other social problems that have arisen recently through, for example, the wider employment of married women, whose rate of sickness is higher, the increase in road accidents, and so on. All these are an extra burden to be borne by the Health Service and by the hospitals in particular.
When the right hon. Gentleman takes some pride in comparing the sum made available by him for the hospitals this year with the actual out-turn last year, he must bear in mind what he said in reply to a Question I asked in the House some time ago, that there is an increase of £6,500,000 in salaries and wages. During the financial year, of course, there has been the extra cost of food supplies, which were not mentioned by him, but which added something to the cost. All of this has to come out of that limited sum of money available. So the real extra sum of money, as against even last year's turn-out, should be looked upon by him as disappointingly small.
§ Mr. Iain Macleod
Of course, the cost of food was included. Every year a certain sum of money is set aside for ordinary cost of living increases. Nothing like the full amount was taken last year because there was a steady cost of living, 1741 and there was a fall in many things of which the Service is a large consumer. Food went up, and food, of course, has been allowed for. But even so it did not anything like swallow the resources I had set aside. As to the £6,500,000 for salaries, there again provision is made for salary increases, and, therefore, it is not to that extent an unforeseen burden. In any case, it would not be a complete burden because the increases come at different times through the financial year.
§ Mr. Blenkinsop
It is not an unforeseen burden. It is a very much seen burden, and another burden which the hospital authorities have to bear out of the resources that the right hon. Gentleman makes available to them. Although it is quite true that these wage and salary agreements are made at different periods of the year so that the whole of the £6,500,000 will not fall in this year, there will be, no doubt, some further increases that are under negotiation at the present time. There always are a certain number of negotiations going on for increases which may still have to be found.
§ Mr. Bevan
The point that my hon. Friend is making and which the right hon. Gentleman apparently has not seen is that we can have an increase in the amount of money which he obtains from the Exchequer for the service, but it does not necessarily follow that that order of increase will reach the patients, because if a large sum is swallowed up in wage increases or on account of food price increases, and cost of maintenance increases, the whole of the increase will not ultimately reach the patients and make for a greater expansion of the National Health Service.
§ Mr. Blenkinsop
We have to face it that the hospitals are having to bear extra charges. The reports from, I should say, every hospital management committee bear out the fact that there are a multitude of economical and valuable schemes which would undoubtedly save those hospital authorities money if they were able to put them into force but which they are not able to put into force because of the attitude that the Minister is adopting.
We had hoped that he might have been able to say something today about the wider and more purposeful, development 1742 of the Service, which, I should have thought, we were all of us anxious to see. I think we all agree that there are wide changes which may be needed in the National Health Service. We are not for a moment suggesting that everything is right with the Service and that no changes are needed, but we would have thought that this is a growing service, which will change as it grows, based upon certain fundamentals.
I had hoped that the Minister would touch on one or two points in which we are all interested concerned with the future development of the Service, such as, for instance, whether a gradual unification of the Service under a single authority is a wise and desirable thing, the position of the general practitioner as against the hospital on the one side and preventive services on the other, the need for much greater attention to be paid to preventive services, and the possibility of bringing within the ambit of the Service the whole question of occupational health, on which we have touched only the fringe. That last is a field on which we would gladly have heard the views of the Minister. There is also the question of the proper relationship between domiciliary and hospital care. It is possible that in some fields, amongst older people, for example, a service may be developed on a domiciliary basis, but we shall need a great expansion of the domiciliary services to meet the demands.
It is not a question of saving money. It is a question of how best to use the resources in order to develop services of that kind. This should not be looked at on the narrow basis of financial saving. It should be looked at on the basis of what is the best service that can be given to the people, what is the most useful way in which the Service can be organised.
There is then, of course, the whole problem of mental cases and the development of our mental services, both domiciliary and institutional. That is a problem which has faced us all, which must be tackled on a much larger scale, and into which much greater resources must be put before we can make any progress.
Instead of finding the Minister playing a vigorous part to get all the resources he needs to make some headway in solving these problems, it seems to us that 1743 he is giving in all too tamely to the pressure of his right hon. Friend to secure narrow financial benefits which are of value to the Chancellor of the Exchequer, but which the Chancellor then proceeds to waste and throw away for economic and social purposes of nothing like the same urgency or need.
On those grounds, on the grounds of, to put it mildly, our very great doubt whether the charges the Minister has imposed have been even financially of real value—on his own showing the prescription charge has not brought the savings he expected; indeed, there have been still further increases in prescriptions—because we believe that the Minister regards the National Health Service as one provided for one section of the community only and not for the community as a whole, we think it right to bring before the Committee today this attack upon the Minister's administration. That is why we are anxious to ensure the return of a Socialist administration, so that the problem of the development of our Health Services is approached on the new basis of a free and comprehensive service, thinking in terms of the economic needs of the community before the narrow financial aims of the present Chancellor of the Exchequer.
§ 5.44 p.m.
§ Mr. Richard Fort (Clitheroe)
The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) has referred to the attack made upon my right hon. Friend and his administration, but I am bound to say that the atmosphere in the House today reminds me much more of the debates we have had from time to time on many of the social services—calm, and on the whole, dispassionate, and often well-informed discussion on details.
I cannot help contrasting as I expect everyone in the Chamber is today this ordinary atmosphere in which we discuss the social services and the roaring and the shouting which greeted my right hon. Friend's appointment of the Guillebaud Committee a few weeks ago. The reason for the change is perhaps no concern of hon. Members on this side. I can only say that I think everybody here must have noticed it. I think, too, that the change has also been noticed by the far wider public outside the Chamber.
1744 The hon. Member for Newcastle-upon-Tyne, East and his right hon. Friend the Member for Ebbw Vale (Mr. Bevan) discussed, rightly, what was the fundamental basis of the Health Service which we have today, and how that basis gives us a guide into the future. The hon. Gentleman, I think not unfairly, quoted my right hon. Friend's description of the Conservative approach to the National Health Service. In quoting that, although fairly, I think he failed to put before the House his own party's fundamental view towards the Service.
Is it that the expenditure on health should be without limit? Is it that any person—to put it in rough and ready unacademic terms—who feels slightly off colour, slightly unwell, perhaps not feeling too grand after the holidays, has a right automatically to go to his doctor or to some other part of the Service to have almost his state of mind analysed to see whether there is anything in his feeling off colour that day? Is it to be absolutely limitless? The difficulty we are in is that, while I agree that those who are ill, as shown by medical science and art, ought undoubtedly to get the best treatment—
§ Mr. Blenkinsop
Is the hon. Member for Clitheroe (Mr. Fort) trying to make out that at the present time it is impossible for a person who is feeling a bit off colour, for whatever reason, to go to his doctor under the Health Service?
§ Mr. Fort
No, far from it. But he will very often have to think twice whether it will be, not only worth the trouble, but worth the 1s. prescription or any other charge.
Taking it more broadly, do hon. Gentlemen opposite think that the expenditure on this Service should be limitless, or, feeling one's way in this matter, as we must do, that it is legitimate to put a confine to the Service, and with it a financial limit? I ask hon. Members opposite this because I have always been uncertain as to exactly what their view is about the future of the National Health Service. Is it to be limitless, given to everyone regardless of any financial consideration at all? Or is there to be a limit which they themselves foresee?
1745 Just now the hon. Member for Newcastle-upon-Tyne, East referred to the taxation my right hon. Friend the Chancellor had introduced in this Budget, and made the point, which his party have been making since the Budget speech, that taxation has been cut to benefit one section of the community. Let us assume for a moment that there had been no cut in taxation. Does he think that all the money which would have resulted in keeping taxation at least year's level would have been given to the Health Service to meet an expenditure there? Or would he have expected some of it to go to the Service, some of it to other social services, and perhaps some of it to other activities of the Government? Is that what he has in mind? If so, if only part of it had gone to the National Health Service, the Service would still have been limited. It is this conception of the limitless service which I find so exceedingly difficult to understand, and whether they favour it or not.
§ Mr. Blenkinsop
May I put the hon. Gentleman out of his troubles. I do not think that anyone is suggesting a limitless Health Service, any more, I hope, than anything else, say, a limitless Army, Navy or Air Force. The expenditure on the Health Service has to be limited in the same way as expenditure on other services are limited, by discussion as to priorities.
§ Mr. Fort
We have at least narrowed down the field of argument between us. We have brought it back to what I thought we should sooner or later bring it back to—a discussion not about great moral issues, but about administrative problems; and that is what, I think, we shall find the debate turning out to be today.
I think that all of us, on either side of the House, are profoundly convinced of the great value of the Health Service to our fellow countrymen. I have lived in countries which have not had that advantage, and I recently visited another, and anyone who sees the unhappiness and uncertainty which is produced in people's minds without a Health Service would not, on the cheapest political occasion, try to dispute that.
I was surprised this afternoon and earlier, on a rather louder occasion, when the right hon. Member for Ebbw Vale 1746 turned with such fervour on the independent Committee—the Guillebaud Committee. He has often said in this House and outside it and in publication that one thing he is so much against is close Treasury control. Here we have an entirely independent body of people not connected with any Ministry and, therefore, indirectly with the Treasury, looking into the Health Service. I sometimes find it difficult—perhaps we all do from time to time—to follow the flights of thought of the right hon. Gentleman. In this particular case it is peculiarly difficult in view of his well-known opinion that the Treasury are the people least qualified in this country to know how to spend money, particularly on the social services.
It is because I have sympathy of a sort when my own interests are aroused with the point of view expressed by the right hon. Gentleman that I really found welcome, from the word "go," the appointment of the Guillebaud Committee. The Central Health Services Council, for the reason why my right hon. Friend put before the Committee, was and is an organisation which, while it has a great many other virtues, seems to me not to be an ideal one for an investigation of this sort. I cannot help feeling that not only is that the opinion of my right hon. Friend and others on this side of the House, but it must also be the opinion widely held throughout the country in view of the gentlemen and ladies who have allowed themselves to be appointed to that Council.
I certainly for my part look forward to the Committee doing a job which, I think, any of us would find it exceedingly difficult to do, and which it would be exceedingly difficult to get done by the Central Health Services Council, and that is for a small body going round investigating and talking to people to put together in a coherent form the vast amount of information which has been published and is available so that all of us can make up our minds, because it is our responsibility to decide what action ought to be taken about it.
We hear, as we expected to hear, the name of the old May committee. It always crops up whenever there is an independent committee of which hon. Members opposite disapprove. Let me remind them that there have been a 1747 good many other independent committees, some of which they themselves approve, such as the one man committee of Lord Beveridge, who inquired into the social services and formed the thinking of a generation on that subject, and the Uthwatt Committee, under Mr. Justice Uthwatt, who, for better or worse, has so affected our thinking about town and country planning.
When one hears the name of the May committee, one feels it is being used for the cheapest sort of political capital rather than as a constructive criticism, such as my right hon. Friend has produced. Personally, I am glad that the terms of reference of the Committee have been limited to investigating costs, because a committee of this sort, with the amount of material which they could have before them and with limitless amount of time, could well take a very long time indeed if they were also investigating administration. Furthermore, I think that in matters of administration the Central Health Services Council is at least quite as qualified a body to give us advice, whereas on matters of cost it would find it more difficult to collect information.
I am glad that the Guillebaud Committee's terms of reference are limited to the question of costs.
§ Mr. W. Griffiths (Manchester, Exchange)
Surely that is wrong. The terms of reference say, in addition to reviewing the present and prospective cost of the National Health Service:To suggest … means whether by modifications in organisation or otherwise.
§ Mr. Fort
Perhaps the hon. Gentleman will continue the quotation:of ensuring the most effective control and efficient use of such Exchequer funds as may be made available."—[OFFICIAL REPORT, 1st April, 1953: Vol. 513, c. 1229.]The emphasis is on the costs. No doubt other hon. Members will mention many of the problems which the Guillebaud Committee might profitably turn their minds to, from the point of view of seeing how the money is being expended and how it might be better expended in the future.
My right hon. Friend mentioned some of the problems—the problem of block grants, ambulance services, and so forth. Then there is the whole problem 1748 of hospital costs on which, at long last, we are beginning to get some information. A special field to which I hope the Guillebaud Committee will turn their attention is the particularly difficult one, I think, of the cost of prescribing. There, perhaps more than in any major part of the Service, one runs into the problem of trying to meet what the patient wishes as well as doing what is necessary for him.
Let me give an example. If one has a headache or something like that a doctor may prescribe something which has a therapeutic effect on the headache, or he may prescribe what is nothing more, but none the less useful for that, than something which one thinks has an effect on the headache—in contrast to an operation which is needed to put an internal disorder right. I believe that the difficulties of keeping the cost of prescriptions within bounds is a good deal greater than is the cost in many other parts of the Service.
It is all very well for the right hon. Gentleman, as he did a few years ago, to talk about, "cascades of medicine pouring down British throats," but there is this feature of what one might call the magic of medicine. I think that has been emphasised, quite apart from our own personal experience, by the figures which Professor Dunlop and those working with him at Edinburgh published last year and this year as a result of their analysis of about 17,000 prescriptions in 1949.
They show that certain very common types of medicine—sedatives, stomachics, tonics, mild analgesics and cough mixtures—head by a long way the list of that sample of prescriptions. Many of them contain the types of medicine to which I have referred, which may have a specific therapeutic effect, or it may be that the patient thinks they are having an effect. It is significant that both in Professor Dunlop's analysis of the prescriptions as well as from what my doctor friends have told me it is in the industrial medical areas where there are relatively few doctors for the large numbers of patients, areas in which doctors have little time for examination, that the number of prescriptions per patient is largest and particularly the placebo types of medicine are prescribed most frequently.
1749 One of the results of the way the National Health Service is working at present, in bringing more doctors into the under-doctored areas—we are beginning to see the effect of the provisions of the 1946 Act in that respect—will be to make it possible for more doctors to carry out longer diagnostic examinations and thus it will be possible to avoid the rushed examination and the bottle of medicine to give some comfort, often giving comfort but at increased cost to the Health Service.
The right hon. Gentleman the Member for Ebbw Vale this afternoon made an attack, as he has frequently done in the past, on the proprietary type of prescription. No one can deny that certain types of proprietary prescriptions really do no more good than the National Formulary prescriptions and cost a great deal more. The fact that vitamins are prescribed in such large numbers as shown in Professor Dunlop's analysis is an example of that, but let us not forget that a great many of the proprietary prescriptions have real medical value.
I am told that digitalis, which has been given for so long for heart conditions, when given in the form of drops often produces an unpleasant side effect in that it makes the patient sick, whereas the proprietary form produced in the form of tablets has the good effect of digitalis without producing the bad side effect. We must be careful about laying down rules for the prescribing of proprietary medicine which are too strict as against the National Formulary ones.
My feeling in the matter as a result of talking to a number of doctors is that, while something can be done, probably under the Health Service and by the regulations of the Ministry of Health, much more can be done by giving doctors a rather more thorough training in pharmacology than they are given at present by making it a subject of their final examinations instead of letting it be, as it is at present, a subject for one of their earlier examinations. I believe it would be very well worth my right hon. Friend's while bringing together representatives from the Royal Colleges and discussing with them the possibility of making sure that doctors are more thoroughly trained in future than they are at present and perhaps, at the same time, encouraging 1750 the establishment of more chairs of pharmacology than we have in England now. At the moment we are deficient in them.
I believe that it is by the better training of doctors rather than by trying to impose rules and regulations from the centre that we shall, in the course of a few years, get a better control of the cost of prescribing than we have had during the last few years. Whether or not such suggestions could be examined by the Guillebaud Committee I am not sure, but luckily, owing to the action of the Opposition today in choosing a wide Motion for our debate instead of the narrow one with which at one time we thought we might be confronted, it has been possible for me, and it will be possible for others who follow, to discuss the problems of the Health Service in a comparatively objective atmosphere.
No doubt we shall have a Division, but I hope that by the end of the day, instead of having had a debate which might or might not—probably not—have echoed outside on the political platforms of the country, we shall have had a much more constructive debate in that we shall have discussed what is really the basic problem of the National Health Service— the administratve detail and how we can get the very best value for our money.
§ 6.7 p.m.
§ Mr. Frederick Messer (Tottenham)
The debate, quite rightly, should prove interesting, especially for those of us who have been taking part in the Service since its beginning. I make no apology for repeating what I said when I last spoke in a health debate. I said that what we require is a complete review of the Service. I do not retract one word of that. We cannot have such a revolutionary change as we have had without weaknesses expressing themselves and without there becoming apparent gaps which need to be closed or require bridges to be built over them.
I want at the outset to express my appreciation of the efforts of the Minister to make himself acquainted with the work that is being done. He has spent a lot of time visiting hospitals. Indeed, he visited a hospital which I know while I was there. I was gratified to hear him say two things today. First, he said that there was no proposal to extend any 1751 changes. The second matter—I regard this as very important—was the position of priority in which he put the mental health service.
The mental health service is not a matter which strikes the headlines. Mental cases are hidden. However, the truth is that in this country today there are homes which are disrupted by the presence in them of defectives. Sometimes something can be done for the defective if we can find a place in which to put him. I propose tomorrow to visit a mental defective colony run by a religious organisation, which does such valuable work that its cases can afterwards go out into the world and be employed. If they had not had the training at that colony, the cases would never have become employed again. They would have remained a part of that inferior section of society to which, unfortunately, so many mental cases are regarded as belonging. I was glad to note that the Minister put the mental service as one of the priorities.
I am a little disturbed at the prominence which always seems to be given to the figure of the total cost of the Service. Everybody talks about £400 million with bated breath as though it were completely new money. It is not. If we are to take finance as something to study, what we should look at is the difference between the cost before the Service came into operation and the cost now. We should never be able to do it, because we never could get the correct figure of what the voluntary service cost. We should never be able to find out all the factors that went to make up those costs before the Service was introduced.
The truth is, of course, that the ratepayers paid for the municipal service; now they pay as taxpayers, but not as ratepayers. No one is paying twice, and it would be as well, therefore, if the hon. Member for Clitheroe (Mr. Fort) were a little more sympathetic about the limit. What is the limit to which we should go? The limit should be the need of the people for a medical service. If there is a service which shuts anybody out then clearly it cannot be a national service. One of the indispensable things in the National Health Service is that it should be comprehensive. Everybody, whether he is a duke or a dustman, should be entitled to go through the same door. 1752 I think the Minister would agree with that.
I said that I thought the service was due for review. I am not certain that the Guillebaud Committee is the right sort of Committee for the job. I should have thought so had I not myself been so often chairman of a committee which had to take evidence, and the committee itself knew little about the technicalities of the matter and so was not in the position to assess the value of the evidence. For instance, when the Guillebaud Committee gets down to the work of finding out how it is to economise, it will be faced with certain problems. I quite agree with economy. Any money that is wasted in this Service is money which ought to be spent on the patient and certainly not allowed to go in a direction where it is not benefiting patients. When this Committee takes evidence, how will it be able to judge when someone comes along and says, "You are wasting an immense amount of money by payments to consultants who ought to go on a sessional basis in the Service instead of continuing as full-time consultants." How is this Committee to know whether or not that is an economy or a waste?
§ Dr. Stross
I do not know whether my hon. Friend knows it, but I put a Question upon that and I had an answer a week or two ago. I was told that the terms of reference could not concern themselves with the terms of service of the medical staffs employed.
§ Mr. Messer
Which means that one avenue for economy cannot be investigated. Those of us who were in the municipal service, which had high standards, know that there were teams of full-time consultants, which meant consultants having full-time jobs. They are now becoming sessional consultants, which means, in effect, that they do their job in a session, with travelling time taken as part of the session. They are permitted Income Tax allowances for travelling expenses, telephone expenses, etc. Surely there is room there for investigation regarding economy.
Then there are merit awards. I will say nothing about them. There are some impartial people who cannot see where the merit is, but the merit awards are there and it is true to say—I think it ought to be said so that the public 1753 may know the facts—that there are consultants today who are getting £2,000 or £3,000 a year who would have been lucky under the old service to have got £1,300 or £1,500. I do not say that I think they should be under-paid, but I think there is a field there for investigation.
The whole reorganisation of the Service ought to be investigated. There are 14 hospital regional boards in the country. Every one of those regions is so drawn that it cuts through the staff of the local health authorities. Let us take the one which starts close to this House, the North-West Metropolitan Regional Board. It travels from Westminster through parts of London, part of Middlesex, parts of Hertfordshire, part of Buckinghamshire, part of Berkshire and the whole of Bedfordshire. That means that that regional board is responsible for the oversight of the hospital service and of all those hospitals using ambulances. Those ambulances are part of the service of the local health authority. Hertfordshire is divided between three regions, so that arrangements have to be made with three different lots of people. Scotland has got it on us in this. Hon. Members from Scotland doubtless boast of the fact that they do not do things like that in Scotland. There the ambulances are under the hospital service, and one would have thought that in this kind of service an essential feature would have been notification.
The first essential is a service of a comprehensive nature, and if that is so, surely the second consideration is that there should be unification. Any of us who have tried our hand at effecting co-ordination of these services will realise how difficult it is. I believe that a great deal of money could be saved if there were a unified service. Let us see how it is divided up. First, there is the training of midwives. The hospitals themselves are responsible for the training of the pupil midwives. The local health authority is responsible for the use of the midwives. The position has arisen in which the local health authority does not know how many midwives are being trained in the hospitals, and the hospitals do not know what is the demand for midwives. The local health authority and the hospital authority are two sets of bodies which ought to be closely related. Efforts are 1754 being made to bridge this gap, but it is not the only thing.
Take the service of tuberculosis. Tuberculosis is a peculiar disease. A patient goes to the general practitioner who, when he suspects it is T.B., calls in the tuberculosis officer. The tuberculosis officer has all the facilities at his command, such as X-ray, sputum tests and so on, and he is able to say whether it is positive or not. The tuberculosis officer is a joint appointment. He is employed in part by the local authority and in part by the regional hospital board. The rest of the clinic in which the tuberculosis officer works is run by the local health authority.
There ought to be some inquiry made whether we cannot bring about unification, because what we find is that in a Hammersmith clinic which is very busy they do not know what beds are available in sanatoria for their patients. The importance of that is that a progressive regional board will deal with domiciliary work as well as hospital work. It will take a T.B. case into hospital for a period if it is necessary, and keep the case there when the lung is collapsed. Then when the patient shows sufficient signs that he is fit to go home he will be taken home, where the treatment will be continued. If there should be a relapse, the patient can go back to hospital. It is not easy, however, because the T.B. officer is regarded by the local authority as almost the sole possession of the regional board, and although he is fairly free, he is still in the difficult position of having two masters. The same is true of mental health, because the local authorities deal with that just as the regional hospital board deals with tuberculosis.
We ought first to investigate the possibility of a re-arrangement of the regional board structure so that the periphery is coterminous with the local authorities. I do not say one local authority, because obviously a regional board would need to be larger than any local health authority. The reason is that there must be a population big enough to be divided into different specialist services for which the regional board is responsible. There has been talk of the abolition of regional boards and the independent autonomy of hospital management committees. If that happens, it will mean that we shall have nobody separate from the management committee which can determine that 1755 special parts of hospitals shall be set aside for special cases.
The welcome drop in the figures of tuberculosis is one of the tributes to the service and it has been brought about by more than one method. Streptomycin is not the only answer. The Ministry should be given credit for this—I really ought to say, the Central Health Services Council, but modesty forbids. At any rate, advice was given to the regional hospital boards to let their management committees know that they were expected to set aside 10 per cent. of their bed accommodation for T.B. cases. The hospitals did not like it because, with this new service, low-grade hospitals have been upgraded and have become hospitals for acute cases and have not wanted these long-drawn-out, uninteresting cases. With this advised scheme put into operation, 10 per cent. of the beds meant that there was a big fall in the numbers on the waiting list.
We ought to examine this service, therefore, along the lines of re-organisation. We are told a lot about the hospital service, but that is only one section of the Health Service. There are three sections and it is a pity that there are three separate organisations. The local health authority, with its preventive and environmental service, is as important as any other section. I should think it is better to prevent a person from becoming a patient than to cure him afterwards. Yet the local authority is regarded as the Cinderella and it ought not to be. It is not a service that can be described as in continuous alignment; rather is it a circle of links.
The National Association for the Prevention of Tuberculosis puts as much stress on cure as on any other aspect of prevention. The reason is that if one can control a patient then one controls the possibility of that patient infecting others. The Service should be a complete whole and more attention ought to be given to the preventive side. The Minister might consider whether or not the executive councils might not be part of the local health authorities. There would thus be a saving in administrative costs and we would bring the general practitioner into close relationship with the preventive service, which is necessary. The order ought to be patient, general practitioner 1756 in the home and domiciliary work, and the hospital doing what both the others, have failed to do, curing the patient.
I feel that there is room for this investigation which should be along the line of the efficiency of the Service without regard to economy, because economy would flow from it. Economy is not just a question of saving money but of getting the best value for the money being spent. There are one or two minor things that the Minister might do. For instance, there is present in the House, though not officially, the Parliamentary Secretary to the Ministry of Food. What a ridiculous thing it is that the Ministry of Food will not allow a hospital the benefit of subsidy if it bakes its own bread. I have just received a letter from somebody who did not know I was going to speak in this debate—in fact, I did not know myself. The letter, which comes from a big mental hospital, reads:The latest addition to our provisions costs is an estimated amount of over £2,100 due to the increase in the price of flour. National bread is not to be dearer because the subsidy paid to bakers will be adjusted but no subsidy can be claimed in respect of bread baked by hospitals. …It appears, therefore, that one Government Department is showing how economical it is at the expense of another Government Department. I should have thought that hospitals ought to have been permitted to claim this subsidy and, if there is any inquiry, the circular governing this is BS/C/2.
Nobody thinks the Health Service more important than I do. I should hate to see any doctrinaire opposition to a committee of inquiry but, if there is to be a committee, I want it to be on the lines of seeing how best we can improve this Service. I am certain that as a consequence of improving it we shall not suffer any great loss. What is represented by the figures which alarm so many people, for instance, the hon. Member for Clitheroe? They do not merely represent the relief of patients from pain and suffering; they do not merely represent life in place of what might be death; they do not merely represent the stamping out of the terrible diseases which attack us. They also represent a higher standard of life for some of the people who are doing the work.
For instance, there is the nursing service. Everybody speaks highly of nurses, 1757 who are the most noble profession that has ever come into existence. When we were debating the Bill introduced by the late F. O. Roberts to provide a 48-hour week for nurses, the then hon. and gallant Member for St. Albans said that it was a shocking suggestion; it was putting them on the level of people who work for their living in factories. Nurses, he said, were made of different material. It was not the cash nexus which attracted them but the nobility of their character, and we prostituted that nobility of character by the wages we paid them.
Let us look at what the nurses have done. Before the operation of the Act, the first-yeair nurse got £130 a year, from which was deducted £75 for emoluments, leaving her £55. I could continue with figures, but the Committee will not want to be bothered with details. Today, however, the first-year nurse gets £150. A third-year nurse gets £250, or approximately £5 a week. I remember the time when they were glad if they got £60 a year. That is where the money is going: it goes in raising the standard of the people who are engaged in the work, as well as in providing opportunities for those who need the service to get it.
I am not bigoted in this matter. I should not oppose any investigation, but I would hate to think that this Committee has been set up should merely come with the recommendation that money be saved in this, that or the other direction. Rather would I see an investigation into the machinery so that we improve the machinery and thereby save the money.
§ 6.32 p.m.
§ Mr. J. Grimond (Orkney and Shetland)
It is a great pleasure to follow the hon. Member for Tottenham (Mr. Messer). He speaks with unrivalled experience and knowledge on these matters and this afternoon he was particularly pertinent. I was much interested in what he said about mental defectives, because I, too, have always thought, although without his experience, that they form an appalling problem in modern life, right from childhood until their old days, when, very often, they become a burden on their families.
I was very interested, also, to hear that the hon. Member for Tottenham does not oppose an inquiry into the Health Service. He put forward many useful points 1758 which might be investigated by the Guillebaud Committee, but he raised the question of whether that Committee could judge of the evidence which was laid before them. I should be interested to hear what the spokesman for the Government has to say on this when replying to the debate. There may be a great deal in what the hon. Member said, and it may be desirable to have assessors—I only throw this out as a suggestion—who can advise the Committee on the expert evidence which they will have to consider. I fully agree that this should not be a Committee simply to try to find means of economy in the Service, but should be a Committee who are looking for ways of improving the Service.
Earlier speakers have touched on the wider aspect of the Health Service, and I agree with the hon. Member for New-castle-upon-Tyne, East (Mr. Blenkinsop) that the argument for a comprehensive health scheme is on social rather than on medical grounds. In other words, except in the particular conditions of physical difficulty such as sometimes exist in, for example, my constituency, I do not think that there are today many people who are denied medical attention, certainly not because they do not have the money to pay for it. On the whole, we have got past that.
The argument for a comprehensive service is that we do not want to split up the people into those who can avail themselves of the fullest opportunities in the field of medicine and those whose opportunities who are to some extent limited, in just the same way as, in the argument for a comprehensive education system, people should, broadly speaking, have an equal opportunity in education.
I say quite openly that I think it was a great fault of my party in the 19th century that they allowed society in this country to be split and that when that had been done they attempted to rectify it by payment of doles from the rich to the poor. Gradually, we must try to get back from that position. Nevertheless, I feel that the first priority is to see that the people who need them most in the first place get the social services; and it must be a gradual process until we come to a fully comprehensive system.
1759 Always, since I have been in the House, I have voted against the Minister of Health on the question of particular charges in the Health Service, and, in general, I have been in disagreement with him. Two things, however, must be said. First, I do not believe that the Minister is out to wreck the scheme. He has devoted a considerable portion of his life to studying it, and on the lowest possible ground of self-interest I can hardly believe that he is seeking to wreck it.
Secondly, on studying the terms of reference of the Committe, I see no reason why they should not do the sort of things which the hon. Member for Tottenham wants to be done. I am the sort of person who is a great trial to all Ministers of Health. When I go to see a doctor, I like to be given a bottle or, at least, some pills. If I am told to run away and to take more exercise and to eat less, I feel very much aggrieved. I sympathise with what the doctor said to the hon. Member for Clitheroe (Mr. Fort). It is a very difficult matter to limit prescriptions. There may be an undesirable psychological effect upon a patient by his being treated too frugally.
On the other hand, it is a great mistake to say that the Health Service is a free service. As I go round my constituency, for every person who complains to me about the charges of the Health Service there are two or three who complain to me about the weight of indirect taxation and the weekly contributions. They happen, I admit, to be people who are very poor—
§ Mr. Grimond
Not entirely. There are many self-employed people with small means who find it quite difficult to make ends meet.
I do not think that there is today much disagreement that some inquiry would be worth while if it resulted in a better Health Service and in some economy— that is not in dispute. Many things have been suggested as subjects for inquiry— the block grant system, transport, the ambulance service, preventive medicine, and so on.
§ Mr. Edward Evans (Lowestoft)
Is not the hon. Member confusing insurance contributions with Health Service charges?
§ Mr. Grimond
I agree that the contribution is not entirely for health. It is for the welfare services of the State as a whole. The charge is for the general sustenance of the welfare services and is, I think, a considerable burden on the people of this country, and on the poorest people.
As I understand it, the objection to the Committee is to the form of the inquiry. As I have said, there is something in what the hon. Member for Tottenham said, and there may be a case for saying that that Committee may not be the best judge of expert evidence. Equally, there is an argument against using the Central Health Services Council. It could be used but, on the other hand, professional people, even with the best will in the world incline perhaps to have a slightly biased view in favour of their own subject. I do not feel that this Committee would necessarily be what might broadly be called a wrecking Committee. Their appointment, however, raises wider questions, which were touched upon by the right hon. Member for Ebbw Vale.
There is, first, the important question as to the division of the available resources between the various services within the Welfare State—education, old age pensions, unemployment benefit, and so on. Obviously, that question will not be tackled by the Committee; nevertheless, it remains an important one. I do not believe that the nation's resources are inexhaustible, and I do not think that we are paying sufficient attention to holding the balance between these services. I feel, for instance, that we are underspending on education. I may be wrong, but I feel that what has happened so often, as in the Health Service, is that suddenly, so to speak, the money has run out and a limit has been set, and charges arbitrarily imposed without regard to maintaining the balance between the services in the Welfare State.
The second very important question is: who is ultimately to decide? I fully sympathise with the right hon. Member for Ebbw Vale that once an independent Committee of this sort is set up and we get their report, that report may well become a great boulder plugged down 1761 in the path of anyone who wants to get some independent thinking on the subject. Again and again, on other subjects, one is met with the answer, "Oh, but a Committee reported on this five years ago, and here is what they said." I hope that we shall get an assurance from the Government that they are not going to use the Report of this Committee as a sort of shield behind which they may crouch, but that they will bring their critical minds to bear on it and not regard it as the last word to be said on the Health Service.
This is a growing and expanding Service and experiment must continue. I would consider it a very great disaster if it were felt that this Report put a block in the way of development of the Service. On the other hand, I think it is difficult for the House of Commons to make up its mind on a technical matter of this sort. That is, perhaps, too big a subject to enter into in this debate. The answer may be the development of specialised Committees of this House.
I think that a possibility of better control by this House lies along that line, but we should insist that in the last resort it is a political and moral question as to how much we spend on the various services in the Welfare State and there is an important political and moral ingredient at least in considering even the question of whether we spend more on hospitals and less on some other part of the Health Service.
There are three other points I want to make which are more germane to the general question. First, there is the question of the dispensing doctors. There are not many of them and I do not think that it is suggested that they are extravagant in their dispensing. I think that question might be looked at again to see whether they can be released from the obligation of collecting shillings. I do not think it fair to make doctors into tax collectors.
Secondly, travel charges, which the Minister who, like many distinguished politicians, started his career by failing to be elected for an island constituency, knows all about. I cannot believe that it is really desirable, in a scheme which is still basically free, to impose such a burden on a comparatively small number 1762 of people such as those in my constituency and in that of the Western Isles when they have to travel for medical attention. The travel charges are out of all proportion to the amount of free medicine they get. I know that if they can prove want they do not have to pay for the prescription, but that is not a principle we want to encourage. Cannot something be done to assist all patients who have long distances to travel?
Another question is: how are the Committee to operate? From whom are they to take evidence? Where are they to take evidence, and so on? As one goes about one meets a great many people who have valuable suggestions to offer about the Service, particularly the poorer patients, to whom the Service makes the most difference. I hope that attention will be given to attracting evidence, not only from professional people, but also from those who either suffer or benefit from the Service.
§ 6.43 p.m.
§ Mr. J. K. Vaughan-Morgan (Reigate)
I hope the hon. Member for Orkney and Shetland (Mr. Grimond) will forgive me if I do not follow him on any of the points he has raised. This has been a very quiet and sedate debate compared with what we expected. I cannot help feeling that this is due to there being no Mr. Whip to chastise the Tories but, instead, a Sunderland scorpion for the Socialists.
I wish to discuss one particular point which I think should fall within the terms of the remit of the Guillebaud Committee. I shall endeavour to be brief because many other hon. Members wish to speak —[An HON. MEMBER: "Not on your side."]—and the average length of speech so far has been extremely long. I want to suggest that the Committee should include an investigation into the powers and duties that appertain to the Ministry of Health. Before there is panic in the official box let me allay the distress by saying that I consider the present duties which fall to the Minister's lot are far too circumscribed. The Minister's duties are mainly concerned today with cure and not enough with prevention of sickness or the promotion of health. There are far too many medical servcies that do not come within the purview of the Minister of Health.
1763 There has been a great change since 1919. When the Ministry of Health was set up then to take the place of the old Local Government Board the Minister had as his duties, first, a concern with environmental health—public health matters such as sewerage, drainage and sanitation; the school medical service; and also maternity and child welfare, and, of course, the existing duties of local government. There was a hint in the debate on the Second Reading in a speech of Lord Addison—Dr. Addison as he then was—that the health powers connected with industry might eventually be taken over. He said:The first thing, if you are going to get a job well done, is to make it somebody's duty to see that it is done, and not leave it to the ill-defined and the combined responsibility of half-a-dozen different sets of people."— [OFFICIAL REPORT, 26th February, 1919; Vol. 112, c. 1830.]The position today is quite different. The National Health Service is virtually the limit of the duties of the Minister and most of the other duties he had in 1919 have been shed. This has produced some rather strange results in the sphere of public health. The Ministry of Housing and Local Government is responsible for drainage, sewerage, water and river pollution, but the Ministry of Health is responsible for the appointment of medical officers of health and sanitary inspectors whose duties are concerned with those subjects. The Minister of Health today has no responsibility for the school medical service. We cannot in any way blame the Labour Government as that has been the position for 20 or 30 years, but I cannot help feeling that if the right hon. Member for Ebbw Vale (Mr. Bevan) had also had responsibility for the school medical service the school dental service would not have suffered in the way it did, in his time.
§ Mr. Vaughan-Morgan
I am delighted to have applause from the benches opposite.
On the matter of food hygiene, the position is that until March, 1948, the Minister had an overall responsibility for food hygiene in hotels and shops. Today, the position—and I have had some difficulty in disentangling the actual responsi- 1764 bilities in this matter—is that the Minister of Health deals with notification of food poisoning and for seeing that food liable to poison the public is not sold to the public.
On the other hand, the Minister of Food is responsible for seeing that local authorities carry out their duty in regard to the hygienic handling of food in public eating places. The Ministry of Food is proceeding with great success and amid popular acclamation towards its ultimate demise and I hope when it does so it will be possible to see that these duties are taken over by the Ministry of Health. I hope, then, that the Minister of Health will undertake what is so badly needed—a large scheme of public education in food handling and hygiene. Much of the handling of food in this country today is a disgrace to a civilised country.
The largest and biggest anomaly of all is that the Minister of Health has no responsibility for the industrial health services. The hon. Member for Newcastle-on-Tyne, East (Mr. Blenkinsop) referred to the question of occupational health services. The fact is that we have today a factory health service and a medical factory inspectorate under the Ministry of Labour. That employs hundreds of doctors who are already in the National Health Service and surely no man should serve two masters.
§ Mr. Vaughan-Morgan
I am sorry, but it is surely tied up with the National Health Service and is an extension of that Service.
It may be an extension, but matters which arise here are matters which arise on this Vote.
§ Mr. Vaughan-Morgan
Yes, but on the National Health Service Vote I wish to point out means by which ultimately economies may be affected.
§ Mr. Vaughan-Morgan
Not at this stage, I submit. I am pointing out the anomaly that it is not part of the National Health Service.
I believe—I shall have to word my speech slightly differently—that the fact that the Health Service does not entirely cover occupational health is a big gap in our social services today. The next important step to be taken in developing the social services will be to see that industrial health is fully covered, which it is not today. When that day comes I think we shall see a big change in the incidence of illness within the Health Service.
I hope that I am not entirely out of order in referring to the Report of the Dale Committee on Industrial Health Services, which was appointed by the Labour Government. That Committee had very limited terms of reference; but it contained nine laymen out of 13 members. There is some parallel between that Committee and the Guillebaud Committee. I should like also to draw attention to the fact that Sir Geoffrey Vickers, who was a member of that Committee, is also to be on the Guillebaud Committee. His experience will be most helpful in assisting that Committee to consider this point of industrial health generally.
Since you, Mr. Hopkin Morris, have ruled that I must confine myself in narrow terms to the National Health Service, I must not expatiate, as I would have wished to do, on the needs in regard to occupational health. Prevention is obviously better than cure, and I hope that the Guillebaud Committee will show us the way to get better value for the money that is spent is by remembering that fact.
§ 6.53 p.m.
§ Dr. Jeger
I wish to say how much we on this side of the Committee welcome 1766 the support of the hon. Member for Reigate (Mr. Vaughan-Morgan) in advocating a comprehensive health service, which we have been advocating for many years. When we were pushing the claims for the establishment of a health service in this country, we spoke very much on the lines on which the hon. Member has now spoken. We welcome his conversion and would welcome his transfer to this side—
§ Mr. Vaughan-Morgan
Could the hon. Gentleman explain, then, why his Government took no action on the Dale Report?
§ Dr. Jeger
Our Government did take some action, but I would remind the hon. Member that Rome was not built in a day. Everything cannot be done at once; there are limits to what can be done even in a period of office of six or seven years.
I wish to add—I am sure that the hon. Member does not welcome my approval —how much I approve of his advocacy of an occupational health service. I do not think I shall be out of order when I proceed to elaborate that later in my speech. I shall give examples which I hope will meet with your approval, Mr. Hopkin Morris, but I shall leave that matter there for the moment.
The hon. Member for Orkney and Shetland (Mr. Grimond) seemed to be under the impression that the Committee which has been appointed by the Minister will not deal with priorities. We on this side of the Committee object to the establishment of that Committee very largely on the ground that it is to establish or advise the Minister on a definite order of priorities, and we are very much afraid that that order of priorities may be one which will be detrimental to the health of the people of this country. So we disagree with the hon. Member absolutely on that.
§ Mr. Grimond
I meant primarily priorities as between different branches of the welfare services in general. I was saying that the Committee could not deal with the question of whether more was to be spent on education and less on health. That is primarily what I have in mind.
§ Dr. Jeger
They are a different sort of priorities.
1767 The hon. Member for Clitheroe (Mr. Fort) began his speech with what I thought was a cynical question. He wanted to know whether patients were to go to doctors when they felt just a little below par and whether they were to go for minor ailments for which people did not usually expect to go to doctors. I hope that I shall be believed when I say—I speak as having a vested interest, because I am a general practitioner in the medical profession—that a very large percentage of the patients who go to a local doctor do so because they feel below par.
They undergo investigation and examination, and questions are put to them, and very often as a result of their feeling below par they are found to be in the early stages of a very serious complaint. How can we, on the one hand, advise people to go to their doctor at an early stage in order to prevent later trouble, and on the other hand sneer at them because they go at an early stage to their doctors when they feel that they need a certain amount of advice or treatment?
The hon. Member then suggested that the Service must be limited. Of course it must be limited. Everything human is finite; all human effort must be finite; human life is finite. Any amount of money we talk about must be limited; therefore, the Service itself must be limited. But within the limits of human endeavour it is possible to feel that as much as possible must be done to expand this Service and get rid of the greatest possible amount of ill-health. The hon. Member talked about the Government surplus and asked what we would do with the surplus. Would we suggest that it should have gone to the Health Service? Again, we feel that this question of priorities is something that decides the answer.
On another occasion, my hon. Friend the Member for Ebbw Vale (Mr. Bevan) said that the religion of Socialism was the language of priorities. This question of priorities has loomed very largely in this debate. We have had a choice of priorities between the National Health Service and other branches of the social services; we have had the choice of priorities as between various branches of 1768 the National Health Service. We have also to decide on priorities between those sections of the health services under the National Health Service and those branches of the health service which we wish to see inside the National Health Service. Here again I am treading on the forbidden ground of the occupational health service.
I listened very carefully to the Minister talking about his expenditure on hospitals. I could not follow his figures. He talked about an expansion in hospitals costing several million pounds. I searched in the Estimates before I came here and I could not find anything showing any kind of increase either in capital expenditure or in routine day-to-day expenditure on the Service. I still see a large number of aged and chronic sick people for whom it is almost impossible to find any kind of hospital accommodation without placing them upon a very long and slowly decreasing waiting list. I find that mental hospitals are not quite in the state depicted by Hogarth a long time ago but, compared with the advances in other branches of our social services, they have not made very much improvement.
I have examined the Report of the Ministry of Health covering the period up to December, 1951. I reject in advance the taunt that that covers the period of the Labour Government, because the situation has not changed since then and the party opposite have been in power and able to implement their choice of priorities even since December, 1951. I find references in that Report to the starvation of the public health laboratory service and to failure to conduct proper research into the early incidence of rheumatism among miners.
There is also reference to the occupational health service for miners which is in operation inside the National Health Service. There is a reference to the necessity for good primary treatment at the place of the accident or in hospital. It says that there should be perfect continuity of treatment and that the physical and psychological rehabilitation of the miner on his recovery is not enough but that we must also have social and economic rehabilitation too.
I wonder also—and here I risk incurring your displeasure—why we cannot have an extension of the occupational 1769 health service to the whole community of the character of that enjoyed by the miners. This was part of the miners' welfare service in the days before the National Health Service. It was taken over by the Service. It has been greatly extended. There is no reason at all why we should not include in the terms of reference of a properly constituted committee on the lines suggested by many of my hon. Friends an inquiry into the possibility of making the Service so comprehensive that it would include the provision of an occupational health service.
There has been a lot of criticism of the general practitioner, who is the backbone of the Service as it is operated today. The poor general practitioner has been the whipping boy for a good deal of what has been described as unnecessary expenditure. It is true that there are some general practitioners who, either through ignorance or malevolence—a number of general practitioners still do not like the Service—are not playing the game.
Recently I heard of a doctor who regularly prescribes for his barber one pound of cotton wool every week. I understand that the sole purpose for which the barber uses the cotton wool is for inserting it between the neck and the towel when he is shaving his customers or cutting their hair. That is a grave abuse of the Service. I can only hope that the doctor does not realise the purpose to which the cotton wool is put. I know of another doctor who has been prescribing one pound of cotton wool per week for an old lady who has been using it for years to clean a colostomy.
The latter doctor has had an inquiry as to whether he is not over-prescribing under the regulations made by the Ministry of Health. I understand that he has been threatened with a sub-committee of inquiry and a surcharge, so that he will have to pay for the wool if he cannot make good his case. It is all very well to say that general practitioners are extravagant. We must consider the extravagance in relation to the purpose for which goods are used.
The hon. Member for Orkney and Shetland said that he was one of those people who loved to have a bottle when he went to the doctor. Most people are like that. I know that my right hon. 1770 Friend the Member for Ebbw Vale (Mr. Bevan) made the historic statement about cascades being poured down patients* throats, but some people do not feel happy or that they have had proper treatment if they have not bottles of medicine to pour down their necks in cascades.
This is one of the consequences of establishing a vested interest in patients. Here again my right hon. Friend the Member for Ebbw Vale knows that I did not agree with him when he established a capitation fee for patients. We should not give the doctor a vested interest in the number of patients he has. Doctors ought to work on a salary basis. Then the patient would not be of financial interest to him but purely of medical interest. The doctor would receive his salary whether the patient was pleased with him or not. Today, if one displeases one's patient the patient is off elsewhere to another doctor who will be more accommodating. Doctors cannot be expected to work properly under such conditions.
I come back to the question of drugs. We hear of doctors who are penalised because they prescribe cod liver oil and malt for National Health Service patients. Every morning by every post doctors receive dozens of circulars from the drug manufacturers. They are threatened with a list of 5,000 drugs which the Minister tells us he will send out in a month's time. When we get doctors cut off entirely by the caste system in the medical profession from being able to do very much in the way of post-graduate work or to attend hospitals to follow up their cases; when we get doctors shut off in their own little compartments with their noses down to their own little grindstones; and when they have no means of knowing which drugs used are proprietary in the sense that they are advertised to the public and which are proprietary in the sense that they are advertised only to the profession, it is a little hard on the poor general practitioner who is doing his best to carry on his work in very difficult conditions.
I turn to the question of expenditure on the Service as a whole. I believe there are calculations which show that, in the United States of America, where a good deal of money is spent on health, but where about 90 per cent. of it is spent privately and only about 10 per cent. spent 1771 publicly, the amount spent is estimated to be about 4½ per cent. of the national income. We in this country, under present conditions, spend about 90 per cent. of our total health expenditure publicly; it is done for us, by one form or another of a national service, and, of course, the National Health Service spends most of it. The other 10 per cent. we spend ourselves by going to the chemists' shops to provide ourselves with various preparations that we need. The proportion of the national income that is spent in that way is something like 4 per cent.
It does not seem to make a very great deal of difference which way we do it, and it indicates that people will spend on their health just what they need. To keep themselves fit and well, they will spend just what they feel they need to spend, and they will not spend any more beyond that. From the point of view of expenditure, the National Health Service creates its own ceiling, but if I were giving the terms of reference to the Committee which the Minister has set up, I would give them something on these lines to show the absurdity of the situation.
First of all, I would fix a ceiling, but I would take care that, in fixing that ceiling of the cost, I would entirely ignore any kind of rising expenditure or rising costs. I would not worry about coal going up in price, or about an increase in the cost of electricity or about wages going up. I would not concern myself with the fact that I would have to pay the doctors or the nurses more money. I would not worry about any increase in the cost of drugs or concern myself with the fact that money buys less in every walk of life today than it ever did before, and then, if I was careful enough, I could come to this House with such figures as would enable me to claim that I was spending more on the service, while, at the same time, because of all these considerations, I was actually providing less.
Then, I would cut down capital expenditure. I would continue to refrain from establishing (health centres, and, while I am on that subject, perhaps the Minister may avoid the trouble of answering a Question which I was proposing to put down in the next few days by telling us why the health centre in Stoke Newington, the only one established there, is 1772 still not working and is still not staffed. Next, in keeping down capital expenditure, I would carefully avoid laying down even the first bricks of any new kind of hospital, because I think I could then come along to the House and say, "I am very worried about mental hospital conditions," or "I am very worried about doctors' practice conditions," although nothing had been said about them at all.
The third principle I would adopt would be to make the patients pay for beds in hospital, for drugs, for teeth, for elastic stockings and for everything that I could possibly make them pay for, without appearing to be grasping in the process. So I would get away with providing nothing for new services and making the provision for the extension of old ones. I would appoint my committee, not as a political committee or even as an expert committee, but as one carefully knowing nothing of politics or of the administration of the Health Service, and I would then allow it to fall very uncomfortably between the two narrow stools, because then I would be able to say, "I am receiving the best possible advice from the economic side and the medical side, and I am doing my best to create a Health Service which would be a credit to the community."
§ 7.15 p.m.
§ Mr. E. Partridge (Battersea, South)
When we heard from my right hon. Friend the Minister of Health the news that a Committee was to be appointed on the National Health Service, the outcry, especially from the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan), was "Hands off the Health Service," but I notice that, when he rose to speak today, the right hon. Gentleman had somewhat altered the emphasis.
I wonder whether the reason for that is that in the newspapers a few days ago one was able to read that the Manor House Hospital had ordered an inquiry into the cost and efficiency of that hospital. Of course, it is very desirable from their point of view that there should be an inquiry, especially as private, and not public, funds are involved. I have no doubt that the subscribers to the Manor House Hospital want to know whether they are getting value for their money, and I see no reason at all why it should not be equally desirable when public 1773 funds are involved. [HON. MEMBERS: "What paper was that?"] I cannot remember the name of the papers offhand. I think it was "The Times," the paper which has been quoted so often today, but if the hon. Gentleman would like to accompany me into the Library, I am quite sure that I shall be able to show him the newspaper, because it was in the Library that I saw it.
§ Mr. Messer
Is the hon. Gentleman aware that that inquiry will be by the committee that runs the hospital, and not an independent, outside one?
§ Mr. Partridge
That may well be, but it is still an inquiry, and, as I understand it, it is to see that the subscribers to the hospital, as well as the patients there, get value for money.
I say that, especially having regard to the huge amount of money involved in our Health Service—and £400 million is 4 per cent. of the whole national income —and whatever we may think of the desirability of spending more money, we must keep it in due balance with what we earn. This figure is so far in excess of the amount that was originally contemplated. The right hon. Member for Ebbw Vale is always talking about Treasury officials as people who add up sums and always get the wrong answers. As a matter of fact, when the right hon. Gentleman introduced his Bill in 1946, he estimated that the sum required to cover the Service would be £109 million. In the first nine months it amounted to £208½ million, so that the right hon. Gentleman either did not do these little sums, or if he did do them, he got very wrong answers, but that is not surprising, because he does that in most other cases. The figure rose rapidly and it is still soaring.
I am glad we are to have a committee of inquiry. Most certainly, in case there is any doubt about it, we have a mandate for it, because in the Conservative Party manifesto, "Britain Strong and Free," which has been quoted so often in this Chamber—[Interruption] Yes, and we are getting more and more towards that position of being strong and free. In "Britain Strong and Free" we find the following sentence:For this immense sum of money, a better service can be given to those in need of it.1774 That is what we are after. I believe that there are many people who are not receiving the full benefits we would wish them to have.
§ Mr. Partridge
If the hon. Gentleman catches the eye of the Chair, he can ask his question later. In the meantime, I intend to make my speech in my own way.
As I see it, the Health Service is divided broadly into three parts, the preventive service, the immediately and quickly curative service, and the care of the chronic sick, which includes the aged and the mentally deficient about whom the hon. Member for Tottenham (Mr. Messer) was speaking earlier today. I believe that much can be done for this third category even within the amount of money that the country can afford. As I say, when I talk about the chronic sick I include those who, because of their age, have deteriorated both physically and mentally. [Interruption.] This is not a laughing matter.
§ Mr. Partridge
It may be, but we should take this part of our mission seriously. I do not find anything to laugh at in the sufferings of the chronic sick.
§ Mr. Partridge
They did no such thing, and in any case, as the hon. Gentleman ought to know, I was not a Member of the House then, so you cannot make that charge against me.
§ Mr. Partridge
The chronic sick to whom I am particularly referring are not those who have reached that stage with the passage of time, but those who are suffering from a degenerative disease. At 1775 the present time they are accommodated in our hospitals, though they do not need a great amount of medical treatment. Many of them, in fact, need no treatment at all, and certainly not nursing treatment. Provided they are helped to wash and dress in the morning and to get into their chairs, they can fend for themselves for the rest of the day and only need further assistance at night before going to bed.
In my view, the hospital is not the proper place for treatment of that kind. In one hospital that I have in mind there are not sufficient of such patients to occupy a full ward, and therefore they find themselves sharing a ward with aged people who, through no fault of their own, are rather troublesome patients. Such conditions are very detrimental to the chronic sick about whom I am speaking. The psychological effect on them is bad, and their lives are not as happy as they might otherwise be.
I was deeply touched by a visit I paid to the Hostel of God, which I am sure is known to the hon. Member for Tottenham. It is not actually in my constituency, but it is a hospital in which I take a great interest. It is really a home rather than a hospital where the incurable and dying go to spend their final days. It is run by the Sisters of St. Margaret and they minister to the soul as well as to the body. It is a most uplifting thought that the patients in that hospital, so near to meeting their Maker, should lead a happy life. Their whole outlook is bright and cheerful. I believe that if that atmosphere can be obtained in a home of that kind, it could even more easily be provided in the case of the chronic sick.
I do not agree with my hon. Friend the Member for clitheroe (Mr. Fort) that such considerations are outside the terms of reference of the Guillebaud Committee. I believe that the terms of reference would allow the Committee to see whether by modifications in organisation or otherwise such provisions could be made, because it is only in such a way that we can provide for the maintenance of an adequate service. I hope, therefore, that my right hon. Friend will not think that something of that kind is outside the terms of reference, and, if he does, I hope that he will be able to extend them so as to bring an inquiry into this problem within their scope.
§ 7.28 p.m.
§ Mr. James H. Hoy (Leith)
The Minister and the last three hon. Members who have spoken from the benches opposite have all had one thing in common today. They have all complained that this debate was being carried on in a spirit of friendliness and quietness and that there had been no noise about it at all. I must say that the hon. Member for Battersea, South (Mr. Partridge) did his best to upset the temperature. Apparently, it does not matter how my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) puts his case, hon. Members opposite always think he is putting it the wrong way.
I propose to relate this inquiry to the two Health Acts, because we are discussing today a Committee that is going to inquire into the Act as it affects Scotland, and also as it affects England. It would be wrong if one did not say that in many ways, both administratively and otherwise, the Scottish Act is very different from the English Act.
§ Mr. Hoy
I was about to say that. In many ways both the Scottish Act and its administration are better than the English Act. I shall refer to that in detail a little later because I want to ask the Joint Under-Secretary of State, who is to wind up this debate, to give some specific assurances regarding the administration in Scotland.
I cannot agree that there have not been inquiries into the working of the National Health Service. During all the years that I have been a member of the Public Accounts Committee we have spent endless time inquiring into the working of this Service. I know that the Estimates Committee have done exactly the same. With all due respect to the Minister, I must say that this afternoon he did not introduce one item for the committee of inquiry, to investigate that he could not have done administratively. As a matter of fact, all his case this afternoon was on what he had been able to change by administrative action. Certain administrative action has made changes, but I was rather surprised that the Minister used that type of argument to bolster up his case in regard to this committee of inquiry.
The National Health Service has been inquired into from its very inception. I 1777 remember the Public Accounts Committee, under the chairmanship of the right hon. Member for Blackburn, West (Mr. Assheton), an ex-Financial Secretary to the Treasury, inquiring into it. It was made perfectly clear then that we were starting a new scheme. It was a National Health Service to serve the needs of every man, woman and child in this country. Men had been covered under the old National Health Acts, but this Service was extended to cover women and children, and the House determined—and no section of it more so than the Opposition of that day—that in the years to come there was not to be a tight control maintained by the Government over this Health Service. It was to have freedom to operate, and there was not to be Ministerial interference in its operation. I think that those hon. Gentlemen who were in the House at that time will agree that that is a fair statement of the case. We have to consider how it has worked from that stage.
The Comptroller and Auditor-General reported in 1950 that the Health Department's system of control of expenditure by means of annual budgets had not become fully operative or effective in the first two years of the Service. There were certain reasons for it. The Public Accounts Committee made it clear that it was largely due to lack of information or experience and partly to difficulties arising because hospital administrators were unaccustomed to the financial control necessary to satisfy Ministerial responsibility to Parliament.
We have always fought in the House for complete control by the Minister and have never allowed any Minister to shift responsibility to any other Department. Because of that we have demanded a very high form of accountancy. The Committee added—this was the view of both representatives of the Ministry of Health and the Department of Health in Scotland—that they saw no reason to suppose that when the system had had time to settle down it would not be effective. They both felt that, given a decent time, it could settle down and work most effectively to protect the country and the Exchequer from any waste of funds.
It would be relatively simple to set up a very tight form of expenditure, but if we are to have it, let us face the fact 1778 that it would be alien to our first conception of a Health Service working in freedom. It has been suggested that certain other action might be taken. The Minister said that he was not going out for economy and he instanced the fact that last year the Health Service cost £15 million more than in the previous year. I take it that the Minister was speaking on behalf of both Departments.
§ Mr. Iain Macleod indicated assent.
§ Mr. Hoy
That is no argument at all. If the Minister cares to examine the report of his Department and of the Health Department for Scotland he will see that the cost per patient went up last year by 9 per cent. as compared with the previous year. In addition to that, medicines and so on greatly increased in price, and even though there may not be an increase in the sum mentioned, it is no proof that this year was better than the previous year or equalled the treatment administered in the previous year.
I would turn the attention of hon. Gentlemen to the purely Scottish problem. It caused us some concern, with two separate Acts of Parliament, that we have not had any announcement by the Scottish Office, nor have the Scottish Office intimated any reason, why this Service should be inquired into in Scotland. Some of the reasons given by the Minister for the inquiry are certainly not applicable to Scotland.
The Minister said there was great difficulty in the ambulance service in Scotland, but the ambulance system in England is entirely different from that of Scotland. Secondly, he gave it as a reason for examining or for setting up the inquiry. It may be necessary, to put this service right in England, but I hope there is not to be great interference with Scotland as a consequence of it. I do not want to have my English colleagues coming down on me. Even the method of payment for this service is very much different in Scotland from what it is in England. I think my hon. Friend the Member for Tottenham (Mr. Messer) knows that the English have to carry a substantial charge that we do not carry in Scotland, and secondly that the system of running is different.
If the Minister wanted to cure this particular part of the Service, why did not 1779 he and his Department give consideration to the Third Report of the Committee on Estimates which enumerated all the difficulties of the hospital service and, furthermore, made suggestions to the Minister how they might be cured? I am surprised that after 15 months or 16 months have gone the Minister is suggesting to the House that this is one of the matters that the committee might inquire into, without giving information of what his Department have done about the suggestions to which I have referred.
The Minister also said that we could have an inquiry into the staffing of the hospitals. With regard to the establishment, I was not clear. "We know," he said, "that we could lay down a standard for the hospitals." I do not want to do him an injustice, and I am prepared to allow him to interrupt me. Was the right hon. Gentleman arguing that we should lay down a standard?
§ Mr. Macleod
I am not quite sure of the point that the hon. Gentleman is making. If he is talking about manpower policy, of course it is true that the Scottish manpower policy has developed in a rather different way from the method developed in England and Wales. But I certainly think it possible for any hospital to have an establishment laid down for it.
§ Mr. Hoy
That is not quite what the right hon. Gentleman said during his speech, when he appeared to think that a general standard could be applied to the hospital.
I do not want to go into this in great detail, but I would direct the Minister's attention and that of the Secretary of State for Scotland and the Joint Undersecretary of State for Scotland to the opinions of the heads of their Departments. In both cases those heads made it absolutely clear that merely to try to lay down a general standard of staffing for all hospitals was quite impossible; and in fact each one would have to be visited individually before the right staffing arrangements and numbers could be arrived at.
I believe that to be true, and the Scottish Department of Health have already appointed a woman to inquire into the domestic staffing arrangements of the hospitals in Scotland. When the Minister 1780 replies to the debate, perhaps he might like to say something of what has happened. Perhaps the Ministry of Health can tell us if they are also conducting a similar inquiry, because it seems to me that if all these inquiries are taking place now there can be no good reason for having another inquiry. Indeed, we were given an assurance at the Public Accounts Committee last year by both Departments that these investigations were taking place, and the Departments expected to have some evidence and some results to bring forward when they came before the Public Accounts Committee this year.
Something was said at the Public Accounts Committee about the costing system. It ought to be said that the Scottish Department has taken the lead on costing. I understand from the evidence submitted, and from what I have heard, that the Scottish Department of Health has made great headway in this field. If that has been the case, the Scottish Department will have to explain why it wants another inquiry. It seems to me that there will be a great deal of overlapping and time wasting if the Departments already have the information at hand and all that is required is administrative action to put matters right.
A great deal has been said about waste in the Service, and all too frequently the blame has been placed on the subscriber to National Insurance, the ordinary man and woman in the street. Far too frequently people have described the enormous cost of the National Health Service. I have to say in his absence that the hon. Member for Orkney and Shetland (Mr. Grimond) fell into exactly the same trap and conveyed the impression today that these millions of pounds were raised by the weekly contributions of the insured persons. He is quite wrong, of course. Only a small proportion of the weekly contribution goes to the National Health Service and the remaining costs come from the national Exchequer.
Bad cases have been magnified. Bad news makes good news for the daily Press and is given the headlines of publicity. Many of the things that have happened, involving dentists or opticians, have been magnified. It is true that there has been some exploitation, but I remember that the Departments themselves were able to take action to prevent this waste of public money.
1781 In 1950, when the Public Accounts Committee were examining these accounts, we discovered that those who were supplied with surgical boots, belts and trusses through the National Health Service scheme were exploited. The Comptroller and Auditor-General said in his report that the charges were grossly excessive, so much so that the Department returned the tenders and then received back new tenders with the prices slashed for exactly the same goods. Many who did not want to see it become a success were exploiting the Service.
For the reasons that we have enumerated, I do not see why at this stage another committee of inquiry is necessary. There are certainly great differences in the working of the scheme in England and in Scotland and, on the basis of the reports of the Scottish Health Service, it would be difficult for any Minister from the Scottish Office to justify any change. I should much prefer if the Minister paid some little attention to administration. I have heard that there have been changes even in the budgets of the hospitals in Scotland. Because of certain limitations imposed by the Minister on expenditure, cuts have been made in hospital food supplies in Scotland.
I hope that the Government will never carry the economy campaign to the extent that we experienced in the past when domestic servants in hospitals were expected to work long hours for nothing, or to the extent that we shall have to employ nurses to do domestic work. If there is one way to destroy the National Health Service, it is that way. If the Government must tamper with the Service, I hope that they will be careful not to destroy a service which is the pride and admiration of the civilised world.
§ 7.47 p.m.
§ Colonel Malcolm Stoddart-Scott (Ripon)
When he opened the debate the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan) said a great deal about the Central Medical Services Council. He said that it was there to review administration and to offer advice to the Minister on changes in Health Services. After saying that, the right hon. Gentleman spent a considerable time in proving that it was a most unsuitable organisation to advise the Minister. The 1782 right hon. Gentleman ought to know; he set it up. He provided it with its terms of reference. He designed it, and indeed he refused to permit it to publish its annual report. The right hon. Gentleman also said that we on this side wasted no opportunity to depreciate the Health Service at home and only praised it when we went abroad.
§ Colonel Stoddart-Scott
I do not know what the present Minister has done, but when the National Health Service was established, the first Minister of Health did not appoint this Council for the first three years, so there was no opportunity for him to refuse, because there was no Report until he went out of office.
The right hon. Member for Ebbw Vale said we depreciated the Service at home and only praised it abroad. That is far from the truth. Those fortunate people who live in my division have heard me in every speech during the last election campaign praise the Service, say that it has come to stay, that it was one of the most popular things in the Kingdom, and that it had achieved much, but that at the same time there was room for improvement. It was one of my hon. Friends who contrived to have the terms of reference of a committee of the Inter-Parliamentary Union altered so that instead of considering infectious diseases the committee is now to study and consider the right of peoples throughout the world to a free, comprehensive health service. We on this side of the House think that the advantage which we enjoy in this country should be shared by other peoples of the world.
I feel that the right hon. Gentleman the Member for Ebbw Vale is the Senator McCarthy of Great Britain, because he takes the view that anyone who differs with him about the National Health Service is either immoral or unpatriotic. I welcome the setting up of the Committee to inquire into the cost 1783 of the Health Service but, like the hon. Member for Tottenham (Mr. Messer), I would like to have seen another sort of Committee. I should like to have seen a Royal Commission set up with broad terms of reference so that no aspect of the Health Service would fail to come under their scrutiny. I hope that the views that have been expressed in this debate—and some very useful opinions have been expressed on both sides of the Committee—will be considered by the Guillebaud Committee and will receive very careful consideration.
I agree with the hon. Member for Tottenham that the present organisation of the executive councils is not entirely satisfactory. We have got too many of them. In a county town which is also a county borough there are two executive councils. I know of one county town where there are two organisations dealing with exactly the same matters in the same street. We have got to decide what sized community should have one executive council. At present in London there are 3⅓ million people administered by one executive council, while in some other parts of the country there is an executive council for as small a unit as 1,800 people.
Something must be done to obtain a more economic, suitable and equitable number. If we were to cut the number of executive councils we could save at least £500,000 a year. We find that some executive councils administer their areas at a cost of l0d. per head of the population, while others administer them at a cost of 2s. 10d., such is the variation in the cost of administration.
Much has been said about the ambulance service. I hope this will be carefully reviewed by the Committee, and not only from the point of view of the difference between the systems in England and in Scotland. It should be reviewed from the point of view of the type of ambulances that these different organisations have got, and whether they are the right type of vehicle for the work they are called upon to do.
I think, too, that some abuse has crept into the use of our ambulance service, and I attribute it to over enthusiastic doctors and specialists. Where there is an abuse of over-prescribing of drugs the Minister has the power to surcharge 1784 doctors and there should be the same power—I do not know whether the Minister has it or, if he has not, whether he would be prepared to take it—of charging the doctors and specialists who order an ambulance which is not necessary or essential. There have been many exhortations to the doctors, but there is one way of getting them to carry out the wish of the Minister and of Parliament, and that is through the pockets.
§ Mr. Ellis Smith (Stoke-on-Trent, South)
Would the hon. and gallant Gentleman give some examples of these abuses? I know of none.
§ Colonel Stoddart-Scott
I cannot give any specific example, but I do know that the Minister has exhorted that the ambulances should be used only in specific cases. Yet each year more money goes in respect of the ambulance service, the number of miles covered increases and the cost per patient increases. There is no doubt that there is some over-prescribing of ambulances.
The regional hospital boards constitute a very expensive set-up, and the Select Committee on Estimates for 1951–52 recommended that there should be some change in the power of the regional hospital boards. They said that either they must have greater powers or they must be reduced to planning organisations only. I take the view that their powers must be swept away altogether, because on finds that they act as post offices between the hospital management committees and the Minister. Sometimes they are accommodated in very expensive premises, and I think it will be found on investigation that their architects' staff is enormous.
I think, too, that they are helping to increase the difference between the standard of the teaching hospitals and of the other hospitals, and I should like to see the hospital management committees rise in standard to that of the governors of teaching hospitals, and to have increased powers and direct access to the Minister without going through the regional hospital boards. In the City of Leeds, where the patients in my division go for hospital treatment, there is a teaching hospital with 750 beds, which has direct access to the Minister. There is another hospital, with the same specialists, 1785 where medical students are taught, with 2,000 beds, and they have to go through the regional hospital board.
§ Mr. Messer
How would the hon. and gallant Gentleman deal with the hospitals that decline to take the uninteresting cases, such as long-term tuberculosis, chronic cases and so on? The teaching hospitals' first function is to teach. The first function of the other hospitals is service.
§ Colonel Stoddart-Scott
The hon Gentleman did not let me finish my point on the question of hospital re-organisation. There must be a larger overall plan. There must also be some organisation for the specialists. In each region the Ministry have a regional office of their own; the regional offices should be strengthened to enable them to deal with questions like the overall planning of the hospital service. In order to avoid such a great difference between the teaching hospitals and the other hospitals I would bring under the Ministry's regional overall planning the teaching hospitals as well as all other hospitals. It is a great mistake to have teaching hospitals working in one direction and the other hospitals working in another direction. We should do all we can to bring them both on to the same levels.
The regional hospital boards are a great cost to the country. If they were swept away we should save £5 million a year. Every £1 spent on administration, on running large hotels which they cannot fill with their office staff, on providing liquers and cocktails at meals when they entertain—every time money is spent on that kind of thing they are taking money away from the treatment of the sick and the prevention of disease.
§ Dr. Stross
Did I hear the hon. and gallant Gentleman say that liqueurs are provided before meals? It is most unusual.
§ Colonel Stoddart-Scott
The Leeds Hospital Board, when it entertains specialists or distinguished guests, provides out of public funds cocktails before 1786 lunch and liqueurs afterwards. That is a grave departure from what was intended by Parliament. When we vote money for the Health Service we do not expect it to go into liqueurs and cocktails, to gardeners, hothouse plants and other things on which the Leeds Regional Boards are spending money.
I think we are all in agreement on our hospital finance in all quarters of the Committee. It is unanimously felt that the time has arrived when we should consider some form of block grant for our hospital financing. The Minister was quite right when he said that rising prices, increased costs and the change in the value of money made it extremely difficult to work out a block grant system, but I should have thought it was possible to divide hospital costs into two—maintenance cost which could be on a three years system, and capital expenditure on hospitals which could be on a five years system. I do not think it is necessary to have just one block grant for the whole of the hospital expenses.
I hope the Committee will bear in mind that the Comptroller and Auditor-General drew attention in his Report published a fortnight ago to the fact that our hospitals have lost no less than £580,000 this year on running farms and gardens. I know that farms and gardens might be an advantage in treating certain conditions in some types of hospital, but nearly £600,000 is a vast sum of money to lose and, when one realises that hospital farms and gardens very often have the advantage of cheap labour, it seems a fantastic amount of money to throw down the drain. I hope some system can be recommended to deal with farms and gardens so that we save at least half a million pounds a year from that item.
We have heard quite a considerable amount about prescriptions and the pharmaceutical aspect of our Health Service. I want to make two suggestions. First, I suggest that we go back to the system we had in the old panel days, when a charge was made for the container. If an individual taking back the container to the chemist's shop got the money back it would save £1 million a year. We are losing a lot of money by not encouraging that sort of thrift, which is not a bad thing to encourage, and should be a national characteristic.
1787 I do not suppose I shall get any support from hon. Members opposite for my other suggestion. It is most illogical that some of the people who pay most towards this Health Service by way of rates and taxes are not able to get their drugs and dressings free if they have a private doctor. If they go to hospital they can have a free bed and get their drugs and dressings free. They can have a free specialist, and if the specialist recommends an artificial limb they can have it free. But they cannot have their own private practitioner and obtain free a bottle of medicine, a tin of ointment or a roll of bandage.
I hope the Committee will consider what the extra cost would be to the Service if everybody were given the same treatment whether they have a doctor inside or out of the Service. I think the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) was recommending the same treatment for all people in the land.
§ Mr. Blenkinsop
Surely the hon. and gallant Gentleman would agree that it would be impossible to do that and still retain control over the authority which has been given for the medicine? The great point about the patient who is under the Health Service is that any prescription that is improperly given can be perceived.
§ Colonel Stoddart-Scott
I am told that it is possible for private practitioners to enter into an agreement with the Minister and, if they prescribe above a certain level, charges could be made. The Minister has the whip hand, because he can always withdraw permission for them to prescribe free medicine and free drugs for their patients if they do not conform to the standard of the Health Service.
I welcome this inquiry. I regret that it is not on a wider basis and that, after five years of the Service, we are not to have a Royal Commission, which I think would have have the advantage of lifting this whole topic out of the realm of party politics.
§ 8.4 p.m.
§ Mr. W. Griffiths (Manchester, Exchange)
The hon. and gallant Member for Ripon (Colonel Stoddart-Scott) will not expect hon. Members on this side of 1788 the Committee to sympathise with his last point. We are aware that the Conservative Party's election programme stated that private patients should be able to secure their drugs through the provisions of the National Health Service. I deeply sympathise with him in his inability to persuade one of the architects of the social policy of the Tory Party to put that part of the party policy into operation when he became a Minister, but I am sure that he will show the same energy on the back benches as do hon. Members on this side in pushing our Ministers when they do not go along fast enough from time to time.
If, as the hon. and gallant Member said, he explained at the General Election all the virtues of the Health Service and praised it, I wonder whether he has been disappointed at the inroads which have already been made on the Service by this Government. He will remember that the Chancellor of the Exchequer gave a specific promise in the course of the election campaign that no further cuts and charges would be made in the National Health Service. That pledge has gone the same way as the one with regard to food subsidies.
It is realised that the National Health Service—barely five years old, already appreciated by a great number of British people, and exciting the admiration of people throughout the world—was a step in our social services of such a revolutionary character and of such a magnitude that it was inevitable that from time to time a review of its operation would have to be carried through. I do not object to the principle of an inquiry. What I object to are the terms of reference laid down by the Minister—especially by a Minister with such a bad record as that possessed by the present one.
As has been said, when we come back to power we are pledged to remove all the charges from the National Health Service. That is the heart of the matter and the fundamental difference between us. I have no objection to an inquiry, but the terms of reference upon which I should have insisted would have been that all economies should be sought whilst preserving the Service free from financial charges to the patient. When the Minister made his announcement on 1st April with regard to the setting up of this Committee, it is true that he was rather forcefully interrogated by my right hon. Friend 1789 the Member for Ebbw Vale (Mr. Bevan). Some people thought that my right hon. Friend was a little rough, but I thought that he was quite justified in protesting as vigorously as he did. Some people thought he was unfairly mistrustful of the Minister of Health. Never mind about the protestations of innocence made on behalf of the Minister; let us look at the book. I have yet to hear the right hon. Gentleman rejoice in the undoubted benefits made available by the National Health Service.
§ Mr. Griffiths
I have never heard him take pleasure or pride in the achievements of the National Health Service.
§ Mr. Macleod
If the hon. Member says that, I would refer to what he said just previously. It is true that the right hon. Member for Ebbw Vale protested when the terms of reference were announced, but if the hon. Member will look at what I said on that occasion he will see that I referred to the Health Service as a splendid experiment.
§ Colonel Stoddart-Scott
On a point of order. The hon. Member for Manchester, Exchange (Mr. W. Griffiths) has spoken about taking charges off drugs and dressings, which also means taking charges off spectacles. Is it not a custom in the House for a Member to declare his interest in such circumstances?
§ Mr. Griffiths
The hon. and gallant Gentleman is a member of the medical profession. I served with him on the original National Health Service Committee in 1946. I do not challenge his interest when he speaks. Many hon. Members on both sides of the House know that I am engaged in the National Health Service and that I am an ophthalmic optician.
The Minister of Health won promotion to the position he now holds on the strength of the performance he gave in the House on 27th March, 1952. His speech on that occasion has been referred to by my right hon. Friend the Member for Ebbw Vale today. I find it a little hard to take from the Minister what he said when he was challenging my right hon. Friend about what he would do if there were more money to spend on the National Health Service. The Minister asked, "What about the mental health 1790 service? If I had £40 million extra to spend, it would go to something like that but not to restoring the charges which are already established." The fact of the matter is that since the right hon. Gentleman has been at the Ministry of Health he has been responsible all the way through for the contraction of the Service. There is nothing in the whole of the National Health Service which he can take credit for expanding or improving. It does not lie in his mouth to talk about priorities. In his speech last March he said:It remains the belief of this party, apart from economic circumstances, that there should be charges in the Health Service.He went on:It seems to me quite absurd that, when the economic reasons reinforce the social and ethical ones, we should not support them."— [OFFICIAL REPORT, 27th March, 1952; Vol. 498, c. 966–7.]In the same speech the right hon. Gentleman referred to Danckwerts Award, which gave £40 million of public money to the general practitioners, representing an average increase in salary to general practitioners of £10 a week. What did the right hon. Gentleman, who said today that if he had money to spare it would go to the mental health service, say about that increase, which was greater than the sum which a schoolmaster receives when he starts in the teaching profession after leaving the training college? The Minister said that it delighted him.
The difference between the two sides of the Committee is deep and fundamental. No wonder we feel alarmed when a Committee is set up with these terms of reference by a Minister who has gone on the record in that way. It has always been a real difficulty for my hon. Friends to understand the Conservative policy towards the National Health Service. The Conservative Party have always been against it. They voted against the original Act on Second Reading and, after a very long Committee stage, on Third Reading. By 1949 they were claiming credit throughout the country for having "fought for it," whatever that meant. At the last General Election the Chancellor of the Exchequer specifically pledged the Tory Party, if they were returned to power, to embark on no further cuts in the National Health Service.
Even in March of last year, when the right hon. Gentleman the Minister was 1791 making the speech to which I have referred, we had speeches from other hon. Members who at that time were more eminent in the Conservative hierarchy than the right hon. Gentleman was. At that time the Minister was the right hon. Gentleman who now leads the House, and on the day on which the present Minister made his speech, the right hon. Gentleman the present Leader of the House said it was:…no pleasure to have to introduce this sort of Bill, but … the background all the time is the economic situation…."—[OFFICIAL REPORT, 27th March, 1952; Vol. 498, c. 853.]There is all the difference in the world between an argument that charges are necessary because of the economic situation and the argument advanced by the right hon. Gentleman that they are socially and ethically justifiable despite the economic and financial condition.
What about the Foreign Secretary? He took part in the debate at a later stage when the Government had introduced their Guillotine Motion, and he said:This is only part of the Government's scheme, and if we as a nation fail to maintain the purchasing power of our money "—He was then interrupted. He went on:We are engaged here in a wide series of plans of which this one is admittedly financially a small element. The whole goes together."— [OFFICIAL REPORT, 23rd April, 1952; Vol. 499, c. 504.]The right hon. Gentleman went on to talk about the Budget.
We ought to know who now speaks on this important matter for the Conservative Party. Is the policy enunciated last year by the Foreign Secretary and the Leader of the House the one to which the Conservative Party now adheres or has the Minister now persuaded his colleagues that their conception of a National Health Service, despite whatever improvement may be brought about in the British economy, is one in which charges must always remain? The Committee ought to be told. It seems to be that in the Tory Party the way to the Front Bench is by means of disagreement with one's leaders. Let the docile ones and the faint-hearts opposite take note of that.
It was not surprising, in view of what the Minister has said from time to time, that the gentleman whom he has 1792 appointed as chairman of the Committee went on record as saying the following the day after his appointment was announced in the House of Commons by the Minister of Health. I picked up the "Daily Express" the day after the announcement in the House on 2nd April, and there I saw a headline:Mr. Guillebaud seeks cuts.The report went on that Mr. Guillebaud said:'The briefing of my team will be to see how far it is possible to cut the cost of the National Health Service without impairing its efficiency. I think it can become more efficient and cost kept down.'That was in the "Daily Express" as a direct quotation from Mr. Guillebaud. It is true that 10 days later a letter appeared in the "Daily Express" in which Mr. Guillebaud denied he used the word "cut." In other words, I suspect that between 2nd April and 13th April someone drew Mr. Guillebaud's attention to the inadvisability of a chairman—
§ Mr. Iain Macleod
I am sorry, but I must interrupt the hon. Gentleman straight away on that. I should not dream, and nobody would dream—I am certain I carry the Committee with me in that—of interfering in a matter like that. The hon. Member has referred to the 10-day interval. The letter from Mr. Guillebaud containing the denial was written at once the same day. The fact that it was not published for 10 days is a matter for the newspaper and is nothing to do with him.
§ Mr. Griffiths
Might I ask the right hon. Gentleman how he knows that? Was he in contact with Mr. Guillebaud?
§ Mr. Macleod
I know it because I was sent a copy of the letter which Mr. Guillebaud sent to the "Daily Express" correcting the report. I did nothing at all to bring the report to Mr. Guillebaud's attention. It was entirely on his own initiative that he sent the letter.
§ Mr. Griffiths
At any rate, my right hon. Friend the Member for Ebbw Vale has been mentioned tonight as having 1793 been reported in the "Daily Express" in connection with the Sunderland bye-election. It seems to me that both cases should be referred to the voluntary Press Council.
Not only do we object to the terms of reference of the Committee, we are fearful of the kind of recommendations that such a Committee might bring in, bearing in mind the Minister who has appointed it, the Minister's record and attitudes, and the first indication that Mr. Guillebaud gave, although his words were misquoted to some extent, of what his attitude was. There is all the difference in the world between the two sides of the Committee. We fear the consequences to health which arise from charges.
That fear was expressed last year. My hon. Friend the Member for Liverpool, Exchange (Mrs. Braddock) referred to the possibility of charges in some sections of the Health Service causing patients to have inferior appliances. Others of my hon. Friends also warned the House of that, but the hon. Member for Wolverhampton, South-West (Mr. Powell) replied in these words:She"—that is, my hon. Friend the Member for Liverpool, Exchange—expressed the fear that the imposition of charges upon appliances would encourage patients to go and obtain quack appliances elsewhere…. It is therefore in the highest degree unlikely that a quack appliance could be produced at less than the patient will have to pay under these regulations."—[OFFICIAL REPORT, 8th April, 1952; Vol. 498; c. 2533.]But the fact of the matter is that already the effect of these charges is resulting in the exact opposite of what the hon. Member said. For the eye service, what my hon. Friend the Member for Liverpool, Exchange said would come to pass has happened. The supply of spectacles from Woolworth's and places like that is on the increase, and the unqualified vendor has re-emerged since these charges have been put on, seeking to prevail upon people to buy inferior articles. The Minister should know about this.
Some considerable time ago I read an article in the "Sunday Express" in which the Parliamentary Secretary to the Ministry of Health was quoted as having expressed the view that the Ministry were disturbed by this sort of thing. This is 1794 the consequence of the charges that were imposed in 1951, and follows from the erection of the financial barrier between the patient and the qualified practitioner.
If the Committee are going to inquire into the Health Service, I would prefer that their terms of reference should specifically include that the principle of a free service should be maintained. Certainly, there are many things at which they can look. I heard the Minister say that in the past year there had been a sharp increase—I think he said 33 per cent.— in the number of part-time workers in the Service. It was my hon. Friend the Member for Tottenham (Mr. Messer) who referred to some of the disabilities under which the Service labours because of the activities of the part-time consultant. How well a good many of us know that. That is something which calls for an examination.
Let me tell the Committee a story about the Westminster Hospital. Somebody I know went to that hospital with a minor hand injury. He was received very courteously and dealt with very promptly. He went through to the radiographer and was X-rayed. Eventually he came back to the houseman with the plates. The houseman looked at those plates and told the patient that in his opinion there was no fracture, but there was an indication of an old injury. He thought that the patient might wish to see an orthopaedic consultant.
The patient said that he thought that would be a very good idea, whereupon the houseman said, "Of course, if you come here it is very doubtful whether you will see Mr. B—. Anyhow, you will have to wait a long time, but I can make a private appointment for you if you wish." This patient said, "Will you really be able to do that?" The houseman replied, "I will do it at once." The houseman got on the telephone, rang up the consultant in Harley Street, and made the appointment. Everything was fixed up and the patient eventually went along to see this consultant privately at a fee of £5. This man held a part-time appointment as a consultant at that hospital.
What happened was that the whole apparatus of the hospital was put behind the subsidising of this man's private practice. The service of the houseman, 1795 the service of the radiographer, the service of the X-ray department, the plates, the telephone and everything is placed at the disposal of that consultant. That kind of behaviour on the part of certain sections of the medical profession is a consequence of these charges.
I see the hon. Lady the Member for Wythenshawe (Mrs. Hill) in her place. I had my attention drawn to what is happening in a hospital in the City of Manchester. Here I am told that expectant mother patients who go to see a part-time consultant from that hospital at his private practice in John Street, Manchester, are told that they will be found a bed on medical grounds in the public ward. We all know that a consultant is entitled to certify on medical grounds that a patient should go into the public ward, but the usual practice with a healthy expectant mother is for the mother to go into the public ward only for her first child. There is evidence, I am told, of what I regard as misbehaviour of this kind on the part of those people in the City of Manchester.
§ Mr. Griffiths
It is not.
There is also another example of this kind of behaviour. We had a debate recently on a Prayer about paid beds. One of my colleagues who is on the regional board in Manchester informed me the other day that they are having the utmost difficulty in persuading the medical staffs—the Minister can look into this—at the Royal Devonshire Hospital, Buxton, to fill paid beds which are kept empty, although there is a long waiting list of sick people who are unable to pay the fees. Those are just some of the things that I think the Committee would do well to look at. Those are matters to which attention should be given, and not the creation—I am obliged to say this— of a feeling that the object of the Guillebaud Committee is to make further inroads into the National Health Service.
My last word is to say quite honestly that I have no hope that we shall return to a National Health Service based upon the principle of a patient getting the best on grounds of medical need irrespective of means until the electorate have an 1796 opportunity of rejecting hon. and right hon. Gentlemen opposite and returning my right hon. Friends to power.
§ 8.28 p.m.
§ Mr. Robert Carr (Mitcham)
There has been a need for some time for a general objective debate on the National Health Service, and I am glad that the form of today's debate has enabled us to range over a wide field and that we are not confined entirely to the question of an inquiry into the Service, although that is the foundation of our debate. Between the first speech and the one to which we have just listened hon. Members on both sides of the Committee have ranged objectively, even in spite of differences of opinion and emphasis, over the field which needed to be covered. However, the last speech departed from that standard.
It seems to me to be pointless for us in this Committee of the House of Commons to be bandying purely party political points, using the Health Service as a fishing rod to catch votes. It is unworthy of us to be doing that when we ought to be considering objectively how we can push on with this Service which was started in the war on an all-party basis. Much of it was implemented on that basis, and it is time that hon. and right hon. Gentlemen opposite ceased unworthy party electioneering out of people's health and instead gave that consideration to it which it deserves. Most hon. Members have done that today.
The hon. Member for Manchester, Exchange (Mr. W. Griffiths) must know that it is wrong to suggest that we on this side opposed the Health Service, when he knows that, although we objected to certain items introduced by the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan), we went on record over and over again as being in favour of a comprehensive National Health Service. Hon. Members opposite know that it is worse than naive—I have to keep within the realms of Parliamentary language—to try at this stage to put it out to the country that we want to destroy the National Health Service and to make personal attacks on my right hon. Friend the Minister. Although hon. Gentlemen may disagree with the way he wants to develop the Service, they must know that he cares deeply about it, has studied it for many 1797 years, and knows more about it than almost any other hon. Member in the House of Commons.
§ Mr. W. Griffiths
First may I say that the fact of the matter, whatever the hon. Gentleman says, is that the party opposite voted against the National Health Service Bill on Second Reading and also on Third Reading after it had been through the Committee stage. Secondly, all that I have said about the Minister is my opinion of his policies based upon quotations from his own speeches and my observation of his attitude to important policy matters throughout the past 18 months. It is not a personal attack.
§ Mr. Carr
I am glad to hear that and, of course, I accept what the hon. Gentleman says about any personal attack on my right hon. Friend. I was not an hon. Member of this House when the National Health Service Bill was discussed, but I know that Parliamentary procedure makes it difficult sometimes to express clearly what we have in mind. I suggest that the hon. Member, and those of his own party who speak like that, are making deliberate use of the difficulty of making one's intention clear in a vote in the House of Commons in order to denigrate and slander our party in the country. It is well known that we on this side did, still do, and will continue to stand for a comprehensive National Health Service.
Personally, I welcome this inquiry. I think there is a need for one by independent people, by fresh minds outside the working of the Service. I believe that the majority of informed and thoughtful opinion in the country agrees that there should be an inquiry, and I believe that the opposition to it is synthetic indignation worked up for purely party political purposes. Hon and right hon. Gentlemen opposite are not only being unfair to the Minister and the Government in suggesting that this inquiry is being made to provide an excuse for cuts, but they may be doing quite the wrong thing.
I have not discussed this with my right hon. Friend, but I can imagine that, having had such an inquiry, he may find his hands strengthened in dealing with his right hon. Friend the Chancellor of the Exchequer. The ceiling was put on the Health Service by the previous Government and. as my right hon. Friend said 1798 in his speech last year, that limit was clamped down arbitrarily. No one has worked out whether, if there has to be a ceiling, £400 million is reasonable and whether that amount is being used in the right way. There is no logical basis at the moment for knowing whether £8, £6, £10 or £12 per head of our population is a reasonable amount to spend on the National Health Service. Therefore, it is possible—I put it no higher—that a thorough inquiry into the Health Service may well strengthen the hand of my right hon. Friend and his successors in dealing with Chancellors of the Exchequer, of whatever party, in putting forward the interests of a comprehensive National Health Service.
The hon. Member for Tottenham (Mr. Messer) felt that the only test of what we could afford and could do in the Health Service should be what was needed medically throughout the country. As an ideal, I agree completely with that, but we must face the fact that the potential demands for the Health Service at this stage in our development are boundless. We can think of more hospitals, specialised types of hospitals, specialised clinics, developments of new services, research, and all the rest. Therefore, whatever we may hold out as an ideal— that medical requirements should be our only limiting factor—we must face the fact that for many years ahead, whatever Government are in power, there must in fact be a ceiling to the resources which are devoted to the Health Service.
§ Dr. Stross
That is an interesting point. Would not the hon. Member also take into account that if there is a ceiling, it should contain within it an understanding that the better the service, the more it must save the country in production by preventing people being ill and so enabling them to work?
§ Mr. Carr
Of course, I agree. That is an important point, and I will return to another angle of it presently. I submit that there must be a ceiling for as many years ahead as we can at present see. It may be a variable ceiling, and I hope it will be a rising ceiling, but a ceiling it must be.
But it is not a question, as the hon. Member for Tottenham said, of we on this side wanting to shut people out of the 1799 Health Service—far from it. It is a feeling which we hold with sincerity that if there must be a ceiling, if there are not sufficient resources to do all that we would like to do, it becomes of vital importance to make sure as far as we can that the most urgent needs are met first and adequately, instead of the inadequate resources being spread too thinly over the whole field. Rightly or wrongly, that is the basis of our philosophy and belief behind what we are trying to do in the National Health Service. It is certainly the philosophy that is held by my right hon. Friend.
Therefore, if we are to live within a ceiling for a number of years ahead, it is more vital than otherwise would be the case to get our priorities right and to get the maximum value from the resources which we can spend on the Health Service. That is why I think there is need for an inquiry, but I should like to see an inquiry on the widest possible fields. If I have any doubts about the Guillebaud Committee, it is because their terms of reference might be too limited. I am, however, encouraged by the fact that my right hon. Friend has, I understand, expressed a readiness to listen to any suggestions that the Committee may wish to put forward as to the fields to which their inquiry should be extended.
During the debate we have heard a lot about priorities. We must not only consider the best use of our resources under the present ceiling and how best to use them to meet existing priorities. We must also consider the best way in which our resources should be used if and when, as we hope, they begin once again to expand. That is a field in which a comprehensive inquiry and review would be of extreme value. If I had more money to spend on the Health Service in this or any future year, I would apply it to two purposes: the care of the old people, and the care of mental health.
Consider, first, the care of old people. In 25 years' time, something like 16 per cent. of our population will be over the age of 65. For every person over retirement age, there will in 25 years' time be only four people of working age engaged on production. The scale of people over 65 will produce a very serious health and social problem as a whole. Therefore, the proper development of a 1800 health service for old people in order to keep them in a proper kind of independence, health and working capabilities to the greatest possible age will be essential for social happiness and for the happiness of the old people themselves and of fundamental economic importance to this country.
On the question of the mental health service, I was rather surprised at the intervention of the right hon. Lady the Member for Fulham, West (Dr. Summers-kill) when she asked my right hon. Friend if it were not better to spend resources on those who were well and normal rather than those who were abnormal. I thought it was a rather shallow point coming from someone with the experience of the right hon. Lady. As my hon. Friend replied, everybody must have their turn, and I think that the turn of those suffering from mental illness has, perhaps, been delayed too much already. But, in addition to that, all Members of Parliament dealing with constituency cases—I was glad that the hon. Member for Tottenham referred to this— must have come across many cases of a family suffering enormous hardship and distress because an unfortunate member of the family is suffering from mental illness and either cannot get into an institution or hospital at all, or is in one under the most unsatisfactory conditions.
If I were given £50 million extra to spend on the Health Service tomorrow I cannot pretend to the Committee that I would not rather spend it on mental health and the health of old people than in abolishing the charges, say, on dentistry. One day I want to see all these charges go, but whilst resources are limited, let us spend on what matters most and meet the greatest needs first. This question of priorities obviously comes very close to the question of charges.
If we have to admit that there must be a ceiling to the Health Service for some years to come, we must also recognise— as I have been illustrating in the case of mental health and the old people—that we may have to have charges as a deliberate act of social policy to canalise resources available into the most urgent channels. That is why in the speech made last year—which has been so much quoted today—my right hon. Friend said that it was not only a matter of economic 1801 necessity. The need may have been sharpened by the economic troubles of the time, but so long as we have to have a limit on the resources we can spend on the Health Service, there may well be a case for charges in order to restrict the use of resources in one less urgent although desirable service in order to provide for the really vital services it is our duty to see made available to those who need them.
That brings me to another point which I hope the Guillebaud Committee will look into. It is not only on what service, if any, there should be charges, but how those charges are to be applied. I am concerned that if we have to accept charges as a matter of policy there should be reasonable and humane ways of escaping the charges when they cannot be afforded by the people who need the services. I must confess that I am not happy at the moment that the test of need to escape the charges which exist falls under the ordinary National Assistance Board procedure.
I know that administrative difficulties exist. I remember discussing this point when we were on the benches opposite and being told that it was administratively impossible to devise a different standard of subsistence level for considering charges under the Health Service compared with the ordinary problems of National Assistance. I hope that this Committee can look at that question because, if we are forced to accept charges, for the reasons I have outlined, for years ahead, it is our duty to ensure that those who cannot afford the charges shall get exemption from them and that the standard of test qualifying for exemption shall not be too severe.
I should like to pass to the general question of economy, which the Committee are particularly charged to look at. Many people, when they talk about economy in the National Health Service, quote a lot of small examples of abuse here, of over-administration there and of red tape of one kind and another. I agree that these are serious where they occur and ought to be eliminated if at all possible. At the same time, do not let us delude ourselves that in any huge national service, however clever we are in skilful administration, there are not always bound to be examples of wasteful treatment here and there.
1802 We all want to see these cases of wasteful treatment reduced to a minimum but if we are really looking for economies in the National Health Service we have to look beyond these examples of waste of that kind. We have to look at the system of organisation itself, at the administrative overheads, for example. The proper role of the regional hospital boards has already been referred to. I do not know that I go all the way with my hon. and gallant Friend the Member for Ripon (Colonel Stoddart-Scott), although I agree with a great deal of what he said. Perhaps more fundamental and more difficult to solve is the dichotomy which exists in the Service between the local health authority parts of it and the rest, where, as the hon. Member for Tottenham mentioned, there is not only a split of functions but this split of areas of administration, which must lead to great waste.
I am one of those—I may be regarded as a heretic by many Members on both sides of the Committee—who for reasons not only of administrative efficiency but for reasons of democracy and the stimulation of interest in our services, which is vital in the Welfare State, would hope that in some way or other the elected representative control in the Health Service may be brought back and may be found in some way to be a solution of this dichotomy which exists at the moment.
Under systems of organisation, the Committee have to consider the whole question of hospital financing which has already been referred to. I cannot go into details about that but if the full block grant system is not found to be possible—there are powerful reasons against it when the expenditure per year is as great as in the Health Service—I hope that the Committee will be able to make some concrete suggestions for throwing back at least more of the responsibility to the point where the money is spent—the individual hospital.
It is a wrong system when economy by a hospital management committee in one year may penalise them in another year. It is fantastic that one has to keep up one's expenditure to a certain level, even perhaps when one might not need to do so, because one is afraid that in one or two years' time, when one has something more urgent to do, one will not get the 1803 money if it is more than one has been spending in years gone by. We must try to find a solution to that problem.
If we are to look for economy, we have to look not only at systems of organisation but systems of treatment of illness. The effect of new drugs must be shortening the lengths of illnesses. The various types of therapy, if they were developed to a larger extent, could speed recovery. All these things could speed up the figures for hospital turnover—the amount of time that a patient spends in hospital. I had hoped that my right hon. Friend, in his speech earlier in the debate, might have given some figures of the changes in hospital turnover. It is rather late to ask now for these figures to be given in this debate, but perhaps we can get at those figures on some future occasion.
If we can develop special services linked with the hospital, such as geriatric clinics, they can be the means of keeping old people out of hospital, which is to their own benefit as well as having a beneficial effect on the Health Service from the point of view of economy. But if we are to get the maximum results and the maximum social efficiency from our Service we must look at it as a whole. We must not regard it simply as a machine for curing illness. That is not a very satisfactory social thing and it is very expensive. We must look at our Service more and more as a machine for preventing illness. That will bring economic as well as social advantages.
Here we return to the theme I mentioned earlier of the importance of the local health authority services and the need to co-ordinate them more closely with the rest of the National Health Service. It is essential to consider closely whether an expansion of the local health authority services will in fact bring considerable economies to our Health Service management and whether that is not the most hopeful direction in which to look for economy.
Let us take the case of old people again. If we had more health visitors to discover in time those in need before they become too bad, if we had more home nursing and home helps to keep them living in their own homes with the necessary amount of assistance they needed in the early stages, and if we had more services such as the meals on wheels 1804 service taking hot meals to the homes of these aged people, we could keep an increasing number of them out of hospitals and other institutions for a longer time. That would be of immense value in terms of the happiness of the old people themselves, and in terms of economy.
It has been estimated that to keep an old person in his own home, with the full service of "meals on wheels" and all the other advantages, costs about £135 a year, but to keep the same old person in hospital costs about £400 a year. Therefore, if we can keep more of them in their homes and fewer in hospitals we shall bring about social benefit and also tremendous financial saving.
I know that I am in danger of being ruled out of order in this direction and I only mention the following subject very briefly for that reason quite apart from the shortage of time. We must also consider our industrial health services. A large proportion of our people work in factories, mines and allied occupations. That is where we can carry out a tremendous amount of preventive medicine. Greater concentration on these services could do a lot to prevent some of the expensive treatment which later falls on the National Health Service budget. I hope that some way may be found so that the Committee can look at that question.
It is in these changes of emphasis and policy that we shall secure economies. It is in these ways that we shall achieve our ideal of the health and welfare of our people at a cost which the country can afford and in a way which will stop the sort of political arguments of which we have had too many in the House of Commons in the last few years.
I finish where I began with an appeal to hon. and right hon. Gentlemen to make a sincere attempt in future to lift the question of the Health Service above the common battle of party politics and the winning of votes. As I said in my opening remarks, a great new surge was started during and after the war. The development of our social services has gone in surges, as history shows. This one was conceived on an all-party basis, whatever any of us may argue on party platforms. It was carried out and implemented to a very large extent on an all-party basis. Let us admit publicly as well as privately that that is so.
1805 Of course we shall differ in our philosophy and in our way of approach to the subject, but let us admit that all of us on both sides are concerned with the furtherance of this ideal and let us stop this flinging of charges that so and so, this Minister and that party wants to destroy or to amputate the Health Service.
I submit that it is unworthy and not what is expected of this House of Commons in dealing with this matter. This is an ideal which we have taken up. Let us pursue it, let us discuss it and argue about the best ways of achieving it, but let us all remember that our object is the betterment of the conditions of our people, and that the National Health Service is a mighty weapon to further that end.
§ 8.55 p.m.
§ Mr. Edward Short (Newcastle-upon-Tyne, Central)
I hope that the hon. Member for Mitcham (Mr. Carr) will forgive me if I do not follow his remarks, but I have only a very few minutes and I want to deal with one particular point. The hon. Member for Clitheroe (Mr. Fort) complained that hon. Members on this side of the Committee were not being sufficiently provocative, and in these few minutes I want to try to remedy that.
I believe that probably the greatest achievement of the Labour Government was that, when they went out of office in 1951, they left behind a nation which was fitter than this nation had ever been before in all our recorded history. In the process of war, medical science made very great strides, but—and this is the important "but"—had it not been for the fact that a Labour Government were elected in 1945, this advance in medical science would have been reserved for the well-to-do. The good sense of the electors prevailed, however, and a Labour Government were elected to pull down the barrier between the people and the doctors and their skill.
The Tories, who have been making such a song about their pride in the National Health Service, opposed both the Second and Third Readings of the Bill. What they were doing when they did that was what the Tory Party have always done. They have always opposed any access by the people to the privileges of the few, and I believe that the charges which they have imposed amount to a 1806 partial withdrawal of that access and the rebuilding of the barriers between the doctors and the people. It is part of the emerging pattern of Tory Britain that Britain has increasing inequalities. There is no doubt whatever in my mind, and in the minds of my hon. Friends that this new Committee is simply intended to provide an alibi for erecting new barriers between the doctors and the people, slowly, imperceptibly and surreptitiously. In prewar days, the poorer people dared not call in a doctor, much less go to consult a specialist.
The massive achievement in making Britain a healthy nation had many very important social effects. Like many other of Labour's achievements, success in one direction created new pressures and difficulties in other directions. Quite apart from the initial pressure on the Service itself, the building of hospitals, clinics and so on, the increasing health of the nation intensified the need for houses, the need for consumer goods and the need for employment.
Success in one direction created greater problems in others, and I believe that in the years to come, when the history of this period is written, this National Health Service will be regarded as the predominent social factor in the second half of the 20th Century. When most hon. and right hon. Gentlemen opposite have passed into the limbo of things forgotten, my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) will have a secure place in the social history of this country.
Now I come to the point to which the hon. Member for Mitcham referred in the closing part of his speech—the effect on production. This is the point I want to make. We are told on every Tory platform, and we heard it at Sunderland hundreds of times, that in October, 1951, the Tory Party took over a bankrupt concern. [HON. MEMBERS: "Hear, hear."] Hon. Members opposite say "Hear, hear," but I have dealt with that point before. Let me tell them of two things they took over—a fitter nation than ever before and a rate of production in all our industries on the level of 143 as compared with 100 in 1948. I believe that those two things are related. The health of the nation was improved and production was up. There is a distinct and clear relationship between the two facts.
1807 This question of production is fundamental if we are to continue as an industrial nation supporting a big population. In 1939, 40 per cent. of our imports were paid for by invisible exports. This year, the figure is only 8 per cent. The remaining 32 per cent. have got to be made up by additional exports, so that production is absolutely fundamental to our survival. I believe that a fit nation produces more than an unfit nation.
Of course, the Tory Party only looks at the Health Service from the point of view of pounds, shillings and pence. But one cannot assess it in pounds, shillings and pence. One can assess it in higher production, higher human happiness and in higher and better welfare. It may only be coincidental, of course, that since the health charges were imposed the figures of illness have gone up and production has gone down. But that is exactly what has happened. Health charges were put on, production went down and the figures for illness went up. As I say, that may be a coincidence, but a three-point coincidence is very rare indeed.
Before I conclude, I will give the House one or two figures. If we compare December, 1951, with December, 1952. we find that the number of persons absent from work through illness increased by 134,000, or 16 per cent., and that industrial production dropped by 2 per cent. If we take January, 1952, and January this year, we find that there was an increase of 13 per cent. in illness and a drop of 2 per cent. in industrial production. I suggest that there is a distinct and clear relationship there, although I would not expect the party opposite to realise it.
Not only have the charges a very important deterrent effect—and the right hon. Gentleman who is now the Lord Privy Seal pointed this out when he was Minister of Health—but they have also a very important psychological effect. I believe that the trade unions of this country will look at the Government's paltry saving on the Health Service in the terms of this year's Budget. What the Government are doing is to save a certain amount of money on the Health Service and to distribute it in increased profits and tax relief among the well-to-do.
1808 The workers of this country have always regarded the free Health Service as their dividend for their extra magnificent productive effort. This Government are filching the dividend of the workers and at the same time permitting higher dividends for the capitalist business men. Of course, this is pure Toryism, and it is the way it has always worked out. The well-to-do are made wealthier and the poor are made poorer. That is the core of Tory philosophy which is once more seeping into every sector of our national life, including the Health Service. The only remedy is to get rid of this mean and reactionary Government.
§ 9.4 p.m.
§ Mr. H. A. Marquand (Middlesbrough, East)
Our decision to put down the National Health Service Votes for debate on one of our Supply Days has been well justified by the debate we have had today. The debate has been remarkable in two respects particularly; it has given hon. Members as well as the Minister an opportunity to survey the work of the Service and has shown that Parliament is not ignorant of the National Health Service, but really knows a great deal about it. I hope that all that has been said today will be studied most carefully by the Committee which the right hon. Gentleman has appointed to advise him about certain aspects of these services. They will find much in speeches from both sides of the Committee of great value to them. The second respect in which this debate has been noteworthy is the reference made by the Minister himself to charges. I hope that I have his words right, but in any case they will have to be studied again tomorrow in print. He said, "I hope we have called a halt to charges." They are very noteworthy words indeed, coming from him. Undoubtedly he will be reminded of them in future, but it would be churlish not to welcome this conversion and to say with what pleasure we heard that hope expressed by the right hon. Gentleman. I do not want to overstate it; he did no more than hope, and I know that he made no promise.
We have been discussing the Estimates of the National Health Service with reference to all the other claims on the national purse. In doing that we must face the fact that the share of the nation's 1809 real resources going to the National Health Service has declined in recent years and, as far as we can see, is still declining. There has been more than one reference today to a speech which the right hon. Gentleman made on 27th March, 1952, before he held office, when he said:I suggest that between now and the next Budget we should study the proportion which health ought to bear to the whole of our national expenditure."—[OFFICIAL REPORT, 27th March, 1952; Vol. 498, c. 962.]That next Budget has come and gone and we have not had today the pleasure of hearing the result of the right hon. Gentleman's study of that problem.
In so far as other people have studied the problem, the conclusion seems to be, at any rate of the well-informed correspondent of "The Times"—without going into any estimate that anyone else has made—that the proportion which our National Health Service bears today to current spending on goods and services is less than it was in 1950–51, or in the calendar year 1951, the last year for which it was possible to make these calculations. "The Times" correspondent says that this slight diminution in the drain of the National Health Service on resources must have continued in 1952.
I am sure that it must have done. I do not think that anyone really doubts that. We were advised in "The Times" this morning not to exaggerate this point, and not to lay too much emphasis on the diminution. But the diminution is there. I do not want to exaggerate it, but I want to emphasise it and to draw the attention of the Committee to the fact that it is taking place.
But the proportion which the National Health Service expenditure bears to the total income of the nation is dropping, because the present Government have stuck closely to the £400 million ceiling figure which the Minister said in that same speech everyone would agree was irrational. Nevertheless, irrational though it may be, the Government have stuck to that figure, and our present condition has been reached because, regardless of surrounding circumstances, the Government have held to it.
The Joint Under-Secretary for Scotland may remind us that the ceiling was fixed by Sir Stafford Cripps and that the £400 million was fixed by my right hon. Friend 1810 the Member for Leeds, South (Mr. Gaitskell); but I would remind the hon. and gallant Gentleman that Sir Stafford Cripps in his speech used the words "in present circumstances," and my right hon. Friend the Member for Leeds, South said "for the time being." There was never any intention on the part of either of them that the ceiling should continue completely irrespective of rising prices, and there was no intention on their part to cripple the Service by providing for it year after year a diminishing proportion of the national wealth of the country.
That being so, and without wanting to go back and argue too much over the past, if "The Times," which has certainly not been tremendously friendly to the Labour Government on the subject of the National Health Service, admits that it is true then that is very disquieting and should have the attention of Parliament and of the nation. Surely the time has at last come when we could make some advance and get back to the same sort of proportion of national resources, if not even improve on it a little, as we had in 1951.
The time has come for an advance from the position we are in today because of the changed economic circumstances in the first place, because it was possible in the Budget of 1952 to give tax reliefs and it was possible again in the Budget of 1953 to give tax reliefs, whereas the ceiling of £400 million was imposed at a time when it was necessary to increase taxation by £170 million. Those were the circumstances in which this figure of £400 million was imposed, when there was a great increase in national expenditure on grounds of rearmament. Circumstances have so changed since then that the Chancellor each year in the present Government has been able to reduce taxation. Surely it is not unreasonable to claim that there should now be provision in these Estimates not for the figures which we have seen but for larger figures.
Secondly there is a case for an advance today not only because there is more money available to the Chancellor of the Exchequer, as he has shown by giving a lot of it away, but because of the improved availability of resources. To quote one small example, the hon. Member for Kidderminster (Mr. Nabarro) at Question time on Thursday last drew the 1811 attention of his right hon. Friend to the fact that today, because of the availability of steel, and implements made from steel, it is possible to make available to hospitals improved boilers and fuel saving appliances which are badly needed. The right hon. Gentleman was put in the unfortunate position of having to say that though he knew these things were available he had not got the necessary money. That is not good economy; it is false economy to deprive hospitals of fuel saving appliances which could, in the long run, reduce the, drain on coal.
At the same time as the right hon. Gentleman is denied, by lack of money from the Chancellor, the ability to build additional hospitals, which I am sure he wants to build, his right hon. Friend the Minister of Works is allowed to spend over a period of three years £10 million on rebuilding London offices. The resources are becoming available in much greater volume than they were, and it is only right and proper that the National Health Service should not be denied its share of that expansion in national resources.
Thirdly, I would say that there is a justification for an advance at this time because of the evidence that exists of hardship caused by the charges. I shall not elaborate on that, because several examples have been given by my hon. Friends. On Thursday the right hon. Gentleman gave some very startling figures to my hon. Friend the Member for Stoke-on-Trent, Central (Dr. Stross) in regard to the very sharp decline in the supply of certain surgical supports. Evidence has been given this evening by my hon. Friend the Member for Manchester, Exchange (Mr. W. Griffiths) about spectacles. Without exaggerating —and trying only to place myself in the mind and position of the right hon. Gentleman—surely he must feel that, although he does not want to get rid of all the charges, he wants to make some adjustments, if only he is given the opportunity by being given the money to match the increased availability of resources.
The need for an increased expenditure on the National Health Service arises for many reasons. There is the increase in population which has taken place since the Service started. More important than that, there has been an increase, within 1812 that population, in the proportion of aged people, who need more medical care and attention than the younger ones. That is undeniable. In addition, as the Parliamentary Secretary told us the other night, in consequence of the increase in population there is also an increase in the mentally-afflicted persons of one kind and another. That remains fairly constant in proportion to population.
There is the obsolescence of our hospital equipment. It is perfectly true that during the war virtually no new hospitals were built, but in the years immediately following the war—although the right hon. Gentleman has told me that the figures are not available—a very large proportion of the resources which we could then devote to building had to go to the repair of war damage. Hon. Members have only to stand on the Terrace of the House of Commons and look over to St. Thomas' Hospital to see just one example of what I mean. Because of this inability to do little more than make good war damage it is quite true that no new hospitals have been built for far too long. It is necessary to remind public opinion and the Committee which will look into this matter that our hospital capital equipment is very seriously run down.
Finally, there are the needs of the new towns and the new housing estates, many of which are now condemned to make do with totally inadequate and makeshift accommodation. I know that that it is perfectly possible to say, "All these things existed in your time, and when you were responsible." That is quite true, but my point is that more resources are becoming available to tackle these problems, and the Chancellor of the Exchequer has proved that the money is available by giving it away to the Income Tax payers.
I have been looking at the figures of capital expenditure on the acquisition of land and the building and conversion of hospitals. It is always very difficult to find one's way among these figures in the Estimates, especially as those for Scotland are in one part of the book and those for England and Wales in the other. It seems that in 1951–52, £12.7 million was provided for the building and conversion of hospitals and the acquisition of land. In 1952–53 only £11.6 million was provided, and in this year the same amount is estimated to be required.
1813 Surely costs have risen in the meantime? Surely this £11.6 million is not only numerically less than the figure for 1951–52 but is physically a great deal less, because of the rise in costs? It is important that this Committee, or whoever will take over the job of surveying the Health Service, should realise that the building of new hospitals is to be advocated not only on humanitarian grounds, and because it would make life easier for those who work or have to be patients in hospitals, but because it would result in a great economy within the hospital service itself. Too many of our hospitals are hopelessly out-of-date and consequently very expensive to run. We need to build more economical hospitals. As has already been said, we need more long-stay annexes for old people and for patients who are being rehabilitated.
So I hope that the Minister will ask the Guillebaud Committee to look at the extent to which the service could be run more economically by providing better capital equipment and, particularly, whether it might not be a sensible method to present the capital accounts of the Health Service separate from the current accounts so that there would not be the tendency all the time to lump the capital expenditure of the year within the total amount which the Chancellor thinks he is spending on the current National Health Service.
I was relieved to hear what the right hon. Gentleman had to say about hospital current expenditure for the coming year. The arrangements which he has made, as far as we could gather from his speech —they need more careful study—seem to be good. They will make available to him more finance for the current needs of the hospitals. However, he will agree that it is a once-for-all remedy. The reduction of stocks and so on can only be done once, and it will not yield him an extra £15 million next year. In considering the future of the National Health Service, we need to bear that clearly in mind.
It still looks as if the needs of the hospitals, not merely for capital equipment but also for current expenditure, will continue to rise. We welcome the Minister's announcement about the presentation of the Report from Sir Henry Cohen about drugs of no therapeutic value. He 1814 will have all the support that my hon. Friends can give him in carrying out the recommendations. He said that, in regard to proprietary medicines, he did not rule out more drastic measures if those which he had in mind should fail, and I can promise him that if he thinks more drastic measures are necessary he will encounter no difficulty on this side of the Committee, and I hope he will find no difficulty anywhere else.
I now come to the question of the Committee itself. The right hon. Gentleman said that the case for there being something to be inquired into was unanswerable. I am still a little doubtful. I still cannot help feeling that the right hon. Gentleman himself, with the aid of his Department, of hon. Members and our debates and Committees and the Central Health Service Council, must know all the facts and ought to make up his own mind about them. Many of my hon. Friends have said that there is plenty to be inquired into, and it is not on the grounds that we dislike an inquiry into the organisation of the Health Service or into the various matters which had been suggested by the Minister and his hon. Friends and by my hon. Friends—some very useful factual topics which can be inquired into have been mentioned—that we are doubtful about the wisdom of appointing the Committee.
Many hon. Members opposite have said with great regret in their voices that they expected a much stormier debate than we have had and could not understand why everything had become much more peaceful than they had thought it would be. The answer is simple. When the announcement was first made of the establishment of the Committee the terms of reference which were read to us contained the most important phrase "to avoid a rising charge." Immediately we saw in front of us a Committee, which was confronted with an inevitably rising expenditure on the National Health Service—for the reasons which I described earlier—being told, "But you must keep within a ceiling. Now go away and recommend what we can do about the cost of the Health Service." We naturally felt—we could draw no other conclusion —that the intention was that this Committee should look for some new forms of charge to be imposed. Little wonder that we were indignant.
1815 But since then the terms of reference, if not altered, have been emasculated. The House of Commons should be very grateful to the Trades Union Congress for what they did in that matter, because when the Congress was asked to nominate a member to serve on the Committee, it queried the terms of reference. It was given what is euphemistically called "a clarification." The Chancellor of the Exchequer has told us that the terms do not mean they have to work to a ceiling. They have been given no ceiling. Well, if that is so, words do not mean what they say. I think it would have been better if the right hon. Gentleman had come here tonight and said, "I have written to the Committee and I have told them quite formally that these words were dropped out of the terms of reference altogether."
The right hon. Gentleman himself said that the Central Health Services Council could not look into this question on the grounds of the terms of reference, and so some suspicion is left in my mind because of that. I should like to know— I hope the Joint Under-Secretary of State for Scotland will address his mind to this point when he comes to reply—what the terms of reference mean. We must ask for a definite pledge from the Government that the Committee will be free to recommend policies which could result in more expenditure, if they see fit. Will this Committee be free, having surveyed the Service, to recommend changes and improvements in it which will involve increased expenditure? We should like a definite answer to that specific question.
The right hon. Gentleman spoke very forthrightly about the position of the mental health service. I entirely sympathise with him on that, and he knows that I feel as strongly as he does. We all know that the mental hospitals are seriously overcrowded, and that there are long lists of mental defectives awaiting admission to mental deficiency institutions. The right hon. Gentleman asked me whether I would put first things first and go ahead with a scheme for increased accommodation and a better service for these people. Of course I would.
Whatever system prevails or whatever Government are in power there will always be the question of priorities within 1816 the National Health Service. We would not and could not in one year approve a capital expenditure programme of £1,000 million which he told us would be necessary fully to improve the hospitals of this country. But what we definitely and emphatically say—we will confirm our opinion in the Lobbies tonight—is that this Government's priorities are all wrong. When they have more than £100 million for distribution their priority is not the needs of the hospitals, but of the Income Taxpayer, and we reject that policy absolutely and utterly.
§ 9.30 p.m.
The Joint Under-Secretary of State for Scotland (Commander T. D. Galbraith)
I agree with the right hon. Gentleman the Member for Middlesbrough, East (Mr. Marquand) that we have had a thoughtful and quiet debate, and I do not think it has been any worse for being quiet. It has been a debate which the Government welcomed, as my right hon. Friend said when opening and speaking after the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan). We hoped that it would attract a considerable number of helpful and constructive criticisms of a great service on which the welfare and health of the people of this country depend. Having listened to the greater part of the debate, I would say that our hopes have been realised in part. Helpful and constructive suggestions have been put forward in several speeches, and we have had a most helpful contribution from the hon. Gentleman the Member for Tottenham (Mr. Messer) who, when speaking on the National Health Service, always speaks with great thought and clarity.
Criticisms in regard to the appointment of the Guillebaud Committee have been fully answered by my right hon. Friend and I do not intend to deal with that aspect of our debate other than to clear up a matter raised by the hon. Member for Tottenham. Speaking on savings, he said he believed that if we were to have a full-time service instead of having it in part a part-time service, we could save money. So far as the health Ministers are concerned we have no evidence to support that view.
Well, the hon. Gentleman was interrupted by the hon. Member for Stoke-on-Trent, South (Mr. Ellis Smith) and I want to correct the impression which apparently that hon. Member has. The Guillebaud Committee can study the merits of whole-time and part-time services—that is, the consultants' service. What my right hon. Friend said a few days ago was that the committee would not deal with actual rates of payment. I hope I have succeeded in making that point clear.
There was another point about the committee put by the hon. Gentleman the Member for Leith (Mr. Hoy). He asked why the Secretary of State for Scotland had joined in the appointment of that committee, which would therefore examine the National Health Service in Scotland as well as in England and Wales. So far as I could ascertain, he did not think that Scotland needed an inquiry. Of course, everyone knows that Scotland has her own National Health Service, with her own Act and with her own Health Minister. The differences between the Scottish service and the English service, are purely matters of administrative machinery and do not affect the facilities enjoyed by the public. Indeed, it is inevitable that the people of the two countries should have the same benefits in the service which is largely financed by the British Exchequer.
In so far as the differences in administrative structure may have a bearing on the value of money, it is a positive advantage that those structures should come under review. That should ensure that the best features of both Services are embodied in the findings of the Committee. I can assure the hon. Gentleman that Scottish needs and circumstances will be considered fully by the Committee. As the hon. Gentleman knows, the chairman was and is a member of the Royal Commission on Scottish Affairs and he is therefore well aware of Scottish feeling. One of the other members of the Committee comes from Scotland namely, Professor Cook of Glasgow University. I am certain also that the Committee will arrange sittings in Scotland and hear Scottish evidence. That also answers the question put to me by the hon. Gentleman the Member for Orkney and Shetland (Mr. Grimond).
1818 The hon. Member for Leith also questioned, as did other hon. Members, why this Committee should be set up and why the Estimates Committee or the Public Accounts Committee should not have dealt with this matter. The terms of reference of the Estimates Committee ask it toreport on what, if any, economies consistent with the policy implied in these Estimates may be effected therein.The Public Accounts Committee, of course, deals with financial rectitude on matters that are in the past. It would not appear, therefore, that either of these Committees would be suitable for the purpose which my right hon. Friends have in view.
I should have thought that they were very valuable material on which the Guillebaud Committee might get to work. [Interruption.] I have not got very much time, and I hope that the Committee will allow me to proceed with what I wish to say.
I want to refute the mistaken and unwarranted charges, which have been made again today, as to the intentions of my right hon. Friend the Minister of Health and of the Government in relation to the National Health Service, and which, I think, might be summed up in the intervention by the right hon. Member for Ebbw Vale when, if I have his words correctly, he spoke of his rather manoeuvring to save than manoeuvring to destroy. For this purpose, and also to show the progress that has been made by the National Health Service, in which every one of us is interested—we want to see it the most efficient Service that we can possibly get—I want to rely on facts and not merely on imagination. I shall, therefore, give certain vital statistics which, I think, dispose entirely of these charges which have been made against the Government.
I start with the figures for infant mortality, in which there has been a steady and continuous decline in recent years. 1819 Whereas in England and Wales deaths per 1,000 live births in 1947 were 41.4, they fell in 1952 to 27.6. In Scotland there has been an exactly similar trend, the respective figures being 55.8 in 1947 and 35.2 in 1952. In other words, the fall in England and Wales has been 33 per cent, and in Scotland 37 per cent. [HON. MEMBERS: "Hear, hear."] I am glad that the Committee appreciate the significance of these figures and understand that the progress continues with the present Government in office.
Exactly the same thing can be said about the stillbirths position, for which the figures are declining. The Scottish figures show a fall of from 30.5 to 26 2 per 1,000 births, and the figure for England and Wales a fall of from 24.1 to 22.6. Then there is the question of maternal mortality, in which also there has been a steady improvement. The death rate is now standing at less than one per 1,000 births. These, surely, are instances of very striking advances that have been made, but they are nothing like the improvement which has taken place in regard to respiratory tuberculosis, on which I want to say a word.
Since 1947, in England and Wales the death rate per 100,000 of the population has fallen from 47 to 21—
—and in Scotland it has fallen, equally dramatically, from 66 to 27. So far as Scotland is concerned, the fall in the last two years has been most marked because there has been a fall of no less than 42 per cent.— [Interruption]. I do suggest that the Committee must recognise that the credit for a very remarkable transformation should be given to those scientific discoveries, such as streptomycin—which was mentioned by an hon. Member, speaking today—and the new drug generally known as P.A.S. and also to the advancement of surgical and medical techniques. It also has to be recognised that the expansion of our hospital facilities has made it possible to apply these new methods rapidly and effectively.
§ Mr. Woodburn
The claim has been made several times that all this improve- 1820 ment is due to new drugs. Are there any statistics to show how many of the patients have been given these new drugs? How many cases have been treated with the new drugs? My impression is that it is a very small percentage.
The right hon. Member will appreciate that I did not attribute it all to new drugs, but did say that it was also due to the advancement in surgical and medical techniques. I am sure the Committee will agree that as a result the chances of those afflicted with this disease are very much brighter than they were a few years ago.
Although on paper there would not appear to be any great reduction in the incidence of the disease, that is due at least in part to the much better and more complete ascertainment now possible as a result of mass radiology. I want to illustrate that, and I am making use of Scottish figures for this purpose. The number examined by this process in 1947 was 65,000. Last year it was 250,000 and no less than one-seventh of the new cases notified arose as a result of that examination. So far as notifications are concerned, there have been variations in the past five years, sometimes a little up and sometimes a little down. That is no doubt due to the much more extensive use of mass radiology.
In Scotland the figures went up slightly between 1947 and 1949 and since then they have been steadily going downwards. Last year notifications were 700 below the figure at which they stood in 1947. In England and Wales notifications moved within even narrower limits. I think we have to expect fluctuations of that nature, but it is reassuring to note that the long-term downward trend, interrupted by the war, has now been resumed and in Scotland last year we experienced the biggest percentage drop since before the war. One of the essentials in dealing with tuberculosis is the supply of beds. In the United Kingdom as a whole the number has increased during the past three years by no less than 5,800—an increase for England and Wales of 17 per cent. and in Scotland of 25 per cent.
We could make even more beds available if we could get more nurses. Another 200 nurses in Scotland would 1821 enable us to clear our waiting lists within a comparatively short period. We are hopeful that more nurses will be forthcoming as a result of an extension of a scheme wherein student nurses have the opportunity of volunteering to do three months of their training in T.B. nursing. We believe that will soon make a very considerable contribution to the nursing situation. I am able to tell the Committee that the student nurses themselves find this a very popular form of nursing.
The Swiss scheme, as the hon. Member probably well knows, was for the purpose of supplying extra beds we could not get manned at home. The treatment in Switzerland is no better than the treatment which is received in our own country—in England, Wales and Scotland. There is, in the meantime, no intention of discontinuing the scheme, but new considerations would of course arise if we could man up the number of beds which would enable us to clear our waiting lists within a reasonable period.
In other parts of the hospital service there have also been improvements since 1950. There has been an increase of 3 per cent. in the total number of beds in all our hospitals; there has been an increase of 6 per cent. in the total number of nurses. I hope that the Committee will observe from those figures that instead of staffing standards being lowered they have been raised since this Government took office.
I should like to say a few words about hospital finance because, as has been said today, hospital running costs account for more than half, indeed about two-thirds of the cost of the National Health Service. It is, therefore, of the utmost importance that we should ensure that we get value for money, and in particular that the patient shall derive the utmost benefit from the money being spent. To enable us to ensure that very careful and detailed costing is essential. It is perfectly true that some people object to this detailed costing. It is true that a comparative study of hospital costs, even 1822 without a detailed departmental analysis, is of some value in that it directs attention to particular hospitals which obviously call for further investigation, but in order to get a really reliable comparison between different hospitals a detailed analysis is essential.
If I can put it like this, from an all-in cost figure it is very difficult indeed to distinguish between a high figure which is due to the inclusion of an inherently costly unit, such as a maternity unit, and a high cost which is due to a removable cause; and conversely the inclusion of a low-cost unit—one for patients who do not require much active treatment—can mask an unduly high cost in other parts of the hospital. The Committee will agree that it is of the utmost importance that we should be able to analyse costs, and the question is how best we can analyse them so as to obtain a true picture of relative efficiency, and also control the expenditure within any particular hospital by ascertaining year by year how the expenditure of the various Departments compares.
It was to help solve that problem that the King Edward Hospital Fund for London and the Nuffield Provincial Hospital Trust were asked to obtain information about alternative schemes of costing. I am sure that the Committee would like me to express the thanks of my right hon. Friend and the Government, and indeed of the House, to these two bodies for having undertaken that investigation. They have now submitted their Reports, and they advocate the adoption, in more or less detail, of a system of departmental or unit costing such as I have endeavoured to indicate a few moments ago. These reports are now, together with the experience of simpler forms of costing which we have employed in our hospitals hitherto, being studied by the Health Departments and the hospital authorities in order to devise the most beneficial system and also to ascertain the fields in which the operation of the system will more than pay its way.
§ Mr. Blenkinsop
On the point of costing, can the right hon. and gallant Gentleman say whether he proposes to carry out any further and wider experiment than has already been undertaken?
We wish to examine the Reports before we go ahead. I shall have something to say about these ad hoc inquiries later.
We hope to get a flexible system which will be suitable for hospitals of varying size, and that, as the result of that, expenditure may be directed to those hospitals from which patients will derive most benefit. There are those who are doubtful whether any real benefit will acrue so I should like to give the Committee the the result of certain ad hoc studies which have been undertaken up to now. In one of our Scottish regions the regional hospital board retained as catering adviser a man who had had wide commercial experience. As a result of his survey and the practical demonstrations which he has undertaken a saving is forecast of nearly £25,000 in a food bill of £120,000. That saving has been secured not by reducing standards of feeding; on the contrary, there has been a definite improvement in the quantity, quality and variety of food served in the hospitals concerned.
In another region the regional hospital board arranged for a detailed survey of its laundry facilities. The result has been that my right hon. Friend the Secretary of State for Scotland has approved the regrouping and re-arrangement of the laundry facilities at a capital cost of £150,000 with an annual saving in operating cost of £40,000.
Obviously, if we can make economies on that scale we will have more money to be devoted to the development of hospital services. But, apart from that, I assure the Committee that we have been building up the Service ever since we came into office. I want to give certain figures to prove that contention. In 1951–52 the net running costs of our hospital services was £258 million. In 1952– 53 they rose to £272 million and the estimate for this year is £287 million.
These increases are not merely the result of the increased cost of supplies or increases in salaries and wages. They include the additional running cost of new developments and improvements in standards which have been introduced during the year. I assure the Committee that these are substantial. The Committee will be able to appreciate that when I give the figure for the extra running costs of developments and improvements in standards which will come into operation in 1824 the present year. The figure is estimated at no less than £4,500,000.
I should like to have said something about the ageing population, which has been mentioned by a number of hon. Member's including the hon. Member for Mitcham (Mr. Carr). I have not got time to develop the matter fully, but I would say that, in conformity with medical opinion, the policy of the Government is to try to keep old people interested and healthy, and that we believe can best be accomplished by making it possible for them to continue to live in their own homes. It will be realised that if we are to attain that object we must have more home helps, more home nurses and more health visitors. Therefore, the whole Committee will welcome the increases which local authorities have been able to arrange in these three directions.
I have to sit down a little earlier than usual because the right hon. Gentleman the Member for Ebbw Vale intends to move an Amendment, but before I resume my seat I should like to pay a tribute in which I believe every hon. Member will join. It is to those who are mainly responsible for the very great improvement that has taken place in our vital statistics in recent years. They are, of course, the scientists, the chemists, the doctors and the nurses, the local authorities and those who are employed on public health questions and also the officers of the Ministry of Health and of the Department of Health for Scotland.
§ Dr. Summerskill
The right hon. and gallant Gentleman should recall what that great medical expert Sir Wilson Jameson said during the period of office of the Labour Government. In a report to the Ministry of Health he said that the decrease in the infantile mortality rate must be related to the enlightened food policy of the Labour Government.
I am sure that the House will be grateful for that intervention.
The Government have been charged with political cowardice, a charge which has been repeated today, in that it entrusted to an outside Committee an inquiry into all the aspects of the National Health Service. We have also been charged with a desire to wreck the Service. I hope it is now clear beyond all doubt that the Government are guilty of 1825 neither of these things, but that, on the contrary, by setting up the Guillebaud Committee, my two right hon. Friends have taken a wise and prudent step towards ensuring that the patient receives the best possible treatment and the nation receives value for money. There has not been one word said in this debate that shakes my conviction of the truth of that statement.
Far from wrecking this Service, which we, together with hon. and right hon. Gentlemen opposite, did so much to build up—[Interruption.] Oh. yes, I know that hon. Members have brought up the fact that we voted against the Second Reading of the Bill, but I do not think the hon. Gentleman was in the House when we put forward the reasoned Amendment on
§ which we voted; if he had read it, he would not have made that somewhat silly charge. Far from wrecking the Service, this Government are fostering and encouraging it, and today I claim that it is a stronger and more efficient instrument, more capable of safeguarding the health of this nation, than it has ever been before. It is, therefore, with the utmost confidence that I ask the Committee to grant the supply for which the Government now ask.
Whereupon Motion made, and Question put:
That a further sum, not exceeding £15, be granted for the said Service.—[Mr. Bevan.]
§ The Committee divided: Ayes, 268; Noes, 293.1829
|Division No. 173.]||AYES||[9.58 p.m.|
|Attend, Sir Richard||de Freitas, Geoffrey||Hughes, Cledwyn (Anglesey)|
|Adams, Richard||Deer, G.||Hughes, Emrys (S. Ayrshire)|
|Albu, A. H.||Delargy, H. J.||Hughes, Hector (Aberdeen, N.)|
|Allen, Scholefield (Crewe)||Dodds, N. N.||Hynd, J. B, (Attercliffe)|
|Anderson, Alexander (Motherwell)||Donnelly, D. L.||Irvine, A. J. (Edge Hill)|
|Attlee, Rt. Hon. C. R.||Driberg, T. E. N.||Irving, W. J. (Wood Green)|
|Awbery, S. S.||Dugdale, Rt. Hon. John (W. Bromwich)||Isaacs, Rt. Hon. G. A.|
|Bacon, Miss Alice||Ede, Rt. Hon. J. C.||Janner, B.|
|Baird, J.||Edelman, M.||Jay, Rt. Hon. D. P. T.|
|Balfour, A.||Edwards, John (Brighouse)||Jeger, George (Goole)|
|Barnes, Rt. Hon. A. J.||Edwards, W. J. (Stepney)||Jeger, Dr Santo (St. Pancras, S.)|
|Bartley, P.||Evans, Albert (Islington, S.W.)||Johnson, James (Rugby)|
|Bellenger, Rt. Hon. F. J.||Evans, Edward (Lowestoft)||Jones, David (Hartlepool)|
|Bence, C. R.||Evans, Stanley (Wednesbury)||Jones, Jack (Rotherham)|
|Benn, Hon. Wedgwood||Fernyhough, E.||Jones, T. W. (Merioneth)|
|Benson, G.||Fienburgh, W.||Keenan, W.|
|Beswick, F.||Finch, H. J.||Kenyon, C.|
|Bevan, Rt. Hon. A. (Ebbw Vale)||Fletcher, Eric (Islington, E.)||Key, Rt. Hon. C. W.|
|Bing, G. H. C.||Follick, M.||King, Dr. H. M.|
|Blackburn, F.||Foot, M. M.||Kinley, J.|
|Blenkinsop, A.||Forman, J. C.||Lee, Frederick (Newton)|
|Blyton, W. R.||Fraser, Thomas (Hamilton)||Lee, Miss Jennie (Cannock)|
|Boardman, H.||Freeman, John (Watford)||Lever, Harold (Cheetham)|
|Bowden, H. W.||Freeman, Peter (Newport)||Lever, Leslie (Ardwick)|
|Bowles, F. G.||Gaitskell, Rt. Hon. H. T. N.||Lewis, Arthur|
|Braddock, Mrs. Elizabeth||Gibson, C. W.||Lindgren, G. S.|
|Brockway, A. F.||Glanville, James||Lipton, Lt.-Col. M.|
|Brook, Dryden (Halifax)||Gordon Walker, Rt. Hon. P. C.||Logan, D. G.|
|Brown, Rt. Hon. George (Belper)||Greenwood, Anthony (Rossendale)||MacColl, J. E.|
|Brown, Thomas (Ince)||Greenwood, Rt. Hn. Arthur (Wakefield)||McGhee, H. G.|
|Burke, W. A.||Grenfell, Rt. Hon. D. R.||McGovern, J.|
|Burton, Miss F. E.||Grey, C. F.||McInnes, J.|
|Butler, Herbert (Hackney, S.)||Griffiths, David (Rother Valley)||McKay, John (Wallsend)|
|Callaghan, L. J.||Griffiths, Rt. Hon. James (Llanelly)||McLeavy, F.|
|Carmichael, J.||Griffiths, William (Exchange)||MacMillan, M. K. (Western Isles)|
|McNeil, Rt. Hon. H.|
|Castle, Mrs. B. A.||Hall, Rt. Hon. Glenvil (Colne Valley)||MacPherson, Malcolm (Stirling)|
|Champion, A. J.||Hall, John T. (Gateshead, W.)||Mainwaring, W. H.|
|Chapman, W. D.||Hamilton, W. W.||Mallalieu, E. L. (Brigg)|
|Chetwynd, G. R.||Hannan, W.||Mallalieu, J. P. W. (Huddersfield, E.)|
|Clunie, J.||Hargreaves, A.||Mann, Mrs. Jean|
|Coldrick, W.||Harrison, J. (Nottingham, E.)||Manuel, A. C.|
|Collick, P. H.||Hastings, S.||Marquand, Rt. Hon. H. A.|
|Corbet, Mrs. Freda||Hayman, F. H.||Mason, Roy|
|Cove, W. G.||Healey, Denis (Leeds, S. E.)||Mayhew, C. P.|
|Craddock, George (Bradford, S.)||Healy, Cahir (Fermanagh)||Mellish, R. J.|
|Crosland, C. A. R.||Henderson, Rt. Hon. A. (Rowley Regis)||Messer, F.|
|Crossman, R. H. S.||Herbison, Miss M.||Mikardo, Ian|
|Cullen, Mrs. A.||Hewitson, Capt. M.||Mitchison, G. R.|
|Daines, P.||Hobson, C. R.||Monslow, W.|
|Dalton, Rt. Hon. H.||Holman, P.||Moody, A. S|
|Darling, George (Hillsborough)||Holmes, Horace (Hemsworth)||Morley, R.|
|Davies, Ernest (Enfield, E.)||Houghton, Douglas||Morrison, Rt. Hon. H. (Lewisham, S.)|
|Davies, Harold (Leek)||Hoy, J. H.||Moyle, A.|
|Davies, Stephen (Merthyr)||Hudson, James (Ealing, N.)||Mulley, F. W.|
|Murray, J. D.||Robinson, Kenneth (St. Pancras, N.)||Thomson, George (Dundee, E.)|
|Nally, W.||Rogers, George (Kensington, N.)||Thornton, E.|
|Neal, Harold (Bolsover)||Ross, William||Thurtle, Ernest|
|Noel-Baker, Rt. Hon. P. J.||Royle, C.||Timmons, J.|
|O'Brien, T.||Shackleton, E. A. A.||Tomney, F.|
|Oldfield, W. H.||Shawcross, Rt. Hon. Sir Hartley||Turner-Samuels, M.|
|Oliver, G. H.||Shinwell, Rt. Hon. E.||Ungoed-Thomas, Sir Lynn|
|Orbach, M.||Short, E. W.||Usborne, H. C.|
|Oswald, T.||Shurmer, P. L. E.||Viant, S. P.|
|Padley, W. E.||Silver man, Julius (Erdington)||Wallace, H. W.|
|Paget, R. T.||Silverman, Sydney (Nelson)||Webb, Rt. Hon. M. (Bradford, C.)|
|Paling, Rt. Hon. W. (Dearne Valley)||Simmons, C. J. (Brierley Hill)||Weitzman, D.|
|Paling, Will T. (Dewsbury)||Skeffington, Arthur||Wells, Percy (Faversham)|
|Palmer, A. M. F.||Slater, Mrs. H. (Stoke-on-Trent)||Wells, William (Walsall)|
|Pannell, Charles||Slater, J. (Durham, Sedgefield)||West, D. G.|
|Pargiter, G. A.||Smith, Ellis (Stoke, S.)||Wheeldon, W. E.|
|Parker, J.||Smith, Norman (Nottingham, S.)||White, Mrs. Eirene (E. Flint)|
|Paton, J.||Snow, J. W.||White, Henry (Derbyshire, N.E.)|
|Peart, T. F.||Sorensen, R. W.||Whiteley, Rt. Hon. W.|
|Plummer, Sir Leslie||Soskice, Rt. Hon. Sir Frank||Wigg, George|
|Popplewell, E.||Sparks, J. A.||Wilcock, Group Capt. C. A. B.|
|Porter, G.||Stewart, Michael (Fulham, E.)||Wilkins, W. A.|
|Price, Joseph T. (Westhoughton)||Stokes, Rt. Hon. R. R.||Willey, F. T.|
|Price, Philips (Gloucestershire, W.)||Strachey, Rt. Hon. J.||Williams, David (Neath)|
|Proctor, W. T.||Strauss, Rt. Hon. George (Vauxhall)||Williams, Rev. Llywelyn (Abertillery)|
|Pryde, D. J.||Stross, Dr. Barnett||Williams, Ronald (Wigan)|
|Pursey, Cmdr. H.||Summerskill, Rt. Hon. E.||Williams, Rt. Hn. Thomas (Don V'll'y)|
|Rankin, John||Swingler, S. T.||Williams, W. T. (Hammersmith, S.)|
|Reeves, J.||Sylvester, G. O.||Winterbottom, Richard (Brightside)|
|Reid, Thomas (Swindon)||Taylor, Bernard (Mansfield)||Woodburn, Rt. Hon. A|
|Reid, William (Camlachie)||Taylor, John (West Lothian)||Wyatt, W. L.|
|Rhodes, H.||Taylor, Rt. Hon. Robert (Morpeth)||Yates. V. F.|
|Richards, R.||Thomas, David (Aberdare)||Younger, Rt. Hon. K|
|Robens, Rt. Hon. A.||Thomas, George (Cardiff)|
|Roberts, Albert (Normanton)||Thomas, Iorwerth (Rhondda, W.)||TELLERS FOR THE AYES:|
|Roberts, Goronwy (Caernarvon)||Thomas, Ivor Owen (Wrekin)||Mr. Pearson and Mr. Arthur Allen.|
|Aitken, W. T.||Channon, H.||Godber, J. B.|
|Allan, R. A. (Paddington, S.)||Churchill, Rt. Hon. Sir Winston||Gomme-Duncan, Col. A.|
|Alport, C. J. M.||Clarke, Col. Ralph (East Grinstead)||Gough, C. F. H.|
|Amery, Julian (Preston, N.)||Clarke, Brig. Terence (Portsmouth, W.)||Gower, H. R.|
|Amory, Heathcoat (Tiverton)||Cole, Norman||Graham, Sir Fergus|
|Arbuthnot, John||Colegate, W. A.||Gridley, Sir Arnold|
|Ashton, H. (Chelmsford)||Conant, Maj. R. J. E.||Grimond, J.|
|Assheton, Rt. Hon. R. (Blackburn, W.)||Cooper, Son. Ldr. Albert||Grimston, Hon. John (St. Albans)|
|Astor, Hon. J. J.||Cooper-Key, E. M.||Grimston, Sir Robert (Westbury)|
|Baker, P. A. D.||Craddock, Beresford (Spelthorne)||Hall, John (Wycombe)|
|Baldock, Lt.-Cmdr. J. M.||Cranborne, Viscount||Harden, J. R. E.|
|Baldwin, A. E.||Crookshank, Capt. Rt. Hon. H. F. C.||Hare, Hon. J. H.|
|Banks, Col. C.||Crosthwaite-Eyre, Col. O. E.||Harris, Frederic (Croydon, N.)|
|Barber, Anthony||Crouch, R. F.||Harris, Reader (Heston)|
|Barlow, Sir John||Crowder, Sir John (Finchley)||Harrison, Col. J. H. (Eye)|
|Baxter, A. B.||Crowder, Petre (Ruislip—Northwood)||Harvey, Air Cdre. A. V. (Macclesfield)|
|Beach, Maj. Hicks||Cuthbert, W. N.||Harvey, Ian (Harrow, E.)|
|Beamish, Maj. Tufton||Davidson, Viscountess||Harvie-Watt, Sir George|
|Bell, Philip (Bolton, E.)||Davies, Rt. Hn. Clement (Montgomery)||Hay, John|
|Bell, Ronald (Bucks, S.)||De la Bére, Sir Rupert||Heald, Sir Lionel|
|Bennett, F. M. (Reading, N.)||Deedes, W. F.||Heath, Edward|
|Bennett, Dr. Reginald (Gosport)||Digby, S. Wingfield||Higgs, J. M. C.|
|Bennett, William (Woodside)||Dodds-Parker, A. D.||Hill, Dr. Charles (Luton)|
|Bevins, J. R. (Toxteth)||Donaldson, Cmdr. C. E. McA||Hill, Mrs. E. (Wythenshawe)|
|Birch, Nigel||Donner, P. W.||Hinchingbrooke, Viscount|
|Bishop, F. P.||Doughty, C. J. A.||Hirst, Geoffrey|
|Black, C. W.||Drayson, G. B.||Holland-Martin, C. J.|
|Boothby, R. J. G.||Drewe, C.||Hollis, M. C.|
|Bossom, A C.||Duncan, Capt. J. A. L.||Hope, Lord John|
|Bowen, E. R.||Duthie, W. S.||Hopkinson, Rt. Hon. Henry|
|Boyd-Carpenter, J. A.||Eccles, Rt. Hon, D. M.||Hornsby-Smith, Miss M. P.|
|Boyle, Sir Edward||Elliot, Rt. Hon. W. E.||Horobin, I. M.|
|Braine, B. R.||Erroll, F. J.||Horsbrugh, Rt. Hon. Florence|
|Braithwaite, Sir Albert (Harrow, W.)||Finlay, Graeme||Howard, Gerald (Cambridgeshire)|
|Braithwaite, Lt.-Cdr. G. (Bristol, N. W.)||Fisher, Nigel||Howard, Hon. Greville (St. Ives)|
|Bromley-Davenport, Lt.-Col. W. H.||Fleetwood-Hesketh, R. F.||Hudson, Sir Austin (Lewisham, N.)|
|Brooke, Henry (Hampstead)||Fletcher-Cooke, C.||Hudson, W. R. A. (Hull, N.)|
|Brooman-White, R. C.||Ford, Mrs. Patricia||Hulbert, Wing Cdr. N. J.|
|Browne, Jack (Govan)||Fort, R.||Hurd, A. R.|
|Bullard, D. G.||Foster, John||Hutchinson, Sir Geoffrey (Ilford, N.)|
|Bullus, Wing Commander E. E.||Fraser, Sir Ian (Morecambe & Lonsdale)||Hutchison, Lt.-Com. Clark (E'b'rgh W.)|
|Burden, F. F. A.||Fyfe, Rt. Hon. Sir David Maxwell||Hyde, Lt.-Col. H. M.|
|Butler, Rt. Hon. R. A. (Saffron Walden)||Galbraith, Rt. Hon. T. D. (Pollok)||Jenkins, Robert (Dulwich)|
|Campbell, Sir David||Galbraith, T. G. D. (Hillhead)||Jennings, R.|
|Carr, Robert||Garner-Evans, E. H.||Johnson, Eric (Blackley)|
|Cary, Sir Robert||Glyn, Sir Ralph||Johnson, Howard (Kemptown)|
|Jones, A. (Hall Green)||Nicholson, Godfrey (Farnham)||Spearman, A. C. M.|
|Joynson-Hicks, Hon. L. W.||Nicolson, Nigel (Bournemouth, E.)||Speir, R. M.|
|Kaberry, D.||Nield, Basil (Chester)||Spence, H. R. (Aberdeenshire, W.)|
|Keeling, Sir Edward||Noble, Cmdr. A. H. P.||Spens, Sir Patrick (Kensington, S.)|
|Kerr, H. W.||Nugent, G. R. H.||Stanley, Capt. Hon. Richard|
|Lambert, Hon. G.||Nutting, Anthony||Stevens, G. P.|
|Lancaster, Col. C. G.||Oakshott, H. D.||Steward, W. A. (Woolwich, W.)|
|Langford-Holt. J. A.||Odey, G. W.||Stewart, Henderson (Fife, E.)|
|Law, Rt. Hon. R. K.||O'Neill, Phelim (Co. Antrim, N.)||Stoddart-Scott, Col. M.|
|Leather, E. H. C.||Ormsby-Gore, Hon. W. D.||Storey, S.|
|Legge-Bourke, Maj. E. A. H.||Orr, Capt. L. P. S.||Strauss, Henry (Norwich, S.)|
|Legh, Hon. Peter (Petersfield)||Orr-Ewing, Charles Ian (Hendon, N.)||Stuart, Rt. Hon. James (Moray)|
|Lennox-Boyd, Rt. Hon, A. T.||Orr-Ewing, Sir Ian (Weston-super-Mare)||Studholme, H. G.|
|Lindsay, Martin||Osborne, C.||Summers, G. S.|
|Linstead, H. N.||Partridge, E.||Sutcliffe, Sir Harold|
|Llewellyn, D. T.||Peake, Rt. Hon. O.||Taylor, William (Bradford, N.)|
|Lloyd, Maj. Sir Guy (Renfrew, E.)||Perkins, W. R. D.||Teeling, W.|
|Lloyd, Rt. Hon. Selwyn (Wirral)||Peto, Brig. C. H. M.||Thomas, Rt. Hon. J. P. L. (Hereford)|
|Lockwood Lt.-Col. J. C.||Peyton, J. W. W.||Thomas, Leslie (Canterbury)|
|Longden, Gilbert||Pickthorn, K. W. M.||Thompson, Kenneth (Walton)|
|Low, A. R. W.||Pilkington, Capt. R. A.||Thompson, Lt.-Cdr. R. (Croydon, W.)|
|Lucas, Sir Jocelyn (Portsmouth, S.)||Pitman, I. J.||Thorneycroft, Rt. Hn. Peter (Monmouth)|
|Lucas, Sir Jocelyn (Portsmouth, S.)|
|Lucas, P. B. (Brentford)||Powell, J. Enoch||Thornton Kemsley, Col. C. N.|
|Lucas-Tooth, Sir Hugh|
|McAdden S. J.||Price, Henry (Lewisham, W.)||Tilney, John|
|McCallum, Major D.||Prior-Palmer, Brig. O. L.||Touche, Sir Gordon|
|McCorquodale, Rt. Hon. M. S.||Profumo, J. D.||Turner, H. F. L.|
|Macdonald, Sir Peter||Raikes, Sir Victor||Vane, W. M. F.|
|McKibbin, A. J.||Rayner, Brig. R.||Vane, W. M. F.|
|Mackie, J. H. (Galloway)||Redmayne, M.||Vaughan-Morgan, J. K.|
|Maclay, Rt. Hon. John.||Rees-Davies, W. R.||Vosper, D. F.|
|Maclean, Fitzroy||Remnant, Hon. P.||Wade, D. W.|
|Macleod, Rt. Hon. Iain (Enfield, W.)||Renton, D. L. M.||Wakefield, Edward (Derbyshire, W.)|
|Macmillan, Rt. Hon. Harold (Bromley)||Roberts, Peter (Heeley)||Wakefield, Sir Wavell (St. Marylebone)|
|Macpherson, Niall (Dumfries)||Robertson, Sir David||Walker-Smith, D. C.|
|Maitland, Comdr. J. F. W (Horncastle)||Robinson, Roland (Blackpool, S.)||Ward, Hon. George (Worcester)|
|Maitland, Patrick (Lanark)||Rodgers, John (Sevenoaks)||Ward, Miss I. (Tynemouth)|
|Manningham-Buller Sir R. E.||Roper, Sir Harold||Waterhouse, Capt. Rt. Hon. C.|
|Markham, Major S. F.||Ropner, Col. Sir Leonard||Watkinson, H. A.|
|Marlowe, A. A. H.||Russell, R. S.||Webbe, Sir H. (London & Westminster)|
|Marples, A. E.||Ryder, Capt. R. E. D.||Wellwood, W.|
|Marshall, Douglas (Bodmin)||Salter, Rt. Hon. Sir Arthur||Williams, Rt. Hon. Charles (Torquay)|
|Marshall, Sir Sidney (Sutton)||Sandys, Rt. Hon. D.||Williams, Gerald (Tonbridge)|
|Maude Angus||Savory, Prof. Sir Douglas||Williams, Sir Herbert (Croydon, E.)|
|Maudling, R.||Schofield, Lt.-Col. W.||Williams, Paul (Sunderland, S.)|
|Maydon Lt.-Comdr. S. L. C.||Scott, R. Donald||Williams, R. Dudley (Exeter)|
|Scott-Miller, Cmdr. R.||Wills, G.|
|Medlicott, Brig. F.||Shepherd, William||Wilson, Geoffrey (Truro)|
|Mellor, Sir John||Simon, J. E. S. (Middlesbrough, W.)||Wood, Hon. R.|
|Molson, A. H. E.||Smithers, Peter (Winchester)||York, C.|
|Morrison, John (Salisbury)||Smithers, Sir Waldron (Orpington)|
|Mott-Radclyffe, C. E.||Smyth, Brig. J. G. (Norwood)||TELLERS FOR THE NOES:|
|Nabarro, G. D. N.||Snadden, W. McN.||Mr. Buchan-Hepburn and|
|Nicholls, Harmar||Soames, Capt. C.||Sir Herbert Butcher.|
Question put, and agreed to.
§ Original Question again proposed.
§ It being after Ten o'Clock, and objection being taken to further proceeding, The CHAIRMAN left the Chair to report Progress, and ask leave to sit again.
§ Committee report Progress: to sit again Tomorrow.